PROVIDER MANUAL 2018

Transcription

1 PROVIDER MANUAL 2018

2 Table of Contents WELCOME LETTER... 7 SECTION 1: KEY CONTACT INFORMATION... 8 Key Contact Information... 8 Telephone & Prompts... 8 Fax... 8 Web/ Claims... 8 Member Services... 8 Member Enrollment... 8 Clinical Operations... 8 Dental... 8 Pharmacy... 9 Provider Network... 9 Compliance... 9 Third Party Liability... 9 Interpreter Services... 9 SECTION 2: INTRODUCTION TO COMMONWEALTH CARE ALLIANCE What Is Commonwealth Care Alliance? Our Mission Our Vision Our Approach SECTION 3: MEMBER ELIGIBILITY Senior Care Options Eligibility Requirements One Care Eligibility Requirements Member Identification Card Senior Care Options One Care Interpreter Services Prevent Discrimination Office Access Parity Office Access and Availability SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Emergency Medical Treatment and Labor Act Behavioral Health Services Home Health Services Skilled Nursing Facility Services (SNF) Rev 12/2017 Back to the top Page 1 of 83

3 Radiology Services Durable Medical Equipment (DME) SECTION 5: CENTRALIZED ENROLLEE RECORD SECTION 6: CLAIMS AND BILLING PROCEDURES Contact Information for Provider Claims and Billing Support Billing Members Claims Submission Electronic Data Interchange Claims Three EDI Options Clearinghouse Submitters: Direct Submitters: Single Claims Submitters: Reprocessing EDI Claims Electronic Fund Transfer (EFT) EFT Advantages: Explanation of Benefits (EOB) Statements Paper Claims Use of Invoices Use of Modifiers Timely Claims Submission Checking Claim Status Web Portal Resubmission of Paper Claims Provider Appeals Payment Policy National Drug Coverage Extended Care Facility Billing Information Behavioral Health Billing Information Licensure and Modifiers Significant Events with Reimbursement Impact Serious Reportable Events Hospital Acquired Conditions Provider Preventable Conditions SECTION 7: CLINICAL DOCUMENTATION AND MEDICARE RISK ADJUSTMENT Clinical Documentation Processes Documentation Compliance Coding Compliance Educational Resources Rev 12/2017 Back to the top Page 2 of 83

4 Medicare Risk Adjustment: General Guidelines and Recommendations General Medicare Risk Adjustment Guidelines Annual Assessment Process SECTION 8: COORDINATION OF BENEFITS AND THIRD PARTY LIABILITY Member Covered by Employer Sponsored Health Insurance Plan Member Involved in a Motor Vehicle Accident Occupational Injuries SECTION 9: PHARMACY PROGRAM Formulary Prior Authorization Step Therapy Program Extended Day Supply Medication Therapy Management Program SECTION 10: INFORMATION FOR ANCILLARY PROVIDERS EXTENDED CARE FACILITIES, DURABLE MEDICAL EQUIPMENT, & VISION Extended Care Facilities Prior Authorization Level of Care Determinations Status Change Form (SC-1) For SCO Members Member Enrollment Centers (MEC) Durable Medical Equipment Durable Medical Equipment Medical/Surgical Supplies Prior Authorization Eligibility Service Specifications for Durable Medical Equipment Accessibility Repairs Equipment Delivery and Removal Dental Vision Service Specifications for Vision Accessibility Repairs Eyewear Care SECTION 11: BEHAVIORAL HEALTH SERVICES PROVIDERS Behavioral Health Inpatient Covered Services Behavioral Health Outpatient Covered Services Rev 12/2017 Back to the top Page 3 of 83

5 Behavioral Health Diversionary Covered Services Clinical Conditions and Criteria for Behavioral Health Inpatient Services Access and Availability for Behavioral Health Office Visits Access and Availability for Behavioral Health Emergency or Urgent Visits Referral Tracking for Substance-Abuse Treatment Providers SECTION 12: LONG TERM SERVICES AND SUPPORT PROVIDERS Long Term Services and Supports Other LTS may be brought to the member in his/her home or residence Clinical Conditions, Criteria & Authorization for Long Term Services and Supports Long Term Services and Supports Coordinator (LTSC) Geriatric Support Services Coordinator (GSSC) SECTION 13: QUALITY IMPROVEMENT PROGRAM Quality Program Objectives Program Monitoring and Evaluation Collaboration with Contracted Providers in the Creation, Implementation, and Monitoring of the Quality Program Improvement Plan Prioritized Quality Initiatives Compliance with CMS and MassHealth Healthcare Effectiveness Data and Information Set Guidelines (HEDIS) Consumer Assessment of Healthcare Providers and Systems (CAHPS ) Health Outcomes Survey (HOS) Quality of Care Concerns Confidentiality SECTION 14: PROVIDER CREDENTIALING Credentialing and Re-credentialing Process Types of Providers Credentialed Information Required for Credentialing Your Right to Review and Correct Erroneous Information Your Right to Be Informed Credentialing File Review, Determinations, Notice and Reporting Credentialing/Recredentialing Criteria Recredentialing Ongoing Monitoring and Off-Cycle Credentialing Reviews and Actions Credentialing Appeals Process for Practitioners Right of Appeal Notice Practitioner Request for Appeal Credentialing Committee Reconsideration Rev 12/2017 Back to the top Page 4 of 83

