Participating Provider Manual

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1 Participating Provider anual

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4 CONTENTS 1. INTRODUCTION 5 2. HIPAA 6 3. CARE ANAGEENT OVERVIEW 7 4. PROVIDER ROLES ENROLLENT AND ASSESSENT THE CARE PLANNING PROCESS CHANGE IN EBER STATUS DISENROLLENT COVERED SERVICES, REFERRALS, AND AUTHORIZATIONS EERGENCY AND URGENT CARE BILLING & CLAIS EBER COPLAINTS AND APPEALS SWH QUALITY INITIATIVES PROVIDER SERVICES 43 A. APPENDICES A. SWH Service Area 47 B. SWH Covered Services 50 C. SWH Primary Care Physician Assessment 55 D. SWH ember ID Card 57 E. SWH Referral/Authorization Form 58 F. Sample HCFA 1500 and SWH Required Fields 59 G. Sample UB92 Form and SWH Required Fields 64 H. SWH Remittance Advice 69 I. SWH Provider Information Form 70 J. SWH Provider Consent Form 71 K. SWH Sample Individual Care Plan 73 SENIOR WHOLE HEALTH PROVIDER ANUAL 3

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6 1 INTRODUCTION About Senior Whole Health Senior Whole Health (SWH) is a Senior Care Organization (SCO), a next generation managed care organization for asshealth eligible seniors age 65 and over. This first-of-its-kind program has been initiated through a Commonwealth and federal partnership between assachusetts edicaid (asshealth) and edicare. As a SCO, SWH works with its provider network to coordinate a comprehensive array of supportive and interventional services to address our ember s medical, behavioral, long-term care, and social needs. Purpose of This anual This manual contains information intended for all SWH providers. It is intended to guide you in your participation in Senior Whole Health. In the event information contained in this manual differs from your contract, your contract takes precedence. Contacting Senior Whole Health Senior Whole Health can be reached at the following address and telephone numbers: Senior Whole Health 58 Charles Street Cambridge, A (888) (voice) (617) (fax) Web: Senior Whole Health s regular business hours are onday through Friday, 9A to 5P. In case of medical emergency, a Senior Whole Health Nurse Case anager can be reached after business hours at the above phone number. SENIOR WHOLE HEALTH PROVIDER ANUAL 5

7 2 HIPAA Health Information Portability Accountability Act (HIPAA) Senior Whole Health strives to ensure that both SWH and its participating providers conduct business in a manner that safeguards patient/ember information as a Covered Entity in accordance with the privacy regulations enacted pursuant to the Health Insurance Portability and Accountability Act (HIPAA). SWH recognizes its responsibility under the HIPAA privacy regulations to request the minimum necessary ember information from providers necessary to accomplish the intended purpose. Likewise, participating providers should request the minimum necessary ember information required to accomplish the intended purpose from SWH. HIPAA privacy regulations allow the transfer or sharing of ember personal health information (PHI) when requested by SWH to maintain the Centralized Enrollee Record (CER), to conduct business to and make decisions. Examples of communications by SWH include updating ember demographic information, making an authorization or resolving a payment appeal. Such requests are considered part of the HIPAA definition of treatment, payment or health care operations. Senior Whole Health systems are designed to ensure that ember personal health information is managed in a confidential and secure manner. ethods of Communication Via facsimile: Fax machines used to transfer and receive SWH medically sensitive information should be maintained in a secure environment where access is restricted to individuals who need ember information to perform their jobs. Faxes containing ember information should be marked with PHI on the cover sheet. Facsimiles should be sent to SWH s secure clinical fax at Via mail: Via telephone: ail should be sent in an envelope marked Confidential PHI and addressed to a specific individual at Senior Whole Health. When contacting Senior Whole Health, all providers will be asked to positively identify themselves before private health information will be discussed with them. If you need to leave a voice mail message for a Senior Whole Health associate, please leave the minimum amount of ember information required to accomplish the intended purpose. For additional information about HIPAA, please visit the CS website at 6 SENIOR WHOLE HEALTH PROVIDER ANUAL

8 3 CARE ANAGEENT OVERVIEW Senior Whole Health (SWH) embers are voluntarily enrolled asshealth eligible seniors age 65 and over who live in the SWH service area. Our geriatric care model is designed to promote optimal functioning and quality of life for embers in their preferred place of residence. The model is based on interdisciplinary care management involving Primary Care Physicians, SWH Nurse Case anagers, social workers from local Aging Services Access Points (ASAPs) and other providers. Our goal is to coordinate care, interdisciplinary assessment, treatment, and other interventions in order to minimize disability, promote positive health behaviors, and maintain our ember s health status. Senior Whole Health s Service Area Senior Whole Health s service area encompasses six counties in Eastern assachusetts. It includes all or part of the following counties: Bristol (Fall River, New Bedford) Essex (ethuen, Lawrence and Lowell) iddlesex (Cambridge, Watertown, Waltham) Norfolk (Brookline, Dedham, Norwood) Plymouth (Brockton) Suffolk (Boston) For a complete list of locations where Senior Whole Health is enrolling embers, please see Appendix A. Common Terms and Definitions The following terms are commonly used in this guidebook: Aging Services Access Point (ASAP) An entity organized under assachusetts General Law (.G.L.) c.19 4B that contracts with the Executive Office of Elder Affairs to manage the Home Care Program in assachusetts and that performs various services for, and on behalf of, elderly residents of assachusetts. Complex Care Needs Any condition, set of conditions, or situation that, in the judgment of SWH, requires intensive coordination of multiple services on behalf of the ember. For example, clinical eligibility for institutional long term care; medical illness, psychiatric illness, or cognitive impairment that requires skilled nursing to manage essential unskilled services and care; factors/conditions indicating a ember is at-risk of further impairment and/or reduction of functional capacity that could result in elevated care needs if not addressed; inability to independently perform two (2) or more SENIOR WHOLE HEALTH PROVIDER ANUAL 7

