Provider Manual. MassHealth CarePlus. CeltiCareHealth.com 2017 CeltiCare Health Plan of Massachusetts, Inc.TM All rights reserved.

Transcription

1 MassHealth CarePlus Provider Manual Effective September 2017 CeltiCareHealth.com 2017 CeltiCare Health Plan of Massachusetts, Inc.TM All rights reserved.

2 CeltiCare Health Contact Info at a Glance For your convenience, we have included this quick reference guide to assist you in the day-to-day operations of your office. CeltiCare Health 200 West Street, Suite 250 Waltham, MA CeltiCareHealth.com Department Telephone Number Fax Number Provider Services/Claims Member Services / (TDD/TTY) Care Management Prior Authorization Pregnancy Notification Member Appeals and Grievances NurseWise (24/7 Availability) N/A Cenpatico Behavioral Health Cenpatico Specialty Therapy (STRS) NEHEN N/A NIA N/A AcariaHealth (Specialty Drugs) US Script (Prior Authorization) OptiCare Managed Vision Nurtur N/A Home Health Care Orthotics and Prosthetics Frequently Used Addresses FOR MORE INFORMATION ON ELECTRONIC FILING, CONTACT: CeltiCare Health Centene EDI Department Ext EDIBA@centene.com SUBMIT CLAIM DISPUTES TO: CeltiCare Health Attn: Claim Disputes PO Box 3000 Farmington, MO SUBMIT HOME CARE CLAIMS TO: CeltiCare Health Attn: Claims PO Box 3080 Farmington, MO SUBMIT BEHAVIORAL HEALTH CLAIM DISPUTES TO: Cenpatico Behavioral Health Attn: Claims Disputes PO Box 6000 Farmington, MO SUBMIT VISION CLAIMS OR APPEALS TO: OptiCare Managed Vision P.O. Box 7548 Rocky Mount, NC Or EDI: Payer Code or CeltiCare Health Plan of Massachusetts, Inc. TM SUBMIT PAPER CLAIMS, RECONSIDERATIONS, AND CORRECTED CLAIMS TO: CeltiCare Health Attn: Claims PO Box 3080 Farmington, MO SUBMIT MEDICAL APPEALS TO: Plan Utilization Management Decisions Attn: Utilization Management 200 West Street, Suite 250 Waltham, MA SUBMIT PHARMACY CLAIMS TO: US Script PBM 2425 West Shaw Avenue Fresno, CA SUBMIT BEHAVIORAL HEALTH CLAIMS TO: Cenpatico Behavioral Health Attn: Claims PO Box 7200 Farmington, MO SUBMIT HI-TECH RADIOLOGY PRIOR AUTHORIZATION REQUESTS TO: NIA (Web submission only) SEND REFUNDS TO: CeltiCare Health Collections Center Drive Chicago, IL i

3 ii CeltiCare Health CarePlus Provider Manual CeltiCare Health Plan of Massachusetts, Inc. TM

4 iii Welcome to CeltiCare Health CeltiCare Health Plan of Massachusetts, Inc., (CeltiCare Health) is a managed care organization (MCO) whose mission is to provide quality healthcare coverage to our Members. Our number one priority is the promotion of healthy lifestyles through preventive healthcare. CeltiCare Health works to accomplish this goal by partnering with Primary Care Providers (PCPs) who oversee the healthcare of our Members. Centene Corporation, parent company of CeltiCare, has been providing health insurance to individuals for nearly 30 years. Centene provides comprehensive managed care services to individuals receiving benefits under Medicaid and other government-sponsored healthcare programs. Centene operates local health plans, and offers a wide range of health insurance solutions to individuals and the rising number of uninsured Americans. It also contracts with other healthcare and commercial organizations to provide specialty services. CeltiCare Health is committed to building collaborative partnerships with Providers. CeltiCare Health serves our Massachusetts Members in a responsive and professional manner; consistent with our core philosophy that quality healthcare is best delivered locally. Headquartered in the Greater Boston area, all CeltiCare Health employees who work with Members, Providers, or Regulators are based in Massachusetts. CeltiCare Health consistently demonstrates its ongoing commitment to delivering and effectively managing high quality healthcare and service coordination to our Members by: Ensuring access to primary and preventive care services Ensuring that all Medically Necessary physical and behavioral healthcare services are delivered seamlessly in the most appropriate setting to achieve optimal outcomes Assuring the continuity and quality of care, by being focused and responsive to the needs of our Members and our Providers CeltiCare Health s Care Management Programs, Clinical Policies, and Provider Resources are designed to keep these objectives at the forefront of every interaction with our Members and Providers. We value our Members and our Providers. We believe that enhanced communication is key to maximizing efficiency and improving quality from our Members first point of contact with CeltiCare Health to each encounter with our Providers. We invite each and every one of our Members and Providers to become actively engaged in a partnership of shared and informed decision-making which transcends culture, promotes health, prevents illness and results in the best possible outcomes. Please feel free to reach out to us with any questions or feedback. We welcome your input. CeltiCare Health Plan of Massachusetts, Inc. TM

