OptiCare - Kentucky Spirit Health

Transcription

http://www.opticare.com/
PROVIDER MANUAL
Table of Contents
Section I
-
Introduction
• Who is OptiCare Managed Vision?
• How to use this Office Staff Guide
1
2
Section II
-
Plan Specific Information
Section III
-
Routine Eye Care
•
•
•
•
•
The Routine Eye Exam
Billing for Routine Eye Exams
Diabetic Eye Examinations
Dilation Protocol
Low Vision Exams
Section IV
•
•
•
•
•
•
•
•
•
•
•
•
-
1
1
1
2–4
4
Utilization Management
Overview
Emergency Care
Services Not Typically Performed by Eye Care Providers
Excluded Services
Assistant Surgeons
Out-of-network eye care services
Continuity of Care
How to obtain an authorization or pre-certification
Approval for Facility Use
Referrals
UM Appeals
Pre-certification Request Form
1-2
2
3
3
3
3
4
4
4
4-5
5-10
11
P.O. Box 7548 Rocky Mount, NC 27804
OptiCare Managed Vision
Fax: 252-451-2945
Customer Service: 800-840-7032
1
Table of Contents
Section V
-
Payment for Services
• Methods for Filing Claims
• OptiCare Web Site
• Emdeon
• Mail
• Clean Claims Mail Coversheet
• General Filing Tips
• Claim Attachments
• Place of Service Codes
• Modifiers and definitions
• Filing for Routine Payment
• Filing for Hardware Payment
• Filing for ASC and Facility Services
• Coordination of Benefits
• Global Fees/Surgical Follow-up
• Co-Management of Care
• Multiple Surgeries
• Payment Methodologies
• Definitions
• Verifying Claim Status
• Sample HCFA Form
• Sample UB-92 Form
• Non-Covered Services
• After-Hours Office Visit
• Telephone Consultations
• Billing for Missed Appointments
• Incomplete Claims
• Correcting a Claim
• Responding to an Incorrect Payment When You Notice It
• Responding to an Incorrect Payment When OptiCare Notices It
• OptiCare Claim Appeal Process
• OptiCare Claim Appeal Request Form
1-4
5
6-7
8
9
10-11
12
12
12-13
13-17
18
18
18-19
19
19-20
21
22-23
24-25
26
26-27
27
27
27
28-30
31
Fax: 252-451-2945
2
Table of Contents
Section VI
-
Quality Management
• Quality Management Program Overview
• Provider Grievance Process
Section VII
•
•
•
•
•
•
•
•
•
•
•
•
•
•
-
1
2-4
Administrative Information
Provider Credentialing & Recredentialing
Provider Performance Standards
Access to Care Standards
Notify OptiCare if…
Reporting Suspected Fraud and Abuse
Copy of Panel Participation Request Form
Copy of Office Address Information Form
Discounts on Prescription Eye Wear
OptiCare Standard Provider Research Procedures
OptiCare Appeal Form
Member Complaints
Cultural Competency Program
Notice of Privacy Practices
OptiCare’s Core Privacy Principles
Section VIII
-
Glossary of Terms
Section IX
-
Forms
•
•
•
•
•
•
•
1-2
2
3-4
4
5
6
7-8
9
9
10
11
11-15
15
15- 17
Web Enrollment Security Letter
Clean Claims Mail Cover Sheet
Claims Status Check Form
Claims Appeal Form
Medical Pre-certification Request Form
Notice of Facility Use Form
Panel Participation Request Form
Section X
-
1
2
3
4
5
6
7
Updates/Newsletters
Fax: 252-451-2945
3
Section I: Introduction
Who is OptiCare Managed Vision?
With eye care experience dating back to 1955, OptiCare has the unique
qualification and the financial stability necessary to stay abreast of the everchanging trends in eye care.
OptiCare administers eye care benefits nationwide. These benefits range from
routine vision care to full medical/surgical eye care. Our state-of-the-art
information systems, together with our professional staff overseeing Quality
Management, Member Services, Claims Processing, Utilization Management,
Credentialing, Provider Relations and Network Development, create a powerful
combination that enables OptiCare to successfully compete nationally while
maintaining its user-friendly, service-oriented philosophy.
EYE CARE IS OUR BUSINESS.
Fax: 252-451-2945
1
Section I: Introduction
How to use this Manual
Purpose of this Manual
The Office Staff Manual includes general information about OptiCare policies,
procedures and billing information. As you contract with OptiCare for additional
plans, you will receive the applicable plan-specific information and Fee
Schedules/Benefit Information Summaries for insertion in the Plan Specific
Section (2) of this manual. This Office Staff Manual has been designed to assist
providers and their office staffs with the administration of OptiCare’s eye care
plans.