9 activities of daily living (ADLs). Geriatric Care odel An interdisciplinary approach to provide assessment, prevention, treatment and other interventions that minimize disability, promote positive health behaviors and maintain health status and function for embers. Geriatric Support Services Coordinator (GSSC) An ASAP employee who is a social worker with geriatric experience and is certified by SWH to participate as part of a primary care team. GSSCs help conduct initial and ongoing assessments of the health and functional status of embers. GSSC Assessment The assachusetts Long Term Care Assessment Tool. This is a standard assessment tool used by GSSCs to assess a ember s environmental, supportive, and social service needs. The assessment is conducted in a ember s home or residence. inimum Data Set Version 2.0 (DS 2.0) A federally standardized assessment tool for use in nursing facilities to assesses a person s functional and clinical status. edicare and asshealth each require use of this assessment tool as a condition of reimbursement. inimum Data Set Home Care (DS-HC) A standardized assessment tool for use with community based persons to assess a person s functional and clinical status. asshealth requires this tool to determine a ember s Senior Care Options program rating category. Primary Care Team (PCT) A Primary Care Team is a group of health care providers with experience in geriatric practice consisting at least of a ember s Primary Care Physician, Geriatric Support Services Coordinator (GSSC) (for community-based embers), and Senior Whole Health Nurse Case anager. The Primary Care Team functions under the clinical direction of the PCP. It develops Individual Care Plans for embers and works together to assure effective coordination and delivery of care. The PCP may include other professional and support disciplines at his/her discretion. Features of Senior Whole Health Care anagement Coordinated, Integrated Care Each SWH ember selects a Primary Care Physician (PCP) from the SWH network. The PCP is responsible for the overall clinical direction of a ember s care. SWH also contracts with community based social workers called Geriatric Support Services Coordinators (GSSCs). For SWH embers residing in community-based settings, GSSCs participate in ember assessment activities and help to integrate non-medical support services into care plans. They help to navigate the network of community support and information services available to seniors. Upon enrollment, each SWH ember is assigned a SWH Nurse Case anager. The SWH Nurse Case anager acts as a single contact point for embers, GSSCs, PCPs and providers and caregivers involved in a ember s care. Communication and collaboration between the PCP, GSSC and the SWH Nurse Case anager is the basis for development of Individual Care Plans and for their effective implementation. This model is designed to support coordination of care at multiple levels. 8 SENIOR WHOLE HEALTH PROVIDER ANUAL

10 Continuous Assessment An Initial Assessment process is initiated for each SWH ember upon enrollment. Ongoing reassessments are conducted: At least every six (6) months for embers without Complex Care Needs; At least every three (3) months for embers with Complex Care Needs; or At any time a ember experience a significant change in health or functional status. The PCP, the GSSC and the SWH Nurse Case anager may each be involved in collecting information about a ember s physical, functional, clinical and mental health status, support systems and environmental needs. The standard assessment tools used include: Primary Care Physician Assessment Tool (See SWH PCP Assessment Appendix B) GSSC functional and environmental assessment for community based embers DS-HC for community-based embers who have Complex Care Needs; and DS 2.0 for embers who reside in extended care facilities. The SWH Nurse Case anager initiates, arranges, and monitors assessment activity, compiles assessment results and works with the PCP and other providers to develop the ember s Individual Care Plan. The SWH Nurse Case anager is responsible for ensuring that reassessments are conducted at regular intervals and for contacting the PCP to initiate assessments if there is a significant change in a ember s health status. Primary Care Team (PCT) embers with Complex Care Needs have a Primary Care Team (PCT). SWH forms a Primary Care Team for all nursing home residents, nursing home certifiable embers, and embers with chronic mental illness, Alzheimer s and/or dementia. Other embers may also have a Primary Care Team at the discretion of SWH. At a minimum, a PCT is comprised of the PCP, SWH Nurse Case anager and, if a ember is a community resident, a GSSC. Some embers may need broader representation on the PCT. At the discretion of the PCP, other professionals and support disciplines may be invited to participate in evaluation and planning services. The PCP provides clinical direction and oversight to the team and the SWH Nurse Case anager facilitates provider participation. The SWH Nurse Case anager drafts care plans, arranges meetings and ensures that PCT participants have necessary information. PCT meetings may be telephonic, electronic or face-to-face, as circumstances dictate. SENIOR WHOLE HEALTH PROVIDER ANUAL 9