6 Appeals Panel Hearing and Notice Re-Application following Denial or Termination Role of the Credentialed Primary Care Provider (PCP) Role of the Credentialed Specialist Organizational Providers Recredentialing of Organizational Providers Quality of Care Issues Credentialing Contact Information SECTION 15: MARKETING GUIDELINES Provider-Based Activities Provider Affiliation Information SECTION 16: Compliance and FRAUD, WASTE & ABUSE programs Commonwealth Care Alliance s Compliance Program Commonwealth Care Alliance s Fraud, Waste & Abuse Program Regulations General Compliance and Fraud, Waste & Abuse Training How to Report any Suspected Compliance Concerns: Policies and Procedures SECTION 17: PROVIDER TRAINING Provider Training Requirements Primary Care Providers Behavioral Health Facility Human Rights One Care Specific Training for Providers One Care Providers on Care Teams SECTION 18: FORMS Attached Forms Appointment of Representative (Form CMS-1696)* EDI Transactions Questionnaire Electronic Funds Transfer (EFT) Electronic Remittance Notice Notice of Privacy Practices Prior Authorization Standardized Request Form Mass Collaborative Prior Authorization Standardized Request Form Behavioral Health Prior Authorization Form - Cardiac Imaging Prior Authorization Form - CT/CTA/MRI/MRA Prior Authorization Form - PET PET CT Prior Authorization Form Massachusetts Medication Requests Prior Authorization Form Repetitive Transcranial Magnetic Stimulation Request Prior Authorization Form Psychological and Neuropsychological Assessment Rev 12/2017 Back to the top Page 5 of 83

7 Provider Referral Form: SCO Provider Referral Form: One Care Rev 12/2017 Back to the top Page 6 of 83

8 WELCOME LETTER January 2018 Dear Commonwealth Care Alliance Provider: Welcome to the Commonwealth Care Alliance provider manual. The provider manual has recently undergone revisions and includes updates on doing business with Commonwealth Care Alliance. The manual includes information about our Senior Care Option and One Care programs. Commonwealth Care Alliance is committed to partnering with providers to ensure our members receive the highest quality coordinated care possible, and we have designed this administrative resource to provide you with comprehensive information about our programs and plan. In addition to detailed Commonwealth Care Alliance program information, you will find our policies and procedures, referral and claim information, and other useful reference materials that we hope will make working with Commonwealth Care Alliance staff and members as simple as possible. Commonwealth Care Alliance members are encouraged to be active participants in their health care. When members enroll in Commonwealth Care Alliance, they receive a Member Handbook, which outlines the terms of benefits. Copies of the handbook may be obtained by contacting the Commonwealth Care Alliance Member Services Department at (866) If you have any questions regarding the information in this provider manual, please call Provider Relations at (617) Sincerely, Provider Relations Rev 12/2017 Back to the top Page 7 of 83

9 SECTION 1: KEY CONTACT INFORMATION SECTION 1: KEY CONTACT INFORMATION Key Contact Information Contact Telephone & Prompts Fax Web/ Claims Office P.O. Box Portsmouth, NH TTY Massachusetts Relay Service (800) (800) (TTY 711) Claims Refunds and escalations Corrected Claims Claims status Claim receipt, check run (800) New providers, contracting, and EDI Electronic billing set up or problems (603) Member Services General questions Initial contact Member appeals Service denials - Process; how to respond (866) (617) memberservices@commonwealth care.org Member benefits Member information; coverage Member eligibility MassHealth (888) Member Enrollment Outreach and Marketing Referrals for potential members Clinical Operations Clinical Decision Support Team and prior authorization Benefit and service authorizations Dental Claims to be processed Scion (866) (617) rkatzman@commonwealthcare.or g (866) (855) (855) Website: Rev 12/2017 Back to the top Page 8 of 83

10 SECTION 1: KEY CONTACT INFORMATION Member eligibility Scion Claims issues Scion m Provider relations Scion Pharmacy General questions Questions, vendor Provider Network Provider Relations Training, orientation, general questions Provider Enrollment New provider enrollment, provider date edits (866) (857) e.org (866) (617) care.org are.org Provider contracting Requests to become a Commonwealth Care Alliance provider Medical or Behavioral Health Compliance Concerns and reporting Fraud, waste, and abuse and compliance concerns Third Party Liability COB, third party, Q & A (617) ext Interpreter Services The provider or member may contact CCA s Member Services department at (866) and they will connect them to the appropriate interpreter telephonically. (800) Compliance Hotline **anonymous** (866) ccacontracting@commonwealthca re.org ccacompliance@commonwealthc are.org **not anonymous** tplcoordinator@commonwealthcar e.org Please have the following information available: Members name and ID number. Our Member Services department is available during the hours of 8:00 a.m. to 8:00 p.m. (Monday thru Friday) 8:00am to 6:00pm (Saturday and Sunday). Rev 12/2017 Back to the top Page 9 of 83

11 SECTION 2: INTRODUCTION TO COMMONWEALTH CARE ALLIANCE SECTION 2: INTRODUCTION TO COMMONWEALTH CARE ALLIANCE This section introduces Commonwealth Care Alliance and describes its mission, vision, and approach to giving the highest quality health care to its members. What Is Commonwealth Care Alliance? Commonwealth Care Alliance, Inc. is a nonprofit care delivery system committed to providing integrated health care and related community support services. Created in 2003, Commonwealth Care Alliance is a consumer-governed organization offering a full spectrum of medical and social services for people with complex needs covered under Medicaid and for those dually eligible covered by both Medicaid and Medicare, including: Older adults (aged 65+) Individuals over 21 years of age with serious physical, cognitive, or chronic mental health disability Commonwealth Care Alliance is organized as a consumer-governed care system to ensure that the empowered consumer voice is built into all of our activities. The fact that the founding partners of Commonwealth Care Alliance are Community Catalyst, Health Care For All, and Boston Center for Independent Living attests to this commitment, and thus fundamentally breaks new ground for the role of health care advocacy. A unique feature of our model of care is the importance of the value of community caregivers and respect for relationship forged in trust between members and member caregivers. Our Mission At Commonwealth Care Alliance, our mission is to provide the best possible care, tailored individually to the members we serve throughout Massachusetts elders and people across the age spectrum with special healthcare needs. To accomplish this, we bring to scale proven clinical strategies that improve care and manage costs, within a team-based, consumer-directed, prepaid care delivery program. Our Vision It is our vision to bring people with complex medical and behavioral health needs high quality and personalized care resulting in improved health and better self-management of chronic illness. Our Approach Although the characteristics of the varied populations to be served by Commonwealth Care Alliance are quite different, experience has demonstrated common care system principles that are key to improving care and managing costs. These principles include: A top to bottom clear exclusive mission to serve vulnerable populations Specialized administrative and clinical programmatic expertise New approaches to care management and care coordination that support primary care clinicians through a team approach involving nurse practitioners, nurses, behavioral health clinicians, and/or non-professional peer counselors 24 hour/7 day a week personalized continuity in all care settings at all times Selective comprehensive primary care networks and selective networks of physician specialists, health care facilities, human service agencies, community based organizations, and institutional long term care services facilities Flexible benefit designs Promotion of member empowerment and self-management strategies Full integration of medical, behavioral health and long term care services State of the art clinical information technology support for the care delivery and payment system Rev 12/2017 Back to the top Page 10 of 83

