Provider Reference Guide CARE

Transcription

1 Provider Referece Guide CARE

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3 I This Hadbook Itroductio 4 Importat Telephoe Numbers 5 Rights ad Resposibilities Provider Rights ad Resposibilities 6 Cotiuity of Care 7 Provider Termiatio or Chage of Status Notificatio 7 Other Chages /Routie Maiteace 8 Practitioer Appeals Process/Provider Feedback 8 Notificatio Process To Providers 9 Health Traditio Health Pla ad Participatig Provider Relatioship 9 Member Rights ad Resposibilities 11 Health Traditio Commercial Plas Pla Descriptios 12 Determiig Membership Eligibility 13 Determiig Beefits 14 Health Promotio Resources 15 Medical Maagemet 14 Urget ad Emergecy Care 16 Prior Authorizatio 17 Referrals 18 Medical Guidelies 18 Case Maagemet 19 DME, Supplies 19 Metal Health/Chemical Depedecy 19 Chiropractic Maagemet 20 Autism Spectrum Disorder 21 Claims 22 Claims Submissio 22 Time Limit for Claims Filig 22 Telephoe Iquiry o Claims 22 Appealig Claims 22 For More Iformatio 22 Health Traditio/BadgerCare Plus 23 Pla Descriptio 23 Verifyig Membership Eligibility 23 Beefits 23 Health Promotio Resources Disease Prevetio ad Welless Resources 24 Medical Maagemet 25 Urget ad Emergecy Care 25 Prior Authorizatio 26 Referrals 27 Medical Guidelies 27 Case Maagemet 28 DME, Supplies 28 Disease Maagemet 28 Metal Health/Chemical Depedecy 29 Chiropractic Maagemet 30 Claims 31 Claims Submissio 31 Time Limit for Claims Filig 31 Telephoe Iquiry o Claims 31 Appealig Claims 31 For More Iformatio 31 Geeral Iformatio Quality Maagemet Program 32 Credetialig/Recredetialig 34 Credetialig New Providers 34 Recredetialig 34 Program Overview 34 Ogoig Moitorig of Practitioers i HTHP Network 40 Suspesio of Practitioers from HTHP Network 40 Network Access Stadards 41 HTHP Access Stadards 41 Quality of Services 42 Leased Networks 43 Pharmacy 44 Complaits ad Grievaces 45

4 Itroductio This resource is a provider referece guide for accessig iformatio for Health Traditio products ad affiliated health plas. It is desiged to give etwork practitioers ad their staff a overview of Health Traditio plas, processes ad procedures. The guide provides istructios, helpful hits ad resource cotacts for Health Traditio, icludig iformatio o: Pla descriptios Membership eligibility Beefits Medical maagemet Claims Quality maagemet This guide is also available o our Web site: The Provider Referece Guide is divided ito five sectios: Importat Telephoe Numbers, Rights ad Resposibilities, Health Traditio Commercial Plas, BadgerCare Plus ad Geeral Iformatio. Each sectio provides a overview of the admiistrative fuctios for each pla type. The guide has bee desiged to make it versatile ad easy for you to locate ad access iformatio. As pla iformatio is added or updated, ew iserts will be set to you to keep this guide curret. We hope you fid this Provider Referece Guide helpful. If you have ay commets or suggestios o how to improve this guide, please cotact the Network Developmet Departmet at Health Traditio Health Pla at (608)

5 Importat Telephoe Numbers Customer Service (Premier, Premier Plus, Premier Oe, 65Plus) (toll-free) Customer Service (BadgerCare Plus) (toll-free) The Nurse Lie at Mayo Cliic Health System - Fracisca Healthcare (Premier, Premier Plus, Premier Oe, 65Plus) (toll-free) The Nurse Lie at Mayo Cliic Health System - Fracisca Healthcare (BadgerCare Plus) (toll-free) Health Traditio Health Pla or (toll-free) Health Traditio BadgerCare Plus Member Advocate or (toll-free) Health Traditio BadgerCare Plus Provider Advocate Mayo Cliic Tobacco Quitlie (toll-free) Referral Coordiators or (toll-free) Utilizatio Maagemet Coordiators or (toll-free) Wiscosi BadgerCare Plus Provider Services (toll-free) Customer Service (toll-free) 5

6 Rights ad Resposibilities Provider Rights ad Resposibilities ad Other Importat Iformatio Rights ad Resposibilities To discuss appropriate treatmet optios, medical ecessity or appropriateess of care or ay iformatio that the provider determies to be i the best iterest of the member with the Pla. To be reimbursed for Covered Services provided i a timely maer as determied by the provider agreemet. To make referrals to other providers for specialty care or secod opiios withi the Health Traditio etwork ad obtai writte approval from the Health Traditio Utilizatio Maagemet Departmet whe it is felt that care is ecessary outside of the Health Traditio etwork. To review Health Traditio s medical criteria used i makig utilizatio maagemet decisios. To a resolutio i a fair ad timely maer of ay disputes that may arise uder the participatig provider agreemet. To reasoable access to determie member eligibility ad beefits To provide ad coordiate the health care eeds of Health Traditio members. To provide services to Health Traditio members free from discrimiatio i service delivery o the basis of age, color, hadicap, geder, creed, atioal origi, acestry, sexual orietatio, arrest or covictio records, marital status, political affiliatio or religio. To maitai the provider-patiet relatioship with the member ad allow members to participate i their health care decisios. To utilize participatig Health Traditio providers, facilities, (for example, hospitals, surgery ceters) ad acillary services (for example, labs, x-ray). To udergo successful credetialig ad recredetialig accordig to Health Traditio s criteria. To accept the egotiated reimbursemet rate as paymet i full for covered services provided to members, excludig deductibles, co-paymets ad coisurace. To esure Health Traditio members right to privacy ad cofidetiality of all commuicatios ad records ad to be compliat with HIPAA requiremets. To participate i Health Traditio s utilizatio ad quality maagemet programs, icludig allowig Health Traditio access to member medical records as outlied i the Provider Agreemet. To submit claims i a stadardized format ad i a timely maer. To idetify complaits ad grievaces by members ad forward them i a timely maer to Health Traditio. To have a policy that complies with 42CFR i the Code of Federal Regulatios. To assist Health Traditio Health Pla members i obtaiig prior authorizatio, as ecessary, to facilitate claim paymet. To iform the Health Traditio Medical Director whe Health Traditio Health Pla procedures or actios are perceived as threateig the health or well-beig of the member. To uderstad that Health Traditio Health Pla does ot dey patiet care, but simply makes paymet decisios based o the member s coverage through Health Traditio Health Pla. To commuicate with members ad Health Traditio Health Pla i a way that assumes that all parties are actig i good faith with the goal beig good care for the member. 6