11 Individual Care Plans (ICP) Individual Care Plans are based on assessments of a ember s medical, functional and mental health status including a ember s home environment and support systems. The ICP is a detailed written description of the scope, frequency and duration of services to be provided to the ember. The SWH Nurse Case anager works with the PCP and GSSC to prepare a draft ICP for review by the PCT and final approval by the PCP. Once the PCP, in consultation with other PCT embers, approves the plan, the ICP is reviewed with the ember or the ember s designated representative. This is a critical step in the process because it helps to ensure compliance and cooperation from the ember, the family, and other informal support persons. For ember s with Complex Care Needs, the ember or their designated representative will be asked to sign the Individual Care Plan. Once an ICP is approved, SWH will authorize the recommended services in the care plan and arrange for their implementation and monitoring. Centralized Enrollee Record (CER) Senior Whole Health is developing a web-based Centralized Enrollee Record (CER) to assist providers in managing embers care. The purpose of the CER is to help the PCP/PCT better manage a ember s care by incorporating both clinical and non-clinical information into an easily accessible and secure location for providers. The CER is not an electronic medical record. It allows a provider to view ember related data from a number of data sources including care plans, assessments, claims and authorizations. It is an up-todate summary overview of a ember s health status, support systems, contacts, demographics and current medication information. It identifies a ember s emergency contact information and advance directives/health proxy information. Senior Whole Health makes the CER available through a secure, Internet portal. For more information please contact your Senior Whole Health provider representative. 10 SENIOR WHOLE HEALTH PROVIDER ANUAL

12 4 PROVIDER ROLES The Role of the Primary Care Physician Each SWH ember selects, or is assigned, a SWH Primary Care Physician (PCP). The PCP is responsible for overseeing the provision of care for his or her SWH embers. The PCP assumes clinical responsibility for each ember upon the effective date of enrollment. Specific PCP responsibilities include, but are not limited to: Providing and/or coordinating the provision of covered services to embers; Performing a clinical assessment of a ember (the PCP Assessment) upon enrollment and at proscribed periodic intervals; Developing and approving a ember s Individual Care Plans in collaboration with the SWH Nurse Case anager; Providing non-symptomatic office visits within thirty (30) calendar days of a ember s request. Providing urgent care and symptomatic office visits within 48 hours of a ember s request. Assisting in the transition of a ember s care at the time of enrollment from existing nonparticipating providers, if necessary. Participating in the development and management of Primary Care Teams, including the provision of clinical oversight. The Role of the SWH Nurse Case anager The SWH Nurse Case anager is the primary SWH liaison between the ember, the PCP, the GSSC and other providers involved in a ember s care. The Nurse Case anager s role is to facilitate communication, coordinate and arrange for services and assessments, and routinely monitor a ember s health status. Specific responsibilities of the Nurse Case anager and other SWH staff are: Scheduling appointments, coordinating and collecting information by phone, and reviewing all aspects of the Initial and Ongoing assessments with the PCP, the GSSC (if appropriate), the nursing home and other involved providers; Conducting or arranging for DS-HC assessments; Summarizing ember assessments and working with Primary Care Team embers to draft Individual Care Plans; Working with the PCP in development of effective Primary Care Team, and to scheduling and coordinating PCT meetings; SENIOR WHOLE HEALTH PROVIDER ANUAL 11

13 Coordinating implementation of Individual Care Plans, including authorization of services and review of the ICP with the ember and/or the ember s designated representative and caregivers; aintaining up-to-date information in the ember s Centralized Enrollee Record; Conducting utilization and case management activities and notifying the PCP/PCT of any changes in the status of a ember. The Role of the Geriatric Support Services Coordinator Geriatric Support Services Coordinators (GSSCs) are social workers employed by an Aging Services Access Point (ASAP). There are a number of ASAPs in assachusetts. Every geographic region of the Commonwealth is part of an ASAP service area. In Appendix A, ASAPs are cross referenced to the SWH service area. Among other sources of funding, ASAPs contract with the assachusetts Executive Office of Elder Affairs to provide a variety of services to community-based elderly assachusetts residents. SWH contracts with ASAPs in each part of its service area to provide GSSC services. GSSCs have experience in community long-term care and are familiar with the variety of local and state resources available to help support seniors. GSSCs perform the following activities: Participate in Initial and Ongoing Assessments of the functional status of community based embers, including in-home assessments; Collaborate with the PCP and SWH Nurse Case anager, and participate on PCTs, if required, to determine the appropriateness of long term care services; Collaborate with the PCP/PCT and SWH Nurse Case anager to develop community-based care plans and related service packages necessary to improve or maintain a ember s health and functional status; Arrange and coordinate the provision of appropriate community long term care and social support services as part of an approved care plan; onitor the provision and functional outcomes of community-based services; Track ember transfers from one setting to another and inform the SWH Nurse Case anager about any such changes. 12 SENIOR WHOLE HEALTH PROVIDER ANUAL

