TABLE OF CONTENTS. Changes are periodically made to the information in this manual. This manual was last updated 3/2018.

Transcription

1 PROVIDER MANUAL

2 TABLE OF CONTENTS HEALTH PLAN OVERVIEW... 3 PRODUCTS... 9 PROVIDER PORTAL...11 CREDENTIALING PROCESS...12 CLAIMS, TIMELY FILING, AND EOPS...18 CLAIMS CODING PROCESS...24 EDI TRANSACTION PROCESS...25 AUTHORIZATION PROCESS...26 SKILLED NURSING FACILITY (SNF) AUTHORIZATION GUIDELINES...46 CHIROPRACTIC CARE OVERVIEW...49 ADMISSIONS AND CONCURRENT REVIEW PROCESS...51 CARE MANAGEMENT...56 CASE AND DISEASE MANAGEMENT...66 MEMBER GRIEVANCE AND APPEALS PROCESS...70 PROVIDER APPEALS...72 PHARMACY...74 QUALITY IMPROVEMENT...78 PUBLICATIONS...82 Changes are periodically made to the information in this manual. This manual was last updated 3/2018. Prevea360 Health Plan Provider Manual Revised 3/2018 2

3 PREVEA360 HEALTH PLAN OVERVIEW Prevea360 Health Plan, would like to take this opportunity to welcome you into our provider network! The Prevea360 Health Plan Provider Manual serves as a resource for policies and procedures that affect claim submission. If you have questions relating to this information, or are unable to find information that you are looking for, please refer to the phone directory below or access prevea360.com to contact the appropriate department for assistance. CUSTOMER CARE CENTER Customer Care Center (877) Monday Thursday 7:30 am to 5:00 pm Friday 8:00 am to 4:30 pm CARE MANAGEMENT Utilization Management (877) Point of Service Prior Authorizations (877) Case & Disease Management Referrals (877) Care Management Fax Number (608) CLAIMS Claims Manager (877) Information Systems for Electronic Claims Transmission dhpedi@deancare.com DRUG PRIOR AUTHORIZATIONS Drug Prior Authorization Fax (920) Navitus Health Solutions (866) WEBSITE Prevea360 Health Plan Website prevea360.com ADDRESS Address Prevea360 Health Plan P.O. Box Madison, WI ABOUT PREVEA360 HEALTH PLAN Dean Health Plan and Prevea Health are partners for Prevea360 Health Plan. Dean Health Plan is the underwriter for all Prevea360 Health Plan Policies, Network Provider Contracting and Claims processing administrator for Commercial and ASO lines of business in the Prevea360 network service area. The Prevea360 network includes the following counties: Brown, Calumet, Door, Kewaunee, Manitowoc, Marinette, Oconto, Outagamie, Shawano and Sheboygan. Prevea360 Health Plan Provider Manual Revised 3/2018 3

4 VISIT OUR WEBSITE Preave360 Health Plan offers a wealth of information through the Prevea360 website at prevea360.com. PROVIDER NETWORK SERVICES The Provider Network Services department includes our Provider Network Consultants (PNCs), who are responsible for educating all existing and new plan providers within the Prevea360 Health Plan provider network. Provider education includes: Updating our providers on new policies and procedures via Provider newsletter, provider mailings, or workshops Orientations for new practitioners and facilities Ongoing education for network providers (i.e. Quality Improvement, Utilization Management, and Customer Relations processes, authorization training, etc.) Provider Network Services maintains the provider files, the administration of the provider contracting process, and the provider manual. Additionally, our provider newsletters are coordinated and distributed by Provider Network Services to keep providers up to date on any changed health plan procedures, benefits, or other areas of interest involving the health plan. Provider News is available at prevea360.com/for-providers/provider-newsletter.aspx Who can I contact for questions and assistance? Please contact your designated Provider Network Consultant at (877) or Providerrelations@prevea360.com. PROVIDER UPDATES AND CHANGES To ensure that Prevea360 Health Plan has the most current demographic information for our network providers, contact your Provider Network Consultant for any of the following situations: New Physicians: When multi-specialty or independent clinic physicians add to their staff; requests to consider this physician for plan provider status should be directed, in writing, to Provider Network Services. Approval by Prevea360 Health Plan Senior Administration is required before a credentialing application will be sent for completion/review. Prevea360 Health Plan Provider Manual Revised 3/2018 4