7 Rights ad Resposibilities Provider Rights ad Resposibilities ad Other Importat Iformatio To recogize that Health Traditio Health Pla is obligated to develop policies ad procedures o beefit admiistratio ad to admiister these i a fair ad cosistet maer eve though this occasioally results i deial of paymet for idividual members. To uderstad that Health Traditio Health Pla has may differet beefit plas that members may choose from. A beefit may be payable for oe member, but may ot be payable for aother, depedig o the beefit pla that each member has chose. For all ipatiet admissio requests to Health Traditio Health Pla, providers are required to sed cliical iformatio to Health Traditio Health Pla for review. It is the provider s resposibility to cotiue to iform the member of the pla s authorizatio status throughout the admissio. If a admissio is approved, the Health Traditio Case Maagemet Dept. will otify the provider verbally. This otice cotais a trackig umber which the provider ca referece i discussio with the pla. It is the provider s resposibility to cotact the member ad facility ad iform them that the ipatiet stay is approved, whether this is a pre-certificatio, a cocurret review, or a retrospective review. I the evet a admissio is deied, Health Traditio will otify the provider verbally ad the provider ad member i writig. This otice cotais a trackig umber which the provider ca referece i discussio with the pla. If it is a deial of a cocurret review, it is the provider s resposibility to otify the facility ad member of the deial if the member is still ipatiet. Cotiuity of Care Whe a provider termiates ad remais withi the service area, Health Traditio ad the provider are joitly resposible to provide cotiuity of care uder certai circumstaces, as required by law. Health Traditio esures access to primary care providers util the ed of the curret pla year. If a member is udergoig a course of treatmet with a termiatig provider who is ot a primary care provider, Health Traditio is required to provide coverage for the remaider of the course of treatmet or for up to 90 days, whichever is less. If the member is a woma who is i the secod or third trimester of pregacy whe the provider termiates, she may receive care util the completio of postpartum care for herself ad her ifat. Provider Termiatio or Chage of Status Notificatio All participatig providers shall otify Health Traditio i writig at least sixty (60) days prior to experiecig ay of the followig chages: Mergig with aother practice A idividual practitioer leavig a practice Relocatio New owership Closed to curret or ew patiets Customer Service (toll-free) 7

8 Rights ad Resposibilities Provider Rights ad Resposibilities ad Other Importat Iformatio Other Chages/Routie Maiteace Providers have the resposibility to relay chages related to such thigs as office locatios, telephoe umbers, practice affiliatios, tax idetificatio umbers, service hours, ame chages ad billig service. This iformatio is critical ad should be commuicated to Health Traditio as soo as the chage is aticipated. Please cotact Health Traditio Network Developmet at the followig address to relay chages: Health Traditio Health Pla Att: Network Developmet PO Box 188 La Crosse, WI Practitioer Appeals Process/Provider Feedback HTHP ecourages feedback ad iput from all cotracted providers withi the HTHP provider etwork as it relates to ay medical or admiistrative matter withi the Health Pla. Providers may cotact the Health Traditio Network Maagemet Departmet (for admiistrative issues) or oe of our Associate Medical Directors at (608) to provide feedback, suggestios or guidace about the Pla s performace, policies or how best to improve the services to members/cosumers. HTHP has the authority to establish, modify ad implemet various policies ad procedures with regard to such matters that iclude, but are ot limited to: cliical practice guidelies, quality assurace, utilizatio maagemet, quality improvemet, credetialig, provider disputes ivolvig admiistrative matters ad codig. HTHP will accept proposals to modify or make a exceptio to a established policy or procedure. The policies are reviewed at least aually ad do take ito accout feedback ad recommedatios from participatig providers o how to improve the process ad overall care to members/cosumers. Providers ca cotact the Health Traditio Network Maager or Associate Medical Director to discuss or review Pla policies ad procedures. If HTHP deies a claim or a beefit, which therefore results i a partial paymet or a deial to a practitioer, or makes a determiatio that is usatisfactory to the practitioer, the practitioer of care is etitled to appeal the deial. HTHP will maitai a process for practitioer appeals. It is recommeded that the practitioer first cotact the HTHP Network Maagemet Departmet or the HTHP Director of Admiistratio at (608) to discuss the matter. This could iclude delayed paymets to providers, request a exceptio to a policy or the cosideratio of chage i HTHP s process or procedure. Formal appeal requests will be cosidered, if submitted i writig, by a appropriate represetative of HTHP. We require that practitioers respod promptly to ay requests for iformatio regardig this appeal. This will assist HTHP i providig a timely respose to the appeal filed with the Pla. If the practitioer is dissatisfied with the decisio made by the HTHP represetative, the practitioer may request a peer to peer coversatio with a Associate Medical Director. If the practitioer cotiues to be dissatisfied with the decisio made by Health Traditio, he/she may request that the decisio be reviewed by the Executive Director at HTHP for admiistrative decisios or the HTHP Medical Director for cliical determiatios. The results of this fial review shall be cosidered fial ad bidig upo HTHP ad the practitioer. HTHP will use practitioer appeals (both oral ad writte) as a source of feedback to improve HTHP s resposiveess to the provider etwork ad to improve overall health pla operatios. If you have a questio or cocer about ay aspect of a Health Traditio utilizatio maagemet decisio, you may take the followig steps: 8