5 The CeltiCare Health Provider Manual is located on our website at: Health.com. The online version of the manual contains several hyperlinks to assist you in navigating through the manual to frequently-viewed materials or other helpful Provider Resources. The Provider Manual can also be downloaded and printed for your convenience. If you already have a hard copy of this manual, the table below identifies the website paths that correspond to each hyperlink identified in the table. iv Hyperlink Provider Resources Pharmacy Information Quality Improvement Program Preferred Drug List Prior Authorization List Website Path Home > Provider > Documents & Resources Home > Provider > Pharmacy Home > Provider > Quality Improvement Program Home > Current Members > Preferred Drug Lists Home > Provider > Documents & Resources CeltiCare Health Plan of Massachusetts, Inc. TM

6 v Contents Welcome to CeltiCare Health... iii Information about our Members Member Services Member Materials Member Eligibility and Enrollment Verifying Eligibility Newborn Transition of Care Member Connections Community Connections Home Connections Phone Connections Connections Plus Value Added Benefits NurseWise OB Care Management Domestic Violence Member Rights and Responsibilities Privacy Matters to our Members Member Satisfaction Member Inquiries Member Grievance, Adverse Action, Appeals, and Board of Hearing (BOH) Member Grievances How Members File a Grievance Behavioral Health Inquiries and Grievances Member Internal Appeals How to File an Appeal First-Level internal Appeals (Non-Expedited) Behavioral Health Appeals Second-Level Internal Appeals (Non-Expedited) CeltiCare Health Plan of Massachusetts, Inc. TM

7 Expedited Internal Appeals Notification of Appeal Decision (First-Level & Second-Level) Access to Appeal File by Member or Member s Appeal Representative External Reviews by Board of Hearings (BOH) BOH Submission and Timeline Provider Responsibilities Communication between Provider and Member Marketing Activities Advance Directives Cenpatico Advance Directives The Role of the Primary Care Provider PCP Availability PCP Responsibilities Other PCP Responsibilities Member Disenrollment Accessibility Emergency Services PCP Accessibility PCP Referrals Specialist Accessibility Behavioral Health Services Accessibility Coordination of Behavioral Health Services Continuity of Care Coordination Coordination and Communication between Behavioral Health Providers and PCP The following information should be included in the report to the PCP: Consent for Disclosure State Agency and Behavioral Health Provider Coordination Provider Assistance with Public Health Services Credentialing Requirements Credentialing Committee On-Site Review CeltiCare Health Plan of Massachusetts, Inc. TM vi

8 Re-credentialing Provider Rights Right to Appeal Adverse Credentialing Determinations Provider Complaints Medical Records Required Information Medical Record Requirements -Inpatient Hospital Medical Records Requirements- Inpatient Services in Mental Hospitals Release of Medical Records Medical Records Transfer for New Members Provider Relations Department Provider Updates Modifications with Substantial Impact on Provider Rights and Responsibilities Policy Updates for Subcontractors Provider Notifications to CeltiCare Health Covered Services CeltiCare Health CarePlus MCO Covered Services List CeltiCare Health CarePlus MCO Behavioral Health Covered Services Non-CarePlus MCO Covered Services List Medical Management Overview and Medical Necessity Prior Authorization Overview Cenpatico Prior Authorization Process Cenpatico Prior Authorization for Medications Cenpatico Medical Necessity STRS Appeals PCP Referral to Specialist Specialist Referral to Specialist for Treatment or Second Opinion Self-Direction How to Request Prior Authorization Prior Authorization Summary Table CeltiCare Health Plan of Massachusetts, Inc. TM vii

9 Utilization Management Decisions Prior Authorization Response Timelines Continuity of Care Medical Necessity Review Criteria Clinical Practice Guidelines Cenpatico Behavioral Health Medical Necessity Cenpatico Specialty Therapy & Rehabilitation Medical Necessity New Technology Requirements for Providers to Notify CeltiCare Health Emergency Services Notification of Pregnancy Notification of Birth Notification of Observation Stays Concurrent Review Cenpatico Concurrent Review Discharge Planning Cenpatico Discharge Planning Retrospective Review Care Management Program Continuity of Care Emergency Department Diversion Program Disease Management Asthma Program Diabetes Program Hypertension/Hyperlipidemia Program COPD Program Heart Failure Program Tobacco Cessation Back Pain Management Program Weight Management Program CeltiCare Health Plan of Massachusetts, Inc. TM viii

10 Behavioral Health Disease Management Program CeltiCare Health Pharmacy Program Pharmacy and Therapeutics Committee (P&T) CeltiCare Health Preferred Drug List (PDL) Prior Authorization for Prescriptions Working with AcariaHealth, Our Specialty Pharmacy Provider Mandatory Generic Substitution Unapproved Use of Preferred Medication Specific Exclusions Newly Approved Products Quantity Limitations Step Therapy Over-The-Counter Medications Exception Requests Quality Improvement Program Program Structure Practitioner Involvement Program Scope and Goals Performance Improvement Process Healthcare Effectiveness Data and Information Set (HEDIS) Provider Satisfaction Survey Consumer Assessment of Healthcare Provider Systems (CAHPS ) Survey Cultural Competency Overview Goals and Objectives Cultural Standards What is Cultural & Linguistic Competence? Need for Culturally Competent Services Cultural Competency Development Delivery of Care and Services How CeltiCare Health Supports Cultural and Linguistic Care CeltiCare Health Plan of Massachusetts, Inc. TM ix