5 All applications must be the original, a photocopy, or faxed copy. Furthermore, Prevea360 Health Plan does not allow practitioners to see Prevea360 Health Plan members until they have completed the credentialing process. No retroactive effective dates are granted. Providers who do not have to be credentialed will have the same effective date as the notification date. Providers need to be responsible for notifications to us regarding their effective dates. Physician Extenders & Locum Tenens: Prevea360 Health Plan welcomes physician extenders (Physician Assistants or Nurse Practitioners) to participate in the plan provider network. All mid-level practitioners are required to complete the credentialing process. Prevea360 Health Plan requires our plan providers notify us in advance of the need for a locum tenens. The plan provider utilizing a locum tenens should inform their Provider Network Consultant with the name of the locum tenens and the expected coverage time involved. ADDING A NEW PRACTITIONER TO YOUR PRACTICE Prevea360 Health Plan is a closely managed HMO and our contracts may restrict by practitioner. If you are requesting to add a new practitioner to your practice, Prevea360 Health Plan will first need to approve the addition prior to starting the credentialing process. Once Prevea360 Health Plan has approved your request, we will contact you to submit a credentialing application; if already provided, Prevea360 Health Plan will pass the application to the Credentialing Department. If Prevea360 Health Plan denies your request to add a new provider to your practice, you will be notified. Any questions regarding this process can be directed to your assigned Provider Network Consultant. A written request with the following information is needed in order for Prevea360 Health Plan to consider adding a new professional to your practice: Practitioner name and degree Location(s) where they will practice (if multiple locations, note their primary location) Primary specialty, board certification status, and secondary specialty (if applicable) License number and state issued Status (full time, part time, fill-in, or outreach if not full-time, please provide the practitioner s expected hours) If the practitioner is an addition or a replacement (if a replacement, note the name of the practitioner they are replacing and their termination date) Billing information (i.e. NPI 2, TIN, and whether the clinic or hospital will be doing the billing) If the practitioner is a PA/PA-C, APNP, NP, or CNM, note their supervising physician s name, specialty, and practice location HOSPITAL UPDATES AND CHANGES All of the following requests need to be submitted in writing to the attention of your Provider Network Consultant. Please provide as much advance notice as possible to avoid any disruption to your patient s authorization submission, or claim payments. The following are examples of facility demographic changes that should be communicated to your Provider Network Consultant: Facility name Location and/or address Phone number Accreditation NPI or TIN additions/changes Requests for the following are required to have prior approval through the Provider Network Services department. Please communicate these requests in advance to your designated Provider Network Consultant: Prevea360 Health Plan Provider Manual Revised 3/2018 5

6 To expand or add new clinics and/or office locations To add additional services and/or programs PRACTITIONER UPDATES AND CHANGES All of the below requests need to be submitted in writing to the attention of your Provider Network Consultant. Please provide as much advance notice and information regarding the new practitioner and/or change to the practitioner s status, as soon as possible, to avoid any disruption to your patients or claim payments. Provider Demographic Information: o Name o Specialty o Office locations o Gender o Hospital Affiliations o Tax ID changes o Medical Group Affiliations o Website URL o o Facility handicap accessibility Medicare Certification Number Professionals must have Medicare Certification Number listed on credentialing application No retro claims payment (if Medicare certification numbers is pending, provider is required to update us once received) Providers need to notify their patients in writing in advance for practitioner terminations, clinic closures, etc. TERMINATIONS Practitioner Terminations Please communicate any contracted practitioner terminations in writing to your Provider Network Consultant with as much advance notice as possible (minimum of 30 days prior to the termination). Include the following information in your notification: Practitioner name and degree Practice location(s) Termination date Reason for termination (i.e. moving to a new practice, retirement, etc.) Where the practitioner will be providing services (if still actively practicing) A copy of your member notification letter communicating the practitioner s termination Clinic/Facility Terminations Please communicate any contracted clinic terminations in writing to your Provider Network Consultant with as much advance notice as possible (minimum of 60 days prior to the termination). This information is necessary as Prevea360 Health Plan adheres to the state statute for Continuity of Care policy. Include the following information in your notification: Location name Address Termination date If applicable, which practitioners at the terminating location will be moving to another contracted location A copy of your member notification letter communicating the clinic termination Prevea360 Health Plan Provider Manual Revised 3/2018 6

7 OTHER SITUATIONS Please communicate the following situations to your Provider Network Consultant in writing: Leave of Absence/Vacation: when a practitioner will be out of the office, vacationing, or on extended leave, and another facility or location will be covering his/her practice. Prevea360 Health Plan requires written notification to include: o Name o Location o Duration of the covering practitioner or facility The covering practitioner must be a plan provider and have completed the credentialing process. Panel Status: when a practitioner finds it necessary to discontinue accepting new patients or limit his/her practice (following this page is a Patient Acceptance Form that is required to be completed to communicate this information see below for template). PROVIDER SERVICE OBJECTIONS Providers in the Prevea360 Health Plan network that refuse to provide a service to members based on moral or religious objections must notify their Provider Network Consultant in writing of the objection and its basis in a timely manner. Prevea360 Health Plan will notify the member so that the member can seek another like network provider that is available to provide the service in question. PREVEA360 HEALTH PLAN TERMINATION OF PATIENT/PRACTITIONER RELATIONSHIP POLICY & PROCEDURE Contracted providers are required by Prevea360 Health Plan to send copies of member termination of care notification letters to their assigned Provider Network Consultant. Practitioners may terminate a member s care only with good cause. The following are examples of good cause, in which a member: Physically injured or threatened a practitioner or other member of the clinic staff. Repeatedly and materially refused to pay coinsurance, copayments, or deductibles associated with Prevea360 claims after all reasonable collection efforts have been exhausted. Displayed verbally abusive behavior or harassment towards a practitioner or other member of the clinic staff. Repeatedly refused to cooperate with the practitioner, was non-compliant with medical care, or there was a breakdown in the practitioner-patient relationship. Failed to attend or late cancel 3 or more scheduled appointments after having received a written warning. Communicated to the practitioner that they would like to select a different practitioner. The following should be included in the termination of care letter, per Prevea360 guidelines: 1. Member s full name, including middle name (not just initial) 2. Member s date of birth (optional) 3. Member s address, which can be in address line 4. Clinic/facility name 5. Practitioner name 6. Notice in the body of the letter stating that the member may see the practitioner for 30 days from the date the member received the termination notice if the member presents for urgent or emergent care 7. Reason for the termination a. If reason is due to the member missing or late-canceling appointments, include when their initial warning letter was sent to them b. If reason was due to non-payment, include proof of attempts to collect payment 8. Prevea360 Health Plan s Customer Care Center phone number (877) Copy of a patient authorization form, as the member may want to transfer care to a different clinic/facility Prevea360 Health Plan Provider Manual Revised 3/2018 7

