Provider Manual IA Health Link and hawk-i providers.amerigroup.com/ia IA-PM

Transcription

1 Provider Manual IA Health Link and hawk-i providers.amerigroup.com/ia IA-PM

2 Amendment History Document Modifications Date Changed By Version Amerigroup 1.1 Contract and RFP Review Readiness Review Team 1.20 Provider Services Policy Review 1.21 LTC Bureau Policy Review 1.22 HCBS Policy Review 1.22 Medical Services Policy Policy Review 1.23 Eligibility Policy Review 1.4 IME Leadership Review Clarified Comments 1.5 IME Medicaid Modernization Returned to MCO for corrections Project Management Office 2.0 Accept corrections and Amerigroup respond to comments 2.1 Readiness Review Team Cycle 2 Joint Review IME SME Team 2.2 IME Managed Care Director Liz Matney 2.3 IME Medicaid Modernization Janelle McDonald Project Management Office 3.0 Accept corrections and Amerigroup respond to comments 3.1 Formatting clean up, place Amerigroup holders replaced, responded to comments 3.2 Reflect contract amendments Amerigroup 3.3 Updated Amerigroup covered/noncovered services 3.4 Accept corrections and Amerigroup respond to comments 3.5 Accept corrections and respond to comments Amerigroup The master copy of this document is available on line. Hard copies are for information purposes only and are not subject to document control.

3 Table of Contents CHAPTER 1: INTRODUCTION Welcome About This Manual Legal Requirements Contacts Before Rendering Services After Rendering Services Operational Standards, Requirements and Guidelines Additional Resources Accessing Information, Forms and Tools on Our Website Websites CHAPTER 2: LEGAL AND ADMINISTRATIVE REQUIREMENTS Proprietary Information Updates and Changes CHAPTER 3: CONTACTS Overview Amerigroup Contacts CHAPTER 4: COVERED AND NONCOVERED SERVICES Covered Services Covered Services: Medicaid Services Noncovered Services: Medicaid Services Covered Services: hawk-i Noncovered Services: hawk-i Covered Services: Iowa Health and Wellness Plan Benefits Noncovered Services: Iowa Health and Wellness Plan Covered Services: Family Planning Covered Services Covered Services: Iowa Department of Public Health Covered Services: Home and Community Based Services (HCBS) Covered Services: Value-Added Services Covered Services: Healthy Rewards Program State Covered Services Noncovered Services Services Requiring Precertification Dental Services Vision Services Nonemergency Transportation Services CHAPTER 5: LONG-TERM SERVICES AND SUPPORTS Overview Waiver Descriptions Precertification Requirements Person-centered Case Management Model Initial Discovery, Assessments and Informed Consent Person-Centered Service Planning IA-PM Table of Contents: Page 3

4 Incorporating Member Choice in Funding Decisions Identification Processing Referrals to LTSS Services Transition and Discharge Planning Discharge Planning Responsibilities of the LTSS Provider Consumer Direction (Consumer Choice Option) Electronic Visit Verification Client Participation Nursing Facility Preadmission Screening and Resident Review LTSS Continuity of Care Critical Incident Reporting and Management CHAPTER 6: BEHAVIORAL HEALTH SERVICES Overview of Behavioral Health at Amerigroup Goals Values Principles Objectives Recovery and Resiliency General Provider Information Health Home Services Services Requiring Precertification Member Records and Treatment Planning Adverse Incident Reporting (including Psychiatric Medical Institution for Children, Children s Mental Health Waiver and Habilitation Program Services) Psychotropic Medication Utilization Management Process Behavioral Health Authorization Time Standards Notification or Request Preauthorization Clinical Criteria Behavioral Health Medical Necessity Determination and Peer Review Nonmedical Necessity Adverse Decisions Provider Appeals, Grievance and Payment Disputes Avoiding an Adverse Decision Behavioral Health Drug Utilization Review Program Post-Discharge Outreach, Diversion Plans and Crisis Assessments Clinical Practice Guidelines Provider Training Critical Incident Reporting and Management Behavioral Health Waivers (i) Habilitation Waiver CHAPTER 7: MEMBER ELIGIBILITY Overview How to Verify Member Eligibility Identification Cards CHAPTER 8: MEDICAL MANAGEMENT IA-PM Table of Contents: Page 4