9 Rights ad Resposibilities Provider Rights ad Resposibilities ad Other Importat Iformatio If you would like to discuss the case with a Health Traditio physicia reviewer, cotact Health Traditio Health Pla at or toll-free at If iformal discussios are ot satisfactory or you do ot agree with the decisio, you may appeal i writig to: Health Traditio Health Pla Att: Operatios Departmet P.O. Box 188 La Crosse, WI The letter should iclude a summary of the diagosis, services ad cliical documetatio to support the basis for the appeal. A expedited appeal for services that require immediate attetio may be requested by callig Health Traditio at or (toll-free). Notificatio Process To Providers Health Traditio Health Pla esures otificatio to providers regardig obligatios to Health Traditio Health Pla through the followig mechaisms: 1) Notices regardig cotract chages ad clarificatio of obligatios uder the cotract will be provided i the Health Traditio Health Pla Participatig Provider Agreemet. This icludes: requests for chages i ay fee or reimbursemet schedule, which will be provided with at least 30-day writte otice, chages regardig cotract provisios, chages i State, Federal or other regulatory agecy requiremets i which the Provider will be required to comply ad termiatios of cotractual relatioships. 2) Notificatio to Providers regardig chages i policies ad procedures icludig, but ot limited to: Prior authorizatios, referral guidelies, billig requiremets/terms for Paymets, participatio stadards (Provider Maual), quality improvemet iitiatives ad performace criteria, data reportig requiremets, grievace ad appeals resposibilities ad rights (member ad provider) ad drug formulary requiremets. 3)Health Traditio will provide at least a 60-day writte otice regardig the chages i #2 of the above requiremets. All otices must be received by provider sixty (60) days prior to the effective date. This will be accomplished through: certified mail, had delivery, direct mailig, fax, Web site postigs, electroic mail, iteret availability, ad provider maual updates. Health Traditio Health Pla ad Participatig Provider Relatioship Please cotact the Health Traditio Health Pla Network Maager at (608) for iformatio about ay of the followig items: A listig of all idividuals or etities who are party to the writte agreemet. Coditios for participatio as a participatig provider. Obligatios ad resposibilities of Health Traditio Health Pla ad the Participatig Provider, icludig ay obligatios for the Participatig Provider to participate i Health Traditio s maagemet, complait, or other programs. Evets that may result i the reductio, suspesio, or termiatio of etwork participatio privileges. Customer Service (toll-free) 9

10 Rights ad Resposibilities Provider Rights ad Resposibilities ad Other Importat Iformatio The specific circumstaces uder which Health Traditio Health Pla may require access to members/cosumers medical records as part of Health Traditio s programs or health beefits. Health care services to be provided ad ay related restrictios. Requiremets for claims submissio ad ay restrictios o the billig of members/cosumers. Participatig provider paymet methodology ad fees. Mechaisms for dispute resolutio by Participatig Providers. Term of the cotract ad procedures for termiatig the cotract. Requiremets with respect to preservig the cofidetiality of patiet health iformatio. Prohibitios regardig discrimiatio agaist members/cosumers. 10

11 Rights ad Resposibilities Member Rights ad Resposibilities Rights To choose. Members have the right to choose a persoal health care provider from Health Traditio s etwork of health care providers. Health Traditio ecourages members to establish a relatioship with that health care provider. To iformatio. Members have the right to iformatio about the beefit pla relatig to covered services ad excluded health care beefits, available health care providers, prevetive care, their illess ad its care, the process to make kow a complait or request, ad policies/procedures relevat to their care. To privacy ad cofidetiality. Members have the right to privacy ad cofidetiality of all commuicatios ad records o covered services received. To participate i their care. Members have the right to be active i decisios about their treatmet. Members have the right to a cadid discussio of appropriate or medically ecessary treatmet optios for their coditio, regardless of cost or beefit coverage. Members have the right to be iformed about the risks ad beefits of treatmet ad to refuse care. To preset a complait/grievace. Members have the right to voice cocers about their care ad to receive a prompt ad fair review of ay complaits. To be treated with respect ad digity. Members have the right to be treated with respect ad digity regardless of race, age, geder or creed. To be treated with respect ad digity. Members have the right to be treated with respect ad digity regardless of race, age, geder or creed. Resposibilities To kow their beefits ad resposibilities. Members have a resposibility to uderstad their health pla beefits ad follow the required procedures. Kow how to use the pla s provider etwork ad ask questios about items they do t uderstad. To provide accurate iformatio. Members have a resposibility to provide accurate ad complete iformatio about their health history ad eligibility/ erollmet. Members have a resposibility to show their membership card each time they receive services ad to fulfill ay fiacial obligatios they may icur. To participate i their care. Members have a resposibility to participate i their care by askig questios to uderstad their illess, followig the recommeded/agreed upo treatmet pla, ad makig healthy lifestyle choices to try to maitai their health ad prevet illess. To keep their appoitmets. Members have a resposibility to keep their appoitmets or to give early otice if they must cacel. To show cosideratio ad respect. Members have a resposibility to show cosideratio ad respect to health care providers ad staff. Customer Service (toll-free) 11

