New York WellCare Advocate Complete FIDA (Medicare-Medicaid Plan) Provider Manual

Transcription

1 2015 New York WellCare Advocate Complete FIDA (Medicare-Medicaid Plan) Provider Manual

2 Table of Contents Table of Contents... 1 Section 1: Welcome to WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)... 4 Mission and Vision... 4 Purpose of this Manual... 4 WellCare Advocate Complete FIDA... 5 WellCare Advocate Complete FIDA Products... 5 Provider Services/Plan Contact Information... 5 Website Resources... 6 Section 2: Provider and Participant Administrative Guidelines... 8 Provider Administrative Overview... 8 Responsibilities of All Providers... 9 Access Standards...11 Responsibilities of Primary Care Providers...12 Assignment of Primary Care Provider...13 Termination of a Participant...13 Domestic Violence and Substance Abuse Screening...14 Smoking Cessation...14 Adult Health Screening...14 Cultural Competency Program and Plan...14 Cultural Competency Survey...16 Participant Administrative Guidelines...16 Enrollment and Disenrollment Information...16 Participant Identification Cards...16 Eligibility Verification...17 Evidence of Coverage/Participant Handbook...17 Participant Rights and Responsibilities...18 Primary Care Providers...19 Women s Health Specialists...19 Hearing-Impaired, Interpreter and Sign Language Services...20 Section 3: Quality Improvement...21 Overview...21 Quality Improvement Activities...21 Provider Participation in the Quality Improvement Program...22 Participant Satisfaction...22 Patient Safety to include Quality of Care and Quality of Service...22 Clinical Practice Guidelines...23 Healthcare Effectiveness Data and Information Set...23 Medicare Star Rating System...23 Medical Records...24 Web Resources...26 Section 4: Utilization Management, Care Management and Disease Management...27 Utilization Management...27 Overview...27 Medical Necessity...27 Prior Authorization...27 Notification...28 Concurrent Review...28 Discharge Planning...29 Retrospective Appeal Review...30 Effective: January 1, 2015 Page 1 of 93

3 Referrals...30 Criteria for Utilization Management Determinations...30 Organization Determinations...31 Reconsideration Requests...33 Emergency Services...33 Transition of Care...33 Continued Care with a Terminated Provider...34 Continuity of Care...34 Medicare Quality Improvement Organization Review Process...35 Second Opinion...36 Notification of Hospital Discharge Appeal Rights...36 Availability of Utilization Management Staff...37 Care Management Program...37 Overview...37 Provider Access to Care Management...38 Model of Care...39 Disease Management Program...40 Overview...40 Candidates for Disease Management...41 Access to Care and Disease Management Programs...41 Section 5: Claims...42 Overview...42 Timely Claims Submission...42 Claims Submission Requirements...43 Claims Processing...45 Encounters Data...48 Participant Expenses and Maximum Out-of-Pocket...50 Provider-Preventable Conditions...50 Reopening and Revising Determinations...51 Disputed Claims...51 Corrected or Voided Claims...51 Reimbursement...53 Overpayment Recovery...54 Benefits During Disaster and Catastrophic Events...55 Section 6: Credentialing...56 Overview...56 Practitioner Rights...57 Baseline Criteria...58 Liability Insurance...58 Site Inspection Evaluation...59 Covering Physicians...59 Allied Health Professionals...59 Ancillary Health Care Delivery Organizations...59 Re-Credentialing...60 Updated Documentation...60 Office of Inspector General Medicare/Medicaid Sanctions Report...60 Sanction Reports Pertaining to Licensure, Hospital Privileges or Other Professional Credentials...60 Participating Provider Appeal through the Dispute Resolution Peer Review Process...60 Delegated Entities...62 Section 7: Appeals and Grievances...63 Effective: January 1, 2015 Page 2 of 93

4 Appeals...63 Provider Retrospective Appeals Overview...63 Provider Retrospective Appeals Decisions...63 Participant Appeal Process...64 Expedited Appeals...65 Standard Pre-Service and Retrospective Appeals (Level 1 Appeal)...66 Participant Appeal Decisions...66 Grievances...68 Provider...68 Participant Grievance Overview...68 Grievance Submission...69 Grievance Resolution...69 Section 8: Compliance...72 Compliance Program - Overview...72 Marketing FIDA Plans...73 Code of Conduct and Business Ethics...73 Overview...73 Fraud, Waste and Abuse...73 Confidentiality of Participant Information and Release of Records...74 Disclosure of Information...75 Section 9: Delegated Entities...76 Overview...76 Compliance...76 Section 10: Behavioral Health...78 Overview...78 Continuity and Coordination of Care Between Medical and Behavioral Health Providers...78 Responsibilities of Behavioral Health Providers...78 Section 11: Pharmacy...80 Formulary...80 Additions and Exceptions to the Formulary...81 Coverage Limitations...81 Generic Medications...81 Step Therapy...81 Prior Authorization...81 Quantity Limits...82 Therapeutic Interchange...82 Mail Service...82 Injectable and Infusion Services...82 Coverage Determination Request Process...82 Obtaining a Coverage Determination Request...82 Medication Appeals...83 Section 12: Definitions and Abbreviations...84 Definitions...84 Abbreviations...90 Section 13: WellCare Advocate Complete FIDA Resources...93 Effective: January 1, 2015 Page 3 of 93

5 Section 1: Welcome to WellCare Advocate Complete FIDA (Medicare-Medicaid Plan) WellCare Health Plans, Inc. (WellCare) provides managed care services targeted exclusively to government-sponsored health care programs, focused on Medicare, Medicaid and Children s Health Insurance Programs, including prescription drug plans and health plans for families, and the aged, blind and disabled. WellCare s corporate office is located in Tampa, Florida. WellCare serves approximately 4 million participants as of September 30, WellCare s experience and exclusive commitment to these programs enable WellCare to serve its participants and providers as well as manage its operations effectively and efficiently. Mission and Vision WellCare s vision is to be the leader in government-sponsored health care programs in partnership with the participants, providers, governments, and communities it serves. WellCare will: Enhance its participants' health and quality of life; Partner with providers and governments to provide quality, cost-effective health care solutions; and Create a rewarding and enriching environment for its associates. WellCare s core values include: Partnership Participants are the reason WellCare is in business; providers are WellCare s partners in serving its participants; and regulators are the stewards of the public's resources and trust. WellCare will deliver excellent service to its partners. Integrity WellCare s actions must consistently demonstrate a high level of integrity that earns the trust of those it serves. Accountability All associates must be responsible for the commitments WellCare makes and the results WellCare delivers. Teamwork With its fellow associates, WellCare can expect and is expected to demonstrate a collaborative approach in the way it works. Purpose of this Manual This Manual is intended for providers who have contracted with WellCare Advocate Complete FIDA (Medicare-Medicaid Plan) to deliver quality health care services to its participants enrolled in a Fully-Integrated Duals Advantage (FIDA) Demonstration Medicare-Medicaid Plan (MMP). WellCare Advocate Complete FIDA is a managed care plan under contract with CMS and the State to provide the fully-integrated Medicare and Medicaid benefits. This Manual serves as a guide to providers and their staff to comply with the policies and procedures governing the administration of WellCare Advocate Complete FIDA and is an extension of, and supplements, the provider participation contract providers entered into with WellCare Advocate Complete FIDA (Agreement). This Manual is available on WellCare Advocate Complete FIDA s website at A paper copy is available at no charge to providers upon request. In accordance with the provider Agreement, participating WellCare Advocate Complete FIDA providers must abide by all applicable provisions of this Manual, as may be modified from time to time upon notice. WellCare Advocate Complete FIDA may change this Manual to reflect changes in its policies and procedures and all revisions shall become binding 30 days after WellCare Advocate Complete FIDA s notice to providers, or such lesser time for WellCare Effective: January 1, 2015 Page 4 of 93

6 Advocate Complete FIDA s compliance with laws, government payor contracts, or accreditation requirements. WellCare Advocate Complete FIDA will notify providers of changes to this Manual in the form of Provider Bulletins or Manual updates, which shall be provided to providers by mail, facsimile, or other electronic means. WellCare Advocate Complete FIDA may release Provider Bulletins that are state-specific and may override the policies and procedures in this Manual. WellCare Advocate Complete FIDA As a Medicare-Medicaid Plan (MMP) organization, coverage includes comprehensive Medicare and Medicaid, and supplemental services including*: All physical health care; All long-term services and supports (LTSS) Services; Consumer direction for personal care services ; Additional services currently only available through Home and Community-Based Services (HCBS) waivers; Additional supplemental services not currently required in NY Medicaid managed care plans; All behavioral health care; Nursing facility services; All services available in the State s Office for People With Developmental Disabilities (OPWDD) Comprehensive Waiver; Outpatient prescription drug coverage; Dental, vision and hearing benefits; and Any other benefits specified by the State as part of this program. *Subject to change. WellCare Advocate Complete FIDA Products WellCare Advocate Complete FIDA products are designed to offer enhanced benefits to its participants as well as cost-sharing alternatives. WellCare Advocate Complete FIDA products are offered to allow flexibility and offer a distinct set of benefits to fit participant needs in each area. Please refer to WellCare Advocate Complete FIDA s website at for more information. WellCare Advocate Complete FIDA s product, described below, and other products, may change from time to time as WellCare Advocate Complete FIDA obtains a license to issue benefits plans under a government contract. MMP Health Maintenance Organization (HMO) Similar to a traditional Medicare Advantage (MA) plan. All services must be provided by a participating MMP provider unless an emergency or urgent need for care arises, or such service is not available in-network. Some services require prior authorization by WellCare Advocate Complete FIDA or members of the participant s Interdisciplinary Team (IDT). Provider Services/Plan Contact Information Providers may contact the appropriate departments, including WellCare Advocate Complete FIDA s Provider Services Department, by referring to the phone numbers and information in the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Effective: January 1, 2015 Page 5 of 93

7 In addition, WellCare Advocate Complete FIDA s Provider Relations representatives are available to assist providers. Providers may contact their local market office for assistance. Website Resources WellCare Advocate Complete FIDA s website, offers a variety of tools to assist providers and their staffs. Available resources include: Provider Manual; Quick Reference Guide; Clinical Practice Guidelines; Clinical Coverage Guidelines; WellCare Advocate Complete FIDA Companion Guide; Forms and documents; Pharmacy and provider lookup (directories); Authorization look-up tool; Training materials and job aids; Newsletter; Participant rights and responsibilities; and Privacy statement and notice of privacy practices. Secure Provider Portal Benefits of Registering WellCare Advocate Complete FIDA s secure online Provider Portal offers immediate access to an assortment of useful tools. Providers can create unlimited individual sub-accounts for staff participants, allowing for separate billing and medical accounts. All providers who create a login and password using their Provider Identification (Provider ID) number have access to the following features: Claims submission status and inquiry: Submit a new claim, check the status of an existing claim, and customize and download reports. Participant eligibility: Verify participant eligibility. Authorization requests: Submit authorization requests, attach clinical documentation and check authorization status. Providers can also print and/or save copies of authorization forms. Pharmacy services and utilization: View and download a copy of the Formulary, see drug recalls, access pharmacy utilization reports and obtain information about WellCare Advocate Complete FIDA s pharmacy services. Training: Take required training courses and complete attestations online. Reports: Access reports such as active participants, authorization status, claims status, eligibility status, pharmacy utilization, and more. Provider news: View the latest important announcements and updates. Personal inbox: Receive notices and key reports regarding the provider s claims, eligibility inquiries and authorization requests. How to Register Please visit Effective: January 1, 2015 Page 6 of 93

8 After registering for WellCare Advocate Complete FIDA s website, providers should retain login and password information for future reference. For more information about WellCare Advocate Complete FIDA s Web capabilities, providers may Provider Services or their Provider Relations representative. Additional Resources Another valuable resource is the Quick Reference Guide, which contains important addresses, phone/fax numbers and authorization requirements. The Quick Reference Guide can be located at Effective: January 1, 2015 Page 7 of 93

9 Section 2: Provider and Participant Administrative Guidelines Provider Administrative Overview In accordance with generally accepted professional standards, participating New York MMP providers must: Meet the requirements of all applicable State and Federal laws and regulations, including without limitation, Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, and the Rehabilitation Act of 1973; Agree to cooperate with WellCare Advocate Complete FIDA in its efforts to monitor compliance with its Medicare-Medicaid Plan (MMP) contract(s) and/or Medicare- Medicaid Plan (MMP) rules and regulations, and assist WellCare Advocate Complete FIDA in complying with corrective action plans necessary to comply with such rules and regulations; Retain all agreements, books, documents, papers, and medical records related to the provision of services to WellCare Advocate Complete FIDA participants as required by State and Federal laws; Provide Covered Services in a manner consistent with professionally recognized standards of health care [42 C.F.R (a)(3)(iii)]; Use physician extenders appropriately. Physician Assistants (PA) and Advanced Registered Nurse Practitioners (ARNPs) should provide direct participant care within the scope or practice established by the rules and regulations of the State and WellCare Advocate Complete FIDA guidelines; Assume full responsibility to the extent of the law when supervising PAs and ARNPs whose scope of practice should not extend beyond statutory limitations; Clearly identify their title (examples: M.D., D.O., ARNP, PA) to participants and to other health care professionals; Honor at all times any participant request to be seen by a physician rather than a physician extender; Administer treatment for any participant in need of health care services they provide; Respond within the identified timeframe to WellCare Advocate Complete FIDA s requests for medical records in order to comply with regulatory requirements; Maintain accurate medical records and adhere to all WellCare Advocate Complete FIDA policies governing the content and confidentiality of medical records as outlined in Section 3: Quality Improvement and Section 8: Compliance; Allow WellCare Advocate Complete FIDA to use provider performance data; Ensure that: o all employed physicians and other health care practitioners and providers comply with the terms and conditions of the Agreement; o the physician maintains written agreements with all contracted physicians or other health care practitioners and providers, which agreements contain similar provisions to the Agreement; Maintain an environmentally safe office with equipment in proper working order to comply with city, State and Federal regulations concerning safety and public hygiene; Effective: January 1, 2015 Page 8 of 93

10 Communicate timely clinical information between providers. Communication will be monitored during medical/chart review. Upon request, provide timely transfer of clinical information to WellCare Advocate Complete FIDA, the participant or the requesting party at no charge, unless otherwise agreed; Preserve participant dignity and observe the rights of participants to know and understand the diagnosis, prognosis and expected outcome of recommended medical, surgical and medication regimen; Not discriminate in any manner between WellCare Advocate Complete FIDA participants and non-wellcare Advocate Complete FIDA participants; Ensure that the hours of operation offered to WellCare Advocate Complete FIDA participants are no less than those offered to commercial participants; Not deny, limit or condition the furnishing of treatment to any WellCare Advocate Complete FIDA Advocate Complete FIDA participant on the basis of any factor that is related to health status, including, but not limited to, the following: o medical condition, including mental as well as physical illness; o claims experience; o receipt of health care; o medical history; o genetic information; o evidence of insurability; including conditions arising out of acts of domestic violence; or o disability; Freely communicate with and advise participants regarding the diagnosis of the participant s condition and advocate on the participant s behalf for the participant s health status, medical care, and available treatment or non-treatment options including any alternative treatments that might be self-administered regardless of whether any treatments are Covered Services; Identify participants who are in need of services related to domestic violence, smoking cessation or substance abuse. If indicated, providers must refer participants to WellCare Advocate Complete FIDA-sponsored or community-based programs; and Document the referral to WellCare Advocate Complete FIDA-sponsored or communitybased programs in the participant s medical record and provide the appropriate followup to ensure the participant accessed the services. Responsibilities of All Providers The following is a summary of the responsibilities of all providers who render services to WellCare Advocate Complete FIDA participants. Marketing Medicare-Medicaid Plans Medicare-Medicaid Plan marketing is regulated by the Centers for Medicare & Medicaid Services (CMS) and the State of New York Department of Health. Providers should familiarize themselves with CMS regulations and the CMS Medicare Managed Care Manual and the State specific regulations. However, plan-sponsored marketing for the MMP plan is prohibited. For more information, refer to Section 8: Compliance in this Manual. Effective: January 1, 2015 Page 9 of 93

11 Maximum Out-of-Pocket For certain MMP participant benefit plans, participant expenses are limited by a maximum outof-pocket (MOOP) amount. However, the NY FIDA program does not have a maximum out-ofpocket limitation since all services are provided at no cost to the participant. Advance Directive Participants have the right to control decisions relating to their medical care, including the decision to have withheld or taken away the medical or surgical means or procedures to prolong their life. Advance Directives may differ among states. Each participant (age 18 years or older and of sound mind) should receive information regarding Advance Directives. These directives allow the participant to designate another person to make medical decisions on the participant s behalf should the participant become incapacitated. Information regarding Advance Directives should be made available in provider offices and discussed with the participants. Completed forms should be documented and filed in participants medical records. Providers shall not, as a condition of treatment, require a participant to execute or waive an Advance Directive. Provider Billing and Address Changes Prior notice to a Provider Relations representative or Provider Services is required for any of the following changes: 1099 mailing address; Tax Identification Number (TIN) or Entity Affiliation (W-9 required); Group name or affiliation; Physical or billing address; and Telephone and fax number. Failure to notify WellCare Advocate Complete FIDA prior to these changes will result in a delay in claims processing and payment. Provider Termination In addition to the provider termination information included in the Agreement, providers must adhere to the following terms: Any contracted provider must give at least 90 days prior written notice (180 days for a hospital) to WellCare Advocate Complete FIDA before terminating his or her relationship with WellCare Advocate Complete FIDA without cause, unless otherwise agreed to in writing. This ensures adequate notice may be given to WellCare Advocate Complete FIDA participants regarding the provider s participation status with WellCare Advocate Complete FIDA. Please refer to the provider s Agreement for the details regarding the notice requirements since, under the Agreement, the provider may be required to give more notice than stated above; and Unless otherwise provided in the termination notice, the effective date of a termination will be on the last day of the following month. Please refer to Section 6: Credentialing of this Manual for specific guidelines regarding rights to appeal plan termination (if any). Effective: January 1, 2015 Page 10 of 93

12 WellCare Advocate Complete FIDA will notify in writing all appropriate agencies and/or participants prior to the termination effective date of a participating primary care physician (PCP), hospital, specialist or significant ancillary provider within the service area as required by Medicare-Medicaid Plan program requirements and/or regulations and statutes. Out-of-Area Participant Transfers Providers should assist WellCare Advocate Complete FIDA in arranging and accepting the transfer of participants receiving care out of the service area if the transfer is considered medically acceptable by a WellCare Advocate Complete FIDA network provider and the out-ofnetwork attending physician/provider. Participants with Special Health Care Needs Participants with special health care needs have one or more of the following conditions: Mental retardation or related conditions; Serious chronic illnesses such as Human Immunodeficiency Virus (HIV), schizophrenia or degenerative neurological disorders; Disabilities resulting from chronic illness such as arthritis, emphysema or diabetes; or Children and adults with certain environmental risk factors such as homelessness or family problems that may lead to the need for placement in foster care. Providers who render services to participants with special health care needs shall: Assess participants and develop plans of care for those participants determined to need courses of treatment or regular care; Coordinate treatment plans with participants, family and/or specialists caring for participants; Develop a plan of care that adheres to community standards and any applicable sponsoring government agency quality assurance and utilization review standards; Allow participants needing courses of treatment or regular care monitoring to have direct access through standing referrals or approved visits, as appropriate for the participants conditions or needs; Coordinate with WellCare Advocate Complete FIDA, if appropriate, to ensure that each participant has an ongoing source of primary care appropriate to his or her needs, and a person or entity formally designated as primarily responsible for coordinating the health care services furnished; Coordinate services with other third party organizations to prevent duplication of services and share results on identification and assessment of the participant s needs; and Ensure the participant s privacy is protected as appropriate during the coordination process. Access Standards All providers must adhere to standards of timeliness for appointments and in-office waiting times. These standards take into consideration the immediacy of the participant s needs. WellCare Advocate Complete FIDA shall monitor providers against the standards below to ensure participants can obtain needed health services within acceptable appointment, in-office waiting times, and after-hours standards. Providers not in compliance with these standards will be required to implement corrective actions. Effective: January 1, 2015 Page 11 of 93

13 Type of Appointment Access Standard PCP Urgent < 24 hours PCP Non-urgent < hours PCP Routine < 30 days Specialist < 30 days In-office wait times shall not exceed one (1) hour. PCPs must provide or arrange for coverage of services, consultation, or approval for referrals 24 hours per day, seven days per week. To ensure access and availability, PCPs must provide one of the following: A 24-hour answering service that connects the participant to someone who can render a clinical decision or reach the PCP; Answering system with option to page the physician for a return call within a maximum of 30 minutes; or An advice nurse with access to the PCP or on-call physician within a maximum of 30 minutes. Please see Section 10: Behavioral Health for mental health and substance use access standards. Responsibilities of Primary Care Providers The following is a summary of responsibilities specific to PCPs who render services to WellCare Advocate Complete FIDA participants: Coordinate, monitor and supervise the delivery of primary care services to each participant: See participants for an initial office visit and assessment within the first 90 days of enrollment in WellCare Advocate Complete FIDA; Assure participants are aware of the availability of public transportation where applicable; Provide access to WellCare Advocate Complete FIDA or its designee to examine thoroughly the primary care offices, books, records and operations of any related organization or entity. A related organization or entity is defined as having influence, ownership or control and either a financial relationship or a relationship for rendering services to the primary care office; Submit an encounter to WellCare Advocate Complete FIDA for each visit in which the provider sees the participant or the participant receives a Healthcare Effectiveness Data and Information Set (HEDIS ) service. For more information on encounters, refer to the Section 5: Claims in this Manual; Ensure participants utilize network providers. If unable to locate a WellCare Advocate Complete FIDA-participating provider for services required, contact WellCare Advocate Complete FIDA s Health Services Department for assistance. Refer to the Quick Reference Guide at and Comply with and participate in corrective action and performance improvement plan(s). Primary Care Offices PCPs provide comprehensive primary care services to WellCare Advocate Complete FIDA participants. Primary care offices participating in WellCare Advocate Complete FIDA s provider network have access to the following WellCare Advocate Complete FIDA resources: Effective: January 1, 2015 Page 12 of 93