5 Overview Services Requiring Precertification Services Not Requiring Precertification Starting the Process Requesting Precertification Chronic Condition Health Home and Integrated Health Home Requests with Insufficient Clinical Information Urgent Requests Emergency Medical Services Emergency Stabilization and Post-Stabilization Concurrent Review: Hospital Admissions Concurrent Review: Clinical Information for Continued-Stay Review Concurrent Review: Second Opinions Denial of Service Referrals to Specialists Additional Services: Behavioral Health Additional Services: Vision Care CHAPTER 9: HEALTH SERVICES PROGRAMS Overview Preventive Care: Initial Health Assessments Preventive Care: Well Woman Preventive Care: Taking Care of Baby and Me Preventive Care: Long-acting Reversible Contraception Health Management: Disease Management Centralized Care Unit Health Management: Healthy Families Health Management: Women, Infants and Children Health Education: Amerigroup On Call Health Education: Drug Lock-In Initiative Health Education: Smoking Cessation Provider Assessment of Smoking Use CHAPTER 10: CLAIMS AND BILLING Overview Submitting Clean Claims Methods for Submission Web Portal Submission Electronic Claims Paper Claims National Provider Identifier Atypical Providers Enrollment in Iowa Medicaid ICD-10 Clinical Modification (CM) Claim Filing Limits Claim Forms and Filing Limits Other Filing Limits Claims from Noncontracted Providers Member Copayments and Balance Billing Client Participation/Member Liability IA-PM Table of Contents: Page 5

6 Coordination of Benefits Subrogation Claims Filed With the Wrong Plan Payment of Claims Monitoring Submitted Claims Electronic Fund Transfer Electronic Remittance Advice Claims Overpayment Recovery Procedure Third-Party Recovery Claim Resubmissions Claims Returned for Additional Information Claims Payment Reconsideration Process Claims Payment Appeals State Fair Hearing Timeline for Claims Payment Appeals: Additional Claim Dispute Provisions Reference: Covered Services Reference: Clinical Submissions Categories Reference: Common Reasons for Rejected and Returned Claims Reimbursement Policies Acute Care Hospitals/Critical Access Hospitals Ambulatory Service Center Behavioral Health Facility Federally Qualified Health Center (FQHC) and Rural Health Clinics (RHC) Intermediate Care Facility Skilled Nursing Facility CHAPTER 11: BILLING PROFESSIONAL AND ANCILLARY CLAIMS Overview Coding Initial Health Assessments Adult Preventive Care Preventive Medicine Services: New Patient Preventive Medicine Services: Established Patient Behavioral Health Emergency and Related Professional Services Family Planning Services Immunizations Covered by the Vaccines for Children (VFC) Program Immunizations Coding Maternity Services Maternity Services: Newborns Newborns: Circumcision Sensitive Services Sterilization Hysterectomy Termination of Pregnancy Billing Members for Services Not Medically Necessary Recommended Fields for CMS CHAPTER 12: BILLING INSTITUTIONAL CLAIMS IA-PM Table of Contents: Page 6

7 Overview Basic Billing Guidelines Emergency Room Visits Urgent Care Visits Maternity Services Termination of Pregnancy Inpatient Acute Care Inpatient Sub-acute Care Outpatient Laboratory, Radiology and Diagnostic Services Outpatient Surgical Services Outpatient Infusion Therapies and Pharmaceuticals Ancillary Billing Overview Ambulance Services Ambulatory Surgical Centers Physical, Speech and Occupational Therapies Durable Medical Equipment Durable Medical Equipment: Rentals Durable Medical Equipment: Purchase Durable Medical Equipment: Wheelchairs and Wheeled Mobility Aids Dialysis Home Infusion Therapy Laboratory and Diagnostic Imaging Skilled Nursing Facilities Home Health Care Hospice Additional Billing Resources CMS-1450 Claim Form CMS-1450 Revenue Codes Institutional Inpatient Coding Institutional Outpatient Coding Recommended Fields for CMS CHAPTER 13: MEMBER TRANSFERS AND DISENROLLMENT Overview PCP-Initiated Member Transfers PCP-Initiated Member Disenrollment State Agency-Initiated Member Disenrollment Member-Initiated PCP Reassignment Member-Initiated Disenrollment Process Member Transfers to Other Plans Amerigroup-Initiated Member Disenrollment CHAPTER 14: GRIEVANCES AND APPEALS Overview Providers: Grievances Relating to the Operation of the Plan Providers: When to Expect Resolution for a Grievance Members: Filing a Grievance Members: Resolution Members: Long-term Care Ombudsman IA-PM Table of Contents: Page 7