14 5 ENROLLENT AND ASSESSENT A potential ember or caregiver(s) can learn about Senior Whole Health through a variety of avenues: by contacting SWH directly at , by mail, by referral from friends, family or providers. Providers are an important source of information for potential embers in helping them negotiate choices in a complex and sometimes confusing medical system. Potential embers may reside in their own home, a residential or housing facility, or in a nursing home. Senior Whole Health encourages providers and their office staff to talk to their elderly asshealth patients and/or their primary caregiver(s) about the option of joining a SCO plan. To facilitate a patient s choice, SWH can provide informational packets to providers for distribution to prospective embers upon request. Senior Whole Health Eligibility Requirements Senior Whole Health embers must meet the following eligibility requirements: Be eligible for asshealth Standard benefits Be age 65 years or over Reside in the SWH service area (Appendix A) Potential embers may reside either in the community or in a nursing facility. embers may have both asshealth and edicare, but edicare coverage is not required for enrollment in Senior Whole Health. If interested persons do not have asshealth but think they might qualify, they should contact their asshealth Enrollment Center to assist them in eligibility determination. Potential embers are always welcome to contact Senior Whole Health with questions. asshealth recipients ineligible to enroll in Senior Whole Health include: Recipients diagnosed with End Stage Renal Disease (ESRD); Recipients who are residents of an Intermediate Care Facility for the entally Retarded; Recipients who are inpatient in a chronic disease or rehabilitation hospital; Recipients who have elected hospice, unless SWH contracts with that recipient s hospice provider. Senior Care Options Program Requirements Individuals enrolling in Senior Whole Health must agree to: Live in the Senior Whole Health service area for at least six (6) months of the year; Receive all their services from a Senior Whole Health provider except: 1) in the case of an SENIOR WHOLE HEALTH PROVIDER ANUAL 13

15 emergency; 2) for urgent care under unusual and extraordinary circumstances when the SWH medical provider is unavailable or inaccessible; 3) for urgent care sought out of the service area; 4) for out-of-area renal dialysis services; Select a Primary Care Physician (PCP) from the Senior Whole Health provider network; Participate in assessments at required intervals; Work with his or her PCP and/or Primary Care Team (PCT) in developing and complying with an Individualized Care Plan. Enrollment in Senior Whole Health Step 1: Completing Enrollment Forms Individuals interested in joining Senior Whole Health must complete a SCO Enrollment Form. This form may be obtained from Senior Whole Health by calling 888-SWH-SCO8 ( ) or from the asshealth website at Senior Whole Health Outreach Representatives assist interested applicants or their designated representative in completing the SCO Enrollment form and ensuring that they understand the program requirements. Outreach Representatives review benefits and other pertinent information with potential enrollees. asshealth representatives are also available to assist with the application process. All completed forms should be submitted to Senior Whole Health at: 58 Charles Street Cambridge, A SWH will forward a copy to asshealth. Please note that if asshealth receives the form prior to SWH, it will be sent to Senior Whole Health for processing. At the time of enrollment, the applicant must select a Primary Care Physician (PCP) from the Senior Whole Health network. Effective Date of Coverage Enrollment in Senior Whole Health is effective the first calendar day of the month following submission of the enrollment and other required forms. Enrollment forms must be submitted by 10:00 A of the last business day of the month in order for an individual s enrollment to be effective in the following month. PCPs will receive notification of their ember panels by the tenth business day of the month. PCPs can verify ember eligibility by calling Senior Whole Health or by using the asshealth Recipient 14 SENIOR WHOLE HEALTH PROVIDER ANUAL

16 Eligibility Verification System (REVS). SWH only reimburses providers for care provided to embers eligible on the date of service. SWH ember Card Each SWH ember is issued an identification card. If a ember is unable to present a card, please call SWH at the same number to confirm eligibility. See Appendix D for a sample of the SWH ember card. ember Assessments Initial assessments are critical for the early identification of a new ember s health and functional status so that appropriate and timely treatment or other interventions may be implemented as quickly as possible. For prospective SWH embers who reside in a Skilled Nursing Facility (SNF), the SNF must provide SWH with a copy of the prospective ember s Status Change 1 Form (SC-1) DS 2.0 and anagement inute Questionnaire (Q). If an SC-1 form has not already been submitted to asshealth, it must be submitted as a SCO. As part of the enrollment process, Senior Whole Health administers a modified version of the CS Health Outcomes Survey and obtains a release of medical information from the potential enrollee to begin the initial assessment process. All Senior Whole Health embers must complete an Initial Assessment within 30 days of their effective date of enrollment. embers in certain categories will be assessed more quickly. The table below identifies the timeframes and types of assessments that must be completed for each new ember based on their health or functional status and place of residence. SWH staff will work with the ember s PCP and GSSC to arrange for and schedule all components of the Initial Assessment within the given timeframes. Initial Assessment Timeframes ember Status ember is a nursing home resident or is pending nursing home placement ember is community-based and nursing home certifiable (NHC) ember is community-based with Alzheimer s, dementia (A/D) or chronic mental illness (CI) ember is community-based and is not NHC or AD/CI. Functional Assessments DS 2.0 Completed by nursing home. DS-HC Completed by SWH Nurse. DS-HC Completed by SWH Nurse. Physician Assessments PCP Assessment ASAP Assessments No GSSC assessment except for evaluation for move back to the community Timeframe for Completion of Initial Assessment 5 business days of PCP selection PCP Assessment GSSC Assessment 30 calendar days of PCP selection PCP Assessment GSSC Assessment 30 calendar days of PCP selection None PCP Assessment GSSC Assessment 30 calendar days of PCP selection SENIOR WHOLE HEALTH PROVIDER ANUAL 15

17 The DS-HC or the DS 2.0 may be completed prior to the PCP Assessment. SWH staff will contact the PCP, GSSC and/or nursing home to schedule assessments within the appropriate timeframes. ember transportation will also be arranged as required. 16 SENIOR WHOLE HEALTH PROVIDER ANUAL