14 Support of WellCare Advocate Complete FIDA s Provider Relations, Provider Services, Health Services, Marketing and Sales Departments; The tools and resources available on WellCare Advocate Complete FIDA s website at and Information on WellCare Advocate Complete FIDA network providers for the purposes of referral management and discharge planning. Closing of Provider Panel When requesting closure of the provider s panel to new and/or transferring WellCare Advocate Complete FIDA participants, PCPs must: Submit the request in writing at least 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 WellCare Advocate Complete FIDA participants who were provided services before the closing of the panel; and Submit written notice of the re-opening of the panel, including a specific effective date. Covering Physicians/Providers In the event that participating providers are temporarily unavailable to provide care or referral services to participants, providers should make arrangements with another WellCare Advocate Complete FIDA-contracted and credentialed provider to provide services on their behalf, unless there is an emergency. Covering providers must be credentialed by WellCare Advocate Complete FIDA, and are required to sign an agreement accepting the negotiated rate and agreeing to not balance bill participants. For additional information, please refer to Section 6: Credentialing. In non-emergency cases, should the provider have a covering physician/provider who is not contracted and credentialed with WellCare Advocate Complete FIDA, the provider may contact WellCare Advocate Complete FIDA for approval. For more information, refer to the Quick Reference Guide at Assignment of Primary Care Provider All WellCare Advocate Complete FIDA participants will choose a PCP or one will be assigned to the participant. To ensure quality and continuity of care, the PCP is responsible for arranging all of the participant s health care needs from providing primary care services to coordinating referrals to specialists and providers of ancillary or hospital services. Termination of a Participant A WellCare Advocate Complete FIDA network provider may not seek or request to terminate his or her relationship with a participant, or transfer a participant to another provider of care, based upon the participant s medical condition, amount or variety of care required or the cost of covered services required by the participant. Reasonable efforts should always be made to establish a satisfactory provider and participant relationship in accordance with practice standards. In the event that a participating provider desires to terminate his or her relationship with a participant, the provider should submit adequate documentation to support that although he or she has attempted to maintain a satisfactory provider and participant relationship, the participant s non-compliance with treatment or uncooperative behavior is impairing the ability to care for and treat the participant effectively. The provider should adequately document in the participant s medical record Effective: January 1, 2015 Page 13 of 93

15 evidence to support his or her efforts to develop and maintain a satisfactory provider and participant relationship. If a satisfactory relationship cannot be established or maintained, the provider shall continue to provide medical care for the participant until such time that written notification is received from WellCare Advocate Complete FIDA stating that the participant has been transferred to another provider s practice. The provider should complete a PCP Request for Transfer of Participant form, attach supporting documentation and fax the form to WellCare Advocate Complete FIDA s Provider Services Department. This form is on WellCare Advocate Complete FIDA s website at Domestic Violence and Substance Abuse Screening PCPs should identify indicators of substance abuse or domestic violence. Sample screening tools for domestic violence and substance abuse are located on WellCare Advocate Complete FIDA s website at Smoking Cessation PCPs should direct participants who wish to quit smoking to call WellCare Advocate Complete FIDA s Customer Service Department and ask to be directed to the Care Management Department. A care manager will educate the participant on national and community resources that offer assistance, as well as smoking cessation options available to the participant through WellCare Advocate Complete FIDA. Adult Health Screening An adult health screening should be performed by a provider to assess the health status of all WellCare Advocate Complete FIDA participants. The adult participant should receive an appropriate assessment and intervention as indicated or upon request. Please refer to the adult preventive health guidelines and the participant physical screening tool, both located on WellCare Advocate Complete FIDA s website at Cultural Competency Program and Plan The purpose of the Cultural Competency program is to ensure that WellCare Advocate Complete FIDA meets the unique, diverse needs of its participants, values diversity within the organization, and identifies participants in need of linguistic services and has adequate communication support for such participants. Providers shall recognize and make arrangements to care for the culturally diverse needs of WellCare Advocate Complete FIDA participants they serve. The objectives of the Cultural Competency program are to: Identify participants who have potential cultural or linguistic barriers for which alternative communication methods are needed; Utilize culturally sensitive and appropriate educational materials based on the participant s race, ethnicity, and primary language spoken; Make resources available to meet the unique language barriers and communication barriers that exist in the population; Help providers care for and recognize the culturally diverse needs of the population; Provide education to associates on the value of the diverse cultural and linguistic differences in the organization and the populations served; and Effective: January 1, 2015 Page 14 of 93

16 Decrease health care disparities in the minority populations WellCare Advocate Complete FIDA serves. Culturally and linguistically appropriate services (CLAS) are health care services that are respectful of, and responsive to, cultural and linguistic needs. The delivery of culturally competent health care and services requires health care providers and/or their staff to possess a set of attitudes, skills, behaviors and policies which enable the organization and staff to work effectively in cross-cultural situations. The components of WellCare Advocate Complete FIDA s Cultural Competency program include: Data Analysis o Analysis of claims and encounter data to identify the health care needs of the population; and o Collection of participant data on race, ethnicity and language spoken. Community-Based Support o Outreach to community-based organizations that support minorities and the disabled to ensure that the existing resources for participants are being utilized to their full potential. Diversity o Non-Discrimination WellCare Advocate Complete FIDA may not discriminate with regard to race, religion or ethnic background when hiring associates; o Recruiting WellCare Advocate Complete FIDA recruits diverse talented associates in all levels of management; and o Multilingual WellCare Advocate Complete FIDA recruits bilingual associates for areas that have direct contact with participants to meet the needs identified, and encourages providers to do the same. Diversity of Provider Network o Providers are inventoried for their language abilities and this information is made available in the Provider Directory so that participants can choose a provider that speaks their primary language; and o Providers are recruited to ensure a diverse selection of providers to care for the population served. Linguistic Services o Providers are required to identify participants who have potential linguistic barriers for which alternative communication methods are needed and will contact WellCare Advocate Complete FIDA to arrange appropriate assistance; o Participants may receive interpreter services at no cost when necessary to access covered services through a vendor, as arranged by the Customer Service Department; o Interpreter services available include verbal translation, verbal interpretation for those with limited English proficiency and sign language for the hearing impaired. These services will be provided by vendors with such expertise and are coordinated by WellCare Advocate Complete FIDA s Customer Service Department; and o Written materials are available for participants in large print format, and certain non-english languages, prevalent in WellCare Advocate Complete FIDA s service areas. Electronic Media Effective: January 1, 2015 Page 15 of 93

17 o Telephone system adaptations participants have access to the TTY/TDD line for hearing impaired services. WellCare Advocate Complete FIDA s Customer Service Department is responsible for any necessary follow-up calls to the participant. The toll-free TTY/TDD number can be found on the participant identification card. Provider Education o WellCare Advocate Complete FIDA s Cultural Competency Program provides a Cultural Competency Checklist to assess the provider office s Cultural Competency. Registered Provider Portal users may access the Cultural Competency Program training on WellCare Advocate Complete FIDA s website at A paper copy may be requested by calling WellCare Advocate Complete FIDA s Provider Services Department or contacting a Provider Relations representative. Providers must adhere to the Cultural Competency program as set forth above. Cultural Competency Survey Providers may access the Cultural Competency Survey on WellCare Advocate Complete FIDA s website at Participant Administrative Guidelines Enrollment and Disenrollment Information Prospective participants interested in enrolling in a WellCare Advocate Complete FIDA plan or current participants wishing to change plans should call: WellCare Advocate Complete FIDA (TTY ) Monday Friday, 8 a.m. to 6 p.m. Mailing address: WellCare Advocate Complete FIDA th Ave, 2 nd and 3 rd Floor New York, NY All enrollment effective dates are prospective. Participant-elected enrollment is effective the first day of the month following the initial receipt of a participant s request to enroll or the first day of the month following the month in which the participant is eligible and assigned to WellCare Advocate Complete FIDA (passive enrollment). Passive enrollment is effective no sooner than 60 days after participant notification of the right to select a FIDA Plan and the option to decline passive enrollment. WellCare Advocate Complete FIDA will make information available to participants on the role of the PCP, how to obtain care, what to do in an emergency or urgent medical situation, as well as their rights and responsibilities. WellCare Advocate Complete FIDA will convey this information through various methods including an Evidence of Coverage/Participant Handbook. Participant Identification Cards All WellCare Advocate Complete FIDA participants receive Identification Cards no later than 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the month Effective: January 1, 2015 Page 16 of 93

18 prior to the effective date, whichever is later. The ID cards are intended to identify WellCare Advocate Complete FIDA participants, the type of plan they have, and facilitate their interactions with health care providers. Information found on the participant identification card may include the participant s name, identification number, plan type, PCP s name and telephone number, copayment information (if applicable), health plan contact information and claims filing address. Replacement cards will be issued if the participant loses his or her card. The participant identification card for this program is for all Medicare and Medicaid services covered under this plan. Participants will present a single identification card for both Medicare and Medicaid services. Possession of the participant identification card does not guarantee eligibility or coverage. Providers are responsible for ascertaining the current eligibility of the cardholder. Eligibility Verification A participant s eligibility status can change at any time. Therefore, all providers should request and copy the participant s identification card, along with additional proof of identification such as a photo ID, and file them in the patient s medical record. Providers may do one of the following to verify eligibility: Access the Provider Portal at Access WellCare Advocate Complete FIDA s Interactive Voice Response (IVR) system; or Contact WellCare Advocate Complete FIDA s Provider Services Department. Providers will need a Provider ID number to access participant eligibility through the avenues listed above. Verification is always based on the data available at the time of the request, and since subsequent changes in eligibility may not yet be available, verification of eligibility is not a guarantee of coverage or payment. See the Provider Agreement for additional details. Evidence of Coverage/Participant Handbook All WellCare Advocate Complete FIDA participants receive an Evidence of Coverage/Participant Handbook booklet no later than 10 calendar days from receipt of CMS confirmation of enrollment or by the last day of the month prior to the effective date, whichever is later, and annually thereafter. The Evidence of Coverage (EOC) includes information about all State-covered and FIDA Plan-covered additional benefits, in addition to the required Medicare benefits information. Additional content as required by the State to be included in the EOC/Participant Handbook includes: o Eligibility requirements for FIDA Demonstration enrollment; o Excluded services; o Participant rights and responsibilities; o Services requiring prior authorization; o Self-referral services; o Explanation that the FIDA Plan ID card replaces the Medicare and Medicaid cards; o Assessment and care planning processes; o Access and network adequacy requirements; o How to access services; o How to choose providers; Effective: January 1, 2015 Page 17 of 93

19 o How to access emergency care; o The availability of self-directed services and how to begin self-directing services; o The right to change FIDA Plans and the procedure for requesting a change; o The right to disenroll from the FIDA Demonstration and the procedure for disenrolling; o Consolidated appeal and grievance rights and processes; o Nondiscrimination requirements; o Information on participants right to execute advance directives; o How to contact the NYSDOH call center for any concerns; o How to contact the Participant Ombudsman for any assistance; o How to access additional information in alternative formats or languages; o How to access the FIDA Plan provider directory; o The name of WellCare Advocate Complete FIDA of New York s parent company and any DBA (Doing Business As) that may be used; o Toll-free participant services, care management and nurse advice 24-hour service lines; and o Any other content required by State or Federal regulation. A Summary of Benefits (SB) containing a concise description of the important aspects of enrolling in the FIDA Plan, as well as the benefits offered under the FIDA Plan, applicable conditions and limitations, and any other conditions associated with receipt or use of benefits. A combined provider and pharmacy directory that includes all providers of Medicare, Medicaid and additional benefits. A comprehensive integrated formulary that includes Medicare and Medicaid outpatient prescription drugs provided under the FIDA Plan. A single identification (ID) card for accessing all covered services under the FIDA Plan. All Part D required notices, with the exception of the creditable coverage and late enrollment penalty notices required under Chapter 4 of the Prescription Drug Benefit Manual and the low-income subsidy LIS Rider required under Chapter 13 of the Prescription Drug Benefit Manual. Participant Rights and Responsibilities WellCare Advocate Complete FIDA participants have specific rights and responsibilities when it comes to their care. The participant rights and responsibilities are provided to participants in the participant s Evidence of Coverage/Participant Handbook booklet and are outlined below. Participants have the right to: Have information provided in a way that works for them including information that is available in alternate languages and formats; Be treated with fairness, respect and dignity; See WellCare Advocate Complete FIDA network providers, get Covered Services and get their prescriptions filled in a timely manner; Privacy and to have their protected health information (PHI) protected; Information about WellCare Advocate Complete FIDA, its network of providers, their Covered Services and their rights and responsibilities; Know their treatment choices and participate in decisions about their health care; Use Advance Directives (such as a living will or a durable health care power of attorney); Make complaints about WellCare Advocate Complete FIDA or the care provided and feel confident it will not affect the way they are treated; Appeal medical or administrative decisions WellCare Advocate Complete FIDA has made by using the grievance process; Effective: January 1, 2015 Page 18 of 93

20 Make recommendations about WellCare Advocate Complete FIDA s participant rights and responsibilities policies; and Talk openly about care needed for their health, regardless of cost or benefit coverage, as well as the choices and risks involved. The information must be given to participants in a way they understand. Participants also have certain responsibilities. These include the responsibility to: Become familiar with their coverage and the rules they must follow to get care as a participant; Tell WellCare Advocate Complete FIDA and providers if they have any additional health insurance coverage or prescription drug coverage; Tell their PCP and other health care providers that they are enrolled in WellCare Advocate Complete FIDA; Give their PCP and other providers complete and accurate information to care for them, and to follow the treatment plans and instructions that they and their providers agree upon; Understand their health problems and help set treatment goals that they and their doctor agree to; Ask their PCP, and other providers, questions about treatment if they do not understand; Make sure their doctors know all of the drugs they are taking, including over-the-counter drugs, vitamins and supplements; Act in a way that supports the care given to other patients and helps the smooth running of their doctor s office, hospitals and other offices; Inform WellCare Advocate Complete FIDA if they move; and Inform WellCare Advocate Complete FIDA of any questions, concerns, problems or suggestions by calling WellCare Advocate Complete FIDA s Customer Service Department listed in their Evidence of Coverage booklet. Primary Care Providers Participants enrolled in a WellCare Advocate Complete FIDA Medicaid plan must choose a PCP or they will be assigned to a PCP within WellCare Advocate Complete FIDA s network. To ensure quality and continuity of care, the PCP is responsible for arranging all of the participant s health care needs from providing primary care services to coordinating referrals to specialists and providers of ancillary or hospital services. If a participant does not select a PCP, WellCare Advocate Complete FIDA will assign the participant a PCP within 30 days after WellCare Advocate Complete FIDA is notified of enrollment. WellCare Advocate Complete FIDA will notify the participant of the assignment. PCP assignments are based on the participant s geographic location, any known special health care needs and any known language needs. Participants may change their PCP selection at any time by calling WellCare Advocate Complete FIDA s Customer Service Department. Women s Health Specialists PCPs may also provide routine and preventive health care services that are specific to female participants. If a female participant selects a PCP who does not provide these services, she has the right to direct in-network access to a women s health specialist for Covered Services related to this type of routine and preventive care. Effective: January 1, 2015 Page 19 of 93

21 Hearing-Impaired, Interpreter and Sign Language Services Hearing-impaired, interpreter and sign language services are available to WellCare Advocate Complete FIDA participants through Customer Service. PCPs should coordinate these services for participants and contact Customer Service if assistance is needed. Please refer to the Quick Reference Guide at for the Provider Services telephone numbers. Effective: January 1, 2015 Page 20 of 93

22 Section 3: Quality Improvement Overview WellCare Advocate Complete FIDA s Quality Improvement Program (QI Program) is designed to objectively and systematically monitor and evaluate the quality, appropriateness, accessibility and availability of safe and equitable medical and behavioral health care and services. Strategies are identified and activities implemented in response to findings. The QI Program addresses the quality of clinical care and non-clinical aspects of service and focuses on key areas that include, but are not limited to: Quantitative and qualitative improvement in participant outcomes; Coordination and continuity of care with seamless transitions across health care settings/services; Cultural competency; Quality of care/service; Preventive health; Service utilization; Complaints/grievances; Network adequacy; Appropriate service utilization; Disease and Care Management; Participant and provider satisfaction; Components of operational service; and Regulatory/Federal/State/accreditation requirements. The QI Program activities include monitoring clinical indicators or outcomes, appropriateness of care, quality studies, Healthcare Effectiveness Data and Information Set (HEDIS ) measures and/or medical record audits. WellCare Advocate Complete FIDA s Board of Directors has delegated authority to the Quality Improvement Committee to approve specific QI activities (including monitoring and evaluating outcomes, overall effectiveness of the QI Program and initiating corrective action plans when appropriate) when the results are less than desired or when areas needing improvement are identified. Information regarding the QI Program, available upon request, includes a description of the QI Program and a report on WellCare Advocate Complete FIDA s progress in meeting goals. WellCare Advocate Complete FIDA evaluates the effectiveness of the QI Program on an annual basis. An annual report is published which reviews completed and continuing QI activities. This report addresses the quality of clinical care and service, trends measures to assess performance in quality of clinical care and quality of service, identifies any corrective actions implemented or corrective actions which are recommended or in progress and identifies any modifications to the QI Program. It is available as a written document and is posted to the Provider Portal annually. Quality Improvement Activities The following are Quality Improvement activities performed by WellCare Advocate Complete FIDA on an ongoing basis: Preventive health maintenance; Development and review of Clinical Practice Guidelines; Disease Management initiatives; HEDIS studies; Effective: January 1, 2015 Page 21 of 93

23 Medicare national QI projects; State QI projects; Referrals for quality issues; Provider-specific issues identified through tracking and trending of complaints or referrals; Medical record content reviews please review the Medical Records section below for specific documentation standards and requirements; and Chronic care improvement programs. Provider Participation in the Quality Improvement Program Providers are contractually required to comply with Quality Improvement activities, such as HEDIS activities and medical records reviews. Providers are also invited to volunteer for participation in the QI Program. Avenues for voluntary participation include committee representation, quality/performance improvement projects, and feedback/input via satisfaction surveys, grievances, and calls to Customer Service. Provider participation in quality activities helps facilitate integration of service delivery and benefit management. Participant Satisfaction On an annual basis, WellCare Advocate Complete FIDA conducts a participant satisfaction survey of a representative sample of participants. Satisfaction with services, quality, and access is evaluated. The results are compared to performance goals, and improvement action plans are developed to address any areas not meeting the standard. Patient Safety to include Quality of Care and Quality of Service Programs promoting patient safety are a public expectation, a legal and professional standard, and an effective risk-management tool. As an integral component of health care delivery by all providers, WellCare Advocate Complete FIDA supports identification and implementation of a complete range of patient safety activities. These activities include medical record legibility and documentation standards, communication and coordination of care across the health care network, medication allergy awareness/documentation, drug interactions, utilization of evidencebased clinical guidelines to reduce practice variations, tracking and trending adverse events/quality of care issues/quality of service issues and grievances related to safety. Patient safety is also addressed through adherence to clinical guidelines that target preventable conditions. Preventive services include: Regular checkups; Immunizations; and Tests for cholesterol, blood sugar, colon and rectal cancer, bone density, tests for sexually transmitted diseases, Pap smears, and mammograms. Preventive guidelines address prevention and/or early detection interventions, and the recommended frequency and conditions under which interventions are required. Prevention activities are based on reasonable scientific evidence, best practices, and the participant s needs. Prevention activities are reviewed and approved by WellCare Advocate Complete FIDA s Utilization Management Medical Advisory Committee with input from participating providers and WellCare Advocate Complete FIDA s Quality Improvement Committee. Activities include distribution of information, encouragement to utilize screening tools and ongoing monitoring and measuring of outcomes. While WellCare Advocate Complete FIDA implements Effective: January 1, 2015 Page 22 of 93

24 activities to identify interventions, the support and activities of families, friends, providers and the community have a significant impact on prevention. Clinical Practice Guidelines WellCare Advocate Complete FIDA adopts validated evidence-based Clinical Practice Guidelines (CPGs) and utilizes the guidelines as a clinical decision support tool. While clinical judgment by a treating physician or other provider may supersede CPGs, the guidelines provide clinical staff and providers with information about medical standards of care to assist in applying evidence from research in the care of both individual participants and populations. The CPGs are based on peer-reviewed medical evidence and are relevant to the population served. Approval of the CPGs occurs through the Quality Improvement Committee. Clinical Practice Guidelines, including preventive health guidelines, are on WellCare Advocate Complete FIDA s website at Healthcare Effectiveness Data and Information Set The Healthcare Effectiveness Data and Information Set (HEDIS ) is a tool used by more than 90% of America s managed care organizations to measure performance on important dimensions of care and service. The 2013 tool comprises 80 measures across five domains of care, including: Effectiveness of Care; Access and Availability of Care; Experience of Care; Health Plan Descriptive Information; and Utilization and Relative Resource Use. HEDIS is a mandatory process that occurs annually. It is an opportunity for WellCare Advocate Complete FIDA and providers to demonstrate the quality and consistency of care that is available to participants. Medical records and claims data are reviewed to capture required data. Compliance with HEDIS standards is reported on an annual basis with results available to providers upon request. Through compliance with HEDIS standards, participants benefit from the quality and effectiveness of care received and providers benefit by delivering industryrecognized standards of care to achieve optimal outcomes. Medicare Star Rating System The Medicare Star Rating System is the CMS rating system for evaluating the relative quality of private plans offered to Medicare beneficiaries through the MA program. Plans are measured on a 1 5 star scale. Star ratings exist for both Part C and Part D and focus on a variety of quality and service metrics. Star scores are published on the CMS website, for participants to evaluate health plans during the Annual Enrollment Period (AEP). Plans with a five-star rating receive a High Performing Icon on the website and plans with less than a three-star rating for the past three years receive a Low Performing Icon on the website. Plans are also eligible for a bonus in premium from CMS if they have a four-star or higher rating. Key Components HEDIS: Clinical performance indicators (access to care, receipt of preventive services, and management of chronic conditions). Consumer Assessment of Healthcare Providers and Systems (CAHPS): Survey to evaluate participant satisfaction with providers, health plan, and overall experience. Effective: January 1, 2015 Page 23 of 93

25 Medicare Health Outcomes Survey (HOS): Survey to evaluate physical and mental health and quality of life of Medicare beneficiaries. Administrative Measures: Complaints, customer service, appeals, disenrollment and audit performance. Part D (Pharmacy) Measures: Medication adherence and access to affordable drugs. Medical Records Medical records should be comprehensive and reflect all aspects of care for each participant. Records are to be maintained in a secured, timely, legible, current, detailed and organized manner which conforms to good professional medical practice. Records should be maintained in a manner that permits effective, professional medical review and medical audit processes, and facilitates an adequate system for follow-up treatment. Complete medical records include, but are not limited to: medical charts; prescription files; hospital records; provider specialist reports; consultant and other health care professionals findings; appointment records; and other documentation sufficient to disclose the quantity, quality, appropriateness and timeliness of service provided. Medical records must be signed and dated. WellCare Advocate Complete FIDA conducts reviews of the medical records of contracted providers to determine compliance with established documentation standards, professional practice guidelines and preventive health guidelines. In accordance with WellCare Advocate Complete FIDA s contract with CMS and requirements from Federal and State regulatory agencies, WellCare Advocate Complete FIDA is required to periodically assess the medical records of its participants to demonstrate its compliance with these requirements. Medical record reviews are conducted to assess the quality of care delivered and documented. Medical record reviews consist of a general documentation section and an adult preventive care section. In the medical record review, the two sections are reviewed for compliance with the required elements. If a provider does not attain a composite score of 80% or greater, a corrective action plan and a medical record re-evaluation is required. Information from the medical record review may be used in the re-credentialing process, as well as quality activities. The general documentation requirements for medical records are below. Documentation requirements for adult preventive care are on WellCare Advocate Complete FIDA s website at All medical records, including all entries in the medical record, at a minimum must: be neat, complete, clear, and timely and include all recommendations and essential findings in accordance with accepted professional practice; be signed and include the name and profession of the provider; be legible to readers and reviewing parties; be dated and recorded in a timely manner; include the participant s name (first and last name or identifier) on each page; Effective: January 1, 2015 Page 24 of 93