12 Health Traditio Health Pla Pla Descriptios Health Traditio offers access to a full rage of health care services through a etwork of commuity-based providers i Wiscosi, Miesota ad Iowa. Premier Traditioal HMO pla usig primary care providers to coordiate members medical care. Premier Plus Poit-of-service pla offerig out-ofetwork beefits beyod traditioal HMO services Premier Oe Idividual HMO pla that has the optio to be paired with a Health Savigs Accout. 65Plus Medicare Select product desiged to supplemet traditioal Medicare coverage Cosumer Choice (Health Reimbursemet Accouts) A IRS sposored health pla that allows employers to reimburse for qualified medical expeses paid by participatig employees. Commuity Traditioal Premier (HMO) or Premier Plus (Poit-Of-Service) plas also iclude the Guderse Luthera etwork as a participatig provider. 12

13 Health Traditio Health Pla Determiig Membership Eligibility Health Traditio Premier ad Premier Plus Both plas feature the add o capability of: Cosumer Choice ad/or Commuity Premier Oe Health Traditio 65Plus Each member erolled i Premier, Premier Plus, Premier Oe, 65Plus, Cosumer Choice or Commuity is issued a membership card. The cards cotai the followig iformatio: ABC SAMPLE, JOSEPH Q ABC SAMPLE, SUSAN ABC SAMPLE, BRANDON ABC SAMPLE, JESSICA ABC SAMPLE, PEGGY ABC SAMPLE, ANN ABC SAMPLE, KIM MMSI Group #: XXXX Pla Type: Medical/Pharmacy Rx Group: MCL PCN: SXC RX Bi: PIN: 0001 ABC SAMPLE, JOSEPH Q ABC SAMPLE, SUSAN ABC SAMPLE, BRANDON ABC SAMPLE, JESSICA ABC SAMPLE, PEGGY ABC SAMPLE, ANN ABC SAMPLE, KIM MMSI Group #: XXXX Pla Type: Medical PIN: 0001 ABC SAMPLE, JOSEPH Q ABC SAMPLE, SUSAN ABC SAMPLE, BRANDON ABC SAMPLE, JESSICA ABC SAMPLE, PEGGY ABC SAMPLE, ANN ABC SAMPLE, KIM MMSI Group #: XXXX Pla Type: Medical/Pharmacy Rx Group: MCL PCN: SXC RX Bi: PIN: 0001 ABC SAMPLE, JOSEPH Q ABC SAMPLE, SUSAN ABC SAMPLE, BRANDON ABC SAMPLE, JESSICA ABC SAMPLE, PEGGY ABC SAMPLE, ANN ABC SAMPLE, KIM MMSI Group #: XXXX Group Name: Your Group Name Here Pla Type: Medical PIN: 0001 All Health Traditio pla practitioers, excludig BadgerCare, ca verify membership eligibility by cotactig: Health Traditio Customer Service betwee the hours of 7 a.m. to 7 p.m. (Cetral Time) Moday Friday to aswer questios regardig member eligibility. Coversat the automated assistace lie is available 24 hours a day by callig the same umber at (toll-free). To verify BadgerCare Plus member eligibility, practitioers may call the Automated Voice Respose (AVR) system at or Provider Services at Providers ca also verify eligibility at Oce a user ID is requested, eligibility ca be verified o the web based portal. Customer Service (toll-free) 13

14 Health Traditio Health Pla Determiig Beefits Each Health Traditio health pla has differet beefit levels ad cost-sharig amouts. Coverage for eligible services varies depedig upo the health pla that was selected. For more iformatio o beefit levels, cotact Health Traditio Customer Service. Collectio of Copaymets The copaymet, whe applicable, should be collected each time a member visits the office. Health Traditio is ot resposible for ucollected copaymets. For More Iformatio: Members may call Health Traditio Customer Service from 7 a.m. to 7 p.m. (Cetral Time) Moday Friday for aswers about pla beefits ad practitioer etwork. Practitioers may call Health Traditio Customer Service for questios o beefits, claims admiistratio or member eligibility. Customer Service (toll-free) For questios o prior authorizatio or referrals, practitioers may call the Health Traditio Utilizatio Maagemet departmet. Referrals: (toll-free) Ipatiet Authorizatios: or (toll-free) Please cotact the Provider Relatios Departmet for questios o cotractig or credetialig or (toll-free) Helpful Hits Please have the followig iformatio available whe requestig beefit assistace: Member s ame Member s idetificatio umber Member s date of birth Subscriber s ame 14

15 Health Traditio Health Pla Health Promotio Resources Disease Prevetio ad Welless Resources Health Traditio strogly believes i a proactive approach to health improvemet ad disease prevetio. Listed below are some of the resources available to Health Traditio members: The Nurse Lie at Mayo Cliic Health System - Fracisca Healthcare 24-Hour Nurse lie with health iformatio. Call (toll-free) Smokig Cessatio Prescriptio stregth smokig cessatio aids icluded o the HT formulary. Prescriptio copaymets apply. Couselig sessios via telephoe available Educatioal sessios at various provider sites Mayo Cliic Tobacco Quitlie Call (toll-free) Adult Prevetive Health Guidelie Recommedatios Physical exams Screeigs Tests Immuizatios Pediatric Prevetio Health Guidelie Recommedatios Well child exams Immuizatios Eat Well Move More Rebate Program (available oly to Premier ad Premier Plus members). Rebates for: Fitess Ceter memberships Commuity Supported Agriculture (CSA) shares A New Me Weight Watchers Disease Maagemet Care Ehace Program Health Traditio Web site: Health Educatio ad Patiet Iformatio Brochures ad fact sheets Patiet educatio classes offered at various cliic sites Newsletters Healthmate Health pla iformatio published quarterly for members Customer Service (toll-free) 15