8 Confidentiality Discrimination Additional Options for Filing a Grievance Providers: Appeal Timelines Providers: When to Expect Resolution for an Appeal Providers: Appeals Related to Adverse Determinations Providers: Appeals Related to Non-Medical Necessity Claims Determinations Providers: Mediation and Arbitration Members: Appeals Members: Response to Standard Appeals Members: Resolution of Standard Appeals Members: Extensions Members: Expedited Members: Timeline for Expedited Appeals Members: Response to Expedited Appeals Members: Resolution of Expedited Appeals Members: Long-term Care Ombudsman Members: State Fair Hearing Confidentiality Continuation of Benefits during Appeal CHAPTER 15: CREDENTIALING AND RECREDENTIALING Overview Council for Affordable Quality Healthcare Approved Provider Types Approved Health Delivery Organizations CAQH/UPD Registration: First Time Users CAQH/UPD Registration: Completing the Application Process CAQH/UPD Registration: Existing Users Additional CAQH Resources Contracting Process for Hospital or Facility-Based Providers Credentialing Updates Recredentialing Ownership Disclosure Professional Liability Coverage CHAPTER 16: ACCESS STANDARDS AND ACCESS TO CARE Overview General Appointment Scheduling Services for Members under the Age of Services for Members 21 Years and Older Prenatal and Postpartum Visits Wait Times Nondiscrimination Statement Interpreter Services Missed Appointment Tracking After-Hours Services Amerigroup On Call Continuity of Care IA-PM Table of Contents: Page 8

9 Provider Contract Termination Newly Enrolled Second Opinions Emergency Transportation Emergency Dental Services for Adults and Children Border City Providers CHAPTER 17: PROVIDER ROLES AND RESPONSIBILITIES Overview Primary Care Physicians Referrals Out-Of-Network Referrals Interpreter Services Transitioning Members between Medical Facilities and Home Noncovered Services Specialists Hospital Scope of Responsibilities Ancillary Scope of Responsibilities Responsibilities Applicable to All Providers Office Hours After-Hours Services Licenses and Certifications Eligibility Verification Collaboration Continuity of Care Medical Records Standards Mandatory Reporting of Child Abuse, Elder Abuse or Domestic Violence Updating Provider Information Oversight of Nonphysician Practitioners Open Clinical Dialogue/Affirmative Statement Provider Contract Termination Termination of the Ancillary Provider/Patient Relationship Disenrollees Provider Rights Prohibited Activities Misrouted Protected Health Information CHAPTER 18: CLINICAL PRACTICE AND PREVENTIVE HEALTH CARE GUIDELINES Overview Clinical Practice Guidelines Preventive Health Care Guidelines CHAPTER 19: CASE MANAGEMENT Overview Provider Responsibilities Referral Process Role of the Case Manager Case Management Procedure Transitioning Disenrollees IA-PM Table of Contents: Page 9

10 Continued Access to Care Continuity of Care Process Health Home Services CHAPTER 20: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Overview Quality Assessment and Performance Improvement Program Healthcare Effectiveness Data and Information Set (HEDIS) Quality Management Best Practice Methods Member Satisfaction Surveys Provider Satisfaction Surveys Medical Record and Facility Site Reviews Medical Record Documentation Standards Medical Record Security Storage and Maintenance Availability of Medical Records Medical Record Requirements Advance Directives Medical Record Review Process Facility Site Review Process Facility Site Review: Corrective Actions Preventable Adverse Events CHAPTER 21: ENROLLMENT AND MARKETING RULES Overview Marketing Policies Enrollment Process CHAPTER 22: FRAUD, ABUSE AND WASTE Overview Understanding Fraud, Abuse and Waste Examples of Provider Fraud, Abuse and Waste Examples of Member Fraud, Abuse and Waste Reporting Provider or Recipient Fraud, Abuse or Waste Anonymous Reporting of Suspected Fraud, Abuse and Waste Investigation Process Acting on Investigative Findings False Claims Act Employee Education about the False Claims Act CHAPTER 23: MEMBER RIGHTS AND RESPONSIBILITIES Overview Member Rights Member Responsibilities NCQA Requirements CHAPTER 24: CULTURAL DIVERSITY AND LINGUISTIC SERVICES Overview Interpreter Services IA-PM Table of Contents: Page 10

11 CHAPTER 1: INTRODUCTION Welcome Welcome to the Amerigroup Iowa, Inc. (Amerigroup) network provider family! We are pleased you have joined our Iowa network, which consists of some of the finest health care providers in the state. Amerigroup has been selected by the Iowa Department of Human Services to provide health care services for Amerigroup members enrolled in the IA Health Link or hawk-i programs. IA Health Link and hawk-i cover all Medicaid mandatory eligibility groups, as well as various optional categorically needy and medically needy groups, including children, pregnant women, the aged and individuals with disabilities. Amerigroup represents a growing network of health care providers who make it easier for our members to receive quality care. There is strength in numbers: Amerigroup's health services programs, combined with those already available in our target service areas, are designed to supplement providers' treatment plans. Our programs serve to help improve our members' overall health by informing, educating and encouraging self-care in the prevention, early detection and treatment of existing conditions and chronic disease. We believe hospitals, physicians and other providers play a pivotal role in managed care. We can only succeed by working collaboratively with you and other caregivers. Earning your loyalty and respect is essential to maintaining a stable, high-quality provider network. Together, we can arrange for and provide an integrated system of coordinated, efficient and quality care for our members and your patients. All network providers are contracted with Amerigroup through a Participating Provider Agreement. About This Manual This Provider Manual is designed for contracted Amerigroup providers, hospitals and ancillary providers. Our goal is to create a useful reference guide for you and your office staff. We want to help you navigate our managed health care plan to deliver quality health care to our members. Our goal is to aid you in finding the most reliable, responsible, timely and cost-effective way to deliver quality health care. We recognize that managing our members health can be a complex undertaking, requiring familiarity with the rules and regulations of a complex health care system. This system encompasses a wide array of services and responsibilities; for example, initial health assessments (IHAs), case management, proper storage of medical records, and billing for emergencies. With this complexity in mind, we divided this manual into sections that reflect your questions, concerns and responsibilities before and after an Amerigroup member walks through your doors. The sections are organized as follows: Legal Requirements Contact Information Before Rendering Services After Rendering Services Operational Standards, Requirements and Guidelines Additional Resources IA-PM Chapter 1: Page 11

