Ohana Community Care Services (CCS) Provider Manual

Transcription

1 2013 (CCS)

2 Table of Contents Section 1: About Ohana...5 Purpose of this Manual...5 Program...5 Eligibility...6 Benefits and Services...7 Behavioral Health Case Management...7 Assessments...8 Individualized Treatment Plan...9 Interventions while the Member is in Inpatient Treatment...10 Post-Discharge Interventions...11 Addressing Barriers...11 Provider Services...12 Our Website...13 Section 2: Provider and Member Administrative Guidelines...15 Provider Administrative Overview...15 Excluded or Prohibited Services...16 Responsibilities of All Providers...16 Access Standards...20 Responsibilities of Behavioral Health Providers / Case Managers...20 Case Management Service Frequency and Intensity Requirements...21 Continuity and Coordination of Care Between Medical and Behavioral Health Care...22 Termination of a Member...23 Member Administrative Guidelines...23 Overview...23 Member Handbook...23 Enrollment...23 Member Identification Cards...24 Eligibility Verification...24 Member Rights and Responsibilities...25 Hearing-Impaired, Interpreter and Sign Language Services...27 Section 3: Quality Improvement...28 Overview...28 Medical Records...28 Effective: March 1, 2013 Page 1 of 95

3 Provider Participation in the Quality Improvement Program...31 Reporting Adverse Events...32 Clinical Practice Guidelines...32 Healthcare Effectiveness Data and Information Set...33 Web Resources...33 Section 4: Utilization Management (UM) and Disease Management (DM)...34 Utilization Management...34 Medically Necessary Services...34 Criteria for UM Decisions...35 Utilization Management Process...35 Services Requiring No Authorization...39 Plan Proposed Actions/Notice of Action (NOA)...40 Second Medical Opinion...40 Individuals with Special Health Care Needs...40 Standard, Expedited and Extensions of Service Authorization Decisions...41 Emergency/Urgent Care and Post-Stabilization Services...41 Psychological Testing...43 Transition of Care...43 Disease Management Program...46 Overview...46 Candidates for Disease Management...47 Access to Case and Disease Management Programs...47 Section 5: Claims...48 Overview...48 Timely Claims Submission...48 Tax ID and NPI Requirements...48 Claims Submission Requirements...49 Claims Processing...51 Encounters Data...52 Balance Billing...54 Hold Harmless Dual-Eligible Members...54 Cost Share...55 Non-Covered Services...55 Claims Payment Disputes...55 Corrected or Voided Claims...55 Effective: March 1, 2013 Page 2 of 95

4 Reimbursement...57 Overpayment Recovery...58 Benefits During Disaster and Catastrophic Events...58 Section 6: Credentialing...59 Overview...59 Practitioner Rights...60 Baseline Criteria...61 Site Inspection Evaluation...61 Covering Providers...62 Allied Health Professionals...62 Ancillary Health Care Delivery Organizations...62 Re-Credentialing...62 Updated Documentation...62 Office of Inspector General Medicare/Medicaid Sanctions Report...63 Sanction Reports Pertaining to Licensure, Hospital Privileges or Other Professional Credentials...63 Participating Provider Appeal through the Dispute Resolution Peer Review Process...63 Delegated Entities...65 Section 7: Appeals and Grievances...66 Member Grievances/Complaints...66 Grievances Filed Against a Provider...67 Member Appeals Process...68 Expedited Appeal Process...69 State Administrative Hearing for Regular Appeals...71 Expedited State Administrative Hearings...71 Provider Grievances/Complaints...72 Provider Complaint System...73 Provider Payment Dispute/ Administrative Appeals...74 Submission of Provider Termination Appeal Request...76 Section 8: Compliance...78 Ohana Health Plan s Compliance Program...78 Overview...78 Marketing Hawai i Medicaid Plans...79 Code of Conduct and Business Ethics...79 Overview...79 Effective: March 1, 2013 Page 3 of 95

5 Fraud, Waste and Abuse...80 Confidentiality of Member Information and Release of Records...80 Disclosure of Information...81 Cultural Competency Program and Plan...81 Overview...81 Cultural Competency Survey...83 Section 9: Delegated Entities...84 Overview...84 Compliance...84 Section 10: Pharmacy...86 Overview...86 Preferred Drug List...86 Generic Medications...87 Coverage Limitations...87 Over-the-Counter (OTC) Medications...87 Member Co-Payments...87 Coverage Determination Review Process...88 Medication Appeals...88 Pharmacy Management - Network Improvement Program...88 Ohana s Specialty Pharmacy Exactus Pharmacy Solutions...88 Section 11: Definitions...90 Effective: March 1, 2013 Page 4 of 95