16 Health Traditio Health Pla Medical Maagemet Urget ad Emergecy Care Maaged care laws i Wiscosi iclude a uiform stadard of coverage for emergecy room care. Health Traditio s emergecy care defiitio Emergecy Care Hospital or medical treatmet which is required uexpectedly ad immediately because of a accidetal ijury or emergecy illess. A emergecy shall exist whe a member s symptoms are of sufficiet severity to lead a prudet layperso to reasoably coclude that immediate medical attetio is ecessary. It does ot iclude elective medical treatmet for a illess or ijury for which the eed for care could reasoably have bee foresee. Health Traditio may ot dey coverage for emergecy services that a reasoably prudet layperso would cosider a emergecy. Prior authorizatio is ot required for emergecy care at ay hospital. Health Traditio should be cotacted withi 48 hours or a emergecy hospital admissio. Follow-up services must be provided i the appropriate settig to be eligible for coverage. Emergecy medical services or urget care that is provided to a covered depedet who is a full-time studet attedig school outside the geographic service area of the pla will be covered by Health Traditio. Questios about Emergecy Care: Call the Utilizatio Maagemet departmet at (La Crosse area) or (toll-free). 16

17 Health Traditio Health Pla Medical Maagemet Prior Authorizatio Prior Authorizatio the process of receivig writte approval from the Pla for certai services or products i advace of the service or product beig provided. Prior Authorizatio does ot guaratee paymet of beefits. Prior Authorizatio is required for the followig services: All durable medical equipmet over $750 Certai diet drugs Certai durable medical equipmet items uder $750 Cosmetic services/procedures Elective ipatiet admissio Experimetal/ivestigatioal services/procedures Gastric bypass High-tech radiology services (more specific detail is foud below) Home health care services Hospice care Ijectable drugs All services covered uder Autism Spectrum Disorder Psychological testig Skilled ursig facility admissio Trasplats Trasitioal care To obtai assistace with prior authorizatio, cotact Health Traditio at or (toll-free) or fax at Prior authorizatio requiremets are subject to chage upo otificatio Customer Service (toll-free) 17

18 Health Traditio Health Pla Medical Maagemet Referrals A writte referral form is required whe a practitioer refers a member to a out-of-etwork health care provider. However, a referral is ot required whe a practitioer refers a member to a i-etwork specialist. A list of i-etwork specialists is available to members i their Health Traditio provider directory. The Health Traditio directory ca be accessed o our Web site: Referrals to out-of-etwork health care providers must be approved by the Pla prior to services beig redered. I emergecy situatios, approval must be obtaied as soo as possible after the member receives services from a outof-etwork practitioer. If a member requires services from a specialist ot available i-etwork, Mayo Cliic i Rochester is the preferred out-of-etwork referral ceter. A writte referral must be approved by the Pla prior to services beig redered. The member s i-etwork health care provider coordiates referrals. This is obtaied by completig the exteral referral form which is available o the Mayo Cliic Health System - Fracisca Healthcare itraet or at www. healthtraditio.com. The exteral referral form must be complete or it will ot be processed. Additioal referral forms ca be dowloaded from the Health Traditio Web site, Click o Providers, the click o Forms ad Istructios. Or, cotact a Health Traditio Referral Coordiator at (toll-free) or Completed referral forms ca be faxed to Health Traditio at To obtai assistace with prior authorizatio or referral requiremets, cotact Health Traditio at (toll-free). Medical Guidelies Health Traditio utilizes IterQual, a atioally recogized utilizatio maagemet criteria. These criteria are used i determiatios for: Type of treatmet Frequecy of treatmet Diagostic testig Cotact the Utilizatio Maagemet Departmet at or (toll-free). 18

19 Health Traditio Health Pla Medical Maagemet Case Maagemet Health Traditio provides case maagemet services to high-risk members who require complex medical care. Case maagers work with a member s health care provider to establish ad coordiate a pla of care. Cotact Health Traditio at or (toll-free) if a Health Traditio patiet beig cared for at your facility may beefit from the special assistace of case maagemet. DME, Supplies Durable medical equipmet (DME) items must be purchased from a i-etwork provider to optimize their pla beefit. The idividual health care provider prescribig DME must complete a prescriptio form. The member the takes the prescriptio to a participatig DME provider. Prior authorizatio is required for all covered services greater tha $750. Certai items less tha $750 require prior authorizatio from the health pla (for example, oxyge). Please call Customer Service at (toll-free) for more iformatio. The DME provider will complete a DME authorizatio form ad sed it to Health Traditio for prior authorizatio. This form ca be foud o the Health Traditio Web site, Click o Providers ad the click o Forms ad Istructios. Metal Health/Chemical Depedecy The followig services require prior authorizatio: Elective admissios Urget/emerget ipatiet admissios (otify the Pla withi 48 hours) Day treatmet programs Psychological testig Trasitioal care Prior Authorizatio for Psychological Testig Prior authorizatio is required for ay psychological testig. If services are provided without obtaiig prior approval from the Health Pla, services will be deied. The Prior Authorizatio Request for Psychological Testig form eeds to be completed before services have bee provided. Iformatio required icludes: Patiet ad provider iformatio Patiet diagosis, symptoms ad history Treatmet pla ad goals Specific test or tests required Customer Service (toll-free) 19