11 x Interpretive and Translation Services Evaluation and Assessment Resources Resource Website Billing and Claims General Billing Guidelines Clean Claim Definition Non-Clean Claim Definition Timely Filing Electronic Claims Submission Paper Claims Submission Procedures for Filing a Claim/Encounter Data Electronic Funds Transfer and Electronic Remittance Advice Claim Payment Third Party Liability Administrative Appeals Fraud and Abuse Billing the Member References CeltiCare Health Plan of Massachusetts, Inc. TM

12 11 Information about our Members Member Services CeltiCare Health is committed to helping our Members navigate the healthcare system and our team strives to provide excellent service to each Member. Our goal is to help educate our Members on their Rights and Responsibilities as a CeltiCare Health Member. We are committed to following through on questions our Members may have and will take the time to ensure that each Member understands their Plan. Our Member Services Representatives are knowledgeable and available to help our Members select a Primary Care Provider (PCP), answer questions regarding enrollment, eligibility, benefits, pharmacy, claims and more. We are friendly and professional and we will respect our Members privacy, while maintaining confidentiality, as we research and resolve each inquiry. Providers who have questions about a Member s health insurance coverage may call a CeltiCare Health Provider Services Representative between the hours of 8:00 a.m. and 5:00 p.m., Monday through Friday at ; for hearing impaired, please call TDD/TTY ; or visit us online at celticarehealth.com Member Services Hours of Operations: 8am to 5pm Monday through Friday Phone: Fax: TDD/TTY: Member Materials Members receive a wide variety of information from CeltiCare Health through mailings, on the website, and through face-to-face contact by MemberConnections representatives or at community events. All printed materials may be requested in languages other than the English and Spanish. These materials include: Member Handbook, which includes a List of Covered and Excluded Services, and Member Rights and Responsibilities CeltiCare Health Plan and Programs Information Health Needs Assessment (HNA) Quarterly Newsletters Provider Directory (printed version upon request) CentAccount Program Information MemberConnections Brochure NurseWise and Emergency Information HEDIS-related mailings sent to appropriate Members Pharmacy Changes Flu Prevention CeltiCare Health s Coupon Saver Program Care Management

13 12 Disease Management Product Brochures Member Quick Reference Guides Information packets for Pregnant and Post-Partum Women If you would like to obtain any of these materials for your office, please contact your Provider Services Representative. Member Eligibility and Enrollment Eligibility for MassHealth CarePlus is determined by MassHealth. CeltiCare Health CarePlus Members must be enrolled in MassHealth to be eligible for CeltiCare Health s CarePlus Program. Eligibility for MassHealth CarePlus is based on income, age and household composition. Adults age with incomes up to 133 percent of the Federal Poverty Level (FPL), who are newly eligible for Medicaid State Plan coverage under the Patient Protection and Affordable Care Act of 2010, (ACA), are eligible for MassHealth CarePlus. Adults who are pregnant, disabled, or a parent or caretaker relative of a child under age 19 are not eligible for MassHealth CarePlus, as these individuals are eligible for other MassHealth coverage. Members, who are dually eligible for Medicaid and Medicare, are not eligible for CarePlus. Members, who are deemed medically frail, as determined by EOHHS, are not eligible for CarePlus. Verifying Eligibility Providers are responsible for verifying MassHealth eligibility and enrollment prior to providing any service at each point of service through the EOHHS s Eligibility Verification System (EVS). Providers are not required to verify eligibility prior to providing Emergency Services. MassHealth Department MassHealth Provider and Member Services MassHealth WebEVS (internet access to EVS) Telephone/Web Address / TTY: (for people who are deaf, hard of hearing, or speech disabled.) ma.us/ehsproviderportal/providerlanding/ providerlanding.jsf Hours of Operation Monday through Friday, 8:00 a.m. to 5:00 p.m. Eligibility Inquiries: 24 Hours per Day, 7 Days per Week, except between 3:00 a.m. and 6:00 a.m. on Sundays and for 45 minutes in the early morning each weekday.