26 include the following personal and biographical data in the record: o name; o participant identifier; o date of birth; o gender; o address; o home/work telephone numbers; o emergency contact name and telephone numbers. This may include next of kin or name of spouse; o legal guardianship, if applicable; o marital status; and o if not English, the primary language spoken by the participant and, if applicable, any translation or communication needs are addressed; include allergies and adverse reactions to medication be prominently noted; include a HIPAA protected health information release; include a current medication list; include a current diagnoses/problem list; include a summary of surgical procedures, if applicable; include age-appropriate lifestyle and risk counseling; include screening for tobacco, alcohol or drug abuse with appropriate counseling and referrals, if needed; include screening for domestic violence with appropriate counseling and referrals, if needed; include the provision of written information regarding advance directives to adults (18 years and older); include an assessment of present health history and past medical history; include education and instructions, verbal, written or by telephone; include, if surgery is proposed, a discussion with the participant of the medical necessity of the procedure, the risks and alternative treatment options available; include evidence that results of ordered studies and tests have been reviewed; include consultant notes and referral reports; include evidence of follow-up visits, if applicable; and include appropriate medically indicated follow-up after hospital discharge and emergency department visits. Records of clinical encounters/office visits must minimally include: chief complaint; history and physical examination for presenting complaint; treatment plan consistent with findings; and disposition, recommendations and/or instructions provided. Confidentiality of participant information and records must be maintained at all times. Records are to be stored securely with access granted to authorized personnel only. Access to records must be granted to WellCare Advocate Complete FIDA, or its representatives without a fee to the extent permitted by State and Federal law. Providers should have procedures in place to permit the timely access and submission of medical records to WellCare Advocate Complete FIDA upon request. Effective: January 1, 2015 Page 25 of 93

27 The participant s medical record is the property of the provider who generates the record. However, each participant or their representative is entitled to one free copy of his or her medical record. Additional copies shall be made available to participants upon request and providers may assess a reasonable cost. WellCare Advocate Complete FIDA follows State and Federal law regarding the retention of records remaining under the care, custody, and control of the physician or health care provider. Information from the medical records review may be used in the re-credentialing process as well as quality activities. For more information on medical records compliance, including but not limited to, confidentiality of participant information and release of records, refer to Section 8: Compliance of this Manual. Web Resources WellCare Advocate Complete FIDA periodically updates clinical, coverage, and preventive guidelines as well as other resource documents posted on WellCare Advocate Complete FIDA s website. Please check WellCare Advocate Complete FIDA s website frequently for the latest news and updated documents at Effective: January 1, 2015 Page 26 of 93

28 Section 4: Utilization Management, Care Management and Disease Management Utilization Management Overview The Utilization Management (UM) Program defines and describes WellCare Advocate Complete FIDA s multidisciplinary, comprehensive approach and process to manage resource allocation. The UM Program describes the use of the Health Services Department s review guidelines, WellCare Advocate Complete FIDA s adverse determination process, the assessment of new technology, and delegation oversight. The UM Program includes components of prior authorization, concurrent and retrospective review activities. Each component is designed to provide for the evaluation of health care and services based on participant coverage, appropriateness of such care and services, and to determine the extent of coverage and payment to providers of care. WellCare Advocate Complete FIDA does not reward its associates, practitioners, physicians, or other individuals or entities performing utilization management activities for rendering denials of coverage, services or care determinations. WellCare Advocate Complete FIDA does not provide financial incentives, encourage or promote under-utilization. Medical Necessity Medically necessary services are defined as services that include medical or allied care, goods or services furnished or ordered to: Be necessary to protect life, 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 participant s needs; Be consistent with the generally accepted professional medical standards 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; and Be furnished in a manner not primarily intended for the convenience of the participant, the participant s caretaker, or the provider. Medically necessary or medical necessity for those services furnished in a hospital on an inpatient basis are those services that 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 health goods or services does not, in itself, make such goods or services medically necessary, a medical necessity, or a Covered Service/benefit. Prior Authorization Prior authorization allows for efficient use of Covered Services and ensures that participants receive the most appropriate level of care in the most appropriate setting. Prior authorization may be obtained by the participant s PCP, treating specialist or facility. WellCare Advocate Effective: January 1, 2015 Page 27 of 93

29 Complete FIDA provides a process for making a determination of medical necessity and reviewing benefit limitations for inpatient and outpatient services prior to services being rendered. Prior authorization requirements apply to pre-service decisions. Providers may submit requests for authorization by: Faxing a properly completed Inpatient, Outpatient, Durable Medical Equipment (DME) and Orthotic and Prosthetic, Home Health and Skilled Therapy Services Authorization Request Form; Contacting WellCare Advocate Complete FIDA via phone for inpatient notifications and urgent outpatient services; or Submitting an online authorization request via WellCare Advocate Complete FIDA s Web portal at It is necessary to include the following information in the request for services: Participant name and identification number; The requesting provider s demographics; Diagnosis code(s) and place of service; Services being requested and Physician s Current Procedural Terminology, 4 th Edition (CPT-4) code(s); The treating provider s demographics to provide the service; and Medical history and any pertinent medical information related to the request, including current plan of treatment, progress notes as to the necessity, effectiveness and goals. For the appropriate contact information, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at All forms are located on WellCare Advocate Complete FIDA s website at Notification Notifications are communications to WellCare Advocate Complete FIDA with information related to a service rendered to a participant or a participant s admission to a facility. Notification is required for a participant s admission to a hospital. This enables WellCare Advocate Complete FIDA to log the hospital admission and follow-up with the facility on the following business day to receive clinical information. Notification can be submitted by fax, phone, or via the secure, online portal at for registered providers. The notification information should include participant demographics, facility name and admitting diagnosis. Concurrent Review WellCare Advocate Complete FIDA ensures the oversight and evaluation of participants when admitted to hospitals, rehabilitation centers and skilled nursing facilities (SNF). This oversight includes reviewing continued inpatient stays to ensure appropriate utilization of health care resources and to promote quality outcomes for participants. WellCare Advocate Complete FIDA provides oversight for participants receiving acute care services in the facilities mentioned above to determine the initial/ongoing medical necessity, appropriate level of care, appropriate length of stay, and to facilitate a timely discharge and assist with any discharge needs the participant may have. The concurrent review process is conducted based on the participant s medical condition. Effective: January 1, 2015 Page 28 of 93

30 Concurrent review decisions are made utilizing the following criteria: InterQual Severity of Illness/Intensity of Service criteria; Clinical Coverage Guidelines; American Society of Addiction Medicine (ASAM) Criteria; Hayes Directory; CMS National and Local Coverage Guidelines; and Time Tasking Tool. These review criteria are utilized as a guideline. Decisions will take into account the participant s medical condition and comorbidities. The review process is performed under the direction of the WellCare Advocate Complete FIDA Medical Director. Frequency of onsite and/or telephonic review will be based on the clinical condition of the participant. The frequency of the reviews for extension of initial determinations is based on the severity/complexity of the patient's condition, necessary treatment, and discharge planning activity including possible placement in a different level of care. The treating provider and the facility utilization review staff will provide review information that is collected telephonically or via fax. Clinical information is requested to support the appropriateness of the admission, continued length of stay, level of care, treatment and discharge plans. When a hospital determines that a participant no longer needs inpatient care, but is unable to obtain the agreement of the physician, the hospital may request a Quality Improvement Organization (QIO) review. Prior to requesting a QIO review, the hospital should consult with WellCare Advocate Complete FIDA. Discharge Planning WellCare Advocate Complete FIDA identifies and provides the appropriate level of care as well as medically necessary support services for participants upon discharge from an inpatient setting. Discharge planning begins upon notification of the participant s admission to facilitate continuity of care, post-hospitalization services, referrals to a SNF or rehabilitation facility, evaluating for a lower level of care, and maximizing services in a cost-effective manner. As part of the UM process, WellCare Advocate Complete FIDA will provide for continuity of care when transitioning participants from one level of care to another. The discharge plan will include a comprehensive evaluation of the participant s health needs and identification of the services and supplies required to facilitate appropriate care following discharge from an institutional setting. This will be based on the information received from the institution and/or provider caring for the participant. Some of the services involved in the discharge plan include, but are not limited to: DME; Transfers to an appropriate level of care, such as an inpatient nursing rehabilitation (INR) facility, long-term acute care facility (LTAC) or SNF; Home Health Care; Medications; and Physical, Occupational, or Speech Therapy (PT, OT, ST). Effective: January 1, 2015 Page 29 of 93

31 Retrospective Appeal Review A retrospective appeal review is any review of care or services that have already been provided. WellCare Advocate Complete FIDA will review post-service requests for authorization of inpatient admissions or outpatient services. The review includes making coverage determinations for the appropriate level of services, applying the same approved medical criteria used for pre-service decisions, and taking into account the participant s needs at the time of service. WellCare Advocate Complete FIDA will also identify quality issues, utilization issues, and the rationale behind failure to follow WellCare Advocate Complete FIDA s prior authorization/pre-certification guidelines. WellCare Advocate Complete FIDA will give a written notification to the requesting provider and participant within 30 calendar days of receipt of a request for a UM determination. If WellCare Advocate Complete FIDA is unable to make a decision due to matters beyond its control, it may extend the decision timeframe once, for up to 14 calendar days of the post-service request. Referrals Referrals are requests by a PCP for a participant to be evaluated and/or treated by a participating specialty provider. The PCP must document the reason for the referral and the name of the specialist in the participant s record. The specialist must document receipt of the request for a consultation. WellCare Advocate Complete FIDA does not require a written referral as a condition of payment. No communication with WellCare Advocate Complete FIDA is necessary. Criteria for Utilization Management Determinations The UM Department utilizes review criteria that are nationally recognized and based on sound scientific medical evidence. The UM program uses numerous sources of information including, but not limited to, the following list when making coverage determinations: InterQual; Medical necessity; Participant benefits; Local and Federal statutes and laws; Medicare guidelines; and Hayes Health Technology Assessment. The nurse reviewer and/or Medical Director apply medical necessity criteria in the context of the participant s individual circumstance and capacity of the local provider delivery system. When the above criteria do not address the individual participant s needs or unique circumstance, the Medical Director will use clinical judgment in making the determination. Participants and providers may request a copy of the criteria utilized for a specific determination of medical necessity by contacting Customer Service. The medical review criteria stated below are updated and approved at least annually by the Medical Director, Medical Advisory Committee and Quality Improvement Committee. Actively practicing physicians and other providers with current knowledge relevant to the criteria being reviewed have an opportunity to give advice or comment on the development or adoption of UM criteria and on instructions for applying the criteria. WellCare Advocate Complete FIDA is responsible for: Effective: January 1, 2015 Page 30 of 93

32 Requiring consistent application of review criteria for authorization decisions; and Consulting with the requesting provider when appropriate. One or more of the following criteria are utilized when services are requested that require utilization review: Type of Criteria Coverage and Referral Guidelines InterQual Ingenix Complete Guide to Medicare Coverage Issues Hayes, Inc. Online (Medical Technology) Medicare Carrier and Intermediary Coverage Decisions Medicare National Coverage Decisions Federal Statutes, Laws and Regulations Updated Annually Annually Quarterly Ongoing Ongoing Ongoing Ongoing When applying criteria to participants with more complicated conditions, WellCare Advocate Complete FIDA will consider the following factors: Age; Comorbidities; Complications; Progress of treatment; Psychological situation; and Home environment, when applicable. WellCare Advocate Complete FIDA will also consider characteristics of the local delivery system available for specific participants, such as: Availability of SNFs, sub-acute care facilities, or home care in WellCare Advocate Complete FIDA s service area to support the participant after hospital discharge; Coverage of benefits for SNFs, sub-acute care facilities, or home care when needed; and Local hospitals ability to provide all recommended services within the estimated length of stay. When WellCare Advocate Complete FIDA s standard UM guidelines and criteria do not apply due to individual patient (participant) factors and the available resources of the local delivery system, the Health Services staff (Review Nurse, Care Manager) will conduct individual case conferences to determine the most appropriate alternative service for that participant. The Medical Director may also utilize her or his clinical judgment in completing the service authorization request. All new medical technology or questionable experimental procedures will require review by the Medical Director prior to approval to establish guidelines where applicable. Organization Determinations For all organization determinations, providers may contact WellCare Advocate Complete FIDA by mail, phone, fax or via WellCare Advocate Complete FIDA s website. An organization Effective: January 1, 2015 Page 31 of 93

33 determination is any determination (i.e., an approval or denial) made by WellCare Advocate Complete FIDA or its delegated entity. WellCare Advocate Complete FIDA requires prior authorization and/or pre-certification for: All non-emergent and non-urgent inpatient admissions except for normal newborn deliveries; All non-emergent or non-urgent, out-of-network services (except out-of-area renal dialysis); and Service requests identified in the Medicare Authorization Guidelines that are maintained within the Health Services Department. Refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at For initial and continuation of services, WellCare Advocate Complete FIDA has appropriate mechanisms to ensure consistent application of review criteria for authorization reviews, which include: Medical necessity approved medical review criteria will be referenced and applied; Inter-rater reliability a process that evaluates the consistency of decisions made by licensed staff when making authorization decisions and ensures the consistent application of medical review criteria; and Consultation with the requesting provider when appropriate. Prior Authorization: Standard Organization Determination An organization determination will be made as expeditiously as the participant s health condition requires, but no later than 14 calendar days after WellCare Advocate Complete FIDA receives the request for service. An extension may be granted for 14 additional calendar days if the participant requests an extension or if WellCare Advocate Complete FIDA justifies a need for additional information and documents how the delay is in the interest of the participant. Prior Authorization: Expedited Organization Determination A participant or any provider may request that WellCare Advocate Complete FIDA expedite an organization determination when the participant or his or her provider believes that waiting for a decision under the standard timeframe could place the participant s life, health, or ability to regain maximum function in serious jeopardy. The determination will be made as expeditiously as the participant s health condition requires, but no later than 72 hours after receiving the participant s or provider s request. An extension may be granted for 48 additional hours if the participant requests an extension, or if WellCare Advocate Complete FIDA justifies a need for additional information and documents how the delay is in the interest of the participant. Concurrent Authorization: WellCare Advocate Complete FIDA will make organization determinations for all concurrent authorization requests by the end of the next calendar day from receipt of request. WellCare Advocate Complete FIDA s organization determination system provides authorization numbers, effective dates for the authorization, and specifies the services being authorized. The requesting provider will be notified verbally via telephone or fax of the authorization. In the event of an adverse determination, WellCare Advocate Complete FIDA will notify the participant and the participant s representative (if appropriate) in writing and provide written notice to the provider. Written notification to providers will include the Utilization Management Department s contact information to allow providers the opportunity to discuss the adverse Effective: January 1, 2015 Page 32 of 93

34 determination decision. The provider may request a copy of the criteria used for a specific determination of medical necessity by contacting the Health Services Utilization Management Department. The participant may request a copy of the criteria used for a specific determination of medical necessity by contacting Customer Service. Reconsideration Requests WellCare Advocate Complete FIDA provides an opportunity for the provider to request a reconsideration of an adverse determination within three business days of the decision. The requesting provider will have the opportunity to discuss the decision with the clinical peer reviewer making the denial determination or with a different clinical peer if the original reviewer cannot be available within one business day of the provider request. WellCare Advocate Complete FIDA will respond to the request within one business day. Emergency Services Emergency Services are covered inpatient and outpatient services that are: Furnished by a provider qualified to furnish emergency services; and Needed to evaluate or stabilize an emergency medical condition. It is WellCare Advocate Complete FIDA s policy that emergency services are covered: Regardless of whether services are obtained within or outside the network of providers available; Regardless of whether there is prior authorization for the services. In addition: o No materials furnished to participants (including wallet card instructions) may contain instructions to seek prior authorization for emergency services, and participants must be informed of their right to call 911; and o No materials furnished to providers, including contracts, may contain instructions to providers to seek prior authorization before the participant has been stabilized; In accordance with a prudent layperson s definition of emergency medical condition regardless of the final medical diagnosis; and Whenever a WellCare Advocate Complete FIDA network provider or other WellCare Advocate Complete FIDA representative instructs a participant to seek emergency services within or outside the participant s WellCare Advocate Complete FIDA plan coverage. WellCare Advocate Complete FIDA is not responsible for the care provided for an unrelated non-emergency problem during treatment for an emergency situation. For example, WellCare Advocate Complete FIDA is not responsible for any costs, such as a biopsy associated with treatment of skin lesions performed by the attending provider who is treating a fracture. Transition of Care If a new participant has an existing relationship with a provider who is not part of WellCare Advocate Complete FIDA s provider network, WellCare Advocate Complete FIDA will permit the participant to continue an ongoing course of treatment by the non-participating provider during a transitional period. WellCare Advocate Complete FIDA will honor any written documentation of prior authorization of ongoing Covered Services for a period of 30 calendar days after the effective date of enrollment. Effective: January 1, 2015 Page 33 of 93

35 For all participants, written documentation of prior authorization of ongoing services includes the following, provided that the services were prearranged prior to enrollment with WellCare Advocate Complete FIDA: Prior existing orders; Provider appointments (e.g., dental appointments, surgeries, etc.); and Prescriptions (including prescriptions at non-participating pharmacies). Participants who are inpatient at the time of disenrollment from WellCare Advocate Complete FIDA will be covered by WellCare Advocate Complete FIDA throughout the acute inpatient stay, however, WellCare Advocate Complete FIDA will not be responsible for any discharge needs the participant may have. WellCare Advocate Complete FIDA will take immediate action to address any identified urgent medical needs. Continued Care with a Terminated Provider When a provider terminates or is terminated without cause, WellCare Advocate Complete FIDA will allow participants in active treatment to continue to see that provider either through the completion of their treatment (up to 60 calendar days) or until the participant selects a new provider, whichever occurs first. Care provided after termination shall continue under the same terms, conditions and payment arrangements as they existed in the terminated contract. If an obstetrical provider terminates without cause and requests an approval for treatment for a pregnant participant who is in treatment, the participant will be allowed to, when medically necessary, continue care according to the specific state regulations. For Medicare, the participant will be permitted to continue care until the participant s first post-partum visit is completed. If a provider is terminated for cause, WellCare Advocate Complete FIDA will immediately direct the participant to another participating provider for continued services and treatment. Continuity of Care WellCare Advocate Complete FIDA maintains and monitors a panel of PCPs from which the participant may select a personal PCP. All participants may select and/or change their PCP to another participating WellCare Advocate Complete FIDA Medicare-Medicaid Plan PCP without interference. WellCare Advocate Complete FIDA requires participants to obtain a referral before receiving specialist services and has a mechanism for assigning PCPs to participants who do not select one. WellCare Advocate Complete FIDA will also: Provide or arrange for necessary specialist care and in particular, give female participants the option of direct access to a women s health specialist within the network for women s routine and preventive health care services. WellCare Advocate Complete FIDA will arrange for specialty care outside of WellCare Advocate Complete FIDA s provider network when network providers are unavailable or inadequate to meet a participant s medical needs; Ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all participants, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. WellCare Advocate Complete FIDA arranges and covers translator and interpreter services; Effective: January 1, 2015 Page 34 of 93

36 Establish and maintain written standards, including coverage rules, practice guidelines, payment policies and utilization management that allow for individual medical necessity determinations; Provide coverage for ambulance, ambullette, emergency, urgently needed poststabilization care services and non-emergent services; and Have in effect procedures that: o Establish and implement a treatment plan that is appropriate; o Include an adequate number of direct access visits to specialists; o Are time-specific and updated periodically; o Facilitate coordination among providers; and o Consider the participant s input. Medicare Quality Improvement Organization Review Process For SNFs, Home Health Agencies (HHAs) and Comprehensive Outpatient Rehabilitation Facilities (CORFs), the provider of service must send written notification of a termination of coverage to the participant no later than two calendar days before the proposed end of coverage. The standard Notice of Medicare Non-Coverage letter required by CMS will be issued. This letter includes the date coverage of service ends and the process to request an expedited appeal with the appropriate QIO. Upon notification by the QIO that a participant has requested an appeal, WellCare Advocate Complete FIDA will issue a Detailed Explanation of Non-Coverage which indicates why services are no longer reasonable or necessary or no longer covered for other reasons. If the participant s services are expected to be fewer than two calendar days in duration, the provider should notify the participant or, if appropriate, the participant s representative, at time of admission. If, the services will be rendered in a non-institutional setting, and the span of time between the services exceeds two calendar days, the notice should be given no later than two services prior to termination of the service. WellCare Advocate Complete FIDA is financially liable for continued services until two calendar days after the participant receives valid notice. A participant may waive continuation of services if she or he agrees to be discharged sooner than two calendar days after receiving the notice. Participants who desire a fast-track appeal must submit a request for appeal to the QIO, in writing or by telephone, by noon (12 p.m.) of the first day after the day of delivery of the termination notice or, if a participant receives the Notice of Medicare Non-Coverage more than two calendar days prior to the date coverage is expected to end, by noon (12 p.m.) of the day before coverage ends. Upon notification by the QIO that a participant has requested an appeal, WellCare Advocate Complete FIDA will issue a Detailed Explanation of Non-Coverage which indicates why services are either no longer reasonable or necessary or are no longer covered. Coverage of provider services continues until the date and time designated on the termination notice unless the participant appeals and the QIO reverses WellCare Advocate Complete FIDA s decision. A participant who fails to request an immediate fast-track QIO review in accordance with these requirements may still file a request for an expedited reconsideration with WellCare Advocate Complete FIDA. Effective: January 1, 2015 Page 35 of 93

37 Second Opinion Participants have the right to a second surgical/medical opinion in any instance when the participant disagrees with his or her provider s opinion of the reasonableness or necessity of surgical procedures or whenever the participant is subject to a serious injury or illness. The second surgical/medical opinion, if requested, is to be provided by a provider chosen by the participant. The selected provider may be a provider participating with WellCare Advocate Complete FIDA or a non-participating provider, and the service will be at no cost to the participant. Participants must inform their PCP of their desire for a second surgical/medical opinion. If a participating WellCare Advocate Complete FIDA provider is selected, the PCP will issue a referral to the participant for the visit. If a non-participating provider is required, the PCP is required to contact WellCare Advocate Complete FIDA for authorization. Any tests that are deemed necessary as a result of the second surgical/medical opinion will be conducted by participating WellCare Advocate Complete FIDA network providers. The PCP will review the second surgical/medical opinion and develop a treatment plan for the participant. If the PCP disagrees with the second surgical/medical opinion request for services, the PCP must still submit the request for services to WellCare Advocate Complete FIDA for a determination on the recommendation. The participant may file an appeal if WellCare Advocate Complete FIDA denies the second surgical/medical opinion provider s request for services. The participant may file a grievance if the participant wishes to follow the recommendation of the second opinion provider and the PCP does not forward the request for services to WellCare Advocate Complete FIDA. Notification of Hospital Discharge Appeal Rights Prior to discharging a participant or lowering the level of care within a hospital setting, WellCare Advocate Complete FIDA will secure concurrence from the provider responsible for the participant s inpatient care. WellCare Advocate Complete FIDA will ensure participants receive a valid written notification of termination of inpatient services from the facility according to the guidelines set by Medicare. Hospitals must issue the Important Message (IM) within two calendar days of admission, obtain signature of the patient or the signature of their authorized representative, and provide a signed follow-up copy to the patient as far in advance of discharge as possible, but not more than two calendar days before discharge. This letter will include the process to request an immediate review with the appropriate QIO. Participants who desire an immediate review must submit a request to the QIO, in writing or by telephone, by midnight (12:00 a.m.) of the day of discharge. The request must be submitted before the participant leaves the hospital. If the participant fails to make a timely request to the QIO, she or he may request an expedited reconsideration by WellCare Advocate Complete FIDA. Upon notification by the QIO that a participant has requested an immediate review, WellCare Advocate Complete FIDA will contact the facility, request all relevant medical records, a copy of the executed IM, and evaluate for validity. If after review, WellCare Advocate Complete FIDA concurs that the discharge is warranted, WellCare Advocate Complete FIDA will issue a Effective: January 1, 2015 Page 36 of 93