20 Health Traditio Health Pla Medical Maagemet For additioal authorizatio forms, go to Click o Providers, the click o Forms ad Istructios. Completed authorizatio forms ca be faxed to Metal Health Services at or mailed to: Health Traditio Att: Metal Health Services PO Box 188 La Crosse, WI To obtai assistace with prior authorizatio or referral requiremets, cotact Health Traditio at (tollfree). Prior Authorizatio for High-tech Radiology Services High-tech elective outpatiet imagig procedures require prior authorizatio. Care To Care will be reviewig these authorizatio requests o behalf of Health Traditio. The specific services that require prior authorizatio iclude: CT MRA CTA PET MRI Nuclear Stress Tests Prior authorizatio is required for all Health Traditio plas, with the exceptio of 65Plus Medicare Supplemet Pla. Copies of the determiatio otices will be set to the orderig/referrig provider ad also to the member Practitioers may submit their prior authorizatio requests directly to Care To Care. These requests ca be submitted by: telephoe, fax or web portal usig the followig Care To Care cotact iformatio: Care to Care Call Ceter: Fax: If there are ay questios regardig this process, please cotact Care To Care directly at , Moday through Friday, 7 a.m. to 5 p.m. Cetral Time. Chiropractic Maagemet Health Traditio has a agreemet with HSM, Ic., to maage our chiropractic etwork. Maagemet services provided by HSM, Ic., iclude: Provider selectio assistace Provider credetialig Provider cotractig Claims paymet admiistratio Utilizatio maagemet Quality maagemet Please cotact Health Traditio Customer Service at (toll-free) to verify chiropractors participatig i the etwork. For iformatio o chiropractic pla procedures, please refer to your HSM, Ic., provider admiistrative maual. If you do ot have a maual available, please cotact HSM, Ic., at (toll-free). 20

21 Health Traditio Health Pla Medical Maagemet Autism Spectrum Disorder Health Traditio Health Pla has developed a complete provider etwork for services covered withi the Autism Spectrum Disorder (ASD). For more specific iformatio about the coverage of ASD, please referece the provisios foud i the Wiscosi Statute (12m) ad the Wiscosi Isurace Code For this complex diagosis, it is very importat for the treatmet team to work together. Please remember to sig Releases of Iformatio or ecourage your patiets to sig releases so that the treatmet team may effectively provide the services eeded. Prior Authorizatio Health Traditio does require prior authorizatio for covered services uder these provisios. You ca also cotact the Health Traditio Utilizatio Maagemet Departmet at (608) or toll-free at (888) to submit ay prior authorizatio requests. Services will be based upo a approved treatmet pla of evidece-based behavioral therapies from a authorized healthcare provider. Prior authorizatio forms ca be foud o the Health Traditio website at Click o Providers ad the Forms ad Istructios. Look for the Autism Prior Authorizatio form uder the Medical headig. Network Participatio If you are a provider for ASD services ad are iterested i joiig the Health Traditio provider etwork, please cotact our Network Developmet Departmet at (608) Customer Service (toll-free) 21

22 Health Traditio Health Pla Claims Claims Submissio Submit claims o a stadard CMS-1500 form or UB-04 claim form. Electroic claim submissio is preferred. Cotact Provider Relatios for assistace. Sed claims to: MMSI Att: Claims Departmet st Street NW Rochester, MN Time Limit for Claims Filig For best results, submit claims withi 60 days of the date of service. Clea claims will be processed withi 30 days of receipt. Claims must be submitted withi 15 moths of the iitial service date to receive reimbursemet for services redered. Claims received by Health Traditio with missig or icomplete data fields will be retured uprocessed. Telephoe Iquiry o Claims If paymet or rejectio is ot received withi 45 days of claim(s) submissio or you disagree with the way your claim was processed, first call Customer Service at (toll-free). Keep a copy of the claim to provide iformatio to the Customer Service Represetative. The Customer Service Represetative will assist you if resubmissio or correctio is required. Appealig Claims If you disagree with the way Health Traditio processed your claim, you may appeal by submittig a writte request statig the reaso for appeal, supportig documetatio ad your desired resolutio. Sed to: Health Traditio Att: Operatios Departmet PO Box 188 La Crosse, WI For More Iformatio: Cotact Health Traditio Customer Service at (toll-free) if you have ay questios o the followig issues: Member eligibility Beefit descriptio Claims status Reimbursemet Coordiatio of beefits Claims appeal 22

23 Health Traditio BadgerCare Plus Beefits Pla Descriptio Health Traditio BadgerCare Plus HMO Pla serves the Stadard, Bechmark ad Core populatios. Members must receive services from a Health Traditio provider. Members are eligible for all services that are covered by BadgerCare Plus. Visits to i-etwork specialists do ot require a referral. A referral is required for ay services outside of the Health Traditio etwork except i emergecy care situatios. Verifyig Membership Eligibility Providers ca verify eligibility by callig Wiscosi BadgerCare Plus Provider Services at or (toll-free). All erolled members must be Wiscosi residets. If a member is ot erolled i a BadgerCare Plus HMO, but o fee-forservice Medicaid BadgerCare Plus, they are eligible to use ay Wiscosi Medicaid certified provider. All BadgerCare Plus members are issued a Forward Health ID card with a magetic strip o the back. There are three ways for providers to verify the members eligibility: Purchase a swipe machie to read the magetic strip Utilize the EDSNET dial-up system olie Call Wiscosi Provider Services at (toll-free) Beefits Members erolled i the Health Traditio BadgerCare Plus HMO program through Health Traditio are etitled to the same beefits foud i the Wiscosi fee-for service BadgerCare Plus Program. Members caot be billed for ay BadgerCare Plus covered service. For more specific iformatio about BadgerCare Plus beefits, please refer to the Wiscosi BadgerCare Plus Provider Hadbooks or call Wiscosi BadgerCare Plus Provider Services at (toll-free). Customer Service (toll-free) 23