8 Practitioner-Member Communication Prevea360 Health Plan shall ensure that Prevea360 Health Plan allows open practitioner-member communication regarding appropriate treatment alternatives and shall not penalize practitioners for discussing medically necessary or appropriate care with members. MEMBER INTERPRETATION SERVICES It is Prevea360 Health Plan s philosophy to help each and every member regardless of any language barriers that might exist. To that end, Prevea360 Health Plan employs the services of translation and interpretation professionals to assist with in-person and telephonic encounters at Prevea360 Health Plan, as well as written documentation upon request, when the member has limited English proficiency or is hard of hearing. These services are available through the Customer Care Center at (877) Providers shall use best efforts to provide their own interpreter services for Prevea360 Health Plan members with limited English proficiency upon request. PREVEA CARE AFTER HOURS If members are not sure if they should wait to see their primary care provider or go to Urgent Care they can call Prevea Care After Hours at (920) or toll-free (888) 2PREVEA. Staffed by an experienced medical team, Care After Hours is a convenient way for members to get the medical advice when the health centers are closed. Whether it s an injury, illness or medical question, they will answer your call 24-hours per day, seven days per week. Prevea360 Health Plan Provider Manual Revised 3/2018 8

9 PRODUCTS PREVEA360 HEALTH PLAN PRODUCTS Prevea360 Health Plan offers a variety of products for its employer groups; each designated to serve specific needs. Below is an overview of the types of plans that are available. Prevea360 Network Plan is a plan based on a managed care model in which a primary care provider (PCP) oversees all aspects of an individual's health care needs and emphasizes proactive preventive care. We also offer many Wellness programs, to keep you and your family as healthy as possible. In this affordable model, members identify a PCP or PCP location, at which a member may see any provider without an authorization, from our extensive network of providers. Women may also choose to see a women s health specialist (OBG/GYN) without an authorization. Out-of-network services will require an authorization from your Prevea360 provider, with the exception of urgent or emergency care services. Prevea360 POS Plans not only offers its members Network coverage, but also the freedom to see the providers of their choice, regardless if they are Prevea360 network providers. Members are not required to choose a primary care provider and no authorization is needed to see a specialist. However, when members receive care from Prevea360 Health Plan network providers, they will have lower out-of-pocket costs. Prevea360 PPO Plans were developed with the needs of those living outside of the Prevea360 Health Plan service area in mind. This benefit program utilizes extensive local, regional and national provider networks made up of hospitals, clinics and physicians throughout the PPO service area. Members have the flexibility to choose nonparticipating providers; however coverage benefits are reduced and out-of-pockets expenses are greater. Administrative Services Only (ASO) is a self-insurance arrangement whereby employer provides benefits to employees with its own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents. In self-funded health care, the employer assumes the direct risk for payment of the claims for benefits. The terms of eligibility and covered benefits are set forth in a plan document which includes provisions similar to those found in a typical group health insurance policy. PREVEA360 HEALTH PLAN IDENTIFICATION (ID) CARD Your role as a Prevea360 Health Plan provider is to identify which plan a member has to assure that the correct prior authorization guidelines are followed. We have included an example of the Prevea360 ID Card. We recommend checking the member s ID card at every visit to verify Prevea360 Health Plan coverage. If you have questions regarding member benefits and member identification, please use the Provider Portal (prevea360.com/providerportal), 270/271 or contact Customer Care Center if you have questions regarding member benefits and member identification. If they are an ASO member, please see this ASO Manual deancare.com/dhp/media/documents/providers/manuals/dean- Provider-ASO-Manual pdf?ext=.pdf Prevea360 Health Plan Provider Manual Revised 3/2018 9

10 EXAMPLE OF IDENTIFICATION CARDS (front) (back) AUTOMATIC ASSIGNMENT OF PRIMARY CARE PRACTITIONER If a member does not designate a PCP site and/or practitioner, Prevea360 will automatically assign one based upon the member s residence if one is not selected. In these situations, Prevea360 will send a letter to the member informing them of the PCP site or practitioner assigned. If the member has additional questions, the member can contact the Customer Care Center at (877) Prevea360 Health Plan Provider Manual Revised 3/