14 13 Until the actual date of enrollment, CeltiCare Health is not financially responsible for services the prospective Member receives. In addition, CeltiCare Health is not financially responsible for services Members receive after their coverage has been terminated. Newborn Transition of Care There are no covered dependents in CeltiCare Health CarePlus. CeltiCare Health will facilitate immediate transfer of newborns. Additional information on coverage from other EOHHS programs is available by calling CeltiCare Health Provider Services, , who will direct Providers to MassHealth for assistance in determining Member eligibility about all other health plan options. In addition, Members can learn about all of their MassHealth health plan options by calling the Center at (TTY: ). Member Connections CeltiCare Health believes that it is important to provide education to our Members on how to access healthcare and develop healthy lifestyles in a setting where they feel most comfortable. CeltiCare Health s MemberConnections Program is an outreach program designed specifically to accomplish this goal. The Member Connections Representatives are visible liaisons between CeltiCare Health and the community served. The program recruits staff from the community that establishes grassroots support and awareness of CeltiCare Health within the community. Various program components are provided depending on the needs of the Members. Phone: FAX: Community Connections Community Connections delivers informational presentations regarding services offered by CeltiCare Health and other healthcare resources to the local community. Examples of topics covered during Community Connections include, but are not limited to: Preventive health measures. How to use available programs. Accessing Prenatal and Post-Partum Care. How to obtain assistance in money management. Members are notified of the presentations through mailings, newsletters, web postings, and informational materials placed in community health centers and Providers offices. When possible, a schedule is generated and made available to all CeltiCare Health staff for distribution to the community. At settings when permissible and feasible, the Health Plan will offer: Food/snacks. Educational materials. Promotional items.

15 Home Connections Home Connections are one-on-one meetings with Members in their homes. Home Connections meetings are most commonly held for those Members identified by care management and Providers as needing outreach in their home environment. As part of a Home Connection, Members will be encouraged and assisted with making appointments for medical services, if they have not already done so. This will include appointments with Physicians, Women s Healthcare Providers, Behavioral Health Providers, Dentists, and Optometrists. Representatives will educate Members on how to find or access transportation services and will review important health plan phone numbers with Members. Representatives will also provide Members with information on available community resources, including provisions for emergency food, shelter, clothing, and utility assistance. Please call the MemberConnections department for information on how to access the Home Connections program. Phone Connections Phone Connections are outreach calls to Members who do not wish home visits, cannot make the next Community Connection meeting, or prefer interacting with CeltiCare Health by telephone. When staff initiates the Phone Connection, all efforts will be made to complete the presentation during that contact. Connections Plus CeltiCare Health will deliver a limited use cell phone to Members who are in Care Management and are identified as lacking other viable reliable phone access. The phones are pre-programmed with the phone numbers of the PCP, CeltiCare Health Care Manager, NurseWise, emergency contact, and others depending on the Member s unique situation. Value Added Benefits CeltiCare Health developed a suite of Value Added Services for its Members that includes benefits in addition to the MassHealth CarePlus Covered Services. The Value Added Services were designed to improve Members well-being, and encourage responsible and prudent use of healthcare benefits. Valued Added Benefits include: CentAccount Program: where Members receive $20 for completing their Annual Wellness Visit Coupon Saver Program: where Members get a mailing with a newsletter and coupons that can save money. This comes every three months. Members can also print more coupons from the website,. NurseWise Our Members have many questions about their physical and behavioral health, and how to access primary and emergency care. CeltiCare Health offers NurseWise, a 24-hour nurse line service link, available to all Members for physical/medical and behavioral issues. This service encourages Members to talk with their Physician, and to promote education and preventive care. NurseWise Registered Nurses provide: Basic health education. Nurse triage. Answers to questions about urgent or emergency care access. 14

16 Refer Members with chronic problems, such as asthma, behavior health, diabetes, heart disease, hypertension, COPD, heart failure, back pain, obesity, and tobacco abuse to care management for assessment to determine if they would benefit from education and encouragement to improve their health. Members may use NurseWise after normal business hours to request information about Providers and services available in the community. Providers may contact NurseWise to verify eligibility any time of the day. The NurseWise staff is conversant in both English and Spanish and can offer the Language Line for additional translation services. The nurses document their calls in a web-based data system using Barton Schmitt, M.D. s Triage Protocols for Pediatrics and N-Centaurus to perform triage services. These protocols are widely used in nurse call centers and have been reviewed and approved by Physicians from around the country. Contact NurseWise at OB Care Management If a Member is pregnant, CeltiCare Health will notify MassHealth based on receipt of the Notification of Pregnancy form (NOP) from Providers, and the Member will be transferred to MassHealth Standard. CeltiCare Health offers a Care Management program for members before they get pregnant, Members who are pregnant, (until transferred to Standard), and after pregnancy counseling. The OB Care Management offers a preventive approach that encourages prenatal education for the expectant mother in an effort to achieve the best possible outcomes. Care Management encourages pregnant women to keep their prenatal care appointments; educates Members and their families about pregnancy; identifies Members who may be at high risk for developing complications; and provides support in dealing with medical, socioeconomic, and environmental issues that may contribute to complications or inhibit a Member s ability to receive optimal healthcare. Identifying pregnant Members as early as possible, providing them with resources adequate prenatal care and guidance, as well as addressing complications as effectively as possible, should result in improved outcomes for both the mother and the newborn baby. Phone: Fax: Domestic Violence CeltiCare Health Members may include individuals who are victims of domestic violence and individuals who are at risk for becoming victims of domestic violence. Providers must be vigilant in identifying these Members, complying with mandatory state reporting requirements relating to child abuse and neglect, gunshot wounds, and other events as required under Massachusetts law. Additionally, CeltiCare Health s Member Services or Care Management staff can help Members identify resources to protect them from further domestic violence. For Massachusetts residents, you may refer victims of domestic violence to the National Domestic Violence Hotline for information about local domestic violence programs and shelters within the state of Massachusetts. National Domestic Violence Network Hotline SAFE (7233)