24 Health Traditio BadgerCare Plus Health Promotio Resources Disease Prevetio ad Welless Resources Health Traditio strogly believes i a proactive approach to health improvemet ad disease prevetio. Listed below are resources available to Health Traditio members: The Nurse Lie at Mayo Cliic Health System - Fracisca Healthcare 24-Hour urse-aswered telephoe lie with health iformatio. Call (toll-free) Smokig Cessatio Through the Mayo Cliic Tobacco Quitlie Call (toll-free) Couselig sessios via telephoe available Educatioal sessios at various provider sites Adult Prevetive Health Guidelie Recommedatios Physical exams Screeigs Tests Immuizatios Pediatric Prevetio Health Guidelie Recommedatios HealthCheck well-child exam Immuizatios Disease Maagemet Care Ehace Program Health Traditio Web site: Health Educatio ad Patiet Iformatio Brochures ad fact sheets Patiet educatio classes offered at various cliic sites Newsletters BadgerCare Plus Member Newsletter Health pla iformatio published quarterly, for BadgerCare Plus members 24

25 Health Traditio BadgerCare Plus Medical Maagemet Urget ad Emergecy Care Maaged care laws i Wiscosi iclude a uiform stadard of coverage for emergecy room care. Health Traditio s emergecy care defiitio ad provisios are outlied below: Emergecy Care Hospital or medical treatmet which is required uexpectedly ad immediately because of a accidetal ijury or emergecy illess. A emergecy shall exist whe a member s symptoms are of sufficiet severity to lead a prudet layperso to reasoably coclude that immediate medical attetio is ecessary. It does ot iclude elective medical treatmet for a illess or ijury for which the eed for care could reasoably have bee foresee. Health Traditio may ot dey coverage for emergecy services that a reasoably prudet layperso would cosider a emergecy. Prior authorizatio is ot required for emergecy care at ay hospital. Health Traditio should be cotacted withi 48 hours of a emergecy hospital admissio. Follow-up services must be provided i the appropriate settig to be eligible for coverage. Emergecy medical services or urget care that is provided to a covered depedet who is a full-time studet attedig school outside the geographic service area of the pla will be covered by Health Traditio. Questios about Emergecy Care: Call the Utilizatio Maagemet departmet at (La Crosse area) or (toll-free). Customer Service (toll-free) 25

26 Health Traditio BadgerCare Plus Health Promotio Resources Prior Authorizatio Prior Authorizatio the process of receivig writte approval from the Pla for certai services or products i advace of the service or product beig provided. Prior Authorizatio does ot guaratee paymet of beefits. Prior Authorizatio is required for the followig services: All durable medical equipmet over $750 Certai durable medical equipmet items uder $750 Cosmetic services/procedures Elective ipatiet admissio Experimetal/ivestigatioal services/procedures Gastric bypass High-tech radiology services (more specific detail is foud below) Home health care services Hospice care Ijectable drugs Outpatiet speech therapy services Skilled ursig facility admissio Trasplats Trasitioal care To obtai assistace with prior authorizatio, cotact Health Traditio at or (toll-free) or fax at Prior authorizatio requiremets are subject to chage upo otificatio 26

27 Health Traditio BadgerCare Plus Medical Maagemet Referrals Awritte referral form is required whe a practitioer refers a member to a out-of-etwork health care provider. However, a referral is ot required whe a practitioer refers a member to a i-etwork specialist. A list of i-etwork specialists is available to members i their Health Traditio provider directory. The Health Traditio ad BadgerCare Plus Directory ca be accessed o our Web site: Referrals to out-of-etwork health care providers must be approved by the Pla prior to services beig redered. I emergecy situatios, approval must be obtaied as soo as possible after the member receives services from a outof-etwork practitioer. If a member requires services from a specialist ot available i-etwork, Mayo Cliic i Rochester is the preferred out-of-etwork referral ceter. A writte referral must be approved by the Pla prior to services beig redered. The member s i-etwork health care provider coordiates referrals. This is obtaied by completig a exteral referral form that ca be foud o our Web site: The exteral form must be complete or it will ot be processed. Additioal referral forms ca be dowloaded from the HealthTraditio Web site; click o providers, the click o Forms ad Istructios. Additioal forms ca be requested by cotactig a Health Traditio Referral Coordiator at Completed referral forms ca be faxed to Health Traditio at To obtai assistace with prior authorizatio or referral requiremets, cotact Health Traditio at , or (tollfree). Medical Guidelies Health Traditio utilizes IterQual, a atioally recogized utilizatio maagemet criteria. These criteria are used i determiatios for: Type of treatmet Frequecy of treatmet Diagostic testig Upo request, Health Traditio will share these criteria. Cotact the Utilizatio Maagemet Departmet at or (toll-free). Customer Service (toll-free) 27