12 SECTION 3: MEMBER ELIGIBILITY SECTION 3: MEMBER ELIGIBILITY Senior Care Options Eligibility Requirements Commonwealth Care Alliance Senior Care Options (SCO) is for elders who: Are 65 or older Are eligible for MassHealth Standard* Live in the Commonwealth Care Alliance service area Do not have end-stage-renal-disease (ESRD) Agree to receive all covered health and long term services through Commonwealth Care Alliance *The SCO program is open to MassHealth Standard members with or without Medicare The program is open to elders in all living situations, including: Elders living independently Elders living in the community with support services Elders in long term care facilities (the potential member cannot be an inpatient at a chronic or rehabilitative hospital or reside in an intermediate care facility) One Care Eligibility Requirements Commonwealth Care Alliance One Care is for adults who: Are age 21 through 64 at the time of enrollment Are eligible for MassHealth Standard or CommonHealth Are enrolled in Medicare Parts A and B and eligible for Part D Do not have access to other public or private health insurance that meets basic benefit level requirements Live in the Commonwealth Care Alliance One Care service area Agree to receive all covered medical, behavioral health, and long term services and supports through Commonwealth Care Alliance Note: One Care will not currently enroll people who are in a PACE or HCBS Waiver program. Rev 12/2017 Back to the top Page 11 of 83

13 SECTION 3: MEMBER ELIGIBILITY Member Identification Card Each member receives a Commonwealth Care Alliance identification card to be used for services covered by Commonwealth Care Alliance and prescription drug coverage at network pharmacies for both the Senior Care Options Program and the new One Care Program. Please see an example card below. Senior Care Options One Care Please call Member Services at Commonwealth Care Alliance to verify eligibility and confirm that the membership is still active Rev 12/2017 Back to the top Page 12 of 83

14 SECTION 3: MEMBER ELIGIBILITY Interpreter Services Commonwealth Care Alliance providers must ensure that members have access to medical interpreters, signers and TDD/TTY services to facilitate communication, without cost to them. If the member speaks a language that is not prevalent in the community and/or the provider does not have access to interpretation, CCA will provide telephonic language assistance services. The provider or member may contact CCA s Member Services department at (866) and they will connect them to the appropriate interpreter telephonically. Please have the following information available: Members name and ID number. Our Member Services department is available during the hours of 8:00 a.m. to 8:00 p.m. (Monday thru Friday) 8:00am to 6:00pm (Saturday and Sunday). Prevent Discrimination Commonwealth Care Alliance Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CCA does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. All CCA Providers must: Make covered health services available to all Members Accept and treat Members without discrimination in comparison to such services rendered to your other patients and without discriminating based upon source of payment, sex, age, race, color, religion, origin, health status, or disability Assist our non-english-speaking Members get interpreter services if necessary (Members/Providers can call our Member Services number for translation services (866) ) Office Access Parity Commonwealth Care Alliance providers will ensure that Commonwealth Care Alliance members have equal access or parity to providers as commercial members of other health plans, or as to individuals eligible to receive services through MassHealth s fee-for-service system. This parity may include hours of office operations, after-hours care and provider coverage. Office Access and Availability Commonwealth Care Alliance is committed to providing provider access and availability to its members in a timely manner. In addition to this commitment, the State has provided a timeframe requirement that the Commonwealth Care Alliance provider network needs to adhere to in order to support each member s needs. The timeframe requirements are as follows: Urgent Care and Symptomatic Office Visits. All Urgent Care and symptomatic office visits must be available to Enrollees within 48 hours. A symptomatic office visit is an encounter associated with the presentation of medical symptoms or signs, but not requiring immediate attention. Examples include recurrent headaches or fatigue. Non-symptomatic Office Visits. All non-symptomatic office visits must be available to Enrollees within 30 calendar days. Examples of non-symptomatic office visits include, but are not limited to well and preventive-care visits for Covered Services, such as annual physical examinations or immunizations. Behavioral Health Providers Access and Availability timeframes can be found in Section 11 of this Provider Manual. Rev 12/2017 Back to the top Page 13 of 83

15 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS In accordance with the member s evidence of coverage, certain services performed by contracted providers require a prior authorization before being rendered. Commonwealth Care Alliance s Clinical Effectiveness Department is responsible for reviewing prior authorization service requests from providers. All requests (except Behavioral Health, Specialized Radiology Services & Inpatient/Observation Admissions please see below for details) must be faxed to using the Standardized Prior Authorization Request Form along with the necessary clinical documentation to support the request. Download the form. - Behavioral Health prior authorization service requests must be faxed to using the appropriate form for the service requested along with the necessary clinical documentation to support the request. Download the forms. - Specialized Radiology prior authorization service requests must be faxed to using the appropriate form for the service requested along with the necessary clinical documentation to support the request. Download the forms. - Inpatient/Observation Admissions prior authorization service requests must be faxed to using the appropriate form for the service requested along with the necessary clinical documentation to support the request. Download the forms Prior authorization decisions will be made no later than fourteen (14) calendar days after CCA receives the request (or within seventy-two [72] hours for expedited requests). Services requiring prior authorization by CCA are listed below. If a requested service or item is not listed below, please call Commonwealth Care Alliance at for clarification. Emergency Medical Treatment and Labor Act As defined by the Emergency Medical Treatment and Labor Act (EMTALA 42 CFR (b)), the Commonwealth Care Alliance provider network will provide proper medical screenings and examinations for all individuals who seek care in a provider s emergency department by qualified hospital personnel. A provider will either provide stabilizing treatment for that individual or arrange for another qualified provider to do so. Nothing shall impede or obstruct a provider from rendering emergency medical care to an individual. Rev 12/2017 Back to the top Page 14 of 83