6 Section 1: About Ohana Ohana Health Plan (the Plan), a health plan offered by WellCare Health Insurance of Arizona, Inc., and a licensed health maintenance organization (HMO) based in Hawai i, is a member of the WellCare Group of Companies (WellCare). WellCare Health Plans, Inc., provides managed care services targeted exclusively to government-sponsored health care programs, focused on Medicaid and Medicare, including prescription drug plans and health plans for families, and the aged, blind and disabled. WellCare s corporate office is located in Tampa, Florida. As of December 31, 2012, we served approximately 2.7 million members. Our experience and our exclusive commitment to these programs enable us to serve our members and providers as well as manage our operations effectively and efficiently. Purpose of this Manual This is intended for Plan-contracted (participating) Medicaid providers providing health care service(s) to Plan members enrolled in an Ohana Health Plan Medicaid Managed Care plan. This Manual serves as a guide to the policies and procedures governing the administration of the Plan s Medicaid plans and is an extension of and supplements the Provider Participation Agreement (Agreement) between the Plan and health care providers, who include, without limitation: physicians, hospitals and behavioral health providers (collectively, Providers). This Manual is effective March 1, 2013 and is available on the Plan s website at A paper copy, at no charge, may be obtained upon request by contacting Provider Services or your Provider Relations representative. In accordance with the Policies and Procedures clause of the Agreement, participating Plan Medicaid providers must abide by all applicable provisions contained in this Manual. Revisions to this Manual reflect changes made to Plan policies and procedures. The will be updated electronically, via the Plan s website, within five days of any changes made to it. Revisions shall become binding 30 days after notice is provided by mail or electronic means, or such other period of time as necessary for the Plan to comply with any statutory, regulatory, contractual and/or accreditation requirements. As policies and procedures change, updates will be issued by the Plan in the form of Provider Bulletins and will be incorporated into subsequent versions of this Manual. Program The Plan has contracted with the State of Hawai i, Department of Human Services Med- Quest Division (DHS) to provide the Community Care Services (CCS) program. The CCS program is currently specifically designed for Quest Expanded Access (QExA) Medicaid members who are determined to have a qualifying Serious Mental Illness (SMI) by the DHS and in need of specialized behavioral health services. Upon enrollment in the CCS program, the QExA health plan is no longer responsible for the member s behavioral health services, including psychotropic medications, but shall remain responsible for provision of medical services. Members may choose not to participate in the CCS program. Effective: March 1, 2013 Page 5 of 95

7 The purpose of Ohana s CCS program is to assess, plan, implement, coordinate, monitor and evaluate the options and services required to meet a member s mental health care needs using communication and all available resources to promote quality outcomes. Proper care coordination occurs across a continuum of care, addressing the ongoing individual needs of a member rather than being restricted to a single practice setting. The CCS program emphasizes continuity of care for members through the coordination of care among medical and behavioral health providers. The CCS program will identify and facilitate options and services for meeting each member s behavioral health care needs, while decreasing fragmentation and duplication of care. Ohana s CCS program is built around the individual member, their recovery goals, desired outcomes and service needs. Ohana uses a patient-centered, holistic service delivery approach to coordinate member benefits across all providers and settings. Behavioral Health Case Management, working in tandem with the member and his or her family, providers and community resources, are responsible and accountable for the entire case management cycle, from identification of needs, to care plan development, requesting authorization of services, and monitoring/re-assessment of needs. Eligibility Membership enrollment in the Ohana CCS program is solely determined by DHS. For eligibility criteria please refer to the DHS web site at Individuals enrolled in QExA, who meet qualifying Serious Mental Illness (SMI) are eligible. Adults with a SMI diagnosis who are unstable and moderate-high risk are eligible for these additional intensive services if the adult: Demonstrates the presence of a qualifying diagnosis for at least 12 months or is expected to demonstrate the qualifying diagnosis (as found in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)) for the next 12 months; and Meets at least one of the criteria demonstrating instability and/or functional impairment: o GAF <50; o Clinical records demonstrate that member is unstable under current treatment or plan or care; or o Requires protective services or intervention by housing/law enforcement officials. Eligible diagnoses include: Schizophrenic Disorders (295.1X, 295.2X, 295.3X, 295.6X, 295.9X); Schizoaffective Disorders (295.70); Delusional Disorders (297.1); Mood Disorders-Bipolar Disorders (296.0, 296.4X, 296.5X, 296.6X, 296.7, ); or Mood Disorders-Depressive Disorders (296.24, , ). Members who do not meet the eligibility criteria, but still felt by the Med-QUEST Division s (MQD) medical director or designed that additional service are medically Effective: March 1, 2013 Page 6 of 95