38 Detailed Notice of Discharge providing a detailed reason why services are either no longer reasonable, medically necessary or are no longer covered for other reasons. Coverage of inpatient services continues until the date and time designated on the Detailed Notice of Discharge, unless the participant requests an immediate QIO review. Liability for further inpatient hospital services depends on the QIO decision. If the QIO determines that the participant did not receive valid notice, coverage of inpatient services by WellCare Advocate Complete FIDA continues until at least two calendar days after valid notice has been received. Continuation of coverage is not required if the QIO determines that the coverage could pose a threat to the participant s health or safety. The burden of proof lies with WellCare Advocate Complete FIDA to demonstrate that discharge is the correct decision, either on the basis of medical necessity, or based on other Medicare coverage policies. To meet this burden, WellCare Advocate Complete FIDA must supply any and all information that the QIO requires to sustain WellCare Advocate Complete FIDA s decision. WellCare Advocate Complete FIDA is financially responsible for coverage of services, regardless of whether it has delegated responsibility for authorizing coverage or termination decisions to its providers. If the QIO reverses WellCare Advocate Complete FIDA s termination decision, WellCare Advocate Complete FIDA must provide the participant with a new notice when the hospital or WellCare Advocate Complete FIDA once again determines that the participant no longer requires acute inpatient hospital care. Availability of Utilization Management Staff WellCare Advocate Complete FIDA s Health Services Department provides medical and support staff resources, including a Medical Director, to process requests and provide information for the routine or urgent authorization/pre-certification of services, utilization management functions, and to respond to provider questions, comments or inquiries. Staff is available 24 hours per day, seven days per week, including holidays. For more information on contacting the Health Services Department via Provider Services, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Care Management Program Overview Care Management provides a set of participant centered, goal oriented, culturally relevant and logical steps to assure that participants receive the most appropriate service, and emphasizes care in the least restrictive and most integrated settings that facilitate patient assessment, planning, and advocacy to improve health outcomes for patients. WellCare Advocate Complete FIDA s Care Management Program emphasizes prevention, health promotion, continuity of care and coordination of care. WellCare Advocate Complete FIDA s Care Management teams are led by Registered Nurses and Licensed Clinical Social Workers who will construct the Interdisciplinary Team (IDT) to Effective: January 1, 2015 Page 37 of 93

39 include all relevant participants to meet the participant s needs and develop an appropriate Person-Centered Service Plan. The IDT will coordinate with behavioral health, community based and facility based LTSS providers. Care Managers will work with WellCare Advocate Complete FIDA s internal and external partners to identify community, facility based, LTSS and behavioral health resources to provide the most appropriate services for WellCare Advocate Complete FIDA participants. The Interdisciplinary Team will complete: Clinical Assessment and Evaluation a comprehensive assessment of the participant using the NYDOH Universal Assessment System (UAS) is completed to determine participant s needs and barriers to care. Assessment includes participant s physical, psychological, behavioral, environmental and social needs, as well as support systems and resources, and seeks to align them with appropriate clinical needs; Person-Centered Service Planning collaboration with the participant and/or caregiver, PCP, as well as the all identified service providers (IDT) to identify the best ways to fill any identified gaps or barriers to improve access and adherence to the provider s plan of care; Interdisciplinary Team a collaborative group including participant, participant s designative representative, caregivers, providers including medical, mental, behavioral, community and facility based LTSS providers working to develop and implement participant s Person-Centered Service Plan; Service Facilitation and Coordination working with community based and facility based resources to facilitate participant adherence with the plan of care. Activities may be as simple as reviewing the plan with the participant and/or caregiver or as complex as arranging services, transportation, housing and follow-up of behavioral, mental health services; Participant Advocacy advocating on behalf of the participant within the complex labyrinth of the health care system. Care Managers assist participants with seeking the services to optimize their health. Care Management emphasizes continuity of care for participants through the coordination of care among physicians and other providers; and Language Line WellCare Advocate Complete FIDA has an ongoing contract with Certified Languages International (CLI) to provide linguistic support for its staff, internal, external and community based providers to facilitate transmission of information between health care providers and clients. Behavioral Health Identification, coordination including referrals and monitoring of behavioral and substance abuse conditions are integrated into the care management process. Those diagnoses, which are categorized, as altering the mental status of an individual but are of organic origin are care management responsibilities for all categories of enrollees. The care managers will be responsible for referring or coordinating referrals of enrollees as indicated to Mental Health/Substance Abuse providers. Provider Access to Care Management Refer to Access to Care and Disease Management Programs in the Disease Management section below. Effective: January 1, 2015 Page 38 of 93

40 Model of Care Overview WellCare Advocate Complete FIDA s Model of Care (MOC) is tailored specifically to the dualeligible participants in an effort to meet the populations functional, psychosocial and medical needs in a participant-centric fashion. Comprehensive Medical Assessment: Conducted by WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA s Care Management begins with the NYSDOH Universal Assessment System (UAS). The UAS assesses participant risk in the following areas: functional, psychosocial and medical. Once completed, the UAS is utilized to generate a Person-Centered Service Plan. The comprehensive medical assessment is based on Clinical Practice Guidelines. An Individualized Care Plan is developed utilizing these guidelines. The stratification/acuity of the Comprehensive Medical assessment is an indicator of the needs of the participant. This is always verified with participant/caregiver and providers. WellCare Advocate Complete FIDA utilizes four levels of stratification/acuity starting with level 1 (low risk) and going to level 4 (high risk). Person-Centered Service Plan: Generated by WellCare Advocate Complete FIDA The Care Manager, the participant, and/or caregiver, members of the service s providers including PCP and specialists as appropriate, will work to develop a Person-Centered Service Plan based on the information generated from the Universal Assessment System and Comprehensive Care Plan. The Person-Centered Service Plan will be updated as needed based on the participant s needs and progress along the health care continuum. Interdisciplinary Care Team: WellCare Advocate Complete FIDA and Providers The Care Manager shares the Person-Centered Service Plan (PCSP) with all the participants of the IDT in an effort to provide feedback and promote collaboration regarding the participant s goals and current health status. At a minimum, the IDT includes the participant, the participant s caregiver (if appropriate), the participant s PCP and WellCare Advocate Complete FIDA Care Manager. Other members of the IDT can include specialists, social service support, behavioral health specialists, and/or caregiver and others depending on the participant s specific needs. The Case Manager communicates and coordinates with the members of the IDT to educate participants, provide advocacy, provide assistance with accessing behavioral health and community and facility based LTSS, and assist them as they navigate the health care system. The IDT assists participants in transitioning to new providers if needed, once the PCSP is completed. The LTSS coordination process utilizing the IDT starts with a comprehensive assessment, known as the UAS-NY Community Assessment. Upon completion of the assessment, the IDT members, caregivers, the participant and participant advocates are informed of the assessment findings, and coordinate appropriate services and supports for the participant. The process may involve a behavioral health care manager if there are mental health and substance abuse findings. The care manager will complete an additional assessment (UAS-NY Mental Health Supplement) as part of the process. The care manager will further coordinate appropriate services that are identified to meet the needs reflected in the participant s Person-Centered Service Plan. This process of comprehensive assessment and coordination of care and services occurs at enrollment, every six months, or as needed as defined by a change in the participant s health and/or psychosocial needs. Providers and the IDT may reference the Behavioral Health Effective: January 1, 2015 Page 39 of 93

41 Overview: for FIDA Providers and the IDT training course, which is available on the WellCare Advocate Complete FIDA website, through the secure provider Web portal, and by contacting the assigned Provider Relations representative. Care Transitions: WellCare Advocate Complete FIDA and Providers The Care Manager is responsible for coordinating care when participants move from one setting to another and facilitates transitions through communication and coordination with the participant and their usual practitioner. During this communication with the participant, the Care Manager will discuss any changes to the participant s health status and any resulting changes to the care plan. The Care Manager will notify the participant s usual provider of the transition and will communicate any needs to assist with a smoother transition process. Provider Required Participation To meet the intent of the MIPPA legislation, providers are required to participate in the MOC for all MMPA plan participants. The expectations for participation are as follows: Complete the required MOC training. WellCare Advocate Complete FIDA offers an online training module and printable self-study packet. If providers opt to use the selfstudy packet, WellCare Advocate Complete FIDA requests they return the attestation for reporting purposes. Providers may return the attestation via fax. Both the online module and self-study packet can be accessed at If providers would like to request a copy mailed at no cost, they may contact Provider Services or a Provider Relations representative; Become familiar with WellCare Advocate Complete FIDA s Clinical Practice Guidelines, which are based on nationally recognized evidence-based guidelines; Read newsletters that feature articles regarding the latest treatments for patients; Review and update the participant care plan faxed by the Care Management Department; and Participate in the IDT for all MMPA members in the provider membership panel and give feedback as appropriate. The Care Manager will communicate with the members of the IDT for any updates to the PCSP and will be available to assist the dual-eligible participant to meet the goals of the PCSP. Re-cap of the benefits of the MMPAP Care Management Program: All participants receive a UAS. Participants are stratified according to the severity of their disease process, functional ability and psychosocial needs. A Comprehensive Medical Assessment is completed by the Care Manager and is the basis for the Individualized Care Plan. The Care Manager in collaboration with the participant and the Interdisciplinary Care Team generate the Person-Centered Service Plan based on UAS and CMA. The Person-Centered Service Plan progress and updates are shared with the IDT for review and comments as needed. The Care Manager continues to monitor, educate, coordinate care and advocate on behalf of the participant. Disease Management Program Overview Disease Management (DM) is a population-based strategy that involves consistent care across the continuum by the treatment team and the Disease Manager for participants with certain Effective: January 1, 2015 Page 40 of 93

42 disease states. Elements of the program include educating the participant about the particular disease and self-management techniques, monitoring the participant for adherence to the treatment plan and consistently using validated, industry-recognized, evidence-based Clinical Practice Guidelines to improve participant outcomes. The DM Program includes the following conditions: Asthma adult and pediatric; Coronary Artery Disease (CAD); Congestive Heart Failure (CHF); Chronic Obstructive Pulmonary Disease (COPD); Diabetes adult and pediatric; HIV/AIDS (identified and referred to Care Management); and Hypertension (HTN). Additional programs available include obesity and smoking cessation. Candidates for Disease Management WellCare Advocate Complete FIDA encourages referrals from providers, participants, hospital discharge planners and others in the health care community. Interventions for participants identified vary depending on their level of need and stratification level. Interventions are based on industry-recognized Clinical Practice Guidelines. Participants identified at the highest stratification levels receive a comprehensive assessment by a DM nurse, disease-specific educational materials, identification of a care plan and goals, and followup assessments to monitor adherence to the plan and attain goals. Disease-specific Clinical Practice Guidelines adopted by WellCare Advocate Complete FIDA are on WellCare Advocate Complete FIDA s website at Access to Care and Disease Management Programs WellCare Advocate Complete FIDA s Transition Needs Assessment (TNA) Program assists new participants in their transition from Medicare or another managed care organization to WellCare Advocate Complete FIDA. The program involves outreach to these participants prior to their effective date, and within the first 30 days of their enrollment. During this outreach, participants are gauged for their health care needs including, but not limited to, their primary and specialist providers, current prescriptions, durable medical equipment (DME) and home health. Participants are also screened for eligibility for WellCare Advocate Complete FIDA s Care Management and Disease Management Programs, and any additional behavioral health care needs. If providers would like to refer an established WellCare Advocate Complete FIDA participant as a potential candidate to WellCare Advocate Complete FIDA s Care Management Program or would like more information, providers may call WellCare Advocate Complete FIDA s Care Management Referral Line. For more information on the Care Management Referral Line, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Effective: January 1, 2015 Page 41 of 93

43 Section 5: Claims Overview The focus of the Claims Department is to process claims in a timely manner. WellCare Advocate Complete FIDA has established toll-free telephone numbers for providers to access a representative in WellCare Advocate Complete FIDA s Customer Service Department. For more information on claims submission, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Timely Claims Submission Unless otherwise stated in the provider Agreement, providers must submit clean claims (initial, corrected and voided) to WellCare Advocate Complete FIDA within 180 calendar days from the date of discharge for inpatient services or the date of service for all other services. The start date for determining the timely filing period is the from date reported on a CMS-1500 or 837-P for professional claims or the through date used on the UB-04 or 837-I for institutional claims. Unless prohibited by Federal law or CMS, WellCare Advocate Complete FIDA may deny payment of any claim that fails to meet WellCare Advocate Complete FIDA s submission requirements for clean claims or failure to timely submit a clean claim to WellCare Advocate Complete FIDA. Please note that claims filed by providers who are not part of the network must be filed no later than 15 months after the date the services were furnished. The following items can be accepted as proof that a claim was submitted timely: A clearinghouse electronic acknowledgement indicating claim was electronically accepted by WellCare Advocate Complete FIDA; and A provider s electronic submission sheet that contains all the following identifiers: o patient name; o provider name; o date of service to match Explanation of Benefits (EOB)/claim(s) in question; o prior submission bill dates; and o WellCare Advocate Complete FIDA s product name or line of business. The following items are examples of what is not acceptable as evidence of timely submission: Strategic National Implementation Process (SNIP) Rejection Letter; and A copy of the provider s billing screen. Tax ID and National Provider Identifier Requirements WellCare Advocate Complete FIDA requires the payer-issued Tax Identification Number (Tax ID/TIN) and National Provider Identifier (NPI) on all claims submissions, with the exception of atypical providers. Atypical providers are non-health care providers such as taxi drivers, carpenters and personal care providers. Atypical providers must pre-register with WellCare Advocate Complete FIDA before submitting claims to avoid NPI rejections. WellCare Advocate Complete FIDA will reject claims without the Tax ID and NPI. More information on NPI requirements, including the Health Insurance Portability and Accountability Act of 1996 s (HIPAA) NPI Final Rule Administrative Simplification, is available on the CMS website at Effective: January 1, 2015 Page 42 of 93

44 Taxonomy Providers are encouraged to submit claims with the correct taxonomy code consistent with provider s specialty and services being rendered in order to increase appropriate adjudication. WellCare Advocate Complete FIDA may reject the claim or pay it at the lower reimbursement rate if the taxonomy code is incorrect or omitted. Preauthorization number If a preauthorization number was obtained, the provider must include this number in the appropriate data field on the claim. National Drug Codes WellCare Advocate Complete FIDA follows CMS guidelines regarding National Drug Codes (NDC). Providers must submit National Drug Codes as required by CMS. Strategic National Implementation Process All claims and encounter transactions submitted via paper, direct data entry (DDE), or electronically will be validated for transaction integrity/syntax based on the SNIP guidelines. If a claim is rejected for lack of compliance with WellCare Advocate Complete FIDA s claim and encounter submission requirements, the rejected claim should be resubmitted within timely filing limits. For more information on encounters, see the Encounters Data section below. Claims Submission Requirements Providers using electronic submission shall submit clean claims to WellCare Advocate Complete FIDA or its designee, as applicable, using the HIPAA-compliant 837 electronic format or a CMS 1500/UB-04 (or their successors), as applicable. Claims shall include the provider s NPI, Tax ID and the valid taxonomy code that most accurately describes the services reported on the claim. The provider acknowledges and agrees that no reimbursement or compensation is due for a Covered Service, and no claim is complete for a Covered Service, unless performance of that Covered Service is fully and accurately documented in the participant s medical record prior to the initial submission of any claim. The provider also acknowledges and agrees that at no time shall participants be responsible for any payments to the provider with the exception of participant expenses or non-covered services. For more information on paper submission of claims, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at For more information on WellCare Advocate Complete FIDA s Covered Services, refer to WellCare Advocate Complete FIDA s website at Electronic Claims Submissions WellCare Advocate Complete FIDA accepts electronic claims submission through Electronic Data Interchange (EDI) as its preferred method of claims submission. All files submitted to WellCare Advocate Complete FIDA must be in the ANSI ASC X12N format, version 5010A, or its successor. For more information on EDI implementation with WellCare Advocate Complete FIDA, refer to WellCare Advocate Complete FIDA s Companion Guides on WellCare Advocate Complete FIDA s website at Because most clearinghouses can exchange data with one another, providers should work with their existing clearinghouse, or the clearinghouses WellCare Advocate Complete FIDA uses to establish EDI with WellCare Advocate Complete FIDA. For a list of clearinghouses WellCare Effective: January 1, 2015 Page 43 of 93

45 Advocate Complete FIDA uses, for information on WellCare Advocate Complete FIDA s unique payer identification numbers used to identify WellCare Advocate Complete FIDA on electronic claims submissions or to contact WellCare Advocate Complete FIDA s EDI team, refer to the Provider Resource Guide on WellCare Advocate Complete FIDA s website at HIPAA Electronic Transactions and Code Sets HIPAA Electronic Transactions and Code Sets is a Federal mandate that requires health care payers such as WellCare Advocate Complete FIDA, as well as providers engaging in one or more of the identified transactions, to have the capability to send and receive all standard electronic transactions using the HIPAA designated content and format. Specific WellCare Advocate Complete FIDA requirements for claims and encounter transactions, code sets and SNIP validation are described as follows: To promote consistency and efficiency for all claims and encounter submissions to WellCare Advocate Complete FIDA, it is WellCare Advocate Complete FIDA s policy that these requirements apply to all paper and DDE transactions. For more information on EDI implementation with WellCare Advocate Complete FIDA, refer to the WellCare Advocate Complete FIDA Companion Guides. Paper Claims Submissions Providers are encouraged to submit claims to WellCare Advocate Complete FIDA electronically. Claims not submitted electronically may be subject to penalties as specified in the Agreement. For assistance in creating an EDI process, contact WellCare Advocate Complete FIDA s EDI team by referring to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at If permitted under the Agreement and until the provider has the ability to submit electronically, paper claims (UB-04 and CMS-1500, or their successors) must contain the required elements and formatting described below: All paper claims must be submitted on original (red ink on white paper) claim forms. Any missing, illegible, incomplete or invalid information in any field will cause the claim to be rejected or processed incorrectly. Per CMS guidelines, the following process should be used for clean claims submission: o The information must be aligned within the data fields and must be: On an original red-ink-on-white paper claim form; Typed. Do not print, hand-write or stamp any extraneous data on the form; In black ink; Large, dark font such as, PICA, ARIAL 10-, 11- or 12-point type; and In capital letters. o The typed information must not have: Broken characters; Script, italics or stylized font; Red ink; Mini font; or Dot matrix font. CMS Fact Sheet about UB-04 Effective: January 1, 2015 Page 44 of 93

46 MLN/MLNProducts/downloads/ub04_fact_sheet.pdf CMS Fact Sheet about CMS MLN/MLNProducts/downloads/form_cms-1500_fact_sheet.pdf Claims Processing Readmission WellCare Advocate Complete FIDA may choose to review claims, as necessary, if data analysis deems it appropriate. WellCare Advocate Complete FIDA may review hospital admissions on a specific participant if it appears that two or more admissions are related based on the data analysis. Based upon the claim review (including a review of medical records if requested from the provider) WellCare Advocate Complete FIDA will make all necessary adjustments to the claim, including recovery of payments which are not supported by the medical record. WellCare Advocate Complete FIDA may recoup overpayments from providers who do not submit the requested medical records or who do not remit the overpayment amounts identified by WellCare Advocate Complete FIDA. Three Day Payment Window WellCare Advocate Complete FIDA follows the CMS guidelines for outpatient services treated as inpatient services (including but not limited to: outpatient services followed by admission before midnight of the following day, preadmission diagnostic services, and other preadmission services). Please refer to the CMS Medicare Claims Processing Manual for additional information. Disclosure of Coding Edits WellCare Advocate Complete FIDA uses claims editing software programs to assist in determining proper coding for provider claims payment. Such software programs use industry standard coding criteria and incorporate guidelines established by CMS such as the National Correct Coding Initiative (NCCI) and the National Physician Fee Schedule Database, the American Medical Association (AMA) and Specialty Society correct coding guidelines, and state-specific regulations. These software programs may result in claim edits for specific procedure code combinations. They may also result in adjustments to the provider s claims payment or a request for review of medical records that relate to the claim. Providers may request reconsideration of any adjustments produced by these claims editing software programs by submitting a timely request for reconsideration to WellCare Advocate Complete FIDA. A reduction in payment as a result of claims policies and/or processing procedures is not an indication that the service provided is a non-covered service. Prompt Payment WellCare Advocate Complete FIDA will pay clean claims in accordance with the terms of the Agreement. Rate Updates WellCare Advocate Complete FIDA implements and prospectively applies changes to its fee schedules and CMS s changes to Medicare fee schedules as of the later of: the effective date of the change; or 45 days from the date CMS publishes the change on its website. Effective: January 1, 2015 Page 45 of 93

47 WellCare Advocate Complete FIDA will not retrospectively apply increases or decreases in rates to claims that have already been paid. Coordination of Benefits (COB) WellCare Advocate Complete FIDA shall coordinate payment for Covered Services in accordance with the terms of a participant s benefit plan, applicable state and Federal laws, and CMS guidance. Providers shall bill primary insurers for items and services they provide to a participant before they submit claims for the same items or services to WellCare Advocate Complete FIDA. Any balance due after receipt of payment from the primary payer should be submitted to WellCare Advocate Complete FIDA for consideration and the claim must include information verifying the payment amount received from the primary plan as well as a copy of the EOB. WellCare Advocate Complete FIDA may recoup payments for items or services provided to a participant where other insurers are determined to be responsible for such items and services to the extent permitted by applicable laws. Providers shall follow WellCare Advocate Complete FIDA s policies and procedures regarding subrogation activity. Participants under the Medicare line of business may be covered under more than one insurance policy at a time. In the event: A claim is submitted for payment consideration secondary to primary insurance carrier, other primary insurance information, such as the primary carrier s EOB, must be provided with the claim. WellCare Advocate Complete FIDA has the capability of receiving EOB information electronically. To submit other insurance information electronically, refer to the WellCare Advocate Complete FIDA Companion Guides on WellCare Advocate Complete FIDA s website at WellCare Advocate Complete FIDA has information on file to suggest the participant has other insurance, WellCare Advocate Complete FIDA may deny the claim; The primary insurance has terminated, the provider is responsible for submitting the initial claim with proof that coverage was terminated. In the event a claim was denied for other coverage, the provider must resubmit the claim with proof that coverage was terminated; and/or Benefits are coordinated with another insurance carrier as primary and the payment amount is equal to or exceeds WellCare Advocate Complete FIDA s liability, no additional payment will be made. The Order of Benefit Determination grid below for MMP participants outlines when WellCare Advocate Complete FIDA would be the primary or secondary payer: Order of Benefit Determination Participant Condition Pays First (Primary) Age 65 or older and covered by a group Health Plan because of work or covered under a working spouse of any age Employer has 20 or more employees Other Coverage Pays Second (Secondary) WellCare Advocate Complete FIDA Effective: January 1, 2015 Page 46 of 93