11 PROVIDER PORTAL OVERVIEW OF PORTAL/FUNCTIONALITY The Prevea360 Health Plan Provider Portal is an online resource that assists providers with managing key patient data, simplifying everyday tasks, promoting efficiency in business and streamlining electronic transactions. It has functionality to check HIPAA-compliant real time transactions along with internet-based self-service functionality. Please note that ASO members are not on the Provider Portal. There are two ways to access the Provider Portal: 1. Go directly to prevea360.com/providerportal 2. Go to Provider Tools Login page on prevea360.com and select the Provider Portal link located under the Provider Tools section (prevea360.com/tools-and- Resources/Account-Login.aspx) SERVICES THROUGH THE PROVIDER PORTAL Eligibility & Benefits (270/271 EDI) Transactions This feature provides human readable real time EDI (Electronic Data Interchange) 270/271 transactions. Checking eligibility can be done in four simple steps. The information would include details regarding Prevea360 Health Plan eligibility and benefit plan coverage, copayments and deductibles. Claims Status (EDI 276/277) Transactions This feature provides human readable real time EDI (Electronic Data Interchange) 276/277 transactions, which allows providers to check the status of a claim to see if it is pending, processed, or in a finalized status. Payment Remit-Detailed Electronic Payment Information This feature allows Prevea360 Health Plan to deliver ERAs (Electronic Remittance Advice) or remits to providers online. The ERA will show payment information for a specific claim or by batch. Claim Appeals This feature allows the submission of online claim appeals directly through the Provider Portal for claims that have a finalized status (paid-denied). Appeals Process Please see page 68 for an overview of the appeals process through our Provider Portal. Authorization Online Submission This feature allows the submission of new authorizations and ability to view authorizations that may have been started, saved or submitted. This feature is limited to our fully contracted plan providers. Medical Code Look-Up This feature allows the functionality to search for Procedure, Diagnosis and NDC Codes. If you have questions, please contact your assigned Provider Network Consultant. Prevea360 Health Plan Provider Manual Revised 3/

12 CREDENTIALING PROCESS PRACTITIONER CREDENTIALING AND RECREDENTIALING PROCESS Prevea Clinics, Inc. (Prevea) has developed and implemented a credentialing/recredentialing process for selecting and evaluating practitioners who practice within the P360 Network. Practitioner credentialing applications must be reviewed and approved by the Prevea Credentialing Committee or its delegate prior to being authorized to provide services to Prevea360 members. Recredentialing applications are required to be completed and approved by the Credentialing Committee at least every thirty six (36) months, in order to continue to provide services to Prevea360 members. Providers are sent a recredentialing application with pre-populated information from the previous credentialing cycle. The provider is responsible to update the information on the application. Network Services & Credentialing will review the applications and perform primary source verifications of the required documentation. The Credentialing/Recredentialing process will be completed within 180 days of the date of the practitioner s signature on the application. If the time of the process exceeds 180 days, Credentialing will return the application to the practitioner for review and updating of signatures. Practitioners who fall under the scope of credentialing/recredentialing for Prevea360: Medical practitioners o Medical Doctors (MD) o Dentists (DDS/DMD) o Chiropractors (DC) o Osteopaths (DO) o Podiatrists (DPM) o Optometrists (OD) Behavioral Health practitioners o Psychiatrists and other physicians o Addiction medicine specialists o Doctoral or master's-level psychologists who are state certified or licensed o Master's-level clinical social workers who are state certified or licensed o Master's-level clinical nurse specialists or psychiatric nurse practitioners who are nationally or state certified or licensed o Other behavioral health care specialists who are licensed, certified or registered by the state to practice independently o Master s- Level Qualified Treatment Trainees who are licensed and work at behavioral health facilities that are certified as DHS 35 by the State of Wisconsin o Master s- Level Autism Spectrum Disorder (ASD) Providers- who meet training requirements as set forth in Wisconsin Administrative Code 3.36 (exclusion: Qualified Paraprofessional) All credentialing/recredentialing will be conducted in a non-discriminatory manner. Prevea s policies provide practitioners with an opportunity to review and correct any information used in the credentialing/recredentialing process and ensures that all information obtained in the credentialing/recredentialing process is kept confidential. All practitioners have the right, upon their request, to be informed of the status of their credentialing/recredentialing application. Prevea360 Health Plan Provider Manual Revised 3/

13 Credentialing will notify any applicant of any information obtained during the credentialing/recredentialing process that varies substantially from the information provided to Prevea. by the applicant. Credentialing will allow an applicant to correct erroneous information submitted as a part of their application. Credentialing will allow any applicant to review the information submitted in support of their credentialing/recredentialing application. Applicants have the right, upon request, to be informed of the status of their credentialing/recredentialing application. The applicant can arrange for a review of their individual application at the office of Prevea. Credentialing may request additional information from the applicant or other parties that relates to the information submitted in support of the application or verification of the applicant s credentials and qualifications. This includes, but is not limited to: Information that is missing or incomplete on the application. Clarification of information obtained during the process that varies substantially from the information provided by the applicant. Correcting erroneous information. All applicants must complete an application that includes personal identifiers, professional information, education and experience, medical licensure information, medical specialty, hospital privileges, disciplinary actions, malpractice carrier, and conditions of the application. The application includes and the Credentialing Department verifies completeness of the following statements by the applicant: Ability to perform the essential functions of the position, with or without accommodation, for any condition, physical or mental. Lack of current illegal use of drugs. History of loss of license. History of felony convictions. History of loss or limitation of privileges or disciplinary activity. Attestation to the correctness and completeness of the application. Dates and amounts of current malpractice insurance coverage. Applicants must provide the following information with the application: Signed and dated ATTESTATION and AUTHORIZATION FOR RELEASE OF INFORMATION FORM Completed curriculum vitae form or equivalent information provided. A copy of current malpractice declaration with amounts and dates of coverage. A copy of current Drug Enforcement Agency licensure (as applicable). Network Services & Credentialing collects and reviews information about the applicant s credentials and qualifications, including verification of the following items from primary sources, as applicable: Verification of a valid state license to practice from the appropriate medical licensing authority. The provider cannot provide services outside of the scope of his/her license. Verification of hospital privileges (if applicable). Credentialing look-back period is five (5) years and recredentialing two (2) years. Verification of the applicant s valid Drug Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS) certificate, as applicable for MDs, DOs, DPMs, DDSs, APNPs and ODs. Verification from a physician applicant s residency training program verifying completion, as applicable. Internships, residencies and fellowships are verified during initial credentialing. If a fellowship is completed post credentialing, the Credentialing Department should be notified so that the fellowship can be verified and added to credentialing file. Prevea360 Health Plan Provider Manual Revised 3/

