Provider Manual 2016

Transcription

1 Provider Manual 2016

2 User Guide - Table of Contents Section Introduction 1.1 Provider Welcome 1.2 Kentucky Medicaid Program 1.3 Overview of Passport Health Plan 1.4 Mission and Values 1.5 Important Telephone Numbers 1.6 Claim Submission Section 2.0 Administrative Procedures 2.1 Eligibility 2.2 Passport Health Plan Assignment 2.3 Choosing a Primary Care Provider (PCP) 2.4 Identification Cards 2.5 Member Release for Ethical Reasons 2.6 Health Education and Special Programs 2.7 Credentialing/Re-Credentialing Process 2.8 Provider Terminations/Changes in Provider Information 2.9 Provider Grievances and Appeals 2.10 Members Rights 2.11 Member Grievances and Appeals 2.12 Title VI Requirements: Translator and Interpreter Services Section 3.0 Provider Roles and Responsibilities 3.1 Confidentiality 3.2 The Role of the Primary Care Provider (PCP) 3.3 The Role of Specialists and Consulting Practitioners 3.4 Responsibilities of All Providers

3 Section 4.0 Office Standards 4.1 Appointment Scheduling Standards 4.2 After-Hours Telephone Coverage 4.3 Member to Practitioner Ratio Maximum 4.4 Provider Office Standards 4.5 Medical-Record-Keeping & Continuity &Coordination of Care Standards 4.6 Hospital Care 4.7 Kentucky Health Information Exchange KHIE 4.8 Communication Guidelines Section 5.0 Utilization Management 5.1 Utilization Management 5.2 Review Criteria/Standards for Review 5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High-Cost Medications 5.8 Prior Authorization for Members with Original Medicare / Tricare 5.9 Retrospective Authorization 5.10 Denials Section 6.0 Referrals 6.1 Member Self-Referral (Direct Access) 6.2 Referral Requirements 6.3 Distribution of Referrals

4 Section 7.0 Benefit Summary and Exclusions 7.1 Benefit Summary 7.2 Services Covered Outside Passport Health Plan 7.3 Non-Covered Services Section 8.0 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) 8.1 Overview of EPSDT 8.2 EPSDT Eligibility 8.3 Covered Services 8.4 EPSDT Audits for Screening Elements 8.5 EPSDT Tracking/Member Outreach 8.6 EPSDT Reporting/Billing (Preventive Health Screens/Immunizations) 8.7 EPSDT Expanded Services Section 9.0 Quality Improvement 9.1 Quality Improvement Program Description 9.2 Quality of Care Concerns 9.3 Practitioner Sanctioning Policy Section 10.0 Emergency Care / Urgent Care Services 10.1 Emergency Care 10.2 Out-of-Service-Area Care 10.3 Urgent Care Services 10.4 Lock-In Program Section 11.0 Special Programs 11.1 Case Management 11.2 Health and Disease Management Programs 11.3 Children Living in Out-Of-Home Placements

5 Section 12.0 Outpatient Pharmacy Services 12.1 Prescribing Outpatient Medications for Passport Health Plan Members 12.2 Covered Outpatient Pharmacy Benefits 12.3 Drug Prior-Authorization Procedure 12.4 Lock-In Program Section 13.0 Obstetrical 13.1 Overview 13.2 Member Access to Prenatal Care 13.3 Obstetrical Practitioner s Role 13.4 General Procedure for Prior Authorization of Obstetrical Care and Delivery Section 14.0 Family Planning 14.1 Services 14.2 Network 14.3 Claims Section 15.0 Provider Billing Manual 15.1 Claim Submission 15.2 Provider/Claim Specific Guidelines 15.3 Understanding the Remittance Advice 15.4 Denial Reasons and Prevention Practices 15.5 Timely Filing Requirements 15.6 Corrected Claims and Requests for Reconsideration and/or Refunds 15.7 Contact Information for Claims Questions

6 Section 16.0 Behavioral Health 16.1 Administrative Procedures 16.2 Access to Care 16.3 Behavioral Health Benefits 16.4 Care Management and Utilization Management 16.5 Authorization Procedures and Requirements 16.6 Quality Improvement 16.7 Behavioral Health Provider Billing Manual Section 17.0 Forms and Documents 17.1 Preventive Health, Disease Management & Risk Assessment Forms 17.2 Claim Forms 17.3 Provider Contracting and Provider Network Management Forms 17.4 MAP Forms 17.5 Utilization Management Forms 17.6 Mommy Steps Forms Section 18.0 Dental Network 19.1 Important Contact Information 19.2 Administrative Procedures 19.3 Credentialing/Re-credentialing 19.4 Provider Terminations/Changes in Provider Information 19.5 Standards of Care for Dental Offices 19.6 Dental Benefits 19.7 Care Management and Utilization Management 19.8 Authorization Procedures and Requirements 19.9 Quality Improvement Dental Provider Billing Manual Fraud, Waste and Abuse Cultural Competency

7 Section Acronyms