12 Chapter 1: Introduction Legal Requirements The information contained in this manual is proprietary, will be updated regularly and is subject to change. This section provides specific information on the legal obligations of being part of the Amerigroup network. Contacts This section is your reference for important phone and fax numbers, websites and mailing addresses. Before Rendering Services This section provides the information and tools you will need before providing services, including verifying member eligibility and a list of covered and noncovered services. The section also includes a chapter on the precertification process and coordination of complex care through our Case Management department. We take pride in our proactive approach to health. The chapter on Health Services programs details how we can partner with you to make the services you provide more effective. For example, the initial health assessment (IHA) is our first step in providing preventive care. The health services programs under Disease Management Centralized Care Unit (DMCCU) allow us to collaborate with you to combat the most common and serious conditions and illnesses facing our members, including asthma, cardiovascular disease and diabetes. After Rendering Services At Amerigroup, our goal is to make the billing process as streamlined as possible. This section provides guidelines, detailed coding charts, information on filing claims for professional and institutional services rendered. The Member Transfer and Disenrollment chapter outlines how a member changes primary care physician (PCP) assignment or transfers to another health plan. When questions or concerns come up about claims or adverse determination, our chapter on Grievances and Appeals will take you step-by-step through the process. Operational Standards, Requirements and Guidelines This section summarizes the requirements for provider office operations and Access Standards, thereby ensuring consistency when members need to consult with providers for IHAs, referrals, coordination of care and follow up care. Additional chapters detail provider credentialing, provider roles and responsibilities and enrollment and marketing guidelines. Chapters on clinical practice and preventive health guidelines and case management outline the steps providers should take to coordinate care and help members take a proactive stance in the fight against disease. And finally, we included a chapter documenting our commitment to participate in quality assessments that help Amerigroup measure, compare and improve our standards of care. Additional Resources To help providers serve a diverse and ever-evolving patient population, we designed a special program, Cultural Diversity and Linguistic Services, to improve provider and member communications by providing tools and resources to help reduce language and cultural barriers. In addition, Amerigroup works with nationally-recognized health care organizations to stay current on the latest health care breakthroughs and IA-PM Chapter 1: Page 12

13 Chapter 1: Introduction discoveries. This manual provides easy links to access that information. We also provide forms and reference guides on a wide variety of subjects. Accessing Information, Forms and Tools on Our Website We offer the Provider Manual in hard copy upon request at no cost and post it online. A wide array of tools, information and forms are accessible via the Providers page of our website: providers.amerigroup.com/ia. Throughout this manual, we often will refer you to items located on this resource page. To access this page: Click on any topic in the Table of Contents to view that chapter. Click on any web address to be redirected to that site. Each chapter may also contain cross-links to other chapters, to the Amerigroup website or to external websites containing additional information. If you have any questions about the content of this manual, contact Provider Services at Monday through Friday from 7:30 a.m. through 6 p.m. Central time. Websites The Amerigroup website and this manual may contain links and references to Internet sites owned and maintained by third-party sites. Neither Amerigroup nor its related affiliated companies operate or control, in any respect, any information, products or services on third-party sites. Such information, products, services and related materials are provided as is without warranties of any kind, either express or implied, to the fullest extent permitted under applicable laws. Amerigroup disclaims all warranties, express or implied, including, but not limited to, implied warranties of merchantability and fitness. Amerigroup does not warrant or make any representations regarding the use or results of the use of third-party materials in terms of correctness, accuracy, timeliness, reliability or otherwise. IA-PM Chapter 1: Page 13