14 Verification of Board certification if the applicant states that he/she is board certified. Board certification can be verified using the following websites: o The Official ABMS Directory of Board Certified Medical Specialists, the AOA Official Osteopathic Physicians Profile Report or AOA Physicians Master File, or verification from either ABMS or AOA specialty board(s). o American Board of Oral and Maxillofacial Surgery o American Board of Podiatric Surgery o American Board of Professional Psychology o American Board of Professional Neuropsychology o National Boards of Certified Counselors o American Board of Addiction Medicine Verification through application or curriculum vitae (CV) with a minimum of (5) five years work history in the health care field or since completion of medical or professional school to current. For practitioners who have practiced fewer than 5 (five) years, verification begins with the completion of education to current. Any gap exceeding (6) six months must be clarified either verbally or in writing. The CV or application must include the month and year for each position in the history. If there has been continuous employment for (5) years or more, no month or year are required. Any gap exceeding (1) year must be verified in writing. During recredentialing you will be asked to indicate your work history for previous (3) years. Verification of the applicant s malpractice insurance to verify it is current and adequate. Review of the applicant s history of professional liability claims which result in settlements or judgments paid by or on behalf of the applicant. Network Services & Credentialing reviews the information supplied by the applicant and receives information from the National Practitioner Data Bank (NPDB), which includes previous sanction activity by Medicare and Medicaid. Review of applicant s history of member complaints. *Education verifications and work history are not required to be collected during the recredentialing process, unless new information is identified. Physician applicants who have not completed at least one residency that made them eligible for ABMS or AOA board certification in that specialty must apply as a general practitioner. Credentialing will verify the following during initial credentialing. Practitioner status will remain the same unless notified of any changes. The applicant s training program after receiving their medical degree, which must include at least one year of a medical residency The applicant s work experience as a practitioner must include: verification of five (5) years of medical practice in primary care (Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology or General Practice (GP) References in writing from three (3) practitioners familiar with the applicant s practice and experience in the field of GP. These references should attest to the applicant s performance as a GP physician and the quality of care and professional conduct of the applicant. The Credentialing Committee members review applicant credentialing/recredentialing files. The Credentialing Committee reserves the right to request detailed information when reviewing credentialing or recredentialing applications. Failure to provide information as requested may be the basis for denying participation with Prevea. The Credentialing Committee has sole discretion to approve or deny applications. Criteria that may be used by the committee to review credentials include, but are not limited to: History of illegal or unethical conduct. History of felony convictions. History of acts of dishonesty, fraud, deceit, or misrepresentation. History of involuntary termination of professional employment. Prevea360 Health Plan Provider Manual Revised 3/

15 History of professional disciplinary action or sanction by a managed care organization, hospital, medical review board, licensing agency, or other administrative body. History of NPDB adverse action report. History of misrepresentation, misstatement, or omission of relevant facts. History of physical or mental condition, chemical dependency or substance abuse that may interfere with the ability to practice in their specialty or may jeopardize patient health or safety. History of malpractice lawsuits, judgments, settlements, or other incidents that might indicate problems with competence or quality of care. Demonstrated unwillingness to practice their specialty in a managed care environment and to cooperate with the Credentialing Department in administrative procedures and other matters. Debarment or termination from the Medicare and Medicaid programs by the US Office by Personnel Management. Credentialing Committee members may recommend approval, denial or postponement of a decision until the applicant s qualifications are further clarified. All material obtained in the credentialing process, including complete applications, will be retained by Network Services & Credentialing. Network Services and Credentialing maintains strict confidentiality of all information obtained during the credentialing process, except as otherwise provided by law. Access to the credentialing information is limited to Network Services & Credentialing staff involved in the credentialing process and the Credentialing Committee members. All credentialing applications, files and other materials and information are kept in locked files, except when being reviewed or processed by Network Services & Credentialing staff or members of the Credentialing Committee. INITIAL CREDENTIALING APPLICATION CLOSING A FILE/DENIAL Network Services & Credentialing may close the applicant s file during the initial credentialing process at any time if the Credentialing Supervisor determines that the applicant does not meet the standards of this or any other Prevea Credentialing policy. This can include, but is not limited to: The applicant does not meet all requirements to be approved as a plan practitioner. The applicant is unable or unwilling to provide Credentialing with accurate or complete information regarding questions on their application. The applicant is unable or unwilling to provide Credentialing with verifiable information to support the credentialing process. The applicant is unable or unwilling to provide Credentialing with requested information relating to their credentials, qualifications, history as a medical practitioner, criminal, or illegal activities. The closing of an applicant s credentialing file terminates the credentialing process for that applicant. In the event of closing an applicant s credentialing file, Credentialing will notify the applicant, in writing, stating the reason(s) for closing the file, and returning the applicant s original application materials. The applicant may withdraw their application at any time during the credentialing process. An applicant may reapply to become part of the Prevea360 Network at any time they are able to demonstrate they can meet all requirements for credentialing under this or any other Prevea credentialing policy. Providers denied by the Credentialing Committee during initial credentialing may reapply to be part of the Prevea360 Network after twelve (12) months. Prevea360 Health Plan Provider Manual Revised 3/