8 necessary for the member s health and safety, will be evaluated on a case by case basis for provisional eligibility. Serious Mental Illness or Serious and Persistent Mental Illness Persons who are determined to have a diagnosis of serious mental illness (SMI) or Serious and Persistent Mental Illness (SPMI) are defined as adults who, as the result of a mental disorder, exhibit emotional, cognitive, or behavioral functioning which is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long-term or indefinite duration. People afflicted with SMI or SPMI have mental disability(ies) that is(are) severe and persistent and result in long-term limitation of their functional capacities for primary activities of daily living such as interpersonal relationships, self-care, homemaking, employment, and recreation. Benefits and Services As of the date of publication of this Manual, the following benefits and services (Covered Services) are provided, as medically necessary, to Ohana s CCS members: Inpatient behavioral health hospital services; Ambulatory behavioral health services and crisis management; Medications and Medication Management; Diagnostic services and treatment to include psychiatric or psychological evaluation and treatment; Medically necessary alcohol and chemical dependency services; Methadone management services; Intensive Case Management; Partial hospitalization or intensive outpatient hospitalization; Psychosocial Rehabilitation/Clubhouse; Therapeutic Living Supports (or Specialized Residential Treatment centers); Transitional housing; Representative payee; Supported employment; and Peer specialists. Behavioral Health Case Management The Behavioral Health Case Managers (CM) coordinate care at the point of health care decision-making and bring members and their families and providers of care together to facilitate treatment decisions that are in the member s best interest. Behavioral Health Case Managers work primarily with complex and chronic care management focusing simultaneously on achieving health, maintaining wellness, and containing costs. Involvement of Behavioral Health Case Management in programs of care will decrease fragmentation, improve clinical and financial outcomes of care, and increase satisfaction. The Behavioral Health Case Manager identifies, plans, monitors, and mobilizes resources to facilitate cost-effective outcomes for members with complex or ongoing health care needs. The Behavioral Health Case Managers are a multidisciplinary group of clinicians that includes licensed registered nurses, Licensed Practical Nurses (LPN), licensed social Effective: March 1, 2013 Page 7 of 95

9 workers, licensed behavioral health clinicians and other clinical specialists supervised by a licensed clinician. Assessments Ohana will use the existing assessments that our provider partners are utilizing today. Ohana will not initially mandate a specific form of assessment across all providers. Ohana will ensure the current level of assessment quality is maintained and standardized as much as possible across agencies. A comprehensive multi-axial, bio-psychosocial assessment is the cornerstone of effective recovery for individuals with a SMI. Our philosophy and approach emphasizes that an assessment is an ongoing and dynamic process that is regularly updated. Members will be assessed by the case management agency with which they select to participate. However, each assessment must include, at a minimum, the following core elements: Psychiatric assessment to determine diagnosis to be performed by a psychiatrist. A complete bio-psychosocial assessment to be completed by a behavioral health clinician. Nursing assessment to determine medical needs that may complicate the member's ability to maintain self in the community to be performed by a registered nurse. Acuity assessment to determine level of services needed. Currently Ohana is requiring the Level of Care Utilization System (LOCUS ) tool to determine acuity levels. Historical assessment to determine the member's ability to maintain self in the community with/without assistance, history of hospitalizations, requirement for institutional care, incarcerations, availability of supports within the community, housing supports, crisis supports required to maintain the member in the community to be performed by case manager who reviews records and interviews the member. The historical assessment must include, at a minimum, the following fundamental elements: o Family History: Intellectual disability, psychiatric illness, neurological or other relevant illness; The quality of important relationships between the member and other family members; o Personal and Developmental History: Developmental years, including milestones; Education and job history; History of interpersonal relationships; Personality and behavior prior to the onset of psychiatric illness; Psychosexual history; Notable life events, especially loss, abuse and change in placement or caregivers; o Medical History: Past and present physical illness, with particular attention to high risk co-morbid conditions such as congestive heart failure (CHF), obesity, asthma or diabetes; Effective: March 1, 2013 Page 8 of 95