14 CHAPTER 2: LEGAL AND ADMINISTRATIVE REQUIREMENTS Legal and Administrative Requirements Proprietary Information The information contained in this manual is proprietary. By accepting this manual, providers agree: To use this manual solely for the purposes of referencing information regarding the provision of medical services Iowa Medicaid enrollees who have chosen Amerigroup as their health care plan. To protect and hold the manual s information as confidential. Not to disclose the information contained in this manual. Legal and Administrative Requirements Updates and Changes The Provider Manual, as part of your Provider Agreement and related Addendums, may be updated at any time and is subject to change. In the event of an inconsistency between information contained in the manual and the Provider Agreement between you or your facility and Amerigroup, the Provider Agreement shall govern. In the event of a material change to the Provider Manual, we will make all reasonable efforts to notify you in advance of such change through web-posted newsletters, notifications, fax communications (such as provider bulletins), and/or other mailings. In such cases, the most recently published information should supersede all previous information and be considered the current directive. The manual is not intended to be a complete statement of all Amerigroup policies or procedures. Other policies and procedures not included in this manual may be posted on our website or published in specially targeted communications, as referenced above. This manual does not contain legal, tax or medical advice. Please consult your own advisors for such advice. IA-PM Chapter 2: Page 14

15 CHAPTER 3: CONTACTS Contacts Overview When you need the correct phone number, fax number, website or street address, the information should be right at your fingertips. With that in mind, we have compiled the most-used contacts for you and your office staff for Amerigroup services and support. Contacts Amerigroup Contacts If you have questions about... Amerigroup On Call Contact Amerigroup On Call Phone: (English) (Spanish) TTY: 711 Hours: 24 hours a day, 7 days a week Amerigroup Provider Services Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Website: providers.amerigroup.com/ia Behavioral Health Services Case Management Referrals Amerigroup Medical Management Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: (Inpatient) (Outpatient) Amerigroup Medical Management Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: IA-PM Chapter 3: Page 15

16 Chapter 3: Contacts Amerigroup Iowa Health Link Program If you have questions about... Claims: Electronic Processing Claims: Payment Status Claims: Appeals/Correspondence Claims: Medical Claim Refunds Contact Amerigroup Provider Services EDI Solutions Help Desk: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Providers have four options to submit electronic professional and institutional claims: Availity: payer ID Emdeon: payer ID Capario: payer ID Smart Data Solutions: payer ID Amerigroup Provider Services Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: Amerigroup Provider Services Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: Amerigroup Iowa, Inc. Payment Dispute Unit P.O. Box Virginia Beach, VA Amerigroup Iowa, Inc. P.O. Box Atlanta, GA Credentialing and Recredentialing Phone: Disease Management Referrals Amerigroup Disease Management Phone: TTY: 711 Hours: Monday through Friday, 8:30 a.m.-5:30 p.m. Central time Fax: IA-PM Chapter 3: Page 16

17 Chapter 3: Contacts Amerigroup Iowa Health Link Program If you have questions about... Fraud and Abuse Department Grievances and Appeals Department (Provider) Hospital/Facility Admission Notification Interpreter Services Contact Amerigroup Provider Services Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: For provider grievances and appeals, including claims, contact: Amerigroup Provider Services Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: Amerigroup Medical Management Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: Amerigroup Member Services Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time After hours, contact Amerigroup on Call at: (English) (Spanish) (TTY: 711), available 24 hours a day, 7 days a week Iowa Relay Service (Relay Iowa) TTY: 711/ (ASCII)/ (Voice) (VCO Direct) (Spanish) (Speech to speech) Hours: 24 hours a day, 7 days a week and 365 days a year IA-PM Chapter 3: Page 17

18 Chapter 3: Contacts Amerigroup Iowa Health Link Program If you have questions about... Medical Management Member Services Member Eligibility Contact Amerigroup Medical Management Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: For Member Services, Member Grievances and Appeals, Interpreter Services and personal information changes: Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time After hours, call Amerigroup On Call at (English) (Spanish) TTY: 711 Hours: 24 hours a day, 7 days a week Written correspondence: Amerigroup Iowa, Inc. Central Appeals Processing P.O. Box Virginia Beach, VA Verify eligibility through either Iowa DHS or Amerigroup: Iowa state eligibility information Eligibility and Verification Information System (ELVS) Automated Voice Response Phone: (toll-free) or (local) Hours: 24 hours a day, 7 days a week Website: Amerigroup Provider Services Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: Secure provider portal on our website: providers.amerigroup.com/ia IA-PM Chapter 3: Page 18

19 Chapter 3: Contacts Amerigroup Iowa Health Link Program If you have questions about... Pharmacy Questions and Prescriptions: Providers Pharmacy Questions and Prescriptions: Members Precertification: Behavioral Health Precertification: Medical Precertification: Pharmacy Provider Services Call Center Contact Amerigroup Pharmacy Department Phone: Hours: Monday through Friday, 7 a.m.-7 p.m. Central time Website: providers.amerigroup.com/ia Amerigroup Pharmacy Phone: Hours: Monday through Friday, 7 a.m.-7 p.m. Central time Website: myamerigroup.com/iamedicaid Amerigroup Medical Management Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time All requests may be submitted via the web portal at providers.amerigroup.com/ia Inpatient Fax: Outpatient Fax: Amerigroup Medical Management Phone: TTY: 711 Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: Express Scripts, Inc. Phone: Fax: Hours: 24 hours a day, 7 days a week Website: To request precertification: For provider advocate services, verifying eligibility and benefits, checking claims status and EDI information: Phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Fax: IA-PM Chapter 3: Page 19