16 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS For Services That Require Prior Authorization, Please Refer To Claim Submission Billing Guidelines Below: Commonwealth Care Alliance (CCA) Covered Services One Care and Senior Care Options Prior Authorization (PA) Requirements Place of Service Code Type Code Range on Claim Modifier Unit of Measure Abortion* (One Care Only) No Acupuncture Yes 11,12, 21, 22, 50, CPT N/A N/A 53, 62 Adult Day Health - Basic Yes 11, 49, 99 HCPCS S5102 N/A Per Diem Adult Day Health Complex Yes 11, 49, 99 HCPCS S5102 TG Per Diem Adult Day Health Day Services Yes 11, 49, 99 HCPCS S5102 UD Per Diem Adult Foster Care - Level I Yes 12, 14, 33, 54 HCPCS S5140 N/A Per Diem Adult Foster Care - Level I Alternative Placement No Please note: an authorization for S5140 must be on file in order to utilize modifiers TF, U6, U7. 12, 14, 33, 54 HCPCS S5140 TF U6 U7 Per Diem Per Diem Per Diem Adult Foster Care - Level II Yes 12, 14, 33, 54 HCPCS S5140 TG Per Diem Adult Foster Care - Level II Alternative Placement No. Please note, an authorization for S5140 TG must be on file in order to utilize modifiers U5, TGU6, TGU7. 12, 14, 33, 54 HCPCS S5140 TGU6 TGU7 U5 Per Diem Per Diem Per Diem Adult Foster Care Intake and Assessment No Services 12, 14, 33, 54 HCPCS T1028 N/A Per Admission Group Adult Foster Care (GAFC) Yes (Supportive Housing) 12, 14, 33, 54 HCPCS H0043 N/A Per Diem Ambulance: Emergency Transportation No Rev 12/2017 Back to the top Page 15 of 83

17 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Alzheimer s Assessment Yes 04, 12, 13, 14, 16 HCPCS S5110 N/A Per Session Alzheimer s Coaching Yes 04, 12, 13, 14, 16 HCPCS S5111 N/A Per 15 Minutes Ambulatory/Outpatient Surgery Yes Please call CCA s Member Services for more information (866) Assisted Living (Basic) Yes 13 HCPCS T2031 N/A Assisted Living Special Care/Memory Care Unit Yes 13 HCPCS T2031 TG Per Diem Audiology No Behavioral Health Care Services Please see: Behavioral Health Section Please see: Behavioral Health Section Cardiac Rehabilitation Services Yes 11, 22, 31, 61, 62 CPT/ HCPC / N/A Per Session G0422, G0423 Care Transitions Across Settings No Chemotherapy No Chiropractic Care Yes, after 20 sessions 11, 12, 22, 50, 53, CPT N/A N/A 62 Chore Services - Heavy Yes 04, 12, 13, 14, 16 HCPCS S5121 UB Per 15 minutes Chore Services - Light Yes 04, 12, 13, 14, 16 HCPCS S5120 N/A Per 15 minutes Companion Services Yes 04, 12, 13, 14, 16 HCPCS S5135 N/A Per 15 minutes Companion Services with Transportation Yes 04, 12, 13, 14, 16, 99 HCPCS S5135 TG Per 15 Minutes Day Habilitation - Skills Training and Development Day Habilitation - Therapeutic Behavioral Services Day Habilitation - Community Based wraparound services Yes Yes Yes 11, 18, 49, 99 HCPCS H2014 N/A Per 15 Minutes 11, 18, 49, 99 HCPCS T2020 N/A Per 15 Minutes 11, 18, 49, 99 HCPCS T2021 N/A Per 15 Minutes Rev 12/2017 Back to the top Page 16 of 83

18 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Dental: Emergency Oral Health Dental: Preventive Dental: Restorative fillings Dental: Crowns Dentures Oral Surgery Other No No No Yes Replacement dentures and crowns are limited to coverage once every five years unless authorized differently Commonwealth Care Alliance has selected Scion Dental as dental program administrator for its Senior Care Options and One Care plans. All claims and authorizations must be submitted to Scion. Additional requirements and limitations may apply. Please click here to access the Scion Dental Provider Manual for more information. Additional questions or inquiries should be directed to Scion Dental Provider Relations (855) Diabetic Self-Management Training, Services, and Supplies Yes - for non-formulary Diabetic testing supplies If you have questions, please call member services Diagnostic Services, including but not No limited to endoscopy, colonoscopy, and sigmoidoscopy (or screening barium enema) Dialysis and Supplies No Durable Medical Equipment and Medical Supplies Please Click here for DME PA list. 04, 11, 12, 13, 14, 33, 54, 55, 56, 65, Education and Wellness Programs No Emergency Services No Covered up to $1000 outside of the United States for SCO members only Enteral Therapy No Environmental Aids and Assistive /Adaptive technology Please Click here for DME PA list Rev 12/2017 Back to the top Page 17 of 83