16 RECREDENTIALING APPLICATION DENIAL Providers denied during the recredentialing process will be notified in writing of the decision for denial, and of their rights to appeal the decision. All decisions made by the appeal committee are final. For more detail regarding denials, see section Altering Participation Station. ALTERING PARTICIPATION STATUS Any decision to alter participation will be based on quality of care issues, professional competence or conduct. Prevea360 Health Plan shall follow a standardized policy and procedure for altering a practitioner s participation in the Prevea360 network This policy shall not apply to actions taken pursuant to a practitioner s Participating Provider Agreement with Prevea that do not relate to the above. The action of altering a practitioner's participation with the Prevea360 Network will be recommended by the Credentialing Committee. Reasons for altering of participation include, but are not limited to: Professional state licensure revocation, suspension or limitation. Drug Enforcement Agency licensure revocation or limitation. Debarment or termination from the Medicare or Medicaid programs by the U.S. Office of Personnel Management. Loss or suspension of medical staff membership or restrictions on clinical privileges at any P360 participating hospital for reasons related to quality, professional competence or conduct. Notification which involve imminent danger and/or concerns of quality to members. Notification of quality concerns that warrant altering participation. Reported suspensions from the National Practitioner Data Bank (NPDB). Information received regarding a practitioner or organization will be fully investigated by the credentialing staff and/or the Credentialing Committee Chairperson. All compiled information received will be reviewed by the Credentialing Committee. Forms of investigation may include but are not limited to: Correspondence with practitioner; written and/or verbal. Documentation from previous employers. Documentation from current or past facilities that clinical privileges were held. In the event that the investigation reveals concerns about quality, professional competence or conduct that do not rise to the level of requiring immediate termination, the Credentialing Committee may recommend appropriate actions. The affected practitioner shall remain listed as a participating provider until he or she has waived or exhausted his or her right to an appeal of the adverse action as set forth in Prevea s Credentialing Policy CRC : Complaints About Practitioners. Reporting of quality of care issues to the National Practitioner Data Bank (NPDB) and Wisconsin Department of Regulation & Licensing will be made in accordance with Prevea s Credentialing Policy CRC : Complaints About Practitioners. The range of actions that can be taken by the Credentialing Committee includes but is not limited to: Continued Medical Education (CMEs) as appropriate; Proctoring; Prevea360 Health Plan Provider Manual Revised 3/

17 Communication by Prevea Chief Medical Officer; Ongoing Practice Assessments; or Reduction, suspension or termination of practitioner s participation. In the event that immediate action is required to prevent harm to Prevea360 members, employees or other participating providers, the Credentialing Committee Member may approve an immediate-termination action. Reasons for immediate termination include but are not limited to: Professional state license revocation; Drug Enforcement Agency licensure revocation; Debarment or termination from the Medicare or Medicaid programs by the U.S. Office of Personnel Management; or Loss or suspension of medical staff membership or restrictions on clinical privileges at a Prevea360 participating hospital for reasons related to quality, professional competence or conduct. In the event that Prevea takes immediate action, the Credentialing Department will provide the practitioner written notice of the action, including reasons for the action. Upon receiving the notice, the practitioner may request a hearing as described in Prevea s Credentialing Policy CRC : Complaints About Practitioners. In order to initiate an appeal, the plan practitioner must request an Appellate Review within 30 days of notification, to the Credentialing Committee Chair. The practitioner may submit any substantiating documentation pertinent to the Appeals Committee s review. The Appeals Committee will be appointed by the Chief Medical Officer, and will consist of five (5) appointees, who shall not be members of the current Credentials Committee. None of the appointees can be in direct economic competition with the practitioner. One appointee shall be a non-physician Prevea officer. The Appeals Committee will meet within 30 days of receiving a request for appeal and will conclude its deliberations within 60 days of receipt of the request for an appeal. The practitioner has the right to appear and present information to the Appeals Committee. If the practitioner chooses not to be present at the Appeals Committee meeting, the Appeals Committee will make their final decision based on the information available. This decision will be communicated in writing to the practitioner within 30 days from conclusion of the appeals committee s deliberations. Again, the decision of the Appeals Committee is final. Based on that decision, Prevea will coordinate proper notification to the NPDB and the Department of Regulation and Licensing. Prevea will complete the Adverse Action Report Form developed by the NPDB and will forward the information to the NPDB. Prevea shall follow a standardized policy and procedure for altering a practitioner's participation in the Prevea360 Network for reasons relating to quality of care, competence or professional conduct. Prevea360 Health Plan Provider Manual Revised 3/