17 16 Member Rights and Responsibilities CeltiCare Health wants to ensure that Members and Providers are aware of Member Rights and Responsibilities concerning the Member s health care coverage. Member Rights and Responsibilities can also be found in the Member Handbook and are also posted on the CeltiCare Health website. CeltiCare Health Members have specific rights and Members are entitled to exercise these rights without having their treatment adversely affected by Providers and/or CeltiCare Health. Members have the right to be treated in a manner reflecting respect for their privacy and dignity as a person, without regard to age, gender, race, color, religion, national origin, ancestry, marital status, sexual orientation, income status, physical or mental condition or disability, pre-existing condition, occupation, and/or need for health care services. Members, legal guardians of Members, and legally authorized surrogates for Members have certain rights and responsibilities. It is important that Members and Providers are aware of Member Rights. Members have the right to: Receive Plan Covered Services. Receive Emergency Services 24 hours per day, 7 days per week. Choose a Primary Care Provider (PCP) within the Plan network and expect the PCP to provide for Covered Services. Change their PCP at any time. Be informed of the Plan s policies and procedures regarding services, benefits, practitioners and Providers, and Member rights and responsibilities, and be notified of any significant changes in those policies and procedures. Be made aware of all care and treatment options in advance and in a manner appropriate to the Member s condition and his or her ability to understand those options. A candid discussion of appropriate or Medically Necessary treatment options for a condition, regardless of cost or benefit coverage. Receive a second opinion on a medical procedure and have CeltiCare Health pay for the second opinion visit. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. Participate with practitioners in decisions regarding his or her health care, including the right to refuse treatment to the extent permitted by law, and to be made aware of the potential medical consequences of such action. Execute an Advance Directive to inform health care Providers what to do if he or she becomes unable to make decisions about his or her care. File a Grievance for an unsatisfactory experience with CeltiCare Health or with any of CeltiCare Health s contracted Providers and receive a response with the steps taken to address the Grievance. File an Appeal if he or she disagrees with certain decisions made by CeltiCare Health. Request and receive a copy of his or her medical records and request that they be amended or corrected. Receive privacy during treatment and expect confidentiality of all records and communications. Have questions and concerns answered completely and courteously.

18 Use a Provider as an Appeal Representative. Make recommendations regarding Member Rights and Responsibilities. CeltiCare Health Members have the responsibility to: Provide the Plan and Providers with complete and accurate information necessary to care for him or her, for his or her medical record and for Plan Membership records. Understand his or her health problems and participate in developing mutually agreed upon goals, to the degree possible. Follow the plans and instructions for care that he or she has agreed on with your practitioners. Schedule and keep appointments and to call to cancel or re-schedule appointments as needed. Treat all CeltiCare Health staff, Providers and other Members with respect and dignity. Notify CeltiCare Health of any changes in his or her personal information, such as address, telephone number, marital status, and additions to the family, eligibility or other health insurance coverage. Understand that he or she may be responsible for payment of services he or she receives that are not included in the Covered Services. 17 Privacy Matters to our Members CeltiCare Health must have the Member s written authorization before we use or communicate to others about the Member s health information for purposes other than providing or arranging for their health care, the payment for or reimbursement of the care that was provided, and other related administrative activities. CeltiCare Health is committed to maintaining the privacy of our Members health information. CeltiCare Health is required by law to protect the privacy of the Member s health information and to provide a notice describing Member privacy rights and protections; please visit the Privacy and Protection page at our website. Member Satisfaction We hope our Members will always be happy with CeltiCare Health and our Providers. CeltiCare Health has steps in place to encourage Members and Providers to contact us so that we may answer any questions, and address any issues or concerns that may arise regarding the health care of our Members. CeltiCare Health has developed the following processes to address Inquiries, Grievances, Adverse Actions and Appeals: Internal Inquiry Process Internal Grievance Process Adverse Actions Internal Appeal Process External Review by the Board of Hearings (BOH) of the Massachusetts Executive Office of Health and Human Services (EOHHS). Member Inquiries CeltiCare Health offers an Internal Inquiry process for our Members. An Inquiry is any oral or written question made by, or on behalf of, a Member to CeltiCare Health or its designees that is not the subject of an Adverse Action, and that does not express dissatisfaction about CeltiCare Health or its