19 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Family Planning* (One Care Only) No Family planning services are available through any MassHealth and/or Commonwealth Care Alliance family planning provider. Treatment for medical conditions of infertility*, treatment for AIDS and other HIV related conditions, and genetic testing needs to be received from CCA s providers This service does not include artificial ways to become pregnant. Gender Reassignment Surgery and Related Services Yes Please call CCA s Member Services for more information (866) Genetic Testing Yes Please call CCA s Member Services for more information (866) Grocery Shopping and Delivery Yes 12, 99 HCPCS S5121 N/A Per Order Gym Membership (SCO only) Yes All - S9451 N/A Various (e.g. Per Month / Per Year / Per Weeks) Hearing Aids - Fitting and Refitting No Hearing Aids - Major Repairs Hearing Aids, Replacement and Accessories Home Based Wandering Response System Installation Home Based Wandering Response System Monthly Fee No, unless cost exceeds $500 per line item No, unless cost exceeds $500 per line item or identified on itemized DME PA list. Click here for DME PA list. Yes 04, 12, 13, 14, 16 HCPCS T2028 N/A Per Event Yes 04, 12, 13, 14, 16 HCPCS S5161 U1 Per Month Rev 12/2017 Back to the top Page 18 of 83

20 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Home Delivered Meals Yes 04, 12, 13, 14, 16 HCPCS S5170 N/A Per Meal Home Health, including home health aides, therapies and skilled nursing Yes, please see Home Health Services Please see Home Health Services section Homemaker Service Yes 04, 12, 13, 14, 16 HCPCS S5130 N/A Per 15 Minutes Hospice - Medicare Hospice Commonwealth Care Alliance: The plan covers hospice (including room and board in a facility) under the MassHealth (Medicaid) benefit. No. Medicare pays for Hospice Services if Member elects Medicare Hospice No. Please call CCA s Member Services for more information (866) HCPCS T2044, T2045, T2046 N/A Per Diem Immunizations/Vaccines, including but not No limited to: flu, Hepatitis B, and Pneumococcal vaccines Infusion therapy in an outpatient facility Yes 11, 22, 24 CPT N/A N/A Inpatient Hospital Services, including all inpatient services at following settings: acute inpatient, chronic, rehabilitation, psych-detox, and substance abuse Yes 21, 51, 61 REV N/A Days Interpreter Services No Laboratory Services (excluding genetic testing) No Laundry Yes 04, 12, 13, 14, 16 HCPCS S5175 N/A Per Order Massage Therapy Yes 11, 12, 13, 16, 31, 32, 33, 99 CPT 97124, 97112, 97122, 97140, N/A Per 15 Minutes Medication Dispensing System Yes 04, 12, 13, 14, 16 HCPCS A9279 N/A Per Month Rev 12/2017 Back to the top Page 19 of 83

21 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Medication Dispensing System Installation Yes 04, 12, 13, 14, 16 HCPCS T5999 UB Per Installation Orthotics Please Click here for DME PA list Outpatient Blood Services No Outpatient Hospital Services. Observation No Level of Care Oxygen Please Click here for DME PA list. 12, 13, 14, 16, 33 Peer Support No 11, 12, 99 HCPCS H0038 U1 Per 1 Hour Peer Support - Behavioral Health - Individual Peer Support, Community/Residential, including Individual Living Home Care Services No 11, 12, 99 HCPCS H0038 HE Per 1 Hour Peer Support - Behavioral Health - Community/Residential, group of 2 Peer Support - Behavioral Health - Community/Residential, group of 5 or more Personal Care Homemaker through a Personal Care Agency (PCHM) No 11, 12, 99 HCPCS H0038 UA Per Enrollee per 1 Hour No 11, 12, 99 HCPCS H0038 UB Per Enrollee per 1 Hour Yes 04, 12, 13, 14, 16 HCPCS S Per 15 minutes Personal Care Attendant (PCA) Services Yes 04, 12, 13, 14, 16 HCPCS T Per 15 Minutes Personal Care Management Assessment- Initial Evaluation Personal Care Management Assessment Re-evaluation Yes 04, 12, 13, 14, 16, 99 Yes 04, 12, 13, 14, 16, 99 Personal Care Management Skill Training Yes 04, 11, 12, 13, 14, 16 Personal Care Management No 04, 11, 12, 13, 14, Intake, Orientation & Screening (PCM) 16 Personal Emergency Response System (PERS) Rev 12/2017 Back to the top Page 20 of 83 CPT Per Session CPT TS Per Session HCPCS T Per Month HCPCS T Per Month Yes 04, 12, 13, 14, 16 HCPCS S Per Month PERS Auto Detect Fall Yes 04, 12, 13, 14, 16 HCPCS S5161 SC Per Month

22 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS PERS- Cellular Yes 04, 12, 13, 14, 16 HCPCS S5161 SQ Per Month Personal Emergency Response System (PERS) Installation and Testing Podiatry (excluding surgical procedures) Preventive Services and Screenings, including but not limited to: abdominal aortic aneurysm screening, annual wellness visits, alcohol misuse screening and counseling, bone mass measurement, breast cancer screening (mammograms), cardiovascular disease risk-reduction visit (therapy for cardiovascular disease), cardiovascular disease testing, cervical and vaginal cancer screening, colorectal cancer screening (fecal occult blood test sigmoidoscopy, colonoscopy or screening barium enema), smoking and tobacco use cessation (counseling to stop smoking or tobacco use), depression screening, diabetes screening, HIV screening, medical nutrition therapy services for people with diabetes or kidney disease, obesity screening and therapy to promote sustained weight loss, prostate cancer screening exams, screening for hepatitis C virus (HCV), screening for sexually transmitted infections (STI) and counseling, and any additional preventive services approved by Medicare and/or MassHealth during the contract year Yes 04, 12, 13, 14, 16 HCPCS S Per Session No, unless provided in a nursing home setting. No Primary Care Provider Services No Prosthetic Services and Devices Please Click here for DME PA list Pulmonary Rehabilitation Yes 11, 22, 31, 61, 62 HCPCS G0424 N/A Per Hour Radiation Oncology No Radiology and X-ray Services X-rays do not require a PA. Only specified radiology per itemized list requires PA Please click here for itemized list 11, 21, 22, 23, 50, N/A N/A Rev 12/2017 Back to the top Page 21 of 83