18 6 THE CARE PROCESS The ember s Individual Care Plan is the centerpiece of their care management. The development of care plans begins with the determination of whether or a ember has complex care needs. Complex Care Need Determination After consultation with the PCP, and/or review of the ember s DS-HC or DS 2.0 assessments, Senior Whole Health determines if a ember has Complex Care Needs (CCN). A Complex Care Need is defined as the need for expert coordination of multiple services. This definition includes those embers who are clinically eligible for institutional long-term care. As such, a CCN ember is one who: Resides in a nursing facility, or for whom nursing facility placement is pending; Has a medical illness, psychiatric illness, or cognitive impairment that requires skilled nursing to manage essential unskilled services and care; eets nursing facility clinical criteria but resides in the community (Nursing Home Certifiable NHC); or Has other factors or conditions that require extensive coordination of multiple services. Primary Care Team (PCT) The presence of Complex Care Needs triggers a comprehensive evaluation and care planning process managed by a Primary Care Team. The PCT, under the clinical direction of the PCP, manages care for the ember. At a minimum, the PCT is comprised of the PCP, the SWH Nurse Case anager, and a Geriatric Support Services Coordinator (GSSC) for community-based embers. The PCP helps determine the composition of the PCT based on the ember s needs and the need to assure effective coordination and delivery of care. The PCT may be enlarged to include other professional support disciplines. For example, in the case of a ember with chronic mental illness a mental health provider may be added to the PCT. On an ad-hoc basis, PCTs can consult other providers involved in a ember s care, such as physical or occupational therapists, home health nurses or other providers. The SWH Nurse Case anager plays a pivotal role in the functioning of the team. The Nurse Case anager facilitates team meetings, communicates with team embers, arranges for any additional evaluations and keeps the ember s Individual Care Plan (ICP) current based on the recommendations of the PCT. The PCT is responsible for: 1. Developing an ICP that includes treatment goals (medical, behavioral, functional, and social) and measures progress and success in meeting those goals; SENIOR WHOLE HEALTH PROVIDER ANUAL 17

19 2. Interacting with acute, specialty, long term care, and behavioral health providers to monitor the ember s status and coordinate, or provide, services as outlined in the ember s ICP; 3. Promoting independent functioning of the ember and providing services in the most appropriate, least restrictive environment; 4. Complying with a ember s advance directives for treatment, health care decisions, and use of a health care proxy; 5. Ongoing communication with the ember, the ember s family and significant caregivers about the ember s health and functional status; 6. Conducting ongoing assessments of the ember s health and functional status, adjusting the ICP as necessary, and communicating the information to the ember and ember s caregivers in a timely manner. Individual Care Plan (ICP) All SWH embers receive an ICP. An ICP describes the scope, frequency and duration of services to be provided a ember. The ICP is approved by the PCP and, if applicable, by the PCT. Working collaboratively with the PCP/PCT, the SWH Nurse Case anager facilitates preparation of the ember s ICP. Each care plan has measurable goals and interventions based on problems identified in the initial and ongoing assessments and recommended by participants in the care planning process. Care plans for embers focus on the issues identified in the initial and ongoing assessments. The ICP is reviewed at regular intervals and updated as necessary by the SWH Nurse Case anager, and other SWH staff, through contact with the ember, the ember s caregivers, the PCP and other PCT embers. All services required by a ember s ICP are automatically authorized by SWH; no additional referral or authorization activity is required. The PCT/PCP can modify the ICP at any time by notifying the SWH Nurse Case anager who will facilitate communication and coordination of those involved in the plan. The ICP must be updated as the needs of the ember change and based on the results of regularly scheduled reassessments. A copy of the ICP is available to providers via the SWH Centralized Enrollee Record CER) and will be mailed or faxed to a provider upon request. A sample Individual Care Plan is included in Appendix K. Centralized Enrollee Record (CER) The ICP is only one component of a ember s Centralized Enrollee Record (CER). A CER is maintained by Senior Whole Health on every ember. The ember s CER is a summary of the ember s health status, demographic information, and services. It is created by summarizing information from a number of data sources available to SWH. These include enrollment forms, 18 SENIOR WHOLE HEALTH PROVIDER ANUAL

20 assessment forms, direct entries by SWH staff, authorization and referral activity, and claims including pharmacy and behavioral health. The CER will be available through a secure web-based system. A printed version of the CER is available for providers and embers who do not have access to the web-based system. This source of information is available to providers on a 24-hour, seven-day-per-week basis. The CER is used by the on-call SWH Nurse Case anager so that information can be provided to the PCP, emergency room or other providers should in case information is needed quickly. The CER identifies the ember s PCP and SWH emergency contact numbers and includes a ember s advance directives and health care proxy information. ajor diagnoses, medications and caregiver contact information are also listed. A ember s CER is continually updated by SWH Nurse Case anagers, as well as by other staff or providers with approved access to the medical record. Implementation and onitoring of Care and Health Status Once the Individual Care Plan is finalized and services are authorized, SWH works with the GSSC and appropriate SWH contracted providers to arrange recommended services. The SWH Nurse Case anager maintains responsibility as the contact for providers, embers and family members regarding the status of the services and oversees the authorization process for services. The SWH Nurse Case anager will notify appropriate providers of any ember status change or of any issues that may develop concerning implementation of the care plan. The PCP should contact the SWH Nurse Case anager regarding information or changes needed in service provision. The PCP is responsible for monitoring ember health status and overall provision of clinical services to the ember. Similarly, the GSSC is responsible for monitoring the ember social and functional status and the provision of community-based services to the ember. The SWH Service Coordinator works with the SWH Nurse Case anager as part of the SWH Care Coordination Team to support these roles. The Service Coordinator addresses embers questions or concerns about services and benefits, monitors asshealth eligibility, assists the ember, GSSC, and SWH Nurse Case anager in identifying community-based resources and services to support the ember, arranges ember appointments and assessments, and generally supports the activities of the Care Coordination Team. Reassessments Continuous reassessment, evaluation and care planning are integral components of the SWH geriatric care model. Ongoing assessments are conducted at regular intervals, or upon changes in the ember s health status. SWH will contact the appropriate providers to schedule reassessments and to initiate the care planning process. A ember transition from the community to nursing home environment, whether for a short term or long term admission requires a ember reassessment using the DS 2.0. A ember transition from the nursing home environment to community requires a ember reassessment using the DS-HC. SENIOR WHOLE HEALTH PROVIDER ANUAL 19