19 operations, processes, services, benefits, or Providers. Upon receipt of an Inquiry, CeltiCare Health s Member Service Representative will document the matter and, to the extent possible, attempt to resolve it for the Member at the time of the Inquiry or within one (1) business day. Member Grievance, Adverse Action, Appeals, and Board of Hearing (BOH) CeltiCare Health is committed to ensuring Member satisfaction and to the timely resolution of all Inquiries as well as reports of dissatisfaction by a Member or Member s authorized Appeal Representative about any action or inaction by CeltiCare Health or any of our participating Providers. CeltiCare Health provides processes for Members that allow for the adequate and timely resolution of Inquiries and Grievances. Members have the right to file a Grievance or an Internal Appeal if they have had an unsatisfactory experience with CeltiCare Health or with a Provider or if they disagree with certain decisions made by CeltiCare Health or a Provider and if they have had an Adverse Action. Filing a Grievance will not affect our Member s healthcare services. We want to know our Member concerns so we can improve the services we deliver. By knowing their concerns, we are able to provide better services. Please feel free to contact us at CeltiCare Health Plan of Massachusetts, Inc. or log on to. Member Grievances A Member Grievance is a written or oral expression of dissatisfaction concerning any action or inaction of CeltiCare Health or a Provider. A grievance involving the review of an Adverse Action is an Internal Appeal. All other Member Grievances follow the Internal Grievance Process. While Grievances are typically reported by Members, CeltiCare Health will investigate all reported incidents when there are Member care concerns. Possible subjects for Grievances include, but are not limited to: a) Access b) Quality of Care c) Attitude and Service d) Billing and Financial e) Quality of Practitioner Office Site f) CeltiCare Health Systems and Materials g) Coverage and Benefits h) Failure to respect a Member s Rights A Member may file a Grievance by phone, fax, letter or in person. CeltiCare Health Member Services Representative provide reasonable assistance to the Member, including, but not limited to providing full interpreter services, toll free numbers TTY/TTD, explaining the Grievance process and assisting with the completion of any forms. How Members File a Grievance CeltiCare Health Attn: Appeals and Grievance Coordinator 200 West Street, Suite 250 Waltham, MA

20 19 Phone: Fax: Once a Member s Grievance is received, a Member Services Representative will document the Grievance and refer the matter to the Grievance and Appeals Coordinator for further action. The Grievance and Appeals Coordinator will send a letter of acknowledgement within one (1) business day of receiving the Grievance letting the Member know that we have received their Grievance and the expected date of resolution. Members may designate a representative to act on their behalf including their Provider, and such representative is granted all the rights of a Member with respect to the Grievance process, unless limited in writing by the Member, law or judicial order. The Member must complete and return a signed and dated Authorization of Appeal Representative Form before the deadline for resolving the Grievance. Members or their representatives may call Member Services to receive an Authorized Appeal Representative form, or go to. Failure to complete this form will result in dismissal of the Grievance with notice to the Member. If a Member has any proof or information that supports/will support the Grievance, we will provide a reasonable opportunity for submission of relevant documentation to add to their case. We ask that they send it to us to add to their case. To review the Grievance request, we may need additional clinical information. Included in the Grievance request should be a signed Authorization to Release Information form. If it is not sent in, we will send a form to the Member for their signature. We need to have a signed authorization from within thirty (30) calendar days of the request. Without it, CeltiCare Health may issue a decision on the Grievance without being able to review all of the pertinent information. Members can expect a resolution and a written response within thirty (30) calendar days of CeltiCare Health s receipt. Clinically urgent Grievances will be processed in accordance with the clinical urgency of the situation and no more than two (2) business days from receipt of the Grievance. For a Grievance that involves potential clinical issues, or access to care issues, or the Grievance regards the denial of a Member s request that an Internal Appeal be expedited, appropriate clinical staff will be notified for review and/or follow-up and these types of Grievances will be decided by health care professionals who have the appropriate clinical expertise in treating the Member s medical condition, performing the procedure, or providing the treatment that is the subject of the Grievance. CeltiCare Health will also ensure that the individuals who make the decisions on Grievances are individuals who were not involved in any previous level of review or decision-making. The type of Grievance determines whether the matter is addressed directly with a clinician or by CeltiCare Health s Grievance and Appeals Coordinator. In either case, the Provider is contacted to discuss the matter and asked for a written response stating the facts, including supporting documentation when appropriate. To allow timely completion of the review of all relevant information within the specified time frame, a response from the Provider is expected within five (5) business days unless otherwise agreed upon. The response must address all identified concerns and include corrective actions for each when applicable.

21 When the subject matter involves the act or omission on the part of a CeltiCare Health employee, resolution is made by the employee s department, unless circumstances warrant as determined by the Compliance department, that resolution should be made external to the employee s department. CeltiCare Health s Provider Relations staff assists in resolving Grievances involving non-clinically related actions or omissions of a Provider. Grievances are researched and resolved as quickly as warranted, but no later than thirty (30) calendar days from the oral or written notice of the grievance. The written resolution will include the specific information reviewed/considered, the resolution, applicable policies and procedures providing the basis for the decision, and the Member s right to request a Grievance decision review or an internal appeal, if the resolution results in an Adverse Action. 20 Behavioral Health Inquiries and Grievances Management for all behavioral health related inquiries and Grievances are delegated to CeltiCare Health s behavioral health benefits partner, Cenpatico. Cenpatico is obligated to follow the same Inquiries and Grievances process as outlined above for CeltiCare Health. These BH Grievances are first submitted to CeltiCare Health. For more information, please contact CeltiCare Health directly at Members or their representatives should mail or fax their Behavior Health Grievance to the following: CeltiCare Health Attn: Appeals and Grievance Coordinator 200 West Street, Suite 250 Waltham, MA Fax Phone: Emergency related Dental Services (medically necessary to treat a medical condition) Inquiries and Grievances CarePlus Members: CeltiCare Health reviews all Grievances regarding dental services for CarePlus Members. All Material Subcontractors Inquiries and Grievances for CarePlus Members: CeltiCare Health handles all Grievances for CarePlus Members. Member Internal Appeals CeltiCare Health will ensure that clinical staff that makes decisions regarding Internal Appeals involving clinical issues has appropriate experience in caring for the CeltiCare Health Member s condition or disease and that staff making decisions on the resolution of an Internal Appeals will not have been involved in any prior level of review or decision making.