23 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Respiratory Equipment Please Click here for DME PA list Respiratory Therapy Respite Care Skilled Nursing Facility Services, including services at the following levels: sub-acute, skilled, custodial, medical and nonmedical leave of absence No No Yes, Please see Skilled Nursing Facility Services section Please see Skilled Nursing Facility Services section Supportive Day Program, SCO only (Social Day Care) Yes 11, 49 HCPCS S5101 N/A ½ Day Supportive Home Care Aide Yes 04, 12, 13, 14, 16 HCPCS S5125 N/A Per 15 Minutes Specialty Physician Services, No Including but not limited to the following list and second opinions upon the request of the Member: anesthesiology, audiology, cardiology, dermatology, gastroenterology, gynecology, internal medicine, nephrology, neurology, neurosurgery, obstetrics, oncology, ophthalmology, oral surgery, orthopedics, otolaryngology, podiatry, psychiatry, pulmonology, radiology, rheumatology, surgery, thoracic surgery, vascular surgery, and urology. Therapies: Home Occupational Physical Speech Yes, Please see Home Health Services Section Please see Home Health Services Section Therapies: Outpatient Occupational Physical Speech No Rev 12/2017 Back to the top Page 22 of 83

24 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Tobacco Cessation No Transplant Services Yes Please call CCA s Member Services for more information (866) Transportation: Emergency Transportation: Non-Emergency; Taxi Transportation: Non-Emergency; Wheelchair Van Transportation: Non-Emergency; Patient Attendant/Escort Transportation: Non-Emergency; Stretcher Van No, Emergency Transportation is not covered outside of the United States and its territories Yes N/A CPT A0100 N/A One Way Trip Yes N/A CPT A0130 N/A One Way Trip Yes N/A CPT T2001 N/A One Way Trip Yes N/A CPT T2005 N/A One Way Trip Transportation 1 way trip Yes N/A CPT T2003 N/A One Way Trip Transportation: Mileage Yes N/A CPT A0425 S0215 S0209 Vision Care Services: Eyeglasses and Contact Lenses No SCO - Benefit limit $300 /year per frame. One Care - Benefit limit $125/year per frame N/A Mile Vision Care Services: Other: Comprehensive eye exams (including routine care) Vision training Outpatient physician services or diagnosis and treatment of disease and injuries of the eye. This includes treatment of agerelated macular degeneration. Glaucoma screenings. No Rev 12/2017 Back to the top Page 23 of 83

25 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Behavioral Health Services Commonwealth Care Alliance Covered Services Inpatient Mental Health Care (Inpatient Psychiatric) Inpatient Substance Abuse One Care and Senior Care Options Prior Authorization (PA) Requirements Emergency Admission: No prior authorization is required, but notification is required before bed placement Non-emergency admission: Yes No Prior authorization is not required, but notification is required before bed placement Place of Service Code Type Code Range on Claim Please see above page, Inpatient Hospital Services Please see above page, Inpatient Hospital Services Modifier Behavioral Health Diversionary Services Acute Treatment Services for No Substance Abuse Clinical Support Services for Substance Abuse (Residential Substance Abuse Programs) No Unit of Measure Community Support Program Yes 15 HCPCS H2015 N/A Per 15 Minutes Community Crisis Stabilization No Notification is required within hours Intensive Outpatient Program No 11, 51, 52, 53, 56 REV 905 N/A Per Diem Observation/Holding Beds No, Notification is required within 24 hours Partial Hospitalization No 21,22, 51,52 REV 912 N/A Per Session (Per Half Day) Program of Assertive Community Treatment (PACT) Yes 15 HCPCS H0040 N/A Per Diem Psychiatric Day Treatment Yes 11, 22, 52, 53, 57 HCPCS H2012 N/A Per Hour Rev 12/2017 Back to the top Page 24 of 83

26 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Structured Outpatient Addiction Program Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold No 11, 19, 21, 22, 52, 53, 55, 57 Yes 11, 19, 21, 22, 51, 52, 56 Yes 11, 19, 21, 22, 51, 52, 56 Yes 11, 19, 21, 22, 51, 52, 56 HCPCS H0015 N/A Half Day HCPCS N/A Per Session HCPCS N/A Per Session HCPCS N/A Per Session Behavioral Health Emergency Services Emergency Screening No Services/Short Term Crisis Counseling Medication Management Crisis No Specialing Services Yes for Community or Home Care Aide Behavioral Health Outpatient Services Behavioral (Mental) Health, including but not limited to treatment and therapy, consultations, medication visits, and ambulatory detoxification 11, 41, 51, 52, 54, 55, 56, 61 HCPCS T1004 HE Per 15 Minutes No, unless provided in a day program Substance Abuse Services, including but not limited to acupuncture treatment and methadone maintenance No Rev 12/2017 Back to the top Page 25 of 83

27 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Behavioral Health Special Procedures Electro Convulsive Therapy Yes 11, 19, 21, 22, 51, 52, 56 Neuropsychological Testing Yes 11, 12, 21, 22, 31, 32, 33, 50, 51, 52, 53, 54, 55, 56, 57 CPT N/A Per Session CPT 96118, N/A Per Hour If a requested service or item is not listed above, please call Commonwealth Care Alliance at for clarification. All Non-contracted providers and vendors require Prior Authorization The list has been updated on 01/01/18. Changes were made for clarification. Some of the requirements in member booklets may differ. The requirements provided herewith are provider requirements. Providers need to do diligence to ensure PA is obtained if required. Rev 12/2017 Back to the top Page 26 of 83