10 o o o o History of intellectual or developmental disability; Impairment of vision, hearing, speech or mobility; Psychiatric history; Previous history of contact with services and diagnoses; Risk assessment (harm to self and/or others); History of outpatient treatment and inpatient hospitalizations; Social/Cultural/Spiritual History: Current and previous social circumstances (e.g., marital and employment status); Current and previous living arrangements (e.g., group home, family home, independent living, etc.); Current and previous social support; Current cultural beliefs that may impact recovery; Spiritual or religious beliefs; Substance and alcohol use; Pharmaceutical History: Past and present medications (psychiatric and primary medical, including dosage, route and frequency); Drug adverse effects; Recent change in medication; Known drug allergies; Forensic History: Past and present history of involvement with the legal system; Financial: Income/support; Benefits; and Monthly expenses. Individualized Treatment Plan Each member shall have a single, individualized, coordinated, master recovery plan referred to as an Individualized Treatment Plan (ITP). The ITP is based on information obtained from the assessments described above, and contains evidence of the member's input into all aspects of treatment planning, including service-related decisions. Through the ITP, the member and the member's treatment team will work together to set goals toward recovery. The ITP will help each member of the case management team know what the other team members are doing to help the member. The ITP will describe case management assistance, psycho-therapy, medication, clinical services, general health services, dental services, legal assistance and living-support service needs. The ITP also will address crisis response and will include the preferences of the member and detail the steps to be taken by the Case Management team, the member, and member supports if a crisis occurs. Each member's ITP will guide service delivery even if the member changes providers. ITPs will be developed using a multidisciplinary team approach. The multidisciplinary team must include, at a minimum, the following: The member and, as appropriate, family members and significant others. A psychiatrist - the psychiatrist shall guide the treatment team and will offer clinical expertise for all authorization decisions. The psychiatrist or APRN-Rx to Effective: March 1, 2013 Page 9 of 95

11 member case load ratio shall not exceed 1: 250. Each member shall be seen at least once a month, for a minimum of 15 minutes of face-to-face contact. The provider may apply the visit structure in a flexible manner to accommodate the changing clinical needs of members, but at no time should the capacity be less than the capacity cited in the sentence above. Other behavioral, medical, and social service providers. A CM, who shall be responsible for coordinating the development of and monitoring the implementation of the ITP, and shall act as the communications liaison for the case management team both internally and externally with respect to the ITP. When the member has significant medical issues, a registered nurse shall be included as a member of the case management team, as well as the QExA service coordinator. The ITP shall be completed within 30 days of admission for services, as permitted by the member. The following are required components of an Individual Recovery Plan: A description of the assessments as well as the services offered in measurable behavioral terminology. All member needs identified in the referral assessment packet and the stated needs of the member. A written explanation of any need not addressed shall be in the plan. Identified needs should include any significant medical/dental problems, as well as immediate needs and strengths of the person, to include follow-up actions that are needed immediately. A Crisis Plan, the goal of which is to prevent hospitalization, stabilize, and manage and reduce risk of harm to the member. This plan will also be used to help avoid displacement from housing or other negative consequences that may affect personal functioning and community tenure. The Crisis Plan shall include: o Identification of early signs of relapse, steps to prevent crisis, identification of people, places or events that trigger responses and increase risk for relapse, and identification of strengths and natural resources; o A Wellness Recovery Action Plan (WRAP) may be included to inform the o crisis interventions required, when necessary; and Forensic member information (when appropriate-conditional release, released on conditions, or otherwise under the authority of a court) to include a specific crisis plan to mitigate the risk of admission or readmission to the hospital. All treatments by need area with goals and objectives, key supports with contact information, and timeframes. Documentation of key indicators to be measured to monitor the course and responsiveness to treatment. Interventions while the Member is in Inpatient Treatment An essential part of the CM role is to proactively collaborate with facilities and/or providers to anticipate, plan for, and address the member s potential treatment gaps and needs while the member is in inpatient treatment. The CM partners with the Ohana Concurrent Review Nurse, facility, and/or providers to ensure the member s mental health benefits are being utilized thoughtfully and with longer term post-facility discharge Effective: March 1, 2013 Page 10 of 95

12 planning needs in mind. Some of the CM strategies when reviewing care for members who are in a higher level of care include, without limitation: Requesting permission to participate by telephone in treatment team meetings; Offering assistance in identifying other Covered Services and/or community resources early in the admission; Identifying and contacting the facility s discharge planner; Collaborating with the social worker at the facility regarding proactive discharge planning; Arranging to speak to the attending psychiatrist directly if the facility s review representative is unable to provide adequate information at any point during the admission; Looking for opportunities to provide education and information to members and providers as needed; Requesting a peer-to-peer review with the attending psychiatrist and the Medical Director if the treatment plan does not meet medical necessity or does not have necessary documentation to support the member s care; and Coordinating with and/or assigning a provider case manager for the member. Post-Discharge Interventions The CM will conduct a face to face re-assessment of the CCS member within seven days of discharge from an acute care setting regardless if the acute stay was due to medical or behavioral reasons. As part of the ongoing treatment planning process after discharge from higher levels of care, the CM will identify individualized interventions targeted to help the member sustain treatment gains and return to a more stable level of functioning. Post discharge interventions may include, but are not limited to, the following: Referral to outpatient treatment; Follow up with primary care provider (PCP); Coordination with QExA health plan; and Ensure appropriate discharge medications are available and reconciled with preadmit medications. Addressing Barriers Another important function of CMs is ensuring proper follow-up for members. To that end, CMs will: Assist the member in development of a calendar to track important appointments; Review potential financial issues, transportation problems, lack of understanding, and/or reduced readiness for change; Review the name, address, and phone number of the provider and the appointment schedule with the member to confirm the member s knowledge of the appointment and ability to contact the provider if needed; Review the expectations of the appointment s outcome so the member understands the purpose of the appointment and how to ask meaningful questions during the appointment; and Make contact with the member s family to discuss the plan and engage their support in the area of compliance. Effective: March 1, 2013 Page 11 of 95