22 CeltiCare Health provides Members or an Appeal Representative a reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing, and shall inform the CeltiCare Health Member or an Appeal Representative about the limited time available for this opportunity. A Member may file an internal appeal by phone, fax, letter or in person. CeltiCare Health Member Service Center Representatives provide reasonable assistance to the Member, including, but not limited to, providing full interpreter services, toll-free numbers with TTY/TTD, explaining the appeal process and assisting with the completion of any forms. 21 How to File an Appeal CeltiCare Health Attn: Appeals and Grievance Coordinator 200 West Street, Suite 250 Waltham, MA Phone: Fax: First-Level internal Appeals (Non-Expedited) A treating Provider may file a clinical appeal on behalf of a Member for any decision made by CeltiCare Health to deny, terminate, modify, or suspend a requested health care benefit based on failure to meet Medical Necessity, appropriateness of health care setting, or criteria for level of care or effectiveness of care. Punitive action will not be taken against a Provider who requests an appeal on behalf of a Member. In order to file an appeal on behalf of a Member, or if an individual other than the Member or legal guardian request the appeal, CeltiCare Health must be provided with written authorization from the Member designating the Provider as the Appeal Representative. The Appeal Representative Form should be used for this purpose. The Member must complete and return a signed and dated copy of this form prior to the deadline for resolving the appeal. Failure to do so will result in dismissal of the appeal and notice of dismissal to the Member. CeltiCare Health will review, resolve, and provide the CeltiCare Health Member or Member s Appeals Representative with written notification of the decision for a standard non-expedited Internal Appeal within twenty (20) calendar days of receipt of the Internal Appeal. 1. A Member Appeal must be filed within thirty (30) calendar days of Member s receipt of CeltiCare Health s decision to deny, terminate, modify, or suspend a requested health care service. 2. When filing an Appeal on behalf of a Member, the Provider must identify the specific requested benefit that CeltiCare Health denied, terminated, modified, or suspended, the original date of CeltiCare Health s decision and the reason(s) the decision should be overturned. 3. CeltiCare Health will provide the Member continuing services if applicable pending resolution of the first-level review if the Member submits the request for first-level review within ten (10) days of the adverse action. 4. If the Member does choose to continue to receive services during the Internal Appeal and the Appeal is upheld, the Member may be liable for the cost of those services. 5. Appeals may be filed by telephone, mail, fax or in person. CeltiCare Health will send a written acknowledgment of the Appeal, along with a detailed notice of the appeal process within one (1) business day of receiving the request.

23 6. An Appeal will be handled by a health care professional that has the appropriate clinical expertise in treating the medical condition, performing the procedure or providing the treatment that is the subject of the Adverse Action, and who was not involved in the original Adverse Action. 7. For a standard Internal Appeal resolution, CeltiCare Health will complete the appeal and contact the Member, Appeal Representative, and the Provider within twenty (20) calendar days from the date CeltiCare Health received the first-level internal appeal, either in writing or orally, whichever comes first. 8. The time frame for a standard appeal may be extended for up to five (5) calendar days if the Member or Appeal Representative requests the extension, or if CeltiCare Health requests the extension based on the Member s best interest and there is reasonable likelihood that receipt of more information that can be received within five (5) calendar days would lead to an approval. A clear description of the procedures for requesting Second-level Internal Appeal or a Board of Hearing (BOH) External Appeal, enclosures of CeltiCare Health s Appeals Process, Rights for CarePlus Members, and a Request for a Board of Hearing Form are included with any denial of appeal. 22 Behavioral Health Appeals All behavioral health related appeals are delegated to CeltiCare Health s behavioral health partner, Cenpatico. Cenpatico is obligated to follow the same Internal Appeals process as outlined in the related sections of this manual for CeltiCare Health. For more information please contact Cenpatico directly at To file a Behavior Health Appeal in writing please mail or fax the Appeal to the following: Cenpatico Attn: Appeals Department Research Blvd, Suite 400 Austin, Texas Fax: All other CeltiCare Health Material Subcontractor Appeals for CarePlus Members CeltiCare Health reviews all Appeals, except Behavioral Health for CarePlus Members. Second-Level Internal Appeals (Non-Expedited) In the event that CeltiCare Health s standard First- Level Appeal decision upholds the initial decision, the Member or an authorized Appeal Representative has the right to initiate a second level appeal with CeltiCare Health or waive his or her right to a Second Level Appeal and file an Appeal with the Executive Office of Health and Human Services, Office of Medicaid s Board of Hearings. 1. A Second-Level Appeal must be filed within thirty (30) calendar days of CeltiCare Health s first-level decision to uphold the decision to deny, terminate, modify, or suspend a requested health care service.