28 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Home Health Services Commonwealth Care Alliance Covered Services One Care and Senior Care Options Prior Authorization (PA) Requirements Place of Service Home Health Aide Yes 04, 12, 13, 14, 16 Home Infusion Therapy Yes 04, 12, 13,14, 16, 18 Code Type Code Range on Claim Modifier Unit of Measure HCPCS G0156 N/A 15 Minutes/ Service CPT 99601, N/A = Per Visit (Up to 2 Hours); = Each Additional Hour Independent Nursing/Private Duty Nursing/Continuous Nursing Services Yes 12, 13, 16 HCPCS T1000, T1002, T1003 N/A Per 15 Minutes Occupational Therapy Yes 04, 12, 13, 14, 16 Occupational Therapy Assistant Yes 04, 12, 13, 14, 16 Physical Therapy Yes 04, 12, 13, 14, 16 Physical Therapy Assistant Yes 04, 12, 13, 14, 16 Skilled Nursing Yes 04, 12, 13, 14, 16 HCPCS G0152 N/A Per Visit HCPCS G0158 N/A Per Visit HCPCS G0151 N/A Per Visit HCPCS G0157 N/A Per Visit HCPCS G0299 G0300 G0299 G0300 Social Work Visit Yes 04, 12, 13, 14, HCPCS G0155 N/A Per Visit 16 Speech Therapy Yes 04,12, 13, 14, 16 HCPCS G0153 N/A Per Visit - - UD UD Per Visit Remote Patient Monitoring Services: Tele-health originating site facility fee (Installation/removal of remote monitoring equipment) Remote Patient Monitoring Services: Nurse visit by RN & Nurse visit by LPN Yes 12, 99 HCPCS Q3014 N/A Per event Yes 12, 99 HCPCS T1030, T1031 GT Per Diem *Modifier Applicable Only to Specified Code Rev 12/2017 Back to the top Page 27 of 83

29 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Skilled Nursing Facility Services (SNF) Commonwealth Care Alliance Covered Services One Care and Senior Care Options Prior Authorization (PA) Requirements Place of Service Code Type Code Range on Claim Modifier SNF Custodial Yes 31, 32, 33 REV 120 N/A Days Unit of Measure SNF Custodial Medical LOA (20 No Days Max) SNF Custodial Non Medical No LOA SNF Podiatry Yes N/A Per Service CPT SNF Skill Yes 31, 32, 33 REV 191 N/A Days SNF Sub-Acute Yes 31, 32, 33 REV 192 N/A Days If a requested service or item is not listed above, please call Commonwealth Care Alliance at for clarification. All Non-contracted providers and vendors require Prior Authorization The list has been updated on 1/1/2018. Changes were made for clarification. Some of the requirements in member booklets may differ. The requirements provided herewith are provider requirements. Providers need to do diligence to ensure PA is obtained if required. * Service Applicable Only to Program Specified Rev 12/2017 Back to the top Page 28 of 83

30 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Radiology Services Commonwealth Care Alliance Covered Services Radiology: Cardiac MRI Radiology: CAT (CT) Scan Radiology: CTA (CT Angiography) Radiology: MPI (Myocardial Perfusion Imaging) Radiology: MRA (Magnetic Resonance Angiogram) Radiology: MRI (Magnetic Resonance Imaging) Radiology: MUGA (Multigated Acquisition Scan) Radiology: PET (Positron Emission Tomography) Bone Scan Radiology: PET (Positron Emission Tomography) CT Scan Radiology: PET (Positron Emission Tomography) Scan Stress Echocardiogram TEE (Transesophageal Echocardiogram) TTE (Transthoracic Echocardiogram) One Care and Senior Care Options Prior Authorization (PA) Requirements Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Durable Medical Equipment (DME) Click here for code specific list of Durable Medical Equipment (DME) and other services requiring Prior Authorization (PA) for Commonwealth Care Alliance One Care and SCO Program. Rev 12/2017 Back to the top Page 29 of 83

31 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Provider Claim Submission Billing Guidelines E1399 Durable Medical Equipment Modifier Requirements for Items Billed as E1399 CCA recently updated modifier requirements for certain items billed as E1399. DME items billed as E1399 from the list below are required to have a modifier. Modifiers are used to increase accuracy in compensation, coding consistency, editing, and to capture payment data. The absence or presence of an inappropriate modifier may result in a claim denial. Prior Authorization Required DME Item Code Modifier Description Yes Ramps Portable E1399 U1 Ramps Portable, Medicaid Level of Care 1, as defined by each State Yes Ramps Modular E1399 U2 Ramps Modular, Medicaid Level of Care 2, as defined by each State Yes Stair Lifts E1399 U3 Stair Lifts, Medicaid Level of Care 3, as defined by each State Yes Porch Lifts E1399 U4 Porch Lifts, Medicaid Level of Care 4, as defined by each State Yes Automatic Door Openers E1399 U5 Automatic Door Openers, Medicaid Level of Care 5, as defined by each State Yes Yes Home modifications not listed E1399 U6 Home modifications not listed, Medicaid Level of Care 6, as defined by each State *Beds other than standard or bariatric hospital beds E1399 U7 *Beds other than standard or bariatric hospital beds, Medicaid Level of Care 7, as defined by each State Yes Yes Mattresses other than standard hospital beds due to size or construction (sleep number, tempurpedic, regular inner spring for standard beds) E1399 U8 Mattresses other than standard hospital beds due to size or construction (sleep number, tempurpedic, regular inner spring for standard beds) - Medicaid Level of Care 8, as defined by each State *Exercise equipment > E1399 U9 *Exercise equipment, Medicaid Level of Care 9, as defined by each State Rev 12/2017 Back to the top Page 30 of 83