48 Participant Condition Pays First (Primary) Age 65 or older and covered by a group Health Plan because of work or covered under a working spouse of any age Age 65 or older and covered by a group Health Plan after retirement Disabled and covered by a large group Health Plan from work or from a family participant working Has End-Stage Renal Disease (ESRD) and group Health Plan coverage (including a retirement plan) Has End-Stage Renal Disease (ESRD) and group Health Plan coverage (including a retirement plan) Has End-Stage Renal Disease (ESRD) and group Health Plan coverage and COBRA coverage In an accident where no-fault or liability insurance is involved Workers' compensation/ Jobrelated illness or injury Veteran with Veteran benefits Covered under TRICARE Covered under TRICARE Black lung disease and covered under the Federal Black Lung Program Employer has less than 20 employees Has Medicare Coverage Employer has 100 or more employees First 30 months of eligibility or entitlement to Medicare After 30 months First 30 months of eligibility or entitlement to Medicare Entitled to Medicare Entitled to Medicare Entitled to Medicare and Veterans benefits Service from a military hospital or other Federal provider Covered Medicare services not provided by a military hospital or Federal provider Entitled to Medicare and Federal Black Lung Program WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA Other Coverage Other Coverage WellCare Advocate Complete FIDA Other Coverage Other Coverage Other Coverage Other Coverage Other Coverage WellCare Advocate Complete FIDA Other Coverage Pays Second (Secondary) Other Coverage Other Coverage WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA Other Coverage WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA Non-Covered Medicare service Non-Covered Medicare service Non-Covered Medicare service Other Coverage WellCare Advocate Complete FIDA Effective: January 1, 2015 Page 47 of 93

49 Participant Condition Pays First (Primary) Age 65 or over or disabled and covered by Medicare and COBRA Entitled to Medicare WellCare Advocate Complete FIDA Pays Second (Secondary) Other Coverage Encounters Data Overview This section is intended to give providers necessary information to allow them to submit encounter data to WellCare Advocate Complete FIDA. If encounter data do not meet the requirements set forth in WellCare Advocate Complete FIDA s government contracts for timeliness of submission, completeness or accuracy, Federal and State agencies (e.g., CMS) have the ability to impose significant financial sanctions on WellCare Advocate Complete FIDA. WellCare Advocate Complete FIDA requires all delegated vendors, delegated providers, and capitated providers to submit encounter data to WellCare Advocate Complete FIDA, even if they are reimbursed through a capitated arrangement. Quality and accuracy of the data must be maintained as CMS will use this encounter data to perform risk adjustment analysis. Timely and Complete Encounters Submission For initial submission, encounters should be submitted within 60 days from service month. For resubmission, encounters rejected by WellCare Advocate Complete FIDA must be remediated and 100% resubmitted within 7 calendar days from the date that provider receives the notification/response file from WellCare Advocate Complete FIDA. Encounters can be submitted to WellCare Advocate Complete FIDA on a daily/weekly basis. Provider must maintain a minimum of 95% acceptance rate for all encounters submitted within a calendar month. Encounter Compliance reports will be published to providers on a monthly basis. Providers who fail to comply with the Encounter SLA s are subject to be placed on a 90- day Corrective Action Plan. Fines/Penalties The following applies if Provider is capitated or Health Plan has delegated activities to Provider pursuant to a separate delegation addendum: Provider shall reimburse Health Plan for any fines, penalties or costs of corrective actions required of Health Plan by Governmental Authorities caused by Provider s failure to comply with Laws or Program Requirements, including failure to submit accurate encounters on a timely basis or to properly perform delegated functions. The above apply to both corrected claims (error correction encounters) and cap-priced encounters. Accurate Encounters Submission All encounter transactions submitted via DDE or electronically will be validated for transaction integrity/syntax based on the SNIP guidelines per the Federal requirements. Once WellCare Advocate Complete FIDA receives a provider s encounters, the encounters are loaded into WellCare Advocate Complete FIDA s encounters system and processed. The encounters are subjected to a series of SNIP editing to ensure that the encounter has all the required Effective: January 1, 2015 Page 48 of 93

50 information and that the information is accurate. SNIP levels 1 through 6 shall be maintained since CMS will apply the same edits on the encounter data submitted to them. For more information on Workgroup for Electronic Data Interchange (WEDI) SNIP Edits, refer to For more information on submitting encounters electronically, refer to the Companion Guides on WellCare Advocate Complete FIDA s website at Vendors are required to comply with any additional encounters validations as defined by CMS. These validations change from time to time based on new CMS guidance. Please refer to information on these changes located at Encounters Submission Methods Delegated providers may submit encounters using several methods: electronically, through WellCare Advocate Complete FIDA s contracted clearinghouse(s), via DDE or using WellCare Advocate Complete FIDA s Secure File Transfer Protocol (SFTP) process. Submitting Encounters Using SFTP Process (Preferred Method) WellCare Advocate Complete FIDA accepts electronic claims submission through EDI as its preferred method of claims submission. Encounters may be submitted using WellCare Advocate Complete FIDA s SFTP process. Refer to WellCare Advocate Complete FIDA s ANSI ASC X12 837I, 837P, and 837D Health Care Claim/Encounter Institutional, Professional and Dental Guides for detailed instructions on how to submit encounters electronically using SFTP. For more information on EDI implementation with WellCare Advocate Complete FIDA, refer to WellCare Advocate Complete FIDA s website at Submitting Encounters Using DDE Delegated vendors and providers may submit their encounter information directly to WellCare Advocate Complete FIDA using the DDE portal. The DDE tool can be found on the secure, online provider portal at For more information on free DDE options, refer to the state-specific Provider Resource Guide on WellCare Advocate Complete FIDA s website at Encounters Data Types There are four encounter types for which delegated vendors and providers are required to submit encounter records to WellCare Advocate Complete FIDA. Encounter records should be submitted using the HIPAA-standard transactions for the appropriate service type. The four encounter types are: Dental 837D format; Professional 837P format; Institutional 837I format; and Pharmacy NCPDP format. This document is intended to be used in conjunction with WellCare Advocate Complete FIDA s ANSI ASC X12 837I, 837P, and 837D Health Care Claim/Encounter Institutional, Professional and Dental Guides. Effective: January 1, 2015 Page 49 of 93

51 Encounters submitted to WellCare Advocate Complete FIDA from a delegated provider can be a new, voided or a replaced/overlaid encounter. The definitions of the types of encounters are as follows: New Encounter An encounter that has never been submitted to WellCare Advocate Complete FIDA previously. Voided Encounter An encounter that WellCare Advocate Complete FIDA deletes from the encounter file and is not submitted to the State. Replaced or Overlaid Encounter An encounter that is updated or corrected within the system. Participant Expenses and Maximum Out-of-Pocket The provider is responsible for collecting participant expenses. Providers are not to bill participants for missed appointments, administrative fees or other similar type fees. If a provider collects participant expenses determined to exceed the participant s responsibility, the provider must reimburse the participant the excess amount. The provider may determine an excess amount by referring to the Explanation of Payment (EOP). For certain benefit plans, participant expenses are limited by a maximum out-of-pocket amount. For more information on maximum out-of-pocket amounts, and provider responsibilities as a provider of care to a Medicare participant, refer to Section 2: Provider and Participant Administrative Guidelines. Balance Billing Providers shall accept payment from WellCare Advocate Complete FIDA for Covered Services provided to WellCare Advocate Complete FIDA participants in accordance with the reimbursement terms outlined in the Agreement. Payment from WellCare Advocate Complete FIDA constitutes payment in full. For Covered Services, providers shall not balance bill participants any amount in excess of the contracted amount in the Agreement. An adjustment in payment as a result of WellCare Advocate Complete FIDA s claims policies and/or procedures does not indicate that the service provided is a non-covered service, and participants are to be held harmless for Covered Services. Providers may not bill participants for: The difference between actual charges and the contracted reimbursement amount; Services denied due to timely filing requirements; Covered Services for which a claim has been returned and denied for lack of information; Remaining or denied charges for those services where the provider fails to notify WellCare Advocate Complete FIDA of a service that required prior authorization; Covered Services that were not medically necessary, in the judgment of WellCare Advocate Complete FIDA, unless prior to rendering the service the provider obtains the participant s informed written consent and the participant receives information that he/she will be financially responsible for the specific services. Provider-Preventable Conditions WellCare Advocate Complete FIDA follows CMS guidelines regarding Hospital Acquired Conditions, Never Events, and other Provider-Preventable Conditions (collectively, PPCs). Under Section 42 CFR , as amended, (implemented July 1, 2012), these PPCs are nonpayable for Medicaid and Medicare. Additional PPCs may be added by individual states. Effective: January 1, 2015 Page 50 of 93

52 Never Events are defined as a surgical or other invasive procedure to treat a medical condition when the practitioner erroneously performs: a different procedure altogether; the correct procedure but on the wrong body part; or the correct procedure on the wrong patient. Hospital Acquired Conditions are additional non-payable conditions listed on the CMS website at and include such events as an air embolism, falls and catheter-associated urinary tract infection. Health care providers may not bill, attempt to collect from, or accept any payment from WellCare Advocate Complete FIDA or the participant for PPCs or hospitalizations and other services related to these non-covered procedures. Reopening and Revising Determinations A reopening request made by the provider must be made in writing, clearly stating the specific reason for requesting the reopening. It is the responsibility of the provider to submit the requested documentation within 90 days of the denial to reopen the case. All decisions to grant reopening are at the discretion of WellCare Advocate Complete FIDA. See the Medicare Claims Processing Manual, Chapter 34, for Reopening and Revision of Claim Determinations and Decisions guidelines. Disputed Claims The claims payment dispute process addresses claim denials for issues related to untimely filing, incidental procedures, bundling, unlisted procedure codes, non-covered codes, etc. Claim payment disputes must be submitted to WellCare Advocate Complete FIDA in writing within 90 calendar days of the date of denial of the EOP for participating providers and within 180 days of the date of denial of the EOP for non-participating providers. Please provide the following information on the written provider dispute: Date(s) of service; Participant name; Participant ID number and/or date of birth; Provider name; Provider Tax ID/TIN; Total billed charges; The provider s statement explaining the reason for the dispute; and Supporting documentation when necessary (e.g., proof of timely filing, medical records). To initiate the process, please refer to the Quick Reference Guide located on WellCare Advocate Complete FIDA s website at and submit the dispute via mail, fax or Web. Corrected or Voided Claims Corrected and/or voided claims are subject to timely claims submission (i.e., timely filing) guidelines. To submit a corrected or voided claim electronically: Effective: January 1, 2015 Page 51 of 93

53 For Institutional claims, the provider must include WellCare Advocate Complete FIDA s original claim number for the claim adjusting or voiding in the REF*F8 (loop and segment) for any 7 (replacement for prior claim) or 8 (void/cancel of prior claim) in the standard 837 layout. For Professional claims, the provider must have the Frequency Code marked appropriately as 7 (Replacement for prior claim) or 8 (void/cancel of prior claim) in the standard 837 layout. These codes are not intended for use for original claim submission or rejected claims. To submit a corrected or voided claim via paper: For Institutional claims, the provider must include WellCare Advocate Complete FIDA s original claim number and bill the frequency code per industry standards. Example: Box 4 Type of Bill: the third character represents the Frequency Code Box 64 Place the claim number of the prior claim in Box 64 For Professional claims, provider must include WellCare Advocate Complete FIDA s original claim number and bill frequency code per industry standards. When submitting a corrected or voided claim, enter the appropriate bill frequency code left justified in the left-hand side of Box 22. Example: Any missing, incomplete or invalid information in any field may cause the claim to be rejected. Please note: If providers handwrite, stamp or type corrected claim on the claim form without entering the appropriate Frequency Code 7 or 8 along with the Original Reference Number as indicated above, the claim will be considered an original first-time claim submission. The correction or void process involves the following transaction: The original claim will be negated paid or zero payment and noted Payment lost/voided/missed. The corrected or voided claim will be processed with the newly submitted information and noted Adjusted per corrected bill. This process will pay out the newly calculated amount on this corrected or voided claim with a new claim number. The payment reversal for this process may generate a negative amount, which will be seen on a later EOP than the EOP that is sent out for the newly submitted corrected claim. Effective: January 1, 2015 Page 52 of 93

54 Reimbursement WellCare Advocate Complete FIDA applies the CMS site-of-service payment differentials in its fee schedules for CPT-4 codes based on the place of treatment (physician office services versus other places of treatment). Surgical Payments Reimbursement to the surgeon for surgical services includes payment for charges for preoperative evaluation and care, surgical procedures, and postoperative care. The following claims payment policies apply to surgical services: Incidental Surgeries/Complications A procedure that was performed incidental to the primary surgery will be considered as part of the primary surgery charges and will not be eligible for extra payment. Any complicated procedure that warrants consideration for extra payment should be identified with an operative report and the appropriate modifier. A determination will be made by WellCare Advocate Complete FIDA s Medical Director regarding whether the proposed complication merits additional compensation above the usual allowable amount. Admission Examination One charge for an admission history and physical from either the surgeon or the physician will be eligible for payment, which should be coded and billed separately. Follow-up Surgery Charges Charges for follow-up surgery visits are considered to be included in the surgical service charge and providers should not submit a claim for such visits, and providers are not compensated separately. Follow-up days included in the global surgical period vary by procedure and are based on CMS policy. Multiple Procedures Payment for multiple procedures is based on current CMS percentages methodologies. The percentages apply when eligible multiple surgical procedures are performed under one continuous medical service, or when multiple surgical procedures are performed on the same day and by the same surgeon. Assistant Surgeon Payment for an assistant surgeon and/or a non-physician practitioner for assistant surgery is based on current CMS percentages methodologies. WellCare Advocate Complete FIDA uses the American College of Surgeons (ACS) as the primary source to determine which procedures allow an assistant surgeon. For procedures that the ACS lists as sometimes, CMS is used as the secondary source. Co-Surgeon Payment for a co-surgeon is based on current CMS percentages methodologies. In these cases, each surgeon should report his or her distinct, operative work, by adding the appropriate modifier to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery only once, using the same procedure code. If additional procedures are performed during the same surgical session, separate code(s) should be reported with the modifier 62 added. Modifiers WellCare Advocate Complete FIDA follows CMS guidelines regarding modifiers and only reimburses modifiers reimbursed by CMS. Pricing modifier(s) should be placed in the first position(s) of the claim form. Allied Health Providers Effective: January 1, 2015 Page 53 of 93

55 WellCare Advocate Complete FIDA follows CMS reimbursement guidelines regarding Allied Health Professionals. Overpayment Recovery WellCare Advocate Complete FIDA strives for 100 percent payment quality but recognizes that a small percent of financial overpayments will occur while processing claims. An overpayment can occur due to reasons such as retroactive participant termination, inappropriate coding, duplication of payments, non-authorized services, erroneous contract or fee schedule reimbursement, non-covered benefit(s) and other reasons. WellCare Advocate Complete FIDA will proactively identify and attempt to correct inappropriate payments, including retroactive medical and community-based and facility-based LTSS. In situations when the inappropriate payment caused an overpayment, WellCare Advocate Complete FIDA will limit its recovery effort for NY FIDA to: 36 months from the service date for Medicare benefits. 24 months (NY Insurance Law 3224-b) from the service date for benefits under the Long-Term Support Services (LTSS) and Home and Community Based Waivers (HCBS) programs. These time frames do not apply to fraudulent or abusive billing and there is no deadline for WellCare Advocate Complete FIDA to seek recovery from the provider. In all cases, WellCare Advocate Complete FIDA, or its designee, will provide a written notice to the provider explaining the overpayment reason and amount, contact information and instructions on how to send the refund. If the overpayment results from coordination of benefits, the written notice will specify the name of the carrier and coverage period for the participant. The notice will also provide the carrier address WellCare Advocate Complete FIDA has on file but recognizes that the provider may use the carrier address it has on file. The standard request notification provides 45 days for the provider to send in the refund, request further information, appeal or dispute the retroactive denial. When appeals or disputes result in overpayment reversals, any amounts collected by WellCare Advocate Complete FIDA in connection with the overpayment determination will be refunded to the provider within 45 days. Failure of the provider to respond within the above timeframe will constitute acceptance of the terms in the letter and will result in offsets to future payments. The provider will receive an EOP indicating if the balance has been satisfied. In situations where the overpaid balance has aged more than three months and no refund has been received, the provider may be contacted by WellCare Advocate Complete FIDA, or its designee, to arrange payment. If the provider independently identifies an overpayment it can either a) send a corrected claim (refer to the corrected claim section of the manual), b) contact WellCare Advocate Complete FIDA Customer Service to arrange an off-set against future payments or c) send a refund and explanation of the overpayment to: WellCare Advocate Complete FIDA P.O. Box Tampa, FL For more information on contacting Provider Services, refer to the Quick Reference Guide. Effective: January 1, 2015 Page 54 of 93

56 Benefits During Disaster and Catastrophic Events In the event of a Presidential emergency declaration, a Presidential (major) disaster declaration, a declaration of emergency or disaster by a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, an 1135 waiver by the Secretary may be issued that may temporarily waive or modify certain Medicare, Medicaid, and Children s Health Insurance Program (CHIP) requirements. The purpose of the 1135 waiver is to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in Social Security Act programs and that providers who provide such services in good faith can be reimbursed and exempted from sanctions (absent any determination of fraud or abuse). If an 1135 waiver is absent, WellCare Advocate Complete FIDA will: Allow Part A/B and supplemental Part C plan benefits to be furnished at specified non-contracted facilities (note that Part A/B benefits must, per 42 CFR (b)(3), be furnished at Medicare-certified facilities); Waive in full, requirements for authorization or pre-notification; Temporarily reduce WellCare Advocate Complete FIDA-approved, out-of-network cost sharing to in-network cost sharing amounts; and/or Waive the 30 calendar day notification requirement to participants as long as all the changes (such as reduction of cost sharing and waiving authorization) benefit the participant. Typically, the source that declared the disaster will clarify when the disaster or emergency is over. If, however, the disaster or emergency timeframe has not been closed 30 calendar days from the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, WellCare Advocate Complete FIDA will resume normal operations 30 calendar days from the initial declaration. Type of Claim An institutional claim A professional claim Modifier Condition Code will be DR or Modifier CR Modifier will be CR Code Effective: January 1, 2015 Page 55 of 93

57 Section 6: Credentialing Overview Credentialing is the process by which the appropriate WellCare Advocate Complete FIDA peer review bodies evaluate the credentials and training qualifications of practitioners including physicians, allied health professionals, hospitals, surgery centers, home health agencies, skilled nursing facilities, and other ancillary facilities/health care delivery organizations. For purposes of Section 6: Credentialing in this Manual, all references to practitioners shall include providers providing health or health-related services including the following: physicians, allied health professionals, hospitals, surgery centers, home health agencies, skilled nursing facilities, and other ancillary facilities/health care delivery organizations. This review includes (as applicable to practitioner type): Background; Education; Postgraduate training; Certification(s); Experience; Work history and demonstrated ability; Patient admitting capabilities; Licensure, regulatory compliance and health status which may affect a practitioner s ability to provide health care; and Accreditation status, as applicable to non-individuals. Practitioners are required to be credentialed prior to being listed as a WellCare Advocate Complete FIDA-participating network provider of care or services. The Credentialing Department, or its designee, is responsible for gathering all relevant information and documentation through a formal application process. The practitioner credentialing application must be attested to by the applicant as being correct and complete. The application captures professional credentials and asks for information regarding professional liability claims history and suspension or restriction of hospital privileges, criminal history, licensure, Drug Enforcement Administration (DEA) certification, or Medicare/Medicaid sanctions. Please take note of the following credentialing process highlights: Primary source verifications are obtained in accordance with State and Federal regulatory agencies, accreditation, and WellCare Advocate Complete FIDA policy and procedure requirements, and include a query to the National Practitioner Data Bank. Physicians, allied health professionals, and ancillary facilities/health care delivery organizations are required to be credentialed in order to be network providers of services to WellCare Advocate Complete FIDA participants. Satisfactory site inspection evaluations are required to be performed in accordance with State and Federal accreditation requirements. After the credentialing process has been completed, a timely notification of the credentialing decision is forwarded to the provider. Credentialing may be done directly by WellCare Advocate Complete FIDA or by an entity approved by WellCare Advocate Complete FIDA for delegated credentialing. In the event that Effective: January 1, 2015 Page 56 of 93

58 credentialing is delegated to an outside agency, the agency shall be required to meet WellCare Advocate Complete FIDA s criteria to ensure that the credentialing capabilities of the delegated entity clearly meet Federal and State accreditation (as applicable) and WellCare Advocate Complete FIDA requirements. All participating providers or entities delegated for credentialing are to use the same standards as defined in this section. Compliance is monitored on a regular basis, and formal audits are conducted annually. Ongoing oversight includes regular exchanges of network information and the annual review of policies and procedures, credentialing forms, and files. Practitioner Rights Practitioner Rights are listed below and are included in the application/re-application cover letter. Practitioner s Right to Be Informed of Credentialing/Re-Credentialing Application Status Upon receipt of a written request, WellCare Advocate Complete FIDA will provide written information to the practitioner on the status of the credentialing/re-credentialing application, generally within 15 business days. The information provided will advise of any items pending verification, needing to be verified, any non-response in obtaining verifications, and any discrepancies in verification information received compared with the information provided by the practitioner. Practitioner s Right to Review Information Submitted in Support of Credentialing/ Re- Credentialing Application The practitioner may review documentation submitted by him or her in support of the application/re-credentialing application, together with any discrepant information received from professional liability insurance carriers, State licensing agencies, and certification boards, subject to any WellCare Advocate Complete FIDA restrictions. WellCare Advocate Complete FIDA, or its designee, will review the corrected information and explanation at the time of considering the practitioner s credentials for provider network participation or re-credentialing. The provider may not review peer review information obtained by WellCare Advocate Complete FIDA. Right to Correct Erroneous Information and Receive Notification of the Process and Timeframe In the event the credentials verification process reveals information submitted by the practitioner that differs from the verification information obtained by WellCare Advocate Complete FIDA, the practitioner has the right to review the information that was submitted in support of his or her application, and has the right to correct the erroneous information. WellCare Advocate Complete FIDA will provide written notification to the practitioner of the discrepant information. WellCare Advocate Complete FIDA s written notification to the practitioner will include: The nature of the discrepant information; The process for correcting the erroneous information submitted by another source; The format for submitting corrections; The timeframe for submitting the corrections; The addressee in the Credentialing Department to whom corrections must be sent; WellCare Advocate Complete FIDA s documentation process for receiving the correction information from the provider; and Effective: January 1, 2015 Page 57 of 93