13 To address barriers to medication compliance and the risk of misuse, CMs will: Review the names and doses of medications so the member is knowledgeable about his or her medication; Review the doctor and pharmacy phone numbers to make sure the member can call them as needed; Assess the internal and external motivators, insight and capability of the member s engagement in process; Review the importance of using one pharmacy to fill all prescription so the pharmacist knows all medications used by the member and be alert to side effects, drug interactions, and schedule for refills; Send educational information to the member and/or significant others involved in the member s care to promote an understanding of the importance of compliance with medication and treatment; Review the importance of the member letting the psychiatrist or PCP know about any side effects that the member may experience or concerns he or she has about the treatment; Encourage the member to develop a journal to write down important side effects, or questions the member may have about various appointments; Suggest the use of a pill box, if applicable; and In rare cases, a medication tower with a monitoring system may be authorized by Ohana to help ensure ongoing compliance by very non-compliant members with frequent readmissions. Provider Services Ohana s Provider Services Department is comprised of two teams, Provider Relations and Provider Operations, serving providers on all islands. The Provider Relations team is responsible for provider education, recruitment, contracting, new provider orientation, monitoring of quality and regulatory standards such as Healthcare Effectiveness Data and Information Set (HEDIS ), and investigation of member complaints. The Provider Operations team consists of Contract Operations, collection of credentialing and recredentialing documents, and claims research and resolution. Ohana offers an array of provider services that includes initial orientation and education, either one-on one or in a group setting, for all providers. These sessions are hosted by our Provider Relations representatives. Ongoing education sessions are provided every six months or as necessary in the event providers are not fulfilling program requirements as outlined in the Agreement and/or the. Providers may contact the appropriate departments at the Plan by referring to the Quick Reference Guide on the Plan s website at Provider Relations representatives are available to assist in many requests for participating Plan providers. Contact your local market office for assistance, or call the Provider Service number located on your Quick Reference Guide to request a Provider Relations representative contact you. Effective: March 1, 2013 Page 12 of 95

14 Our Website Through the Plan s website providers have access to a variety of easy-to-use tools created to streamline day-to-day administrative tasks with the Plan. Additional public resources found on the website include: s Quick Reference Guide Clinical Coverage Guidelines Clinical Practice Guidelines Forms and Documents Pharmacy and Provider Look-Up (Directories) Newsletters Training Materials and Job Aids Member Rights and Responsibilities Preventative Health Guidelines and Privacy Statement and Notice of Privacy Practices. Registration is required to utilize certain key features outlined below. Key Features and Benefits of Registering for the Plan s Provider Portal The secure, online Provider Portal of the Plan s website provides immediate access to what providers need most. All participating providers who create a log-in and password using the Plan s Provider Identification (Provider ID) number can leverage the following features: Claims submission status and inquiry: Submit a new claim, check the status of an existing claim, and customize and download reports. Member eligibility and co-payment information: Verify member eligibility and obtain specific co-payment information. Authorization requests: Submit authorization requests, attach clinical documentation and check authorization status. You can also print and/or save copies of authorization forms. Pharmacy services and utilization: View and download a copy of Ohana s Preferred Drug List (PDL), see drug recalls, access pharmacy utilization reports and obtain information about Ohana pharmacy services. Training: Take required training courses and complete attestations online. Reports: Access reports such as active members, 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 your claims, eligibility inquiries and authorization requests. Your Registration Advantage The Plan website allows providers to have as many administrative users as needed and can tailor views, downloading options and details. Providers may also set-up individual sub-accounts for their staff, and keep separate billing and medical accounts. Once registered for our secure portal website, providers should retain log-in and password information securely for future reference. Effective: March 1, 2013 Page 13 of 95

15 How to Register To register, refer to the Ohana Medicaid Provider How-To Guide which is located on the Plan s website at For more information on the Plan s web capabilities, please contact Provider Services or contact Provider Relations to schedule a website in-service. Effective: March 1, 2013 Page 14 of 95