21 Reassessments should be conducted at the following intervals: REASSESSENT SCHEDULE ember Status embers with Complex Care Needs embers without Complex Care Needs Change of Status Reassessment Timeframe Quarterly from the effective date of enrollment Semi-annually from the effective date of enrollment Whenever a ember experiences a major change that: Is not temporary Impacts on more than one area of health status as defined by the DS, or Changes 2 or more activities of daily living (ADLs) 20 SENIOR WHOLE HEALTH PROVIDER ANUAL

22 7 CHANGE IN EBER STATUS Definition of Change in ember Status A change in ember status is defined as one of the following: When a ember experiences a major change in condition that is not temporary, including a change in residence; When a change impacts more than one area of a ember s health status as defined by the DS 2.0, DS-HC; or When a change occurs in two (2) or more activities of daily living (ADLs). Notification of Changes in Status If the SWH Nurse Case anager identifies a change in status, SWH will contact the ember s PCP/PCT, schedule a ember reassessment and facilitate revision to the ember s Individual Care Plan. If the PCP identifies a change in status, the PCP s office should notify the SWH Nurse Case anager so that appropriate reassessments can be arranged. SENIOR WHOLE HEALTH PROVIDER ANUAL 21

23 8 DISENROLLENT Disenrollment from Senior Whole Health may be voluntary or involuntary. A ember, the ember s caregiver or a provider can notify SWH of the ember s interest or intention to disenroll. Once this information is received, SWH attempts to discuss and resolve any outstanding issues with the ember. If the ember wishes to disenroll, SWH sends the ember a disenrollment form which the ember must complete and return to SWH for a disenrollment to occur. Senior Whole Health tracks reasons for disenrollment as a mechanism to improve care delivery and problem resolution. There are situations when a ember is required to disenroll. These instances include loss of eligibility for asshealth, extended time out of the service area or fraudulent use of SWH embership. In general, the last date of coverage is the last day of the month in which the disenrollment is submitted to the asshealth SCO Operations Unit. Reasons For Disenrollment Examples of Voluntary Disenrollment Wishes to change plans Wishes to no longer participate in a SCO plan Examples of Involuntary Disenrollment No longer asshealth eligible Fraudulent use of SWH card Death SWH s ability to furnish services is impaired oved from SWH service area The ember does not meet his or her financial obligations to SWH Voluntary Disenrollment Procedure If a ember indicates s/he is interested in disenrolling, the ember should contact SWH. A SWH Service Coordinator will discuss the reason for disenrollment with the ember and try to address or correct any problems. If the ember still wishes to disenroll, a SWH Disenrollment Form is sent to the ember or the ember s designated representative. The effective date of disenrollment is reviewed with the ember and the ember is informed of the need to receive services from SWH until that date. 22 SENIOR WHOLE HEALTH PROVIDER ANUAL

24 Involuntary Disenrollment Procedure Involuntary disenrollment occurs when: A ember no longer meets eligibility requirements for asshealth; The ability of SWH to provide services to the ember or other embers is compromised; The ember no longer resides in the SWH service area or resides in the SWH service area for less than six (6) months in a the year; The ember fails to meet financial obligations determined by asshealth as the ember s share of cost. A SCO Change/Disenrollment Form will be completed by SWH and submitted to SCO Operations Unit for all involuntary disenrollments. SWH continually monitors a ember s asshealth eligibility. If a ember needs to complete a redetermination application for asshealth eligibility, SWH will attempt to assist the ember in meeting the required deadline. The ember or provider may contact SWH for ember assistance. If the ember is no longer eligible to receive asshealth benefits, the SWH Service Coordinator will notify the ember both by telephone and by mail, or the ember s designated representative, to review the effective date of disenrollment. Providers will be notified of the disenrollment, the reason for disenrollment and the effective disenrollment date. If requested, SWH will assist the ember in requesting a transfer of medical records. If a ember moves out of the area, or leaves the area for more than six months, SWH will attempt to verify the address change and notify the ember both in writing and by phone to outline the disenrollment process and effective date. If a SWH provider feels that his or her ability to provide services to a ember, or to other embers, is impaired because of the ember s behavior or noncompliance, the provider should contact the SWH Nurse Case anager. Senior Whole Health will review the case and try to resolve the issue. If no resolution can be found, the case will be reviewed by the SWH edical Director and submitted to asshealth and CS for review. asshealth and CS need to pre-approve any disenrollments for non-compliance or behavior. SENIOR WHOLE HEALTH PROVIDER ANUAL 23