59 WellCare Advocate Complete FIDA s review process. Baseline Criteria Baseline criteria for practitioners to qualify for provider network participation: License to Practice Practitioners must have a current, valid, unrestricted license to practice. Drug Enforcement Administration Certificate Practitioners must have a current valid DEA Certificate (as applicable to practitioner specialty), and if applicable to the state where services are performed, hold a current Controlled Dangerous Substance (CDS) or Controlled Substance Registration (CSR) certificate (applicable for M.D., D.O., D.P.M., D.D.S., D.M.D.). Work History Practitioners must provide a minimum of five years relevant work history as a health professional. Board Certification Physicians (M.D., D.O., D.P.M.) must maintain Board Certification in the specialty being practiced as a provider for WellCare Advocate Complete FIDA, or must have verifiable education/training from an accredited training program in the specialty requested. Hospital-Admitting Privileges Specialist practitioners shall have hospital-admitting privileges at a WellCare Advocate Complete FIDA-participating hospital (as applicable to specialty). PCP s may have hospital-admitting privileges or may enter into a formal agreement with another WellCare Advocate Complete FIDA-participating provider who has admitting privileges at a WellCare Advocate Complete FIDA-participating hospital, for the admission of participants. Ability to Participate in Medicaid and Medicare Providers must have the ability to participate in Medicaid and Medicare. Any individual or entity excluded from participation in any government program is not eligible for participation in any WellCare Advocate Complete FIDA plan. Existing providers who are sanctioned, and thereby restricted from participation in any government program, are subject to immediate termination in accordance with WellCare Advocate Complete FIDA policy and procedure and the Agreement. Providers who Opt-Out of Medicare A provider who opts-out of Medicare is not eligible to become a participating provider. An existing provider who opts-out of Medicare is not eligible to remain as a participating provider for WellCare Advocate Complete FIDA. At the time of initial credentialing, WellCare Advocate Complete FIDA reviews the state-specific opt-out listing maintained on the designated State Carrier s website to determine whether a provider has opted out of Medicare. The opt-out website is monitored on an ongoing/quarterly basis by WellCare Advocate Complete FIDA. Liability Insurance WellCare Advocate Complete FIDA providers (all disciplines) are required to carry and continue to maintain professional liability insurance, unless otherwise agreed to by WellCare Advocate Complete FIDA in writing. Providers must furnish copies of current professional liability insurance certificates to WellCare Advocate Complete FIDA, concurrent with expiration. Effective: January 1, 2015 Page 58 of 93

60 Site Inspection Evaluation Site Inspection Evaluations (SIEs) are conducted in accordance with Federal, State and accreditation requirements. Focusing on quality, safety, and accessibility, performance standards and thresholds were established for: Office-site criteria; Physical accessibility; Physical appearance; Adequacy of waiting room and examination room space; and Medical/treatment record keeping criteria. SIEs are conducted for: Unaccredited facilities; State-specific initial credentialing requirements; State-specific re-credentialing requirements; and When complaint is received relative to office site criteria. In those states where initial SIEs are not a requirement for credentialing, there is ongoing monitoring of participant complaints. SIEs are conducted for those sites where a complaint is received relative to office site criteria listed above. SIEs may be performed for an individual complaint or quality of care concern if the severity of the issue is determined to warrant an onsite review. Covering Physicians Primary care physicians in solo practice must have a covering physician who also participates with, or is credentialed with, WellCare Advocate Complete FIDA. Allied Health Professionals Allied Health Professionals (AHPs), both dependent and independent, are credentialed by WellCare Advocate Complete FIDA. Dependent AHPs include the following, and are required to provide collaborative practice information to WellCare Advocate Complete FIDA: Advanced Registered Nurse Practitioners (ARNP); Certified Nurse Midwives (CNM); Physician Assistants (PA); and Osteopathic Assistants (OA). Independent AHPs include, but are not limited to the following: Licensed clinical social workers; Licensed mental health counselors; Licensed marriage and family therapists; Physical therapists; Occupational therapists; Audiologists; and Speech/language therapists/pathologists. Ancillary Health Care Delivery Organizations Ancillary and organizational applicants must complete an application and, as applicable, undergo an SIE if unaccredited. WellCare Advocate Complete FIDA is required to verify accreditation, licensure, Medicare certification (as applicable), regulatory status, and liability Effective: January 1, 2015 Page 59 of 93

61 insurance coverage, prior to accepting the applicant as a WellCare Advocate Complete FIDA participating provider. Re-Credentialing In accordance with regulatory, accreditation, and WellCare Advocate Complete FIDA policy and procedure, re-credentialing is required at least once every three years. Updated Documentation In accordance with the Agreement, providers should furnish copies of current professional or general liability insurance, license, DEA certificate, and accreditation information (as applicable to provider type) to WellCare Advocate Complete FIDA, prior to or concurrent with expiration. Office of Inspector General Medicare/Medicaid Sanctions Report On a regular and ongoing basis, WellCare Advocate Complete FIDA or its designee accesses the listings from the Office of Inspector General (OIG) Medicare/Medicaid Sanctions (exclusions and reinstatements) Report, for the most current available information. This information is crosschecked against WellCare Advocate Complete FIDA s network of providers. If participating providers are identified as being currently sanctioned, such providers are subject to immediate termination, in accordance with WellCare Advocate Complete FIDA policies and procedures and the Agreement. Sanction Reports Pertaining to Licensure, Hospital Privileges or Other Professional Credentials On a regular and ongoing basis, WellCare Advocate Complete FIDA, or its designee, contacts state licensure agencies to obtain the most current available information on sanctioned providers. This information is cross-checked against the network of WellCare Advocate Complete FIDA providers. If a network provider is identified as being currently under sanction, appropriate action is taken in accordance with WellCare Advocate Complete FIDA policy and procedure. If the sanction imposed is revocation of license, the provider is subject to immediate termination. Notifications of termination are given in accordance with contract and WellCare Advocate Complete FIDA policies and procedures. In the event a sanction imposes a reprimand or probation, written communication is made to the provider requesting a full explanation, which is then reviewed by the Credentialing/Peer Review Committee. The Committee makes a determination as to whether the provider should continue participation or whether termination should be initiated. Participating Provider Appeal through the Dispute Resolution Peer Review Process WellCare Advocate Complete FIDA may immediately suspend, pending investigation, the participation status of a participating provider who, in the sole opinion of WellCare Advocate Complete FIDA s Medical Director, is engaged in behavior or practicing in a manner that appears to pose a significant risk to the health, welfare, or safety of participants. WellCare Advocate Complete FIDA has a Participating Provider Dispute Resolution Peer Review Panel process in the event WellCare Advocate Complete FIDA chooses to alter the conditions of participation of a provider based on issues of quality of care, conduct or service, and if such process is implemented, may result in reporting to regulatory agencies. The Provider Dispute Resolution Peer Review process has two levels. All disputes in connection with the actions listed below are referred to a first level Peer Review Panel consisting of at least Effective: January 1, 2015 Page 60 of 93

62 three qualified individuals of whom at least one is a participating provider and a clinical peer of the practitioner that filed the dispute. The practitioner also has the right to consideration by a second level Peer Review Panel consisting of at least three qualified individuals of which at least one is a participating provider and a clinical peer of the practitioner that filed the dispute and the second level panel is comprised of individuals who were not involved in earlier decisions. The following actions by WellCare Advocate Complete FIDA entitle the practitioner affected thereby to the Provider Dispute Resolution Peer Review Panel Process: Suspension of participating practitioner status for reasons associated with clinical care, conduct, or service; Revocation of participating practitioner status for reasons associated with clinical care, conduct, or service; or Non-renewal of participating practitioner status at time of re-credentialing for reasons associated with clinical care, conduct, service, or excessive claims and/or sanction history. Notification of the adverse recommendation, together with reasons for the action, the practitioner s rights, and the process for obtaining the first and/or second level Dispute Resolution Peer Review Panel, are provided to the practitioner. Notification to the practitioner will be mailed by an overnight carrier or certified mail, with return-receipt requested. The practitioner has 30 days from the date of WellCare Advocate Complete FIDA s notice to submit a written request to WellCare Advocate Complete FIDA. This request must be sent by a nationally recognized overnight carrier or U.S. certified mail, with return receipt, to invoke the Dispute Resolution Peer Review Panel process. Upon WellCare Advocate Complete FIDA s timely receipt of the request, WellCare Advocate Complete FIDA s Medical Director or his or her designee shall notify the practitioner of the date, time, and telephone access number for the Panel hearing. WellCare Advocate Complete FIDA then notifies the practitioner of the schedule for the Review Panel hearing. The practitioner and WellCare Advocate Complete FIDA are entitled to legal representation at the Review Panel hearing. The practitioner has the burden of proof by clear and convincing evidence that the reason for the termination recommendation lacks any factual basis, or that such basis or the conclusion(s) drawn there from, are arbitrary, unreasonable, or capricious. The Dispute Resolution Peer Review Panel shall consider and decide the case objectively and in good faith. WellCare Advocate Complete FIDA s Medical Director, within five business days after final adjournment of the Dispute Resolution Peer Review Panel hearing, shall notify the practitioner of the results of the first level Panel hearing. In the event the findings are positive for the practitioner, the second level panel review shall be waived. In the event the findings of the first level Panel hearing are adverse to the practitioner, the practitioner may access the second level Peer Review Panel by following the notice information contained in the letter notifying the practitioner of the adverse determination of the first level Peer Review Panel. Effective: January 1, 2015 Page 61 of 93

63 Within 10 calendar days of the request for a second level Peer Review Panel hearing, the Medical Director or her or his designee shall notify the practitioner of the date, time, and access number for the second level Peer Review Panel hearing. The second level Dispute Resolution Peer Review Panel shall consider and decide the case objectively and in good faith. The Medical Director, within five business days after final adjournment of the second level Dispute Resolution Peer Review Panel hearing, shall notify the practitioner of the results of the second level Panel hearing via certified or overnight recorded delivery mail. The findings of the second level Peer Review Panel shall be final. A practitioner who fails to request the Provider Dispute Resolution Peer Review Process within the time and in the manner specified waives all rights to such review to which he or she might otherwise have been entitled. WellCare Advocate Complete FIDA may terminate the practitioner and make the appropriate report to the National Practitioner Data Bank and State Licensing Agency as appropriate and if applicable. Delegated Entities All participating providers or entities delegated for credentialing are to use the same standards as defined in this section. Compliance is monitored on a monthly/quarterly basis and formal audits are conducted annually. Please refer to Section 9: Delegated Entities of this Manual for further details. Effective: January 1, 2015 Page 62 of 93

64 Section 7: Appeals and Grievances Appeals Provider Retrospective Appeals Overview A provider may appeal a claim or utilization review denial on his or her own behalf by mailing or faxing WellCare Advocate Complete FIDA a letter of appeal or an appeal form with supporting documentation such as medical records. Appeal forms are located on WellCare Advocate Complete FIDA s website at Providers have 90 calendar days from WellCare Advocate Complete FIDA s original utilization management review decision or claim denial to file a provider appeal. Appeals after that time will be denied for untimely filing. If the provider feels that the appeal was filed within the appropriate timeframe, the provider may submit documentation showing proof of timely filing. The only acceptable proof of timely filing is a registered postal receipt signed by a representative of WellCare Advocate Complete FIDA, or a similar receipt from other commercial delivery services. Upon receipt of all required documentation, WellCare Advocate Complete FIDA has 60 calendar days to review the appeal for medical necessity and conformity to WellCare Advocate Complete FIDA guidelines and to render a decision to reverse or affirm. Required documentation includes the participant s name and/or identification number, date of services, and reason why the provider believes the decision should be reversed. Additional required information varies based on the type of appeal being requested. For example, if the provider is requesting a medical necessity review, medical records should be submitted. If the provider is appealing a denial based on untimely filing, proof of timely filing should be submitted. If the provider is appealing the denial based on not having a prior authorization, then documentation regarding why the service was rendered without prior authorization must be submitted. Appeals received without the necessary documentation will not be reviewed by WellCare Advocate Complete FIDA due to lack of information. It is the responsibility of the provider to provide the requested documentation within 60 calendar days of the denial to review the appeal. Records and documents received after that time will not be reviewed and the appeal will remain closed. Medical records and patient information shall be supplied at the request of WellCare Advocate Complete FIDA or appropriate regulatory agencies when required for appeals. The provider is not allowed to charge WellCare Advocate Complete FIDA or the participant for copies of medical records provided for this purpose. Provider Retrospective Appeals Decisions Reversal of Initial Denial If it is determined during the review that the provider has complied with WellCare Advocate Complete FIDA protocols and that the appealed services were medically necessary, the initial denial will be reversed. The provider will be notified of this decision in writing. The provider may file a claim for payment related to the appeal, if one has not already been submitted. After the decision to reverse the denial has been made, any claims previously denied Effective: January 1, 2015 Page 63 of 93

65 will be adjusted for payment. WellCare Advocate Complete FIDA will ensure that claims are processed and comply with Federal and State requirements, as applicable. Affirmation of Initial Denial If it is determined during the review that the provider did not comply with WellCare Advocate Complete FIDA protocols and/or medical necessity was not established, the initial denial will be upheld. The provider will be notified of this decision in writing. For denials based on medical necessity, the criteria used to make the decision may be provided in the letter. The provider may also request a copy of the clinical rationale used in making the appeal decision by sending a written request to the appeals address listed in the decision letter. Participant Appeal Process Overview A participant appeal is a formal request from a participant for a review of an action taken by WellCare Advocate Complete FIDA. An appeal may also be filed on the participant s behalf by an authorized representative with written consent or a physician. All appeal rights described in Section 7 of this Manual that apply to participants will also apply to the participant s authorized representative or a physician acting on behalf of the participant. The Plan shall acknowledge appeals to the participant within 15 calendar days of receipt of the appeal. If a decision is reached before the written acknowledgment is sent, the Plan will not send the written acknowledgment. To request an appeal of a decision made by WellCare Advocate Complete FIDA, a participant may file an appeal request verbally or in writing within 60 calendar days of the postmark date on the Notice of Action. If the participant s request is made verbally, WellCare Advocate Complete FIDA will mail an acknowledgment letter to the participant to confirm the facts and basis of the appeal. Examples of actions that can be appealed include, but are not limited to: Denial or limited authorization of a requested service, including the type or level of service; The reduction, suspension or termination of a previously authorized service; The denial, in whole or in part, of payment for a service; and/or The failure to provide services in a timely manner, as defined by CMS. WellCare Advocate Complete FIDA gives participants reasonable assistance in completing forms and other procedural steps for a reconsideration, including but not limited to providing interpreter services and toll-free telephone numbers with TTY/TDD and interpreter capability. WellCare Advocate Complete FIDA ensures that decision-makers assigned to appeals were not involved in appeals of previous levels of review. When deciding an appeal based on lack of medical necessity, a grievance regarding denial of expedited resolution of an appeal, or a grievance or appeal involving clinical issues, the reviewers will be health care professionals with clinical expertise in treating the participant s condition/disease or will seek advice from providers with expertise in the field of medicine related to the request. WellCare Advocate Complete FIDA will not retaliate against any provider acting on behalf of or in support of a participant requesting an appeal or an expedited appeal. Effective: January 1, 2015 Page 64 of 93

66 Appointment of Representative If the participant wishes to use a representative, she or he must complete a Medicare Appointment of Representative (AOR) form. The participant and the person who will be representing the participant must sign the AOR form. The form is located on WellCare Advocate Complete FIDA s website at Prior to the service(s) being rendered, providers may appeal a denial of preauthorization on behalf of the participant if they have the participant s consent in their records. Types of Appeals A participant may request a standard pre-service, retrospective, or an expedited appeal. Standard pre-service appeals are requests for services that WellCare Advocate Complete FIDA has determined are not Covered Services, are not medically necessary, or are otherwise outside of the participant s benefit plan. Retrospective, or post-service, appeals are typically requests for payment for care or services that the participant has already received. Accordingly, a retrospective appeal would never result in the need for an expedited review. These are the only appeals that may be made by the provider on his or her own behalf. Only pre-service appeals are eligible to be processed as an expedited appeal. Appeal Decision Timeframes WellCare Advocate Complete FIDA will issue a decision to the participant or the participant s representative within the following time frames: Expedited Request: 72 hours from receipt of the appeal Standard Pre-Service Request: 30 calendar days from receipt of the appeal Retrospective Request: 30 calendar days as applicable Medicaid Prescription Drug: 7 calendar days from receipt of the appeal Expedited Appeals To request an expedited appeal, a participant or a provider (regardless of whether the provider is affiliated with WellCare Advocate Complete FIDA) must submit a verbal or written request directly to WellCare Advocate Complete FIDA. A request to expedite an appeal of a determination will be considered in situations where applying the standard procedure could seriously jeopardize the participant s life, health or ability to regain maximum function, including cases in which WellCare Advocate Complete FIDA makes a less than fully favorable decision to the participant. In light of the short time frame for deciding an expedited appeal, a provider does not need to be an authorized representative to request an expedited reconsideration on behalf of the participant. However, the provider must have the participant s consent on file. A request for payment of a service already provided to a participant is not eligible to be reviewed as an expedited reconsideration. If an appeal is expedited, WellCare Advocate Complete FIDA will complete the expedited reconsideration and give the participant (and the provider involved, as appropriate) notice of the decision as expeditiously as the participant s health condition requires, but no later than 72 hours after receiving a valid and complete request for reconsideration. Effective: January 1, 2015 Page 65 of 93

67 If WellCare Advocate Complete FIDA denies the request to expedite a reconsideration, WellCare Advocate Complete FIDA will provide the participant with verbal notification and within two (2) calendar days of the expedited appeal determination, WellCare Advocate Complete FIDA will mail a letter to the participant explaining: That WellCare Advocate Complete FIDA will automatically process the request using the 30 calendar day time frame for standard reconsiderations; The participant s right to resubmit a request for an expedited reconsideration and that if any provider indicates that applying the standard timeframe for making a determination could seriously jeopardize the participant s life, health or ability to regain maximum function, the request will be expedited automatically. Standard Pre-Service and Retrospective Appeals (Level 1 Appeal) A participant may file an appeal request either verbally or in writing within 60 calendar days of the postmark date on the Notice of Action. After filing a written appeal, a participant may present his or her appeal in person. To do so, the participant must call WellCare Advocate Complete FIDA to advise that the participant would like to present the appeal in person or via the telephone. If the participant would like to present her or his appeal in person, WellCare Advocate Complete FIDA will arrange a time and date that works best for the participant and WellCare Advocate Complete FIDA. A participant of the management team and a WellCare Advocate Complete FIDA Medical Director will participate in the in-person appeal. After the participant presents the information, WellCare Advocate Complete FIDA will mail the decision to the participant within the time frame specified above, based on the type of appeal. If the participant s request for appeal is submitted after 60 calendar days, then good cause must be shown in order for WellCare Advocate Complete FIDA to accept the late request. Examples of good cause include, but are not limited to: The participant did not personally receive the adverse organization determination notice or received it late; The participant was seriously ill, which prevented a timely appeal; There was a death or serious illness in the participant's immediate family; An accident caused important records to be destroyed; Documentation was difficult to locate within the time limits; and/or The participant had incorrect or incomplete information concerning the reconsideration process. Participant Appeal Decisions Reversal of Denial of an Appeal If, upon standard appeal, WellCare Advocate Complete FIDA overturns its adverse determination denying a participant s request for a service, then WellCare Advocate Complete FIDA will issue an authorization for the request. WellCare Advocate Complete FIDA will authorize the disputed services promptly and as expeditiously as the participant s health condition requires, if the services were not furnished while the appeal was pending and the decision is to reverse a decision to deny, limit or delay services. WellCare Advocate Complete FIDA will also pay for the disputed services, in Effective: January 1, 2015 Page 66 of 93

68 accordance with state policy and regulations, if the services were furnished while the appeal was pending and the disposition reverses a decision to deny, limit or delay services. Affirmation of Denial of a Standard Appeal If WellCare Advocate Complete FIDA affirms its initial action and/or denial (in whole or in part), it will: Issue a Notice of Action Appeal to the participant and/or appellant; Include in the Notice the specific reason for the appeal decision in an easily understandable language with reference to the benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based; Submit a written explanation for a final determination with the complete case file to the Integrated Administrative Hearing Officer at the FIDA Administrative Hearing Unit at the State Office of Temporary and Disability Assistance (OTDA); and Notify the participant of the decision to affirm the initial denial and that the case has been forwarded to the Administrative Hearing Officer. Once a final determination has been made, the Administrative Hearing Officer will notify the participant and WellCare Advocate Complete FIDA. In the event the Administrative Hearing Officer agrees with WellCare Advocate Complete FIDA, the IRE will provide the participant further appeal rights. If the Administrative Hearing Officer reverses the initial denial, the Officer will notify the participant or representative in writing of the decision. Appeal Levels There are four levels of appeals available to FIDA beneficiaries enrolled in this plan after an adverse organization determination has been made. These levels will be followed sequentially only if the original denial continues to be upheld at each level by the reviewing entity: 1. Appeal of adverse organization determination by WellCare Advocate Complete FIDA Level 1 2. Administrative Hearing Level 2 3. Medicare Appeals Council Level 3 4. Federal District Court Level 4 Administrative Hearing: Second Level of Appeal Any adverse appeal decision by WellCare Advocate Complete FIDA is automatically forwarded to the Integrated Administrative Hearing Officer at the FIDA Administrative Hearing Unit at the State Office of Temporary and Disability Assistance (OTDA). This step occurs regardless of the amount in controversy (i.e., there is no amount in controversy minimum imposed). This second level appeal is external to WellCare Advocate Complete FIDA. The Integrated Administrative Hearing Officer shall provide the enrollee with a Notice of Administrative Hearing at least 10 calendar days in advance of the hearing date. Decision Time Frames on Administrative Hearing Standard Time Frames: The Integrated Administrative Hearing Officer shall conduct a phone or in-person hearing and render a decision as expeditiously as the enrollee s condition requires, but always within 7 calendar days for Medicaid prescription drug coverage matters and for all other matters within 90 calendar days of request. Effective: January 1, 2015 Page 67 of 93