18 Claims Submission CLAIMS, TIMELY FILING, AND EOPs To allow for more efficient processing of your claims, we ask for your cooperation with the following: When a physician or a clinic becomes a Contracted Provider, they agree to accept payment made by Prevea360 Health Plan as payment in full. Discounts and withholds are not to be billed to the member or the secondary insurance company. Members may be billed for copayments, coinsurance, deductible amounts, and non-covered services. Prevea360 Health Plan requires providers to use the correct and complete member number. Families share the first nine digits of their subscriber number. The remaining two digits signify the individual member (i.e. spouse, dependents, etc.). Using the correct member numbers on the claims submitted to Prevea360 Health Plan will help us ensure correct claim payment. Prevea360 Health Plan requires contracted providers to file claims in a timely manner. All claims must be submitted in accordance with the claim filing limit stipulated in your Provider Agreement/Contract. Refer to the Timely Filing Guidelines in this section for further instructions. All claims for services regarding work-related injuries or illness should be submitted to the worker s compensation carrier. If claims are denied by the worker s compensation carrier, you may submit the claim along with the denial for consideration by Prevea360 Health Plan. All prior authorization guidelines apply in this situation. You must submit the claim(s) in a timely manner along with the denial as outlined in the timely filing guidelines. Submit subrogation claims (where the third party may have caused the injury or illness due to an auto accident, a slip or fall, and/or a defective product) to Prevea360 Health Plan for processing. We will pursue recovery of those expenses from the at-fault party and/or their liability insurer. All prior authorization guidelines apply in this situation. You must submit the claim(s) in a timely manner as outlined in the timely filing guidelines. Prevea360 Health Plan requires that all services billed be appropriately documented in the patient s medical records in accordance with Prevea360 Health Plan s Medical Records Policy. If the services billed are not documented in the patient s medical record, in accordance with the policy, they will not be considered reimbursable by Prevea360 Health Plan. Prevea360 Health Plan s Medical Records Policy can be found in the Quality Improvement section of this manual. While Prevea360 Health Plan will accept paper or electronically submitted claims, it s recommended to submit electronically to expedite processing and reduce claim rejections. All claims submitted, regardless of submission method, must comply with the applicable national billing rules as well as the published Prevea360 Health Plan Companion Guides. Only the latest published versions of the claim forms will be accepted for processing. Please see the EDI Transactions section for more information on submitting electronically. Coordination of Benefit (COB) claims must be received along with the primary payer s explanation of payment within the TF limit outlined in your agreement with Prevea360 Health Plan; beginning with the date noted on the primary payer s explanation of benefits. Please note, COB claims may also be submitted via electronic data interchange (EDI) on the 837 claims transaction. When submitting COB claims electronically, be sure to add the prior payer s payment information in the relevant segments. Full details can be found in the HIPAA Implementation Guides or the Prevea360 Health Plan Companion Guides. If your office would like to check the status of a claim, please utilize the Provider Portal s claim status functionality or utilize a HIPAA standard 276/277 claims status transaction. Prevea360 Health Plan Provider Manual Revised 3/

19 Providers can send claims to: Prevea360 Health Plan PO Box Madison, WI Failure to submit all required information could result in claim payment denials or reduction in benefits. Corrected Claims Prevea360 Health Plan recognizes that it is sometimes necessary to change a claim or to challenge a decision. Specifically, a corrected claim is any claim that has a change to the original (e.g., changes or corrections to charges, procedure or diagnostic codes, dates of service, member name, etc.). If a provider agrees with the denial and in order for the claim to be reconsidered for payment a corrected claim would be required. If a provider disagrees with the denial determination the claim can be appealed. Please see the Provider Appeals section of the manual for further details. All lines billed on the original claim must also be billed on the corrected claim. All corrections will require an appropriate Claim Frequency Code and Payer Claim Control Number (Original Claim ID). Corrected claims will be returned if any of the requirements are not met. The following table explains specifically which information is required. Scenario #1: Corrected Claims - Not Requiring Supporting Documentation Claim Frequency Code Payer Claim Control Number General Rule 837P & 837I CMS-1500 CMS-1450 Must include one of the Loop 2300: Box 22 Box 4 Type of Bill following: CLM05-3 Resubmission Code 7 - Replacement and/or Original 8 - Void Reference Number Note: Corrected claims submitted with a 1 will be denied as duplicates. Must include the original Prevea360 Health Plan claim number associated with the correction. Loop 2300: REF*F8 Box 22 Resubmission Code and/or Original Reference Number Note: For Institutional claims, this represents the third digit of the Type of Bill being submitted. Box 64 Document Control Number Note: Corrected claims without a Prevea360 Health Plan formatted original claim ID will be rejected. Scenario #2: Corrected Claims Requiring Supporting Documentation Supporting documentation may still be required for certain claim-edit denials related to code bundling, new patient visits, global surgery, diagnosis, unlisted codes, etc. Prevea360 Health Plan Provider Manual Revised 3/