16 Section 2: Provider and Member Administrative Guidelines Provider Administrative Overview This section is an overview of guidelines for which all participating Plan Medicaid Managed Care providers are accountable. Please refer to the Provider Participation Agreement (Agreement) or contact your Provider Relations representative for clarification of any of the following. Providers, in accordance with generally accepted professional standards, must: Meet the requirements of all applicable state and federal laws and regulations including 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 the Plan in its efforts to monitor compliance with its Medicaid contract(s) and/or DHS rules and regulations, and assist us in complying with corrective action plans necessary for us to comply with such rules and regulations; Retain all agreements, books, documents, papers, and medical records related to the provision of services to Plan members 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 Practice Registered Nurses (APRN) should provide direct member care within the scope or practice established by the rules and regulations of DHS and Plan guidelines; Assume full responsibility to the extent of the law when supervising PAs and APRNs whose scope of practice should not extend beyond statutory limitations; Clearly identify physician extender titles (examples: M.D., D.O., APRN, PA) to members and to other health care professionals; Honor at all times any member s request to be seen by a physician rather than a physician extender; Administer, within the scope of practice, treatment for any member in need of health care services; Maintain the confidentiality of member information and records; Respond promptly to the Plan s request(s) for medical records in order to comply with regulatory requirements; Maintain accurate medical records and adhere to all Plan policies governing the content and confidentiality of medical records as outlined in Section 3: Quality Improvement and Section 8: Compliance; Allow Ohana 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 between the provider and the Plan; Effective: March 1, 2013 Page 15 of 95

17 o o to the extent the physician maintains written agreements with employed physicians and other health care practitioners and providers, such agreements contain similar provisions to the Agreement; and 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; Communicate timely clinical information between providers. Communication will be monitored during medical/chart review. Upon request, provide timely transfer of clinical information to the Plan, the member or the requesting party at no charge, unless otherwise agreed; Preserve member dignity and observe the rights of members to know and understand the diagnosis, prognosis and expected outcome of recommended medical, surgical and medication regimen; Not discriminate in any manner between Plan Medicaid members and non-plan Medicaid members; Ensure that the hours of operation offered to Ohana members is no less than those offered to commercial members; Not deny, limit or condition the furnishing of treatment to any Plan member on the basis of any factor that is related to health status, including, but not limited to the following: a) medical condition, including mental as well as physical illness; b) claims experience; c) receipt of health care; d) medical history; e) genetic information; f) evidence of insurability, including conditions arising out of acts of domestic violence; or g) disability; Freely communicate with and advise members regarding the diagnosis of the member s condition and advocate on the member s behalf for the member 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 members who are in need of services related to children s health, domestic violence, pregnancy prevention, prenatal/postpartum care, smoking cessation or substance abuse. If indicated, providers must refer members to Plan-sponsored or community-based programs; and Document the referral to Plan-sponsored or community-based programs in the member s medical record and provide the appropriate follow-up to ensure the member accessed the services. Excluded or Prohibited Services Providers must verify patient eligibility and enrollment prior to service delivery. The Plan is not financially responsible for non-covered benefits or for services rendered to ineligible recipients. Non-covered services are services not covered in the member s Plan contract. Responsibilities of All Providers The following is a summary of the responsibilities of all providers who render services to Plan members. These are intended to supplement the terms of the Agreement, not replace them: Effective: March 1, 2013 Page 16 of 95

18 Comply with all responsibilities set forth in this ; Make available treatment for any member in need of the health care services they provide; Refer Plan members with problems outside of the provider s normal scope of practice for consultation and/or care to appropriate specialists contracted with the Plan; Ensure members utilize network providers, except when they are not available or in an emergency. If unable to locate a participating Plan provider for services required, contact Provider Services for assistance. Refer to the Quick Reference Guide on the Plan s website at Admit members only to participating hospitals, skills nursing facilities (SNFs) and other inpatient care facilities, except in an emergency; Fully disclose to members their treatment options and allow them to be involved in treatment planning; Freely communicate with members about their treatment, regardless of benefit coverage limitations; Provide access to the Plan 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; Comply with the state and federal provider regulatory reporting obligations; Inform the Plan in writing within 24 hours of any revocation or suspension of the Bureau of Narcotics and Dangerous Drugs numbers and/or suspension, limitation or revocation of the provider s license, certification or other legal credential authorizing medical practice in the state of Hawai i; Submit an encounter for each visit where the provider sees the member or the member receives a HEDIS service; Submit encounters. For more information on encounters, refer to Section 5: Claims; Comply with and participate in corrective action and performance improvement plan(s); and Continually educate members regarding how to access services through the Plan s Provider Services. The Right to Inspect, Evaluate and Audit The Centers for Medicare and Medicaid Services (CMS), the State Medicaid Fraud Control Unit and DHS, or their designee, have the right to inspect, evaluate and audit any pertinent books, financial records, medical records, documents, papers and records of any provider involving financial transactions related to the Hawai i Contract and for the monitoring of quality of care being rendered without the specific consent of the member. Providers are required to submit annual cost reports to DHS, if applicable. Providers are prohibited from employing or subcontracting with individuals or entities whose owner or managing employees are on the state or federal exclusions list, and from making referrals for designated health services to health care entities with which the provider or a member of the provider s family has a financial relationship. Effective: March 1, 2013 Page 17 of 95