20 Chapter 3: Contacts Amerigroup Iowa Health Link Program If you have questions about... Transportation Services (Nonemergent) Vision Services Contact LogistiCare Phone: (Reservations) (Ride Assist) TTY: Hours: Monday through Friday, 7 a.m.-6 p.m. Central time Superior Vision Benefit Management, Inc. Provider Services phone: Member Services phone: Hours: Monday through Friday, 7:30 a.m.-6 p.m. Central time Website: IA-PM Chapter 3: Page 20

21 CHAPTER 4: COVERED AND NONCOVERED SERVICES Covered and Noncovered Services Covered Services The following grids list the Medicaid covered services, including notations for services requiring precertification. Because covered benefits periodically change, verify coverage before providing services. Covered and Noncovered Services Covered Services: Medicaid Services Covered services: Medicaid Services Abortions Allergy testing and injections Anesthesia Bariatric surgery Behavioral health intervention services (BHIS) and assertive community treatment (ACT) Breast reconstruction Breast reduction Cardiac rehabilitation Chemotherapy inpatient and outpatient Chiropractic care (therapeutic adjustive manipulation) Colorectal cancer screening Congenital abnormalities correction Diabetes equipment and supplies Diagnostic genetic testing Dialysis Durable medical equipment (DME) and supplies (DMS) Coverage limits May only be approved under the following situations: If the pregnancy is the result of an act of rape or incest. In the case where a woman suffers from a physical disorder, physical injury or physical illness, including a lifethreatening physical condition caused by or arising from the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed. As medically necessary As medically necessary As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (inpatient may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary As medically necessary As medically necessary (may require prior authorization) As medically necessary Limits (may require prior authorization): Up to a three-month supply of medical supplies Diabetic supplies are as follows: o Preferred meters/test strips covered under the pharmacy benefit o Blood glucose test or reagent strips six units per month (one unit = 50 strips) o Urine glucose test strips three units per month (one unit = 100 strips) o Lancets four units per month (one unit = 100 lancets) IA-PM Chapter 4: Page 21

22 Chapter 4: Covered and Noncovered Services Covered services: Medicaid Services Emergency room services Emergency transportation Early and periodic screening, diagnosis and treatment (EPSDT) Family planning services Foot care (podiatry) Genetic counseling Gynecological exams Hearing aids Hearing exams and services Home health care Hospice care Hospitalization Imaging/diagnostics (MRI, CT, PET) Immunizations Infertility diagnosis and treatment Inhalation therapy Inpatient physician services Inpatient surgical services Intensive care unit Intermediate care facility/ intellectual disability IV infusion services Lab tests Maternity and pregnancy services (preconception/interception prenatal postpartum) Medical and surgical supplies Coverage limits o Needles 500 units per month (one unit = one needle) o Reusable insulin pens one every six months o Diaper/brief 80 per 90-day period o Liner/shield/guard/pad per 90-day supply o Pull-on 450 per 90-day period o Disposable under pads per 90-day period o Reusable under pads 48 per 12 months Hearing aid batteries up to 30 batteries per aid in a 90-day period Ostomy supplies and accessories one unit per day of regular wear or three units per month of extended wear Note: Services are limited to members in a medical facility. As medically necessary As medically necessary Covered Covered; additional services may be covered through the Iowa Family Planning Network waiver for members who qualify As medically necessary As medically necessary As medically necessary As medically necessary (may require prior authorization) As medically necessary Limits (may require prior authorization): Skilled nursing care five visits per week Home health aide 28 hours per week Occupational, physical and speech therapy limited to physician-approved visits within rules for restorative maintenance or trial therapy Limit (may require prior authorization): may only be used in five-day spans As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary As medically necessary (may require prior authorization); must meet level of care As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) Covered As medically necessary IA-PM Chapter 4: Page 22