20 Submitters must only submit claims requiring supporting documentation via the CMS-1450 or CMS-1500 form, using version 02/12. No electronic processing of these claims is currently supported. While Prevea360 Health Plan is able to accept the PWK segment on an 837 transaction, we cannot guarantee it is being used in claims processing. In addition, submitters must complete a Code Review Request Form along with any additional, required supporting documentation. In order to abide by HIPAA guidelines, only documentation pertinent to the correction should be submitted. Claim Frequency Code Payer Claim Control Number General Rule CMS-1500 CMS-1450 Must include one of the following: Box 22 Resubmission Box 4 Type of Bill 7 - Replacement Code and/or Original 8 Void Reference Number Note: Corrected claims submitted with a 1 will be denied as duplicates. Must include the original Prevea360 Health Plan claim number associated with the correction. Box 22 Resubmission Code and/or Original Reference Number Note: For Institutional claims, this represents the third digit of the Type of Bill being submitted. Box 64 Document Control Number Note: Corrected claims without a Prevea360 Health Plan formatted original claim ID will be rejected. Acknowledgment of Submitted Claims Prevea360 Health Plan provides acknowledgment of all new claim submissions via the Confirmation Reports Portal. Confirmation reports show all claims accepted in for processing as well as all claims that were rejected and not accepted in for processing. Confirmation reports will be available within 48 hours of when Prevea360 Health Plan receives a claim. This includes claims submitted electronically or on paper. A link to the Confirmation Reports Portal can be found on the Provider Resources page of prevea360.com/tools-and- Resources/Account-Login.aspx. Please contact your Provider Network Consultant to sign up for the Confirmation Reports Portal. If you do not have access, you will receive paper notification of rejections only. Providers should review each report received to confirm all claims were received by Prevea360 Health Plan and to work the rejected claims. The rejected claims portion of the report will include error codes to explain the specific reason a claim was not accepted. Based on the error codes provided, please resubmit the claims with the necessary changes. Providers are required to make corrections and resubmit the claim within the allotted timeframe agreed upon in the contract beginning with the date of receipt. If you are submitting claims electronically, a 999 acknowledgement transaction will be used to indicate whether or not your transaction sets (ST/SE) passed SNIP types 1 and 2 compliance. Please work directly with your clearinghouse or EDI team to validate claim transaction acceptance. In cases of rejected 999s, please use the content of the transaction to understand the errors and resubmit the entire transaction. Please refer to the timely filing guidelines when resubmitting. There is no need to resubmit with an Untimely Filing Waiver Request Form unless you are resubmitting outside of your timely filing guidelines. The following is an example of the Confirmation Reports Portal: Accepted Prevea360 Health Plan Provider Manual Revised 3/

21 Rejected Timely Filing (TF) Guidelines for Initial Submission The initial submission of a claim is subject to the timely filing guidelines outlined in your agreement with Prevea360 Health Plan. When a provider s claims (paper and/or electronic) are received in our Claims Department, Prevea360 Health Plan will provide proof of receipt and return confirmation via the Confirmation Reports Portal to the submitting provider. This receipt will include the date that Prevea360 Health Plan received the paper or electronic claim. If a claim is rejected for improper submission, resubmission must be completed by the provider within the filing limit outlined in your agreement with Prevea360 Health Plan. When you receive your confirmation report back from Prevea360 Health Plan, retain them for your records in the event that you need to file an untimely filing waiver request. Please be aware that when a provider fails to submit a claim timely, rights to payment from Prevea360 Health Plan are forfeited and the provider may not seek payment from the member as compensation for these covered services. Exceptions to Timely Filing Guidelines on Initial Claim Submission Requests for temporary waiver of the TF limit must be made in advance due to computer system conversions or other short term circumstances. Such requests may be made, in writing, to your assigned Provider Network Consultant. Coordination of Benefit (COB) claims must be received within the TF limit outlined in your agreement with Prevea360 Health Plan; beginning with the date noted on the primary payer s explanation of benefits. Crossover claims are exempt from the filing limit. Crossover claims are those claims that are initially filed with CMS, and forwarded by CMS to Prevea360 Health Plan. If the provider had difficulty obtaining Prevea360 Health Plan coverage information from the subscriber, claims must be received within the timely filing limit beginning with the date the Prevea360 Health Plan coverage is identified, but not longer than 180 days from the date of service. Provider shall submit supporting documentation to demonstrate measures the provider has taken to obtain this information. Upon receipt of such information, provider must submit claims and supporting documentation within the filing limit outlined in their agreement. Claims for prenatal visits, which would have been normally billed as part of a global obstetrics (OB) charge, must be billed separately due to a change in physician and need to be submitted within timely filing limit, beginning with the date of delivery. Prevea360 Health Plan will not accept a global obstetrical charge from a provider. Timely Filing Guidelines for Claim Resubmissions/Corrections All resubmitted/corrected claims need to be received by Prevea360 Health Plan within the filing limit outlined in your agreement. The first day of the filing limit for resubmissions/corrections begins with the date upon which Prevea360 Health Plan notifies the Provider a claim has failed processing. You will find this date on the Explanation of Payment (EOP) or your 835. Prevea360 Health Plan Provider Manual Revised 3/