19 For more information on medical records requirements, refer to Section 3: Quality Improvement and Section 8: Compliance. For more information on subcontractors, refer to Section 9: Delegated Entities. No-Show Fees Providers are prohibited from imposing a no-show fee for CCS program members who were scheduled to receive a Medicaid Covered Service. Advance Directive Members have the right to control decisions relating to their medical care, including the decision to withhold or remove medical or surgical means or procedures to not prolong their life. Providers must comply with the advance directives requirements for hospitals, nursing facilities, providers of home and health care hospices and HMOs specified in 42 CFR Part 49, subpart I, and 42 CFR Section (d). Each Plan member, age 18 years or older and of sound mind, should receive information regarding living will and advance directives. They have the right to also designate another person to make a decision should they become mentally or physically unable to do so. The Plan provides information on advance directives in the Member Handbook. Information regarding living will and advance directives should be made available in provider offices and discussed with the members. Completed forms should be documented and filed in members medical records. A provider shall not, as a condition of treatment, require a member to execute or waive an advance directive. Any complaints regarding advance directives should be filed with the Office of Health Care Assurance (OHCA). Provider Billing and Address Changes Prior written notice to your Provider Relations representative 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; Telephone and fax number; Panel changes; and/or Directory listing. Failure to notify the Plan 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 providers must give at least 90 days prior written notice (180 days for a hospital) to the Plan before terminating their relationship with the Plan without cause, unless otherwise agreed to in writing. This ensures that adequate notice may be given to Plan members regarding your participation Effective: March 1, 2013 Page 18 of 95

20 status with the Plan. Please refer to your Agreement for the details regarding the specific required days for providing termination notice, as you may be required by contract to give more notice than listed above; and Unless otherwise provided in the termination notice, the effective date of a termination will be on the last day of the month. In the event a provider voluntarily terminates during the course of a member s treatment, the provider may continue to provide treatment to that member until the current course of treatment is completed or care has been transitioned to another provider. In the case of Plan- or DHS-initiated termination for adverse reasons on the part of the provider, the Plan may transition a member to another provider. The Plan shall immediately transfer a member to another PCP, health plan or provider if the member s health and safety is in jeopardy. Please refer to Section 6: Credentialing of this Manual for specific guidelines regarding rights to appeal plan termination (if any). The Plan will notify in writing all appropriate agencies and/or members prior to the termination effective date of a participating PCP, hospital, specialist or significant ancillary provider within the service area as required by state Medicaid program requirements and/or regulations and statutes. Closing of Provider Panel When requesting closure of your panel to new and/or transferring Plan members, providers 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 Ohana Health Plan members 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 Providers In the event that participating providers are temporarily unavailable to provide care or referral services to Plan members, providers should make arrangements with another Plan-contracted Medicaid (participating) and credentialed provider to provide services on their behalf, unless there is an emergency. Covering providers should be credentialed by the Plan, and are required to sign an agreement accepting the negotiated rate and agreeing to not balance bill Plan members. For additional information, please refer to Section 6: Credentialing. In non-emergency cases, should you have a covering provider who is not contracted and credentialed with the Plan, contact the Plan for approval. For contact information, refer to the Quick Reference Guide on the Plan s website at Effective: March 1, 2013 Page 19 of 95