23 Chapter 4: Covered and Noncovered Services Covered services: Medicaid Services Mental health/behavioral health outpatient treatment Mental health/behavioral health inpatient treatment Midwife services Nonemergency medical transportation (NEMT) Newborn child coverage Noncosmetic reconstructive surgery Nursing facility Nursing services Nutritional counseling Occupational therapy (OT) Orthotics Outpatient surgery Pathology Pharmacy Coverage limits As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) Covered As medically necessary (may require prior authorization) Covered As medically necessary (may require prior authorization) As medically necessary; must meet level of care Limits (may require prior authorization): Intermittent home health services and private duty nursing for members 20 and younger, when medically necessary Up to 16 hours per day As medically necessary The allowed Medicare Part B outpatient therapy cap for OT is $1,920 (may require prior authorization) Limits (may require prior authorization): Two pairs of depth shoes per member in a 12-month period Three pairs of inserts, plus noncustomized removable inserts provided with depth shoes in a 12-month period Two pairs of custom-molded shoes per member in a 12- month period, plus two additional pair of inserts for custommolded shoes in a 12-month period As medically necessary (may require prior authorization) As medically necessary Limits (may require prior authorization): Prior approval is required as stated in the preferred drug list (PDL) at 72-hour emergency supply; this does not apply to medicines to help quit smoking or for hepatitis-c Drug costs are reimbursed only for drugs marketed by manufacturers with a signed rebate agreement Certain nonprescription over-the-counter (OTC) drugs and nondrugs are covered Quantities covered includes: o Up to a 31-day supply at a time, except certain contraceptives, which is at 90 days o OTC drugs minimum of 100 units per prescription, or currently available consumer package o Initial 15-day supply limit for certain drugs o Monthly quantity limit for certain drugs Noncovered drug categories include: o Drugs used for anorexia, weight gain or weight loss o Drugs used for cosmetic purposes or hair growth o Outpatient drugs, if the manufacturer requires it as a condition of sale that associated tests or monitoring services be purchased only from the manufacturer or IA-PM Chapter 4: Page 23

24 Chapter 4: Covered and Noncovered Services Covered services: Medicaid Services Pharmacy (continued) Physical therapy Preventive care Psychiatric Medical Institutions for Children (PMIC) Primary care illness/injury physician services Prostate cancer screening Prosthetics Pulmonary rehabilitation Radiation therapy Screening Pap test Screening mammography Second surgical option Skilled nursing services Sleep studies Special physician services Speech therapy Substance use disorder inpatient/outpatient treatment TMJ treatment Tobacco cessation Tobacco cessation for pregnant women Transplant organ and tissue Urgent care centers/facilities Emergency clinics (nonhospital based) Vision care exams Vision frames and lenses Coverage limits the manufacturer s designee o Drugs prescribed for fertility purposes, except when prescribed for a medically accepted indication other than infertility o Drugs used for sexual or erectile dysfunction o Drugs for symptomatic relief of cough and colds, except listed OTC drugs The legal Medicare Part B outpatient therapy cap for physical therapy is $1,920 (may require prior authorization) Covered As medically necessary (may require prior authorization) Covered As medically necessary As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary As medically necessary Covered Limit (may require prior authorization): up to 120 days annually As medically necessary (may require prior authorization) As medically necessary The legal Medicare Part B outpatient therapy cap for speech therapy is $1,920 (may require prior authorization) Must meet American Society of Addiction Medicine (ASAM) criteria as the utilization management guidelines for substance use disorder services. Note: Additional substance use disorder services may be covered through the Iowa Department of Public Health (IDHP) for members who qualify As medically necessary (may require prior authorization) As medically necessary Covered As medically necessary (may require prior authorization) As medically necessary Limits: one per 12-month period Frame services and single vision and multifocal lens services are covered: Up to three times for children up to age 1 Up to four times per year for children ages 1-3 One frame every 12 months for children ages 4-7; safety frames are covered for children through age 7 One frame every 24 months for members age 8 and older Gas permeable contact lenses are covered: IA-PM Chapter 4: Page 24

25 Chapter 4: Covered and Noncovered Services Covered services: Medicaid Services Coverage limits Vision frames and lenses (continued) Up to 16 lenses for children up to age 1 Up to eight lenses every 12 months for children ages 1-3 Up to six lenses every 12 months for children ages 4-7 Two lenses every 24 months for members age 8 and older Replacement of lost or damaged glasses beyond repair are covered: For adults age 21 and older, once every 12 months For children younger than age 21 Walk-in center services As medically necessary X-rays As medically necessary (may require prior authorization) Covered and Noncovered Services Noncovered Services: Medicaid Services Noncovered Service: Medicaid Services AIDS/HIV parity Clinical trials Counseling and education services Pharmacy Details None available None available None available Noncovered drug categories include: Drugs used for anorexia, weight gain or weight loss Drugs used for cosmetic purposes or hair growth Outpatient drugs if the manufacturer requires as a condition of sale that associated tests or monitoring services be purchased only from the manufacturer or the manufacturer s designee Drugs prescribed for fertility purposes, except when prescribed for a medically accepted indication other than infertility Drugs used for sexual or erectile dysfunction Drugs for symptomatic relief of cough and colds, except listed OTC drugs Covered and Noncovered Services Covered Services: hawk-i Deductible: none Maximum out-of-pocket expense (calendar year): none Lifetime maximum: none Covered services: hawk-i Emergency room facility Coverage limits Covered; emergency services for nonemergent conditions are subject to a $25 copay if the family pays a premium for the hawk-i program IA-PM Chapter 4: Page 25