25 9 COVERED SERVICES, REFERRALS, AND AUTHORIZATIONS Covered Services Senior Whole Health covers a continuum of acute, long-term and community-based services. SWH has the flexibility to authorize services outside of the usual package of benefits to help optimize our embers health and functional status. In addition to the traditionally covered benefits, SWH generally covers many services often provided in the community, including non-emergent transportation, homemaking, personal care, adult day programs and respite care. As both the asshealth and edicare programs evolve, covered services may change. Appendix C of this document contains a list of covered services. This list will be updated annually. In addition, SWH maintains a directory of all contracted providers. This directory will be provided to PCPs annually in written format and will also be made available on the SWH website at Referrals and Authorizations At times Senior Whole Health embers require specialty services that may require referral or authorization. In general, Senior Whole Health uses a one-stop shopping approach to streamline referral and authorization activity. Based on the information from a ember s PCP Assessment and Individual Care Plan, SWH generates referrals and authorization for services needed prospectively. In the case that a ember s conditions changes, ad-hoc referrals/authorizations are generated. Referrals and authorizations are critical components of the SWH case management and utilization management programs. Referral and authorization activity can indicate to Senior Whole Health that changes in a ember s health status have occurred and that the ember s Individual Care Plan (ICP) may need to be revised. Referrals A referral is a notification to SWH by a ember s Primary Care Physician (PCP) of the need for services of a specialty physician, podiatrist or chiropractor. In general, a Referral is valid for a three month or longer period. Referrals are reviewed by SWH to determine if the ember is eligible and if the referred service is a covered benefit. If these conditions are met, SWH issues a Referral Number for use by the specialty provider in billing. 24 SENIOR WHOLE HEALTH PROVIDER ANUAL

26 Referrals may be issued on an as-needed basis for episodic conditions or may be incorporated into the ember s Individual Care Plan for ongoing or chronic conditions. If the Referral is part of the ICP, it is issued upon approval of the ICP. The PCP is responsible for notifying SWH of the need for a referral for any service which is not part of a ember s existing ICP. This may occur via fax, paper, phone or Internet (when available). Authorizations An Authorization is a notification to Senior Whole Health of the need for a specialty service that, in addition to eligibility and benefit coverage, requires review by SWH for medical necessity. Upon review, SWH will issue an Authorization Number for billing purposes. Like referrals, authorizations may be incorporated into an ICP or may be issued on an as-needed basis. Examples of services requiring Authorization include ambulatory surgery, hospitalization, home health care, durable medical equipment, home infusion therapy or non-emergency transportation. Senior Whole Health Covered Services BENEFIT PREVENTIVE SERVICES AND PRIARY CARE PROVIDER CARE REFERRAL NEEDED CO-PAYENT Primary Care Provider Visits Including but not limited to emergency room, inpatient hospital, nursing home and office visits. No $0 Annual Women s Health Visits No $0 Annual ammography No $0 Pap Smear No $0 Bone ass easurement No $0 Colorectal Screenings No $0 Prostate Cancer Screenings No $0 Diabetes onitoring Includes coverage for glucose monitors, test strips, lancets and self-management training. No $0 IUNIZATIONS Pneumococcal Vaccine No $0 Flu Vaccine No $0 Hepatitis B Vaccine No $0 SENIOR WHOLE HEALTH PROVIDER ANUAL 25

27 BENEFIT SPECIALTY PHYSICIAN REFERRAL NEEDED CO-PAYENT Specialty Physician Visits Including but not limited to emergency room, inpatient hospital, nursing home and office visits. Yes $0 Chiropractor Visits Yes $0 Podiatary Visits Yes $0 INPATIENT CARE Inpatient Hospital Care Yes $0 Long Term Nursing Home Care Yes $0 Skilled Nursing Facility Yes $0 EERGENCY AND URGENTLY NEEDED CARE Emergency Care No $0 Urgent Care For conditions that require immediate care but are not life threatening. No $0 ENTAL HEALTH AND SUBSTANCE ABUSE SERVICES Inpatient ental Health Care Yes $0 Inpatient Substance Abuse Care Yes $0 Outpatient ental Health Care Yes, except emergencies $0 Outpatient Substance Abuse Care Yes $0 COUNITY AND HOE-BASED CARE Adult Day Health Attendance at an Adult Day Health center at least 2 days per week. Yes $0 Adult Foster Care/Adult Group Care Yes $0 Home Assessment and Adaptation Services Yes $0 Home Health Care Yes $0 26 SENIOR WHOLE HEALTH PROVIDER ANUAL

28 BENEFIT REFERRAL NEEDED CO-PAYENT Personal Care Services Including personal care, respite care, chore, and companion care Rehabilitation Services Occupational Therapy, Physical Therapy, Speech Therapy Yes $0 Yes $0 OTHER OUTPATIENT CARE Ambulance - Emergency No $0 Dental Services Dental services are limited. Please call SWH for more information. Yes $0 Dialysis Yes $0 Durable edical Equipment Yes $0 Hearing Aids Yes $0 Hospice Yes $0 Laboratory No $0 edical and Surgical Supplies No $0 Oxygen and Respiratory Therapy Yes $0 Prosthetics and Orthotics Yes $0 Radiology Routine No $0 Radiology - Specialty PET Scans Only Yes $0 Vision Care (Optometry) No $0 OUT-OF-AREA SERVICES Out-of-area emergency and urgent care No $0 Out-of-area renal dialysis No $0 PRESCRIPTION DRUG PROGRA Prescription Drugs NOTE: ost Injectibles and related supplies come from mail order through CuraScripts. No $0 SENIOR WHOLE HEALTH PROVIDER ANUAL 27