24 2. For Second-Level Appeals, in order to continue receiving ongoing services during an appeal, the appeal must be requested within ten (10) calendar days of CeltiCare Health s decision to deny, terminate, modify, or suspend a requested health care service. 3. For standard Second-Level Internal Appeals, notice of the decision to the affected parties (Member/Member Representative, Provider, and primary care Provider) must be made within twenty (20) calendar days of the request for a Second-Level Internal Appeal unless the time frame has been extended. The Second-Level review will be conducted by Clinical Reviewers who have the appropriate clinical expertise in treating the medical condition, performing the procedure, or providing the treatment that is the subject of the Adverse Action, and have not been involved in any prior review or determination in the Internal Appeal. All Final Internal Appeal Notices will include the Request for a Fair Hearing Form and information regarding the Member s right to file a BOH appeal and how to do so. Expedited Internal Appeals If a Member, Member s Appeal Representative, or Provider acting as Member s Appeal Representative feels that taking the time for a standard Internal Appeal could seriously jeopardize a Member s life, health or ability to get, maintain or regain maximum function, an Expedited Internal Appeal may be requested. A Member, health care Provider or an Appeal Representative may request an Expedited (fast) Internal Appeal. If the Provider is not involved in the request for an Expedited (fast) Internal Appeal, then we have the right to determine whether or not to process the Appeal as an Expedited (fast) Internal Appeal. Requesting an Expedited (fast) Internal Appeal Requests for the expedited Internal Appeal follow the same process for an Internal Appeal to CeltiCare Health. It can be filed either orally or in writing by the Member, Appeal Representative, and/or Provider. If CeltiCare Health denies a Member s request for an expedited resolution of an Internal Appeal, CeltiCare Health shall: 1. Transfer the Internal Appeal to the timeframe for standard resolution, within twenty (20) calendar days. and 2. Make reasonable efforts to give the Member and the Appeal Representative prompt oral notice of the denial, and follow-up within two (2) calendar days with a written notice. Such notice shall include the Member s right to file a Grievance CeltiCare Health will not deny a Provider s request, on behalf of the Member, that an Internal Appeal be expedited unless CeltiCare Health determines that the Provider s request is unrelated the Member s health condition. 23 Processing an Expedited (fast) Internal Appeal If a request meets the qualifications for an expedited (fast) Internal Appeal, CeltiCare Health will process the Appeal request and notify the Member of our decision orally and in writing, as quickly

25 as the Member s health requires, but not later than seventy-two (72) hours from receipt of the request. The timeframe can be extended by fourteen (14) calendar days. CeltiCare Health will notify the Member, Appeal Representative, and Provider in writing of the decision. We will also try to contact the Member via telephone to tell them about our decision. CeltiCare Health will not take disciplinary action against a Provider who requests an Expedited (fast) Internal Appeal or supports a Member s Expedited Internal Appeal request. If a Member is currently receiving covered services that are under Expedited Internal Appeal, he/she may continue to receive services through the completion of the Expedited Internal Appeal process if the Expedited Internal Appeal is filed on within 10 days of the adverse action and the services being appealed were previously authorized by CeltiCare Health. A Member may be required to pay the cost of services furnished while an Expedited Appeal is pending if the final decision upholds the initial decision. Notification of Appeal Decision (First-Level & Second-Level) If CeltiCare Health does not act upon an Appeal within specified time frames (listed below) the Appeal will be decided in the Member s favor. Any extension deemed necessary to complete review of an appeal must be authorized by mutual written agreement between the Member (or an Appeal Representative) and CeltiCare Health. Standard First-level & Second-level Time frames 20 Calendar days (First-level standard) 20 Calendar days (Second-level standard) 5 Calendar days- 1 time CeltiCare Health (extension) 24 Expedited Appeal Time Frames 72 hours (standard) 14 calendar days (extension) Access to Appeal File by Member or Member s Appeal Representative Members or their Appeal Representative reserve the right to receive a copy of all documentation used in the processing of their Grievance or Appeal. Limitations may be enforced, only if, in the judgment of a licensed health care professional, the access requested is reasonably likely to jeopardize the life or physical safety of the individual or another person. The Member (or an Appeal Representative) must submit their request in writing to CeltiCare Health and it will be processed by the Grievance and Appeals Coordinator, in consultation as necessary with the Compliance Office. Requests for access to Appeal files will be processed as quickly as possible, taking into consideration the Member s condition, the subject of the Appeal, and the time frames for further appeals. External Reviews by Board of Hearings (BOH) The CeltiCare Health Member, or the Member s Appeal Representative, may request the BOH Appeal. Members and their Appeal Representatives must exhaust CeltiCare Health s Internal Appeals process before filing an Appeal with the Board of Hearings (BOH). However, the Member