32 SECTION 4: COVERED SERVICES & PRIOR AUTHORIZATION REQUIREMENTS Yes Yes Yes Yes Yes Yes Yes Shoes for non-diabetic or orthopedic needs E1399 UA Shoes for non-diabetic or orthopedic needs, Medicaid Level of Care 10, as defined by each State Air conditioners E1399 UB Air conditioners, Medicaid Level of Care 11, as defined by each State Reclining chairs with or without seat lift E1399 UC Reclining chairs with or without seat lift, Medicaid Level of Care 12, as defined by each State Bed positioning equipment E1399 UD Bed positioning equipment, Medicaid Level of Care 13, as defined by each State Custom fabricated equipment where cost is greater than allowable E1399 P6 Custom fabricated equipment where cost is greater than allowable Rehab shower commode chairs E1399 Q0 Rehab shower commode chairs, Investigational clinical service Safety equipment (bed alarms, floor mats, monitors) E1399 Q1 Safety equipment (bed alarms, floor mats, monitors) - Routine clinical service provided in a clinical research study A full list of Commonwealth Care Alliance s covered services and prior authorization requirements can be found in the Provider Manual on our website under the Providers tab. For additional questions or inquiries on CCA s requirements please ProviderRelations@commonwealthcare.org. Rev 12/2017 Back to the top Page 31 of 83

33 SECTION 5: CENTRALIZED ENROLLEE RECORD SECTION 5: CENTRALIZED ENROLLEE RECORD Commonwealth Care Alliance utilizes eclinicalworks as its electronic member record (EMR) or centralized enrollee record (CER). In in order to ensure the highest quality, most effective health care to its members, all providers are reminded to review their provider agreement with Commonwealth Care Alliance for provider obligations regarding their documentation in all Commonwealth Care Alliance member clinical records and the obligation to share clinical information with Commonwealth Care Alliance primary care teams and interdisciplinary care teams. SECTION 6: CLAIMS AND BILLING PROCEDURES This section is intended for Commonwealth Care Alliance providers. The information here enables providers to comply with the policies and procedures governing Commonwealth Care Alliance s managed care plans. Updates or changes to this section are made in the form of provider bulletins that Commonwealth Care Alliance provides to you by mail, facsimile, or Commonwealth Care Alliance s website. Commonwealth Care Alliance pays clean claims submitted for covered services provided to eligible Commonwealth Care Alliance members. In most cases, Commonwealth Care Alliance pays clean claims within 30 days of receipt. The receipt date is the day that Commonwealth Care Alliance receives the claim. Claim turnaround timelines are based on the claim receipt date. Filing limits are strictly adhered to and are specified in your contract. Please note that contracted providers must file claims no later than 90 days from date of service unless filing limit is stipulated otherwise in contract. Non-contracted providers must file claims no later than 12 months, or 1 calendar, after the date the services were furnished. Commonwealth Care Alliance accepts both electronic and paper claims with industry-standard diagnosis and procedure codes that comply with the Health Information Portability and Accountability Act (HIPAA) Transaction Set Standards. Detailed instructions for completing both the CMS HCFA 1500 and UB04 claims forms are available. Down Load Instructions If CCA has returned a rejected paper claim due to missing or incomplete information, please make the necessary correction as indicated in the rejection letter and resend the claim following standard billing practice for clean claims submission within the required timely filing limit. Contact Information for Provider Claims and Billing Support Telephone number (800) Customer care center available Monday to Friday 8:30 a.m. 5:00 p.m. Billing Members Providers shall not seek or accept payment from a Commonwealth Care Alliance member for any covered service. Providers must accept Commonwealth Care Alliance payment as payment-in-full as detailed in the Provider s contract with Commonwealth Care Alliance. Providers are responsible for obtaining Prior Authorization from Commonwealth Care Alliance before providing services. Please consult your contract, the Covered Services and Prior Authorization section of this manual, or contact Commonwealth Care Alliance s Member Services Department to determine if prior authorization is needed. Rev 12/2017 Back to the top Page 32 of 83

34 SECTION 6: CLAIMS AND BILLING PROCEDURES Claims Submission Commonwealth Care Alliance accepts submissions of properly coded claims from providers by means of Electronic Data Interchange (EDI) or industry-standard paper claims. The provider acknowledges and agrees that each claim submitted for reimbursement reflects the performance of a covered service that is fully and accurately documented in the member s medical record prior to the initial submission of any claim. No reimbursement or compensation is due should there be a failure in such documentation. Electronic Data Interchange Claims Commonwealth Care Alliance accepts electronic claims through Electronic Data Interchange (EDI) as its preferred method of claims submission. All files submitted to Commonwealth Care Alliance must be in the ANSI ASC X12N format, version 5010A, or its successor version. Claims submitted via EDI must comply with HIPAA transaction requirements. EDI claims are sent via modem or via a clearinghouse. The claim transaction is automatically uploaded into the claims processing system. Commonwealth Care Alliance has a Companion Guide and Training manual that further instructs on the requirements and operations. Click here to access the Companion Guide and Training manual. At a minimum, EDI claims must include: Member First/Last Name Date of Birth Member ID Rendering Provider Rendering Provider NPI Pay To Name Pay To Tax ID Place of Service Diagnosis Code Procedure Code Modifiers Billed Amount Quantity Please the EDI Department directly at ccaedisupport@pcgus.com if you have additional questions regarding EDI transaction data sets or getting set up for EDI claims submission. Contact Customer Service or the secure EZ NET Online Claims Web Portal for all other claim inquiries. For more information on EDI implementation, refer to the 2014 Medicare Billing Fact Sheet Initial EDI Set Up. In order to submit claims electronically to Commonwealth Care Alliance, provider must submit a completed EDI Questionnaire. Questionnaire may be ed to our EDI Department at ccaedisupport@pcgus.com If you require assistance with completing this form, you may contact our EDI Department at ccaedisupport@pcgus.com. Upon receipt and review of a completed EDI Questionnaire, Commonwealth Care Alliance can assist a provider with a recommendation of an appropriate EDI option. Rev 12/2017 Back to the top Page 33 of 83