69 Expedited Time Frame: The Integrated Administrative Hearing Officer shall conduct a phone or in-person hearing and notify the enrollee (and the provider, as appropriate) of the decision within 72 hours of the forwarding of the Plan s decision. The Integrated Administrative Hearing Officer shall issue a written decision that explains in plain language the rationale for the decision and specifies the next steps in the appeal process, including where to file the appeals, the filing time frames and other information required by applicable Federal and State requirements. Participants will be notified by the time frames stated in the contract. Medicare Appeals Council: Third Level of Appeal If an enrollee disagrees with the Integrated Administrative Hearing Officer s decision, they may appeal that decision further to the Medicare Appeals Council, which may overturn the Integrated Administrative Hearing Officer s decision. This serves as the third level of appeal. The enrollee must file the appeal within 60 calendar days to the FIDA Administrative Hearing Unit, which will forward the request for appeal and administrative record to the Medicare Appeals Council. The Council will complete a paper review and will issue a decision within 90 calendar days. Federal District Court: Fourth Level of Appeal An adverse Medicare Appeals Council decision may be appealed to the Federal District Court which serves as the fourth level of appeal. Continuation of Benefits Continuation of benefits for all prior-approved Medicare and Medicaid benefits that are terminated or modified, pending internal FIDA Plan appeals, Integrated Administrative Hearings, and Medicare Appeals Council, must be provided if the original appeal is received by WellCare Advocate Complete FIDA within 10 calendar days of the Notice of Action postmark date (of the decision that is being appealed) or by the intended effective date of the Action, whichever is later. Grievances Provider Medicare/Medicaid providers are not permitted to file a grievance per CMS guidance and State Regulations. Participant Grievance Overview A participant may express their dissatisfaction about any matter other than an adverse action (which is subject to the appeals process). This expression of dissatisfaction is defined as a grievance. The participant or their authorized representative may file a grievance on a participant s behalf, as may a provider with the participant s written consent. All grievance rights described in Section 7 of this Manual that apply to participants will also apply to the participant s authorized representative or a provider acting on behalf of the participant with the participant s consent. If the participant wishes to use a representative, then she or he must complete a Medicare Appointment of Representative (AOR) statement. The participant and the person who will be representing the participant must sign the AOR statement. The form is located on WellCare Advocate Complete FIDA s website at Examples of issues that may result in a grievance include, but are not limited to: Provider Service including, but not limited to: Effective: January 1, 2015 Page 68 of 93

70 o Rudeness by provider or office staff; o Refusal to see participant (other than in the case of patient discharge from office); or o Office conditions. Services provided by WellCare Advocate Complete FIDA including, but not limited to: o Hold time on telephone; o Rudeness of staff; o Involuntary disenrollment from WellCare Advocate Complete FIDA; or o Unfulfilled requests. Access availability including, but not limited to: o Difficulty getting an appointment; o Wait time in excess of one hour; or o Handicap accessibility. A participant or a participant s representative may file a standard grievance request either orally (via Customer Service or in person) or in writing within 60 calendar days of the date of the incident or when the participant was made aware of the incident. Contact information for the Grievance Department is on the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Grievance Submission Standard An oral grievance request can be filed, toll-free, by calling the WellCare Advocate Complete FIDA Customer Service Department. An oral request may be followed up with a written request by the participant, but the time frame for resolution begins the date the oral filing is received by WellCare Advocate Complete FIDA. A written complaint may be filed by mail to: WellCare Advocate Complete FIDA Grievance Department P.O. Box Tampa, FL Alternatively, the complaint may be faxed to A participant, participant s representative, or provider (with appropriate CMS 1696 Appointment of Representative form/power of Attorney for Medicare) may file a standard grievance or any information or evidence concerning a grievance orally or in writing no later than 60 calendar days from date that caused the dissatisfaction. WellCare Advocate Complete FIDA will acknowledge the participant s standard grievance in writing within 15 business days from the date the grievance is received by WellCare Advocate Complete FIDA. The acknowledgment letter will include: Name and telephone number of the Grievance Coordinator; and Request for any additional information, if needed to investigate the issue. Grievance Resolution Standard A participant or participant s representative shall be notified of the decision as expeditiously as the case requires, based on the participant s health status, but no later than 30 calendar days Effective: January 1, 2015 Page 69 of 93

71 after the date WellCare Advocate Complete FIDA receives the oral or written grievance, consistent with applicable Federal law. Unless an extension is elected, WellCare Advocate Complete FIDA will send a closure letter within 3 business days of completion of its review of the participant s grievance. An extension of up to 14 calendar days may be requested by the participant or the participant s representative. WellCare Advocate Complete FIDA may also initiate an extension if the need for additional information can be justified and the extension is in the participant s best interest. In all cases, extensions must be well-documented. WellCare Advocate Complete FIDA will provide the participant or the participant s representative prompt written notification regarding WellCare Advocate Complete FIDA s intention to extend the grievance decision. The Grievance Department will inform the participant of the determination of the grievance as follows: All grievances submitted, either orally or in writing, will be responded to in writing; and All grievances related to quality of care will include a description of the participant s right to file a written complaint with the Quality Improvement Organization (QIO). For any complaint submitted to a QIO, WellCare Advocate Complete FIDA will cooperate with the QIO in resolving the complaint. WellCare Advocate Complete FIDA provides all participants with written information about the grievance procedures/process available to them, as well as the complaint processes. WellCare Advocate Complete FIDA also provides written information to participants and/or their appointed representative(s) about the grievance procedure at initial enrollment, upon involuntary disenrollment initiated by WellCare Advocate Complete FIDA, upon the denial of a participant s request for an expedited review of a determination or appeal, upon the participant s request, and annually thereafter. WellCare Advocate Complete FIDA will provide written information to participants and/or their appointed representatives about the QIO process at initial enrollment and annually thereafter. A complaint may include grievances, appeals and coverage decisions. Complaints can be processed under the appeal procedures, under the grievance procedures, coverage decision process or both depending on the extent to which the issues wholly or partially contain elements that are organization determinations. If an enrollee addresses two or more issues in one complaint, then each issue shall be processed separately and simultaneously (to the extent possible) under the proper procedure. Cases involving an Appeal complaint shall be forwarded to the Appeals Department. Expedited A participant may request an expedited grievance if WellCare Advocate Complete FIDA makes the decision not to expedite an organizational determination, expedite an appeal, or invoke an extension to a review. WellCare Advocate Complete FIDA will respond to an expedited grievance within 24 hours of receipt. The grievance will be conducted to ensure that the decision to not apply an expedited review time frame or extend a review time frame does not jeopardize the participant s health. In all other circumstances where the standard process would significantly increase the risk to a participant s health, WellCare Advocate Complete FIDA will respond and notify the participant within 48 hours after receipt of all necessary information and no more than 7 calendar days after the receipt of the grievance. Effective: January 1, 2015 Page 70 of 93

72 WellCare Advocate Complete FIDA will contact the participant or the participant s representative via telephone with the determination and will mail the resolution letter to the participant or the participant s representative within 3 business days after the determination is made. The resolution will also be documented in the participant s record. Effective: January 1, 2015 Page 71 of 93

73 Section 8: Compliance Compliance Program - Overview WellCare Advocate Complete FIDA s corporate ethics and compliance program, as may be amended from time to time, includes information regarding WellCare Advocate Complete FIDA s policies and procedures related to fraud, waste and abuse, and provides guidance and oversight with respect to the performance of work by WellCare Advocate Complete FIDA, WellCare Advocate Complete FIDA employees, contractors (including delegated entities) and business partners in an ethical and legal manner. All providers, including provider employees and provider sub-contractors and their employees, are required to comply with WellCare Advocate Complete FIDA compliance program requirements. WellCare Advocate Complete FIDA s compliance-related training requirements include, but are not limited to, the following initiatives: Corporate Integrity Agreement (CIA) Training o Effective April 26, 2011, WellCare Advocate Complete FIDA s CIA with the Office of Inspector General (OIG) of the United States Department of Health and Human Services (HHS) requires that WellCare Advocate Complete FIDA maintain and build upon its existing Compliance Program and corresponding training. o Under the CIA, the degree to which individuals must be trained depends on their role and function at WellCare Advocate Complete FIDA. HIPAA Privacy and Security Training o Summarizes privacy and security requirements in accordance with the federal standards established pursuant to HIPAA and subsequent amendments to HIPAA. o Training includes, but is not limited to discussion on: Proper uses and disclosures of PHI; Participant rights; and Physical and technical safeguards. Fraud, Waste and Abuse (FWA) Training o Must include, but not limited to: Laws and regulations related to fraud, waste and abuse (i.e., False Claims Act, Anti-Kickback statute, HIPAA, etc.); Obligations of the provider including provider employees and provider sub-contractors and their employees to have appropriate policies and procedures to address fraud, waste, and abuse; Process for reporting suspected fraud, waste and abuse; Protections for employees and subcontractors who report suspected fraud, waste and abuse; and Types of fraud, waste and abuse that can occur. Providers, including provider employees and/or provider sub-contractors, must report to WellCare Advocate Complete FIDA any suspected fraud, waste or abuse, misconduct or criminal acts by WellCare Advocate Complete FIDA, its participants, or any provider, including provider employees and/or provider sub-contractors. Reports may be made anonymously through WellCare Advocate Complete FIDA s FWA hotline at Details of the corporate ethics and compliance program may be found on WellCare Advocate Complete FIDA s website at Effective: January 1, 2015 Page 72 of 93

74 Marketing FIDA Plans FIDA Plans are subject to rules governing their marketing and participant communications as specified under section 1851(h) and 1932(d)(2) of the Social Security Act; 42 CFR Parts , et. Seq., (b) and (c), , and et. Seq., ; and the Medicare Marketing Guidelines (Chapter 3 of the Medicare Managed Care Manual and Chapter 2 of the Prescription Drug Benefit Manual). FIDA Plans may not market directly to individuals on a one-on-one basis but may provide responses to participant-initiated requests for information and/or enrollment. FIDA Plans may participate in group marketing events and provide general audience materials. Providers must adhere to all applicable laws, regulations and CMS guidelines regarding marketing. Code of Conduct and Business Ethics Overview WellCare Advocate Complete FIDA has established a Code of Conduct and Business Ethics that outlines ethical principles to ensure that all business is conducted in a manner that reflects an unwavering allegiance to ethics and compliance. WellCare Advocate Complete FIDA s Code of Conduct and Business Ethics policy can be found at The Code of Conduct and Business Ethics is the foundation of icare, WellCare Advocate Complete FIDA's Corporate Ethics and Compliance Program. It describes WellCare Advocate Complete FIDA's firm commitment to operate in accordance with the laws and regulations governing WellCare Advocate Complete FIDA s business and accepted standards of business integrity. All associates, covered persons as defined by the CIA, participating providers and other contractors should familiarize themselves with WellCare Advocate Complete FIDA s Code of Conduct and Business Ethics. WellCare Advocate Complete FIDA associates, covered persons, participating providers and other contractors of WellCare Advocate Complete FIDA are encouraged to report compliance concerns and any suspected or actual misconduct using the Compliance Hotline at Suspicions of fraud, waste and abuse may be reported by calling WellCare Advocate Complete FIDA s FWA Hotline at Fraud, Waste and Abuse WellCare Advocate Complete FIDA is committed to the prevention, detection and reporting of health care fraud and abuse according to applicable Federal and State statutory, regulatory and contractual requirements. WellCare Advocate Complete FIDA has developed an aggressive, proactive fraud and abuse program designed to collect, analyze and evaluate data in order to identify suspected fraud and abuse. Detection tools have been developed to identify patterns of health care service use, including over-utilization, unbundling, up-coding, misuse of modifiers and other common schemes. Federal and State regulatory agencies, law enforcement, and WellCare Advocate Complete FIDA vigorously investigate incidents of suspected fraud and abuse. Providers are cautioned that unbundling, fragmenting, up-coding, and other activities designed to manipulate codes contained in the International Classification of Diseases, Ninth Edition (ICD-9), CPT-4, the Healthcare Common Procedure Coding System (HCPCS), and/or Universal Billing Revenue Coding Manual as a means of increasing reimbursement may be considered an improper billing practice and may be a misrepresentation of the services actually rendered. Effective: January 1, 2015 Page 73 of 93

75 In addition, providers are reminded that medical records and other documentation must be legible and support the level of care and service indicated on claims. Providers engaged in fraud and abuse may be subject to disciplinary and corrective actions, including but not limited to, warnings, monitoring, administrative sanctions, suspension or termination as an authorized provider, loss of licensure, and/or civil and/or criminal prosecution, fines and other penalties. Participating providers must be in compliance with all CMS rules and regulations. This includes the CMS requirement that all employees who work for or contract with a Medicaid managed care organization meet annual compliance and education training requirements with respect to FWA. To meet Federal regulation standards specific to Fraud, Waste and Abuse ( ), providers and their employees must complete an annual FWA training program. Compliance with FWA training requirements will be monitored. To report suspected fraud and abuse, please refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at or call WellCare Advocate Complete FIDA s confidential and toll-free WellCare Advocate Complete FIDA compliance hotline at Details of the corporate ethics and compliance program, and how to contact WellCare Advocate Complete FIDA s fraud hotline, may be found on WellCare Advocate Complete FIDA s website at Confidentiality of Participant Information and Release of Records Medical records should be maintained in a manner designed to protect the confidentiality of such information and in accordance with applicable State and Federal laws, rules and regulations. All consultations or discussions involving the participant or her or his case should be conducted discreetly and professionally in accordance with all applicable State and Federal laws, including the privacy and security rules and regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as may be amended. All provider practice personnel should be trained on HIPAA Privacy and Security regulations. The practice should ensure there is a procedure or process in place for maintaining confidentiality of participants medical records and other PHI as defined under HIPAA; and the practice is following those procedures and/or obtaining appropriate authorization from participants to release information or records when required by applicable State and Federal law. Procedures should include protection against unauthorized/inadvertent disclosure of all confidential medical information, including PHI. Every provider practice is required to provide participants with information regarding their privacy practices and to the extent required by law, with their Notice of Privacy Practices (NPP). Employees who have access to participant records and other confidential information are required to sign a Confidentiality Statement. Examples of confidential information include, but are not limited to the following: Medical records; Communication between a participant and a physician regarding the participant s medical care and treatment; All personal and/or PHI as defined under the Federal HIPAA privacy regulations, and/or other State or Federal laws; Any communication with other clinical persons involved in the participant s health, medical and mental care (i.e., diagnosis, treatment and any identifying information such as name, address, Social Security Number (SSN), etc.); Effective: January 1, 2015 Page 74 of 93

76 Participant transfer to a facility for treatment of drug abuse, alcoholism, mental or psychiatric problem; and Any communicable disease, such as AIDS or HIV testing that is protected under Federal or State law. The NPP informs the patient or participant of their participant rights under HIPAA and how the provider and/or WellCare Advocate Complete FIDA may use or disclose the participants PHI. HIPAA regulations require each covered entity to provide an NPP to each new patient or participant. Disclosure of Information Periodically, participants may inquire as to the operational and financial nature of their health plan. WellCare Advocate Complete FIDA will provide that information to the participant upon request. Participants can request the above information verbally or in writing. For more information on how to request this information, participants may contact Customer Service using the toll-free telephone number found on the participant s ID card. Providers may contact Provider Services by referring to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Effective: January 1, 2015 Page 75 of 93

77 Section 9: Delegated Entities Overview WellCare Advocate Complete FIDA may, by written contract, delegate certain functions under WellCare Advocate Complete FIDA s contracts with CMS and/or applicable State governmental agencies. These functions include, but are not limited to, administration and management services, marketing, utilization management, quality assurance, care management, disease management, claims processing, claims payment, credentialing, network management, provider claim appeals, customer service, enrollment, disenrollment, billing and sales, adjudicating Medicare-Medicaid Plan organization determinations, and appeals and grievances (the Delegated Services). WellCare Advocate Complete FIDA may delegate all or a portion of these activities to another entity (a Delegated Entity). WellCare Advocate Complete FIDA oversees the provision of services provided by the delegated entity and/or sub-delegate, and is accountable to the Federal and State agencies for the performance of all delegated functions. It is the sole responsibility of WellCare Advocate Complete FIDA to monitor and evaluate the performance of the delegated functions to ensure compliance with regulatory requirements, contractual obligations, accreditation standards and WellCare Advocate Complete FIDA policies and procedures. Compliance The Delegation Oversight Department is charged with the administrative oversight authority and coordination of all delegated activities. The Delegation Oversight Committee (DOC) is chaired by the Director of Delegation Oversight. Committee participants include QI Directors, contract owners, subject matter experts (SMEs), legal and compliance associates, and representatives from each line of business. Other areas of representation include Utilization Management, Claims, Customer Service, Billing, Credentialing, Provider Relations, Corporate Compliance, Medicare Compliance, Medicaid Compliance, Regulatory Affairs, Medical Economics, Quality Management and Appeals & Grievances. In addition to the monthly scheduled meetings, the Delegation Oversight Committee may conduct weekly ad hoc online meetings as needed. The DOC is the final approval authority for delegation activity. Recommendations for vendor/entity de-delegation are submitted to the Corporate Compliance Committee for final approval. The Delegation Oversight Department participates in all internal compliance programs as directed by the organization. The department also contributes to external market and accreditation audits such as NCQA and EQRO (External Quality Review Organization). Refer to Section 8: Compliance for additional information on compliance requirements. WellCare Advocate Complete FIDA ensures compliance through the delegation oversight process and the Delegation Oversight Committee (DOC). The DOC and its committee representatives: Verify eligibility of all delegated entities for participation in the Medicaid and Medicare programs. Review findings of the pre-delegation audit to evaluate the entity s ability to perform the delegated function. Review and approve entities for delegation of functions. Ensure written agreements with each delegated entity clearly define and describe the delegated activities, responsibilities, and reporting requirements of all parties. Effective: January 1, 2015 Page 76 of 93

78 Conduct formal, ongoing evaluation of the entity s performance and compliance through review of periodic reports submitted, complaints/grievances filed, and findings of the annual on-sight audit. Impose sanctions if the delegated entity s performance is substandard or terms of the agreement are violated. Review and initiate recommendations such as termination of delegation, to the Corporate Compliance Committee for unresolved issues of compliance. Maintain a central database of all pending, active and terminated delegated vendors/ entities to monitor and track functions, performance, and audit schedules. Identify and implement an escalation process for compliance/performance issues. Conduct annual integrity reviews for all delegation auditors. Identify and implement a process for validation of audit tools. Implement a process for notifying contract owners of corrective action plans. Track and trend internal compliance with oversight standards, entity performance and outcomes. Identify and implement an annual training program for internal staff regarding delegation standards, auditing, and monitoring delegated entity/vendor performance. Implement a process for dissemination of any Medicare and Medicaid regulatory changes that may affect the Medicare-Medicaid Plan. Effective: January 1, 2015 Page 77 of 93

79 Section 10: Behavioral Health Overview WellCare Advocate Complete FIDA provides a behavioral health benefit for dually-eligible participants. All provisions contained within the provider manual are applicable to medical and behavioral health providers. Participants may refer themselves for behavioral health services and do not require a referral from their PCP. Some behavioral health services may require prior authorization, including those services provided by non-participating providers. For complete information regarding benefits, exclusions and authorization requirements, or in the event a provider needs to contact the WellCare Advocate Complete FIDA Provider Services Department for a referral to a behavioral health provider, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Continuity and Coordination of Care Between Medical and Behavioral Health Providers PCPs may provide any clinically appropriate behavioral health services within the scope of their practice. Conversely, behavioral health providers may provide physical health care services if, and when, they are licensed to do so within the scope of their practice. Behavioral providers are required to use the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) multi-axial classification when assessing the participant for behavioral health services and document the DSM-V diagnosis and assessment/outcome information in the participant s medical record. Behavioral health providers are encouraged to submit, with the participant s or the participant s legal guardian s consent, an initial and quarterly summary report of the participant s behavioral health status to the PCP. Communication with the PCP should occur more frequently if clinically indicated. WellCare Advocate Complete FIDA encourages behavioral health providers to pay particular attention to communicating with PCPs at the time of discharge from an inpatient hospitalization. WellCare Advocate Complete FIDA recommends faxing the discharge instruction sheet or a letter summarizing the hospital stay to the PCP. Please send this communication, with the properly signed consent, to the participant s identified PCP, noting any changes in the treatment plan on the day of discharge. WellCare Advocate Complete FIDA strongly encourages open communication between PCPs and behavioral health providers. If a participant s medical or behavioral condition changes, WellCare Advocate Complete FIDA expects that both PCPs and behavioral health providers will communicate those changes to each other, especially if there are any changes in medications that need to be discussed and coordinated between providers. To maintain continuity of care, patient safety and participant well-being, communication between behavioral health care providers and medical care providers is critical, especially for participants with comorbidities receiving pharmacological therapy. Fostering a culture of collaboration and cooperation will help sustain a seamless continuum of care between medical and behavioral health and impact participant outcomes. Responsibilities of Behavioral Health Providers WellCare Advocate Complete FIDA monitors providers against these standards to ensure participants can obtain needed health services within the acceptable appointment waiting times. The provisions below are applicable only to behavioral health providers and do not replace the provisions set forth in Section 2: Provider and Participant Administrative Guidelines for medical providers. Effective: January 1, 2015 Page 78 of 93

80 Providers are required to use the strictest access to care standards applicable to this dually-eligible population. Providers not in compliance with these standards will be required to implement corrective actions set forth by WellCare Advocate Complete FIDA. Medicare Type of Appointment Behavioral health provider Urgent Behavioral health provider Post Inpatient discharge Behavioral health provider Routine Behavioral health provider Non-Life Threatening Emergency Behavioral health provider Screening and Triage of Calls Medicaid Type of Appointment Behavioral health provider Emergent Behavioral health provider Urgent Behavioral health provider Post inpatient discharge Behavioral health provider Routine Behavioral health provider Non-Life Threatening Emergency Access Standard < 48 hours < 7 days < 10 days < 6 hours < 30 seconds Access Standard < 1 hour < 24 hours < 5 days < 2 weeks < 6 hours All participants receiving inpatient psychiatric services must be scheduled for psychiatric outpatient follow-up and/or continuing treatment, prior to discharge, which includes the specific time, date, place and name of the provider to be seen. The outpatient treatment must occur within the time frames listed above. In the event that a participant misses an appointment, the behavioral health provider must contact the participant within 24 hours to reschedule. Behavioral health providers are expected to assist participants in accessing emergent, urgent and routine behavioral services as expeditiously as the participant s condition requires. Participants also have access to a toll-free behavioral crisis hotline that is staffed 24 hours per day. The behavioral crisis phone number is printed on the participant s ID card and is available on WellCare Advocate Complete FIDA s website. For information about WellCare Advocate Complete FIDA s Care Management and Disease Management programs, including how to refer a participant for these services, please see Section 4: Utilization Management, Care Management and Disease Management. Effective: January 1, 2015 Page 79 of 93

81 Section 11: Pharmacy WellCare Advocate Complete FIDA s pharmaceutical management procedures are an integral part of the pharmacy program that promote the utilization of the most clinically appropriate agent(s) to improve the health and well-being of WellCare Advocate Complete FIDA participants. The utilization management tools that are used to optimize the pharmacy program include: Formulary; Prior Authorization; Step Therapy; Quantity Limit; and Mail Service. These processes are described in detail below. In addition, prescriber and participant involvement is critical to the success of the pharmacy program. To help patients get the most out of their pharmacy benefit, providers should consider the following guidelines when prescribing: Follow national standards of care guidelines for treating conditions, i.e., National Institutes of Health (NIH) Asthma guideline, Joint National Committee (JNC) VIII Hypertension guidelines; Prescribe drugs listed on the formulary; Prescribe generic drugs when therapeutic equivalent drugs are available within a therapeutic class; and Evaluate medication profiles for appropriateness and duplication of therapy. To contact WellCare Advocate Complete FIDA s Pharmacy Department, please refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at For more information on WellCare Advocate Complete FIDA s benefits, visit WellCare Advocate Complete FIDA s website at Formulary The formulary is a published prescribing reference and clinical guide of prescription drug products selected by the Pharmacy and Therapeutics (P&T) Committee. The formulary denotes any of the pharmacy utilization management tools that apply to a particular pharmaceutical. The P&T Committee s selection of drugs is based on the drug s efficacy, safety, side effects, pharmacokinetics, clinical literature and cost-effectiveness profile. The medications on the formulary are organized by therapeutic class and product name. Drug tier and any requirements/limits (i.e., prior authorization, quantity limits, etc.) are also listed. The formulary is located on WellCare Advocate Complete FIDA s website at Any changes to the list of pharmaceuticals and applicable pharmaceutical management procedures are communicated to providers via the following: Quarterly updates in provider newsletters; Website updates; and/or Pharmacy and provider communication that detail any major changes to a particular therapy or therapeutic class. Effective: January 1, 2015 Page 80 of 93