28 Health Traditio BadgerCare Plus Medical Maagemet Case Maagemet Health Traditio provides case maagemet services to high-risk members who require complex medical care. Case maagers work with a member s health care provider to establish ad coordiate a pla of care. Cotact Health Traditio at or (toll-free) if a Health Traditio patiet beig cared for at your facility may beefit from the special assistace of case maagemet. DME, Supplies The Durable Medical Equipmet (DME) ad Durable Medical Supply (DMS) guidelies are the same as those for the Wiscosi BadgerCare Plus program. DME is covered oly whe prescribed by a physicia. Covered services are limited to items cotaied i the Wiscosi Durable Medical Equipmet Idex. Certai items i this idex require prior authorizatio. Disposable Medical Supplies are also covered. Routie supplies used by a home health agecy that are ot recipietspecific are icluded i the patiet care visit rates ad are ot separately reimbursable. Please refer to the Wiscosi BadgerCare Plus provider hadbook for more specific iformatio or call Wiscosi BadgerCare Plus Provider Services at (toll-free). Disease Maagemet With the Health Traditio Health Pla Care Ehace Program, Health Traditio members i the BadgerCare Plus plas ca get additioal support ad tools to better maage chroic health problems such as: Asthma Diabetes Heart Failure Coroary Artery Disease Chroic Obstructive Pulmoary Disease Chroic Back Pai This volutary program provides traied urses who will offer oe-to-oe educatio ad iformatio desiged to help the patiets maage ad improve their health. As a provider, the urses with the Care Ehace Program will further assist i explaiig the pla of care that you have with your patiets. These urses will also work to keep your office iformed about ay patiet progress i this program. Health Traditio members ca get more iformatio about the Care Ehace Program by callig (866)

29 Health Traditio BadgerCare Plus Medical Maagemet Metal Health/Chemical Depedecy High-tech elective outpatiet imagig procedures require prior authorizatio. Care To Care will be reviewig these authorizatio requests o behalf of Health Traditio. The specific services that require prior authorizatio iclude: The followig services require prior authorizatio: Elective admissios Urget/emerget ipatiet admissios (otify the Pla withi 48 hours) Trasitioal care Prior Authorizatio for Psychological Testig Prior authorizatio is required for ay psychological testig. If services are provided without obtaiig prior approval from the Health Pla, services will be deied. The Prior Authorizatio Request for Psychological Testig form eeds to be completed before services have bee provided. Iformatio required icludes: Patiet ad provider iformatio Patiet diagosis, symptoms ad history Treatmet pla ad goals Specific test or tests required For additioal authorizatio forms, go to Click o Providers, the click o Forms ad Istructios. Completed authorizatio forms ca be faxed to Metal Health Services at or mailed to: Health Traditio Att: Metal Health Services PO Box 188 La Crosse, WI To obtai assistace with prior authorizatio or referral requiremets, cotact Health Traditio at (tollfree). Prior Authorizatio for High-tech Radiology Services High-tech elective outpatiet imagig procedures require prior authorizatio. Care To Care will be reviewig these authorizatio requests o behalf of Health Traditio. The specific services that require prior authorizatio iclude: CT MRA CTA PET MRI Nuclear Stress Tests Prior authorizatio is required for all Health Traditio plas, with the exceptio of 65Plus Medicare Supplemet Pla. Copies of the determiatio otices will be set to the orderig/referrig provider ad also to the member Practitioers may submit their prior authorizatio requests directly to Care To Care. These requests ca be submitted by: telephoe, fax or web portal usig the followig Care To Care cotact iformatio: Care to Care Call Ceter: Customer Service (toll-free) 29

30 Health Traditio BadgerCare Plus Medical Maagemet Fax: If there are ay questios regardig this process, please cotact Care To Care directly at , Moday through Friday, 7 a.m. to 5 p.m. Cetral Time. Chiropractic Maagemet Health Traditio has a agreemet with HSM, Ic. to maage our chiropractic etwork. Maagemet services provided by HSM, Ic. iclude: Provider selectio assistace Provider credetialig Provider cotractig Claims paymet admiistratio Utilizatio maagemet Quality maagemet Please cotact Health Traditio Customer Service at or (toll-free) to verify chiropractors participatig i the etwork. For iformatio o chiropractic pla procedures, please refer to your HSM Ic. provider admiistrative maual. If you do ot have a maual available, please cotact HSM Ic. at (toll-free). 30

31 Health Traditio BadgerCare Plus Claims Claims Submissio Electroic claim submissio is preferred. Submit claims o a stadard CMS-1500 form or UB-04 claim form. Cotact Provider Relatios for assistace. Sed claims to: UCare c/o Health Traditio P.O. Box 70 Mieapolis, MN Time Limit for Claims Filig For best results, submit claims withi 60 days of the date of service. Clea claims will be processed withi 30 days of receipt. Claims must be submitted withi 12 moths of the iitial service date to receive reimbursemet for services redered. Claims received by UCare c/o Health Traditio with missig or icomplete data fields will be retured uprocessed or deied. Telephoe Iquiry o Claims If paymet or rejectio is ot received withi 45 days of claim(s) submissio or you disagree with the way your claim was processed, please fax a Claim Status Adjustmet form to UCare, Att: Health Traditio Claims to If you do ot have oe of these forms, please call Customer Service at or (toll-free). Appealig Claims If you disagree with the way Health Traditio processed your claim, you may appeal by submittig a writte request statig the reaso for appeal, supportig documetatio ad your desired resolutio. Sed to: Health Traditio Health Pla Att: Operatios Departmet P.O. Box 188 La Crosse, WI For More Iformatio: Cotact the Health Traditio Member Advocate at or (toll-free) if you have ay questios o the followig issues: Member eligibility Beefit descriptio Claims status Reimbursemet Coordiatio of beefits Claims appeal Customer Service (toll-free) 31