21 Out-of-Area Member Transfers Providers should assist Ohana in arranging and accepting the transfer of members receiving care out of the service area if the transfer is considered medically acceptable by the Plan provider and the out-of-network attending physician/provider. In the same regard, when a member needs to transfer care to an out-of-area provider, the participating provider(s) should assist the Plan in arranging and providing clinical information to the out-of-area provider. 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 member s needs. The Plan shall monitor providers against these standards to ensure members can obtain needed behavioral health services within the acceptable appointments timeframes, inoffice waiting times, and after-hours standards. Providers not in compliance with these standards will be required to implement corrective actions. Type of Appointment Emergency Urgent Standard Access Standard Immediate Care 24 hours per day, 7 days per week Within 72 hours Within 21 days The member s in-office wait time cannot exceed 45 minutes. Discharge Appointments All members 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 seven days from the date of discharge. In the event that a member misses an appointment, the behavioral health provider must contact the member within 24 hours to reschedule. Providers may contact the Plan for assistance in contacting members when needed. Responsibilities of Behavioral Health Providers / Case Managers Responsibilities of Behavioral Health Case Managers include: Providing the member with clear and adequate information on how to obtain services and make informed decisions about their own behavioral health needs; Providing comprehensive case assessment, case planning, ongoing quarterly monitoring of progress toward goals, and support towards reaching those goals; Completing face-to-face comprehensive assessments on a new Ohana CCS member within 30 days of enrollment into the program. Face-to-face reassessments shall be completed at least annually or sooner if medically necessary; Effective: March 1, 2013 Page 20 of 95

22 Assuring the development of the ITP. The initial ITP shall be developed within 30 days of completing the face-to-face comprehensive assessment after enrollment into the program; ITPs shall be updated every six months or sooner if medically necessary to include a significant change; Coordinating services with other providers such as QExA Service Coordinators, Medicare, the Hawai i Department of Health (DOH) programs excluded from QExA, Medicare Advantage plans, other MCO providers, mental health and Developmentally Delayed/Mentally Retarded providers at DOH; Providing skills development in problem-solving and other skills to remain in/return to the community; Ensuring crisis resolution; Coordinating and integrating the members medical and behavioral health care and services with their health plan, behavioral health provider, and primary care provider; Achieving continuity of members care and cost-effective delivery of services; Assisting the member in obtaining behavioral health interventions, as prescribed by the interdisciplinary team as appropriate, and ensure that these services are received and provided in a timely manner; Ensuring that an active, assertive system of outreach is in place to provide the flexibility needed to reach those members such as the homeless or others, who require services, but who might not access services without intervention due to language barriers, acuity of condition, dual diagnosis, physical/visual/hearing impairments, mental retardation, lack of transportation, etc.; Facilitating member compliance with recommended medical and behavioral health treatment; and Assisting members with DHS eligibility requirements (verifications, etc.) and compliance. Case Management Service Frequency and Intensity Requirements All Ohana behavioral health providers will be required to adhere to the designated case management frequency requirements, as described below. Ohana requires providers to utilize the LOCUS tool for making acuity determinations. Service Level Minimum Service Contact Contact Description Requirement IV. High Intensity Two times per week Face-to-face one time per week. Other contact may be telephonic III. Intensive One time per week Face-to-face two times per month. Other contact may be telephonic II. Intermediate Every other week Face-to-face one time per month. Other contact may be telephonic I. Routine One time per month Face-to-face Effective: March 1, 2013 Page 21 of 95

23 The clinical status and recovery plan of all members receiving case management will be formally reviewed by the Ohana Behavioral Health Director and the CCS Medical Director every six months. More frequent review will be required when significant changes occur in the overall condition or functioning of a member. All recovery plan reviews will be documented in the member s case management record and in the Ohana member record. While face to face visits will be required as above, a full and comprehensive assessment will be required for every CCS member during one of these visits at least annually. It is not expected that a full assessment be completed during each visit; however, Ohana will monitor our case manager providers to ensure these assessments are done annually and after any significant change in mental or physical health status, such as after acute hospitalization or change in psychotropic medication. Continuity and Coordination of Care Between Medical and Behavioral Health Care PCPs may provide any clinically and medically necessary appropriate behavioral health services within the scope of their practice. Conversely, behavioral health providers may provide physical health care services if they are medically necessary and when they are licensed to do so within the scope of their practice. Behavioral providers are required to use the DSM-IV multi-axial classification when assessing the member for behavioral health services and document the DSM-IV diagnosis and assessment/outcome information in the member s medical record. Behavioral health providers are required to submit, with the member s or member s legal guardian s consent, an initial and quarterly summary report of the member s behavioral health status to the PCP. Communication with the PCP should occur more frequently if clinically indicated. The Plan encourages behavioral health providers to pay particular attention to communicating with PCP s at the time of discharge from an inpatient hospitalization (the Plan 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 member s identified PCP noting any changes in the treatment plan on the day of discharge. We strongly encourage open communication between PCPs and behavioral health providers. If a member s medical or behavioral condition changes, the Plan 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. At this time, a release of information (ROI) may need to be obtained to communicate this information. It is strongly recommended that the PCP obtain this ROI as soon as possible. To maintain continuity of care, patient safety and member well-being, communication between behavioral health care providers and medical care providers is critical, especially for members with co-morbidities 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 member outcomes. Effective: March 1, 2013 Page 22 of 95