26 Chapter 4: Covered and Noncovered Services Covered services: hawk-i Ambulance Urgent care facility Routine preventive physical examinations including well-child care and gynecological exam Physician services Outpatient physician services Injections: physician s office Injections: hospital (inpatient or outpatient) Hospital inpatient services Physician surgical services X-ray imaging and laboratory services Maternity services Outpatient rehabilitative therapy (physical, occupational, speech, cardiac and pulmonary) Prosthetic devices Durable medical equipment Nursing facility Home health services Hospice Mental health and substance abuse services (inpatient, outpatient and office) Coverage limits As medically necessary Covered Covered Covered services include: Office visits Physician emergency room visits Inpatient hospital visits and consultations Covered services include: Home visits or nursing facility visits Allergy testing Allergy injections Immunizations (cannot use Vaccines for Children [VFC]) Covered As medically necessary Covered services include: Room and board (semi-private) Services that are covered as medically necessary include: Miscellaneous Outpatient facility or surgi-center Anesthesia Covered services include: Office Inpatient Outpatient Covered services include: Hospital (inpatient or outpatient) Office As medically necessary: Radiation therapy and chemotherapy Covered services include: Physician medical services Hospital inpatient service for maternity o Room and board o Miscellaneous As medically necessary for physical and speech. Not covered for occupational, cardiac or pulmonary. As medically necessary As medically necessary Covered As medically necessary As medically necessary Covered IA-PM Chapter 4: Page 26

27 Chapter 4: Covered and Noncovered Services Covered services: hawk-i Vision services Prescription drugs Hearing evaluation, test and hearing aids Dental services Abortion Morbid obesity treatment Reconstructive surgery Blood and blood administration Coverage limits Covered services include: Medically necessary vision services Routine vision services Eyewear (glasses/contacts) As medically necessary; brand name drugs are not covered if there is a generic equivalent As medically necessary Outpatient hospital charges and anesthesia if criteria are met. Covered for accidental injury. Approved if federal requirements are met. May only be approved: If the pregnancy is the result of an act of rape or incest. In the case where a woman suffers from a physical disorder, physical injury or physical illness, including a life-threatening physical condition arising from the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed. As medically necessary (if criteria are met) As medically necessary to restore function lost or impaired as the result of an illness, injury or a birth defect (even if there is an incidental improvement in physical appearance). Assume covered if medically necessary Covered and Noncovered Services Noncovered Services: hawk-i Noncovered Service: hawk-i Acupuncture Cosmetic procedures Counseling and education services Custodial care Outpatient rehabilitative therapy (physical, occupational, speech, cardiac and pulmonary) Organ transplants Chiropractic Contraceptives Dialysis Diabetes self-management and education EPDST services Exception for certain clinical trials for treatment studies on cancer, approved by the National Cancer Institute or the National Institutes Of Health Inhalation therapy Details None available None available None available None available As medically necessary for physical and speech. Not covered for occupational, cardiac or pulmonary. None available None available None available None available None available None available Must meet criteria None available IA-PM Chapter 4: Page 27

28 Chapter 4: Covered and Noncovered Services Noncovered Service: hawk-i Orthotics PMIC or residential care Sleep apnea treatment Temporomandibular joint disorder Details Arch supports (or in-shoe supports), orthopedic shoes, elastic support and examinations to prescribe or fit such devices None available Osteotomy is not covered. Some services deemed medically necessary are covered. Covered and Noncovered Services Covered Services: Iowa Health and Wellness Plan Benefits Covered service: Iowa Health and Wellness Plan AIDS/HIV parity Allergy testing and injections Anesthesia Breast reconstruction Cardiac rehabilitation Chemotherapy inpatient and outpatient Chiropractic care (therapeutic adjustive manipulation) Clinical trials Colorectal cancer screening Congenital abnormalities correction Counseling and education services Diabetes equipment and supplies Diagnostic genetic testing Dialysis Durable medical equipment (DME) and supplies (DMS) Emergency room services Emergency transportation Early and periodic screening, diagnosis and treatment (EPSDT) Family planning services Coverage limits As medically necessary As medically necessary As medically necessary As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (inpatient may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary (may require prior authorization) As medically necessary Limits noncovered services include: Bereavement, family or marriage counseling Education, other than for diabetes As medically necessary; preferred meters/test strips are covered under the pharmacy benefit As medically necessary (may require prior authorization) As medically necessary Limits noncovered services include: Elastic stockings and bandages Trusses Lumbar braces Garter belts Similar items that can be purchased without a prescription As medically necessary As medically necessary Limits: Oral and vision services are covered only for children ages Covered; additional services may be covered through the Iowa Family Planning Network waiver for members who qualify IA-PM Chapter 4: Page 28