82 Additions and Exceptions to the Formulary To request consideration for the inclusion of a drug to WellCare Advocate Complete FIDA s formulary, providers may write WellCare Advocate Complete FIDA, explaining the medical justification. For contact information, refer to the Quick Reference Guide at For more information on requesting exceptions, refer to the Coverage Determination process outlined below. Coverage Limitations The formulary includes both Medicare and Medicaid coverable medications. The following is a list of non-covered (i.e., excluded) drugs and/or categories: Agents when used for anorexia, weight loss, or weight gain (even if used for a noncosmetic purpose (i.e., morbid obesity)); Agents when used to promote fertility; Agents when used for cosmetic purposes or hair growth; Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee; and Agents when used for the treatment of sexual or erectile dysfunction. Erectile dysfunction drugs will meet the definition of a Part D drug when prescribed for medicallyaccepted indications approved by the Food and Drug Administration (FDA) other than sexual or erectile dysfunction (such as pulmonary hypertension). Generic Medications WellCare Advocate Complete FIDA covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Step Therapy Step therapy programs are developed by the P&T Committee. These programs encourage the use of therapeutically equivalent, lower-cost medication alternatives (first-line therapy) before stepping up to less cost-effective alternatives. Step therapy programs are intended to be a safe and effective method of reducing the cost of treatment by ensuring that an adequate trial of a proven safe and cost-effective therapy is attempted before progressing to a more costly option. First-line drugs are recognized as safe, effective and economically sound treatments. The first-line drugs on WellCare Advocate Complete FIDA s formulary have been evaluated through the use of clinical literature and are approved by WellCare Advocate Complete FIDA s P&T Committee. Medicare Part D drugs requiring step therapy are designated by the letters ST on WellCare Advocate Complete FIDA s formulary. Prior Authorization Prior authorization protocols are developed and reviewed annually by the P&T Committee. Prior authorization protocols indicate the criteria that must be met in order for the drug to be authorized (e.g., specific diagnoses, lab values, trial and failure of alternative drug(s)). Effective: January 1, 2015 Page 81 of 93

83 Part D drugs requiring prior authorization are designated by the letters PA on WellCare Advocate Complete FIDA s formulary. Quantity Limits Quantity limits are used to encourage that pharmaceuticals are supplied in a quantity consistent with FDA-approved dosing guidelines. Quantity limits are used to help prevent billing errors. Part D drugs that have quantity limits are designated by the letters QL on WellCare Advocate Complete FIDA s formulary, and are accompanied by the quantity permitted. Therapeutic Interchange Therapeutic interchange is not a Formulary Benefit Management tool which WellCare Advocate Complete FIDA utilizes. Mail Service Part D drugs that are available through mail order are designated by the letters MS in the Requirements/Limits column of WellCare Advocate Complete FIDA s formulary. A Participant Registration & Prescription Mail Order Form and a Mail Service Pharmacy Prescription Form are located on WellCare Advocate Complete FIDA s website at Injectable and Infusion Services Self-injectable medications, specialty medications and home infusion medications are covered as part of the outpatient pharmacy benefit. Non-formulary injectable medications and those listed on the formulary with a prior authorization will require submission of a request form for review. For more information, refer to the Obtaining a Coverage Determination Request section below. Coverage Determination Request Process The goal of the Coverage Determination Request program is to ensure that medication regimens that are high-risk, have a high potential for misuse or have narrow therapeutic indices are used appropriately and according to FDA-approved indications. The Coverage Determination request process is required for: Drugs not listed on the formulary; Drugs listed on the formulary with a prior authorization; Duplication of therapy; Prescriptions that exceed the FDA daily or monthly quantity limits or prescriptions exceeding the permitted quantity limit noted on the formulary; Most self-injectable and infusion drugs (including chemotherapy) administered in a physician s office; and Drugs that have a step edit (ST) and the first line therapy is inappropriate. Obtaining a Coverage Determination Request Complete a Coverage Determination Request Form and fax it to the Pharmacy Department. The form is on WellCare Advocate Complete FIDA s website at For the appropriate fax number, refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at Effective: January 1, 2015 Page 82 of 93

84 WellCare Advocate Complete FIDA s standard is to respond to Coverage Determination requests within 72 hours for routine requests and 24 hours for expedited requests from the time when WellCare Advocate Complete FIDA receives the request. The provider must provide medical history and/or other pertinent information when submitting a Coverage Determination Request Form for medical exception. If the Coverage Determination Request meets the approved P&T Committee s protocols and guidelines, the provider and/or pharmacy will be contacted with the Coverage Determination request approval. An approval letter is also sent to the participant and a telephonic attempt is made to inform them of the approval. If the Coverage Determination Request is not a candidate for approval based on approved P&T Committee protocols and guidelines, and a medical necessity review is necessary, it will initially be performed by a clinical pharmacist and secondly by a WellCare Advocate Complete FIDA Medical Director for final determination. For those requests that are not approved, a follow-up Drug Utilization Review (DUR) Form is faxed to the provider stating why the Coverage Determination Request was not approved, including a list of the preferred drugs that are available as alternatives, if applicable. A denial letter is also sent to the participant and a telephonic attempt is made to inform them of the denial. Medication Appeals To request an appeal of a Coverage Determination Request decision, contact the Pharmacy Appeals Department via fax, mail, in person or phone. Refer to the Quick Reference Guide on WellCare Advocate Complete FIDA s website at for more information. Once the appeal of the Coverage Determination Request decision has been properly submitted and obtained by WellCare Advocate Complete FIDA, the request will follow the appeals process described in Section 7: Appeals and Grievances. Effective: January 1, 2015 Page 83 of 93

85 Section 12: Definitions and Abbreviations Definitions The following terms as used in this Provider Manual shall be construed and/or interpreted as follows, unless otherwise defined in the participation Agreement the provider has with WellCare Advocate Complete FIDA. Action A denial or a limited authorization of a requested item or service or a reduction, suspension, or termination of a previously authorized item or service; denial, in whole or in part, of payment for an item or service; failure to provide items or services in a timely manner; a determination that a requested service is not a covered benefit (does not include requests for items or services that are paid for fee-for-service outside the FIDA Plan); or failure to make a grievance determination within required timeframes. Appeals A participant s request for review of an Action taken by a FIDA Plan related to items or services. Care Management A collaborative process that assists each participant in accessing services as identified in the participant s Person-Centered Service Plan. The care management process assesses, plans, implements, coordinates, monitors, and evaluates the options and services (both Medicare and Medicaid) required to meet a participant s needs across the continuum of care. It is characterized by advocacy, communication, and resource management to promote quality, cost-effective, positive outcomes. The care management process also provides referral and coordination of other services in support of the Patient-Centered Service Plan. Care management services will assist participants to obtain needed medical, behavioral health, prescription and non-prescription drugs, community-based or facility-based LTSS, social, educational, psychosocial, financial and other services in support of the Person-Centered Service Plan irrespective of whether the needed services are covered under the capitation payment of the Three-way Contract (see definition below). Care Manager An appropriately qualified professional who is the FIDA Plan s designated accountable point of contact for each participant s care coordination and care management services. The care manager is the primary individual responsible for conducting, directing, or delegating care management duties, as needed. Responsibilities include: facilitating Interdisciplinary Team (IDT) activities and communication; facilitating assessment of needs; ensuring and assisting in developing, implementing and monitoring the Person-Centered Service Plan; and serving as the leader of the IDT. Center for Medicare & Medicaid Innovation (Innovation Center) Established by Section 3021 of the Affordable Care Act, the Innovation Center was established to test innovative payment and service delivery models to reduce program expenditures under Medicare and Medicaid while preserving or enhancing the quality of care furnished to individuals under such titles. CMS The Centers for Medicare & Medicaid Services. Community-based Long-Term Services and Supports (LTSS) Community-based LTSS are a range of medical, habilitation, rehabilitation, home care, or social services a person needs over months or years in order to improve or maintain function or health which are provided in Effective: January 1, 2015 Page 84 of 93

86 the person s home or community-based setting such as assisted-living facilities. These home and community-based services are designed to meet an individual's needs as an alternative to long-term nursing facility care and to enable a person to live as independently as possible. Consumer Assessment of Healthcare Providers and Systems (CAHPS) Participant survey tool developed and maintained by the Agency for Healthcare Research and Quality to support and promote the assessment of consumers experiences with health care. Contract Also referred to as the Three-way Contract, this is the participation agreement that CMS and the State have with a FIDA Plan specifying the terms and conditions pursuant to which a participating FIDA Plan may participate in this Demonstration. Covered Services The set of services required to be offered by the FIDA Plans. Cultural Competence Understanding those values, beliefs, and needs that are associated with an individual s age, gender identity, sexual orientation, and/or racial, ethnic, or religious backgrounds. Cultural Competence also includes a set of competencies which are required to ensure appropriate, culturally sensitive health care to persons with congenital or acquired disabilities. Demonstration (also FIDA Demonstration) Medicare-Medicaid Alignment Initiative to better serve individuals eligible for both Medicare and Medicaid ( Medicare-Medicaid Enrollees ). Enrollment The processes by which an individual who is eligible for the Demonstration is enrolled in a FIDA Plan. Facility-based Long-Term Services and Supports (LTSS) Facility-based LTSS are a range of medical, social, or rehabilitation services a person needs over months or years in order to improve or maintain function or health which are provided in a long-term care facility such as a nursing home (not including Assisted Living Residences). FIDA Administrative Hearing Unit The unit within the New York State Office of Temporary and Disability Assistance which reviews adverse decisions made by FIDA Plans. Fully-Integrated Duals Advantage Plan (FIDA Plan) A managed care plan under contract with CMS and the State to provide the fully-integrated Medicare and Medicaid benefits under the FIDA Demonstration. Grievance In accordance with 42 CFR Part , grievance means an expression of dissatisfaction about any matter other than an adverse action. A grievance is filed and decided at the FIDA Plan level. (Possible subjects for grievances include, but are not limited to, the quality of care or services provided and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Participant s rights.) Healthcare Effectiveness Data and Information Set (HEDIS ) Tool developed and maintained by the National Committee for Quality Assurance that is used by health plans to measure performance on dimensions of care and service in order to maintain and/or improve quality. Effective: January 1, 2015 Page 85 of 93

87 Health Outcomes Survey (HOS) Participant survey used by the Centers for Medicare & Medicaid Services to gather valid and reliable health status data in Medicare managed care for use in quality improvement activities, plan accountability, public reporting and improving health. Integrated Administrative Hearing Officer An Administrative Law Judge (ALJ) of the FIDA Administrative Hearing Unit. Interdisciplinary Team (IDT) The team of individuals that will provide person-centered care coordination and care management to participants. Each participant will have an IDT. Each IDT will be comprised, first and foremost, of the participant and/or his/her designee, the designated care manager, the primary care physician, behavioral health professional, the participant s home care aide, and other providers either as requested by the participant or his/her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his/her designee. The IDT facilitates timely and thorough coordination between the FIDA Plan, the IDT, the primary care physician, and other providers. The IDT will make coverage determinations. Accordingly, the IDT s decisions serve as service authorizations, may not be modified by the FIDA Plan outside of the IDT, and are appealable by participants, their providers and their representatives. IDT service planning, coverage determinations, care coordination, and care management will be delineated in the participant s Person-Centered Service Plan and will be based on the assessed needs and articulated preferences of the participant. Medicaid Advantage Plus Program The partially-integrated Medicare and Medicaid managed care program for Medicare-Medicaid Enrollees who require community-based or facility-based LTSS. Medicaid Managed Care Plan A health maintenance organization (HMO) or prepaid health service plan (PHSP) certified under Article 44 of the State Public Health Law that is under contract with NYSDOH to provide most of the Medicaid services in New York. Medically Necessary Those items and services necessary to prevent, diagnose, correct, or cure conditions in the participant that cause acute suffering, endanger life, result in illness or infirmity, interfere with such participant s capacity for normal activity, or threaten some significant handicap. Notwithstanding this definition, FIDA Plans will provide coverage in accordance with the more favorable of the current Medicare and NYSDOH coverage rules, as outlined in NYSDOH and Federal rules and coverage guidelines. Medicaid The program of medical assistance benefits under Title XIX of the Social Security Act and various demonstrations and waivers thereof. Medicaid Waiver Generally, a waiver of existing law authorized under Section 1115(a), 1115A, or 1915 of the Social Security Act. A Section 1115(a) waiver is also referred to as a demonstration. Medicare Title XVIII of the Social Security Act, the Federal health insurance program for people age 65 or older, people under 65 with certain disabilities, and people with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Medicare-Medicaid Coordination Office Formally the Federal Coordinated Health Care Office, established by Section 2602 of the Affordable Care Act. Effective: January 1, 2015 Page 86 of 93

88 Medicare-Medicaid Enrollees For the purposes of this Demonstration, individuals who are entitled to benefits under Medicare Part A, enrolled under Medicare Parts B and D, and receiving full Medicaid benefits. Medicare Waiver Generally, a waiver of existing law authorized under Section 1115A of the Social Security Act. New York State Department of Health (NYSDOH) The agency responsible for administering the Medicaid program in the State of New York and the terms of this Demonstration. New York State Office of Mental Health (OMH) The agency responsible for operating psychiatric centers across the State and regulating, certifying, and overseeing more than 4,500 programs, which are operated by local governments and nonprofit agencies. These programs include various inpatient and outpatient programs, emergency, community support, residential and family care programs. New York State Office of Temporary and Disability Assistance (OTDA) The agency responsible for conducting State Medicaid fair hearings and supervising programs that provide assistance and support to eligible families and individuals. New York State Office of the Medicaid Inspector General The agency responsible for enhancing the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high quality patient care. Nursing Facility Clinically Eligible A standard of eligibility for care in a nursing facility, based on an individual s care needs and functional, cognitive, and medical status as determined upon completion of the NYSDOH Approved Assessment Tool. Nursing Home Transition & Diversion 1915(c) Waiver The Social Security Act Section 1915(c) waiver that gives New York State the Medicaid authority to provide home and community-based services to certain medically needy individuals. These services enable these individuals to live at home or in the community with appropriate supports, rather than in a nursing facility. NYSDOH Approved Assessment Tool Protocol used by the FIDA Plans to conduct a comprehensive assessment of each participant s medical, behavioral health, community-based or facility-based LTSS, and social needs completed by the FIDA Plan IDT. Assessment domains will include, but not be limited to, the following: social, functional, medical, behavioral, wellness and prevention domains, caregiver status and capabilities, as well as the participants preferences, strengths and goals. The State anticipates that the Uniform Assessment System New York (UAS-NY) will be the basis for the tool used to conduct these assessments for participants. Opt Out A process by which an eligible individual can choose not to participate in the Demonstration and receive his/her Medicare benefits through Fee-for-Service (FFS) Medicare and a standalone Part D plan; Program of All-inclusive Care for the Elderly (PACE); or Medicare Advantage. OPWDD New York State Office for People With Developmental Disabilities. Effective: January 1, 2015 Page 87 of 93

89 OPWDD Services Services include: long-term therapy services provided by Article 16 clinic treatment facilities, certified by OPWDD under 14 NYCRR, Part 679 or provided by Article 28 Diagnostic & Treatment Centers explicitly certified by NYSDOH as serving primarily persons with developmental disabilities; day treatment services provided in an intermediate care facility (ICF) or comparable facility and certified by OPWDD under 14 NYCRR, Part 690; Comprehensive Medicaid Care Management services; and home and community-based waiver program services for people with developmental disabilities. Other Supportive Services the IDT Determines Necessary Additional supportive services or items determined by the participant s IDT to be necessary for the participant. This is meant to cover items or services that are not traditionally included in the Medicare or Medicaid programs, but that are necessary and appropriate for the participant. Partially Capitated MLTC Plan A managed care plan that provides Medicaid communitybased or facility-based LTSS to both Medicare-Medicaid enrollees and individuals who qualify only for Medicaid. Participant Individuals enrolled in a FIDA Plan, including the duration of any month in which their eligibility for the Demonstration ends. Participant Communications Materials designed to communicate to participants FIDA Plan benefits, policies, processes and/or participant rights. Participant Ombudsman (PO) An independent, conflict-free entity under contract with NYSDOH to provide participants free assistance in accessing their care, understanding and exercising their rights and responsibilities, and appealing adverse decisions made by their FIDA Plan. The PO will be accessible to all participants through telephonic and, where appropriate, inperson access. The PO will provide advice, information, referral and assistance in accessing benefits, and assistance in navigating FIDA Plans, providers, or NYSDOH. The PO may participate in FIDA Plan Participant Advisory Committee activities. Partnership Plan Social Security Act Section 1115(a) waiver that provides New York State the Medicaid authority to enroll Medicaid enrollees and Medicare-Medicaid Enrollees in a Medicaid MLTC plan. Person-Centered Service Plan (or Plan of Care) A written description in the care management record of participant-specific health care goals to be achieved, and the amount, duration, and scope of the covered services to be provided to a participant in order to achieve such goals. The individual Person-Centered Service Plan is based on assessment of the participant's health care needs and developed by the IDT in consultation with the participant and his/her informal supports. The FIDA Plan will use the NYSDOH Approved Assessment Tool and include consideration of the current and unique psycho-social and medical needs and history of the participant, as well as the participant s functional level and support systems, and clinical and non-clinical needs. The comprehensive assessment identifies services to be provided or arranged to meet the identified needs and includes goals, interventions and expected outcomes. Effectiveness of the Person-Centered Service Plan is monitored through reassessment and a determination as to whether the health care goals are being met. Non-covered services which interrelate with the covered services identified on the Person-Centered Service Plan, and services of informal supports necessary to support the health care goals and effectiveness of Effective: January 1, 2015 Page 88 of 93

90 the covered services, should be clearly identified on the Person-Centered Service Plan or elsewhere in the care management record. Privacy Requirements established in the Health Insurance Portability and Accountability Act of 1996, and implementing regulations, Medicaid regulations, including 42 CFR Parts through , as well as relevant New York privacy laws. Program of All-inclusive Care for the Elderly (PACE) A capitated benefit for frail elderly authorized by the Balanced Budget Act of 1997 (BBA) that features a comprehensive service delivery system and integrated Medicare and Medicaid financing. PACE is a three-way partnership between the Federal government, the State of New York and the PACE organization. Quality Improvement Organization (QIO) A statewide organization that contracts with CMS to evaluate the appropriateness, effectiveness and quality of care provided to Medicare participants. Representative Representative means an individual appointed by a participant or other party, or authorized under State or other applicable law, to act on behalf of a participant or other party involved in the grievance or appeal. Unless otherwise stated in this subpart, the representative will have all the rights and responsibilities of a participant or party in filing a grievance, and in obtaining an organization determination, or in dealing with any of the levels of the appeals process. Self-Direction (also Consumer Direction) The ability for a participant to direct his/her own services through the consumer-directed personal assistance option. Solvency Standards for requirements on cash flow, net worth, cash reserves, working capital requirements, insolvency protection and reserves, established by the State and agreed to by CMS. State The State of New York. Effective: January 1, 2015 Page 89 of 93

91 Abbreviations ACS American College of Surgeons AEP annual enrollment period Agreement Provider Participation Agreement AHP allied health professional AIDS - Acquired Immune Deficiency Syndrome ALJ Administrative Law Judge AMA American Medical Association ARNP Advanced Registered Nurse Practitioner CAD coronary artery disease CAHPS Consumer Assessment of Healthcare Providers and Systems CDS Controlled Dangerous Substance CHF congestive heart failure CIA Corporate Integrity Agreement CLAS culturally and linguistically appropriate services CMS Centers for Medicare & Medicaid Services CNM Certified Nurse Midwife COB coordination of benefits COPD chronic obstructive pulmonary disease CORF comprehensive outpatient rehabilitation facility CPT-4 Physician s Current Procedural Terminology, 4 th Edition CSR Controlled Substance Registration DDE direct data entry DEA Drug Enforcement Agency DM Disease Management DME durable medical equipment DOC Delegation Oversight Committee DSM-IV Diagnostic and Statistical Manual of Mental Disorders DSNP Dual-Eligible Special Needs Plans EDI electronic data interchange EOB Explanation of Benefits EOP Explanation of Payment ESRD end-stage renal disease Effective: January 1, 2015 Page 90 of 93

92 FBDE Full Benefit Dual-Eligible FDA Food and Drug Administration FFS fee-for-service FWA fraud, waste and abuse HEDIS - Healthcare Effectiveness Data and Information Set HHA home health agency HHS US Department of Health and Human Services HIPAA Health Insurance Portability and Accountability Act of 1996 HIV Human Immunodeficiency Virus HMO health maintenance organization HMO-POS health maintenance organization with point of service option HOS Medicare Health Outcomes Survey HRA Health Risk Assessment HTN hypertension ICD-9 International Classification of Diseases, Ninth Edition ICP Individualized Care Plans IDT Interdisciplinary Team INR inpatient nursing rehabilitation facility IPA independent physician association IRE Independent Review Entity IVR interactive voice response JNC Joint National Committee LCSW Licensed Clinical Social Worker LTAC long-term acute care facility MA Medicare Advantage MAC Medicare Appeals Council MIPPA Medicare Improvements for Patients and Providers Act of 2008 MOC Model of Care MOOP maximum out-of-pocket MSP Medicare Savings Programs NCCI National Correct Coding Initiative NDC National Drug Codes NIH National Institutes of Health NPI National Provider Identifier Effective: January 1, 2015 Page 91 of 93

93 NPP Notice of Privacy Practice OA Osteopathic Assistant OB obstetric/obstetrical/obstetrician OIG Office of Inspector General OT occupational therapy OTC over-the-counter P&T Pharmacy and Therapeutics Committee PA Physician Assistant PCP primary care provider PHI protected health information POS point of service PPC provider-preventable condition Provider ID provider identification number PT physical therapy QDWI Qualified Disabled Working Individual QI Qualifying Individual QI Program Quality Improvement Program QIO Quality Improvement Organization RN Registered Nurse SFTP secure file transfer protocol SIE site inspection evaluation SNF skilled nursing facility SNIP Strategic National Implementation Process SSN Social Security number ST speech therapy Tax ID/TIN tax identification number TNA Transition Needs Assessment TOC transition of care UM utilization management WEDI Workgroup for Electronic Data Interchange Effective: January 1, 2015 Page 92 of 93

94 Section 13: WellCare Advocate Complete FIDA Resources WellCare Advocate Complete FIDA Homepage Provider Homepage Quick Reference Guide Provider Manual Forms and Documents Pharmacy Job Aids Clinical Practice Guidelines Clinical Care Guidelines Claims Quality Training and Education Effective: January 1, 2015 Page 93 of 93