29 Obtaining a Referral or Authorization Referral and authorization activity is one of the largest administrative burdens in managed care for providers. It is Senior Whole Health s hope that the majority of referrals and authorizations will be identified as part of a ember s semi-annual/quarterly Individual Care Plan process. However, there will certainly be times when a ember requires a Referral or Authorization for a service. If the referral or authorization has not been generated as part of a ember s ICP, then SWH may be notified by: 1. Completing a SWH Referral & Authorization Form (Appendix G) and fax to SWH at ; or 2. Calling SWH at or toll free at You may check on the Senior Whole Health Web Site, to determine if referral or authorization is already generated. If at the point of making the referral or authorization, Senior Whole Health determines that a ember s ICP needs to be updated or an additional Care Plan needs to be developed, SWH will take responsibility for notifying appropriate members of the Primary Care Team and coordinating the change. After the referral or authorization is approved, SWH will send written confirmation to the specialist or facility by either paper or facsimile. Specialists or facilities can check on the status of a referral or authorization or request a copy of a referral by: 1. Calling Senior Whole Health at or toll free at , or 2. Checking on the Senior Whole Health website, Please note that hospitals are responsible for notifying Senior Whole Health of the need for an authorization for inpatient admissions, observation care and ambulatory surgery procedures. Services Not Requiring Authorization Services not requiring a referral or authorization include the following: 1. Emergency Services Covered inpatient or outpatient services needed to evaluate or stabilize an emergency medical condition or an emergency behavioral health problem furnished by a provider who is qualified to furnish emergency services. An emergency medical condition is one that manifests themselves by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. Senior Whole Health requires treating providers to notify SWH within twenty-four hours of providing 28 SENIOR WHOLE HEALTH PROVIDER ANUAL

30 an emergency service. If Senior Whole Health is not notified within 10 business days, SWH is under no obligation to pay the provider. 2. Urgent Care under certain circumstances Covered services provided when a ember is temporarily absent from the Senior Whole Health service area or under unusual and extraordinary circumstances provided when the ember is in the Service Area but the contracted medical provider is unavailable or inaccessible when such services are medically necessary and immediately required as the result of unforeseen illness, injury or condition. 3. Out-of-Area Dialysis Services 4. Women s Health Services SWH embers can access any network OB/GYN or GYN without a referral from their PCP. The OB/ GYN provider is required to notify SWH of procedures other physical examinations, mammograms and Pap smears. 5. Routine radiology Routine x-rays, CAT Scans, RI/RA, EKGs and EEGs are covered if performed in a PCP s office, a network specialist s Physician or at a network facility. Authorization is required for PET scans. 6. Routine laboratory Retroactive Referrals Referrals or authorizations may be retroactive up to ninety (90) calendar days. SWH must be contacted at for authorization. Claims for unauthorized referrals made past the 90- day limit will not be accepted. Out of Network/Out of Area Services Providers should refer only to other contracted or Participating Providers. Should the need arise to refer to non-participating Providers, the SWH Nurse Case anager or Plan must be contacted in advance for authorization. Exceptions to this include Emergency Conditions, Urgent Care under unusual circumstances, direct-access women s services and out-of-area renal dialysis service. Follow-up care from an out-of-area/out-of-network provider is not covered unless it is authorized by SWH. SENIOR WHOLE HEALTH PROVIDER ANUAL 29

31 10 EERGENCY AND URGENT CARE 24/7 Coverage SWH embers have unrestricted access to emergency care or urgently needed care twenty-four (24) hours a day, 7 days a week. SWH embers can call the SWH toll free number printed on their ember identification card to reach a SWH Nurse Case anager at all times. The SWH Nurse Case anager will assist the ember in accessing care and will communicate as necessary with the PCP and other providers regarding the ember s status. Providers may reach the SWH Nurse Case anager after hours at the main SWH number ( , or toll free at ) for assistance with arranging ember care. The on-call Nurse Case anager has access to the ember s Centralized Enrollee Record and will be able to provide information to assist providers in assessing available care options. Emergency Care An Emergency Condition is a medical or behavioral condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the individual in serious jeopardy; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. Authorization is not required for emergency services (including emergency room and ambulance). Once the emergency is resolved authorization is required for post-stabilization services. SWH must be notified by the emergency care provider as soon as possible, but within one (1) business day. The ember or the ember s caregiver is also asked to notify SWH as soon as possible. The SWH Nurse Case anager is available to provide ember specific information to the emergency care provider by telephone or fax. SWH will notify a ember s PCP within at least one (1) business day after notification by an emergency care provider that the ember has received emergency services. If SWH is NOT notified within ten (10) calendar days of the ember s presentation for emergency services, SWH is not responsible for payment. This is an administrative determination. The following information is required for emergency services notification: ember name, ID number, and date of birth Provider or facility name Date of service Diagnosis(es) 30 SENIOR WHOLE HEALTH PROVIDER ANUAL