This guide is designed to answer the most common questions asked by providers
and their staffs. If you cannot find the answer you need in this manual, please do
not hesitate to contact OptiCare’s Customer Department.
Revisions and Updates
All offices will be notified of any changes or revisions to this manual. An
update/revision will be sent to the office and will be accompanied by a cover sheet
to indicate the subject matter being addressed as well as the page(s) to be replaced
or added and the effective date of the change. Web site updates will be issued to
those offices’ with internet access.
Fax: 252-451-2945
2
Section II: Plan Specifics
Kentucky Spirit Health Plan
Account Name:
Refractive &
Preventative Eye
Care Services
Frequency:
Copay:
Once per calendar year
May vary (refer to www.opticare.com)
Code
92002, 92012, 92004, 92014
92015
Description
Examination Services
Refraction
• Refraction (92015) must be reported separately.
• Eligible diagnoses for routine vision exams: 367.0-367.9, 368.9, or V72.0
• Regardless of final diagnosis, a Member who presents for a routine exam with no chief complaint should
be reported as a routine exam, using the above diagnoses codes as primary. For additional information,
please refer to Section III: Routine Eye Care of the Provider Manual.
Medical Services,
Surgical Services,
and Ocular Drugs
Copay:
May vary (refer to www.opticare.com)
Medically necessary eye care services are covered as indicated in the Member’s evidence of coverage.
Services performed must comply with applicable co-management policies and benefit limitations as defined
by the Kentucky Cabinet for Health and Family Services. These services are covered for recipients of all
ages.
•
•
•
•
•
•
•
•
•
Claims submitted for medical and surgical services shall reflect the usual and customary billed charges.
CPT guidelines for new & established ophthalmological, evaluation & management, and home visits
apply.
CPT codes 99214 or 99215 are limited to two (2) per Member, per diagnosis, per provider.
CPT codes 92002-92014 shall not be billed in conjunction with 99201-99215.
CPT codes 99201-99215 shall not be billed in conjunction with 99241-99255.
Evaluation & Management service code 99211 shall not be payable unless there is actual physicianpatient contact during the visit.
Visual field exams (92081, 92082, and 92083) are limited to one (1) per Member per provider, per date
of service. These codes may not be billed together.
Ophthalmoscopy exams (92230, 92235, 92250, and 92260) are limited to one (1) exam per Member, per
provider, per date of service. These codes may not be billed together.
All medical and surgical services are subject to Current Procedural Terminology (CPT) guidelines,
Correct Coding Initiatives (CCI) rules, Local Carrier Determinations (LCD), and OptiCare Medical
Management policies and procedures.
All claims for medically necessary eye care services and ocular drugs should be directed to OptiCare.
Prior Notification
for Medical/Surgical
Procedures
The following non-emergent surgeries require pre-certification: CPT codes 15822, 15823, 67900, 67904, and
67908. The Pre-Certification Request form is available on the Forms page of OptiCare’s website
(www.opticare.com/forms.aspx). Requests for pre-certifications should be faxed to (252) 451-2133. Services
performed without pre-certification will be denied and the member will be held harmless for payment of benefits
normally covered under their benefit plan. All procedures must be performed at a participating facility. Detailed
instructions for submitting pre-authorization requests can be found on the OptiCare website (www.opticare.com).
Click on Providers, Online Forms and Pre-Authorization Request Form for Kentucky Spirit Members.
Unless specifically addressed within this document there are no other prior notification requirements for medical
or surgical procedures. Reported diagnoses must support medical necessity of procedure and services should be
supported by preferred practice patterns and/or evidence based medicine. Retrospective review will be performed
upon claim data, and providers may be asked to enter into a pre-certification process if practice patterns fall
outside of the expected norm.
Account Name:
Corrective Eyewear
Requirements and
Services
Frequency:
Corrective eye wear is not covered for Kentucky Medicaid Program adults. Members under
twenty-one (21) years of age are eligible for one pair of corrective eyewear, if needed, per
year. Repairs and/or one pair of replacement eyeglasses are covered, if required. No prior
authorization is
required. Providers
are responsible for
unpaid claims denied
due to patient
ineligibility.
Copay:
No copay
All refractive optical
services must be
reported using a
refractive diagnosis
of 367.0-367.9,
368.9, or V53.1.
Code
92340-92342
V2020
V2100 - V2399
V2784
V2760
92370, 92371
S0500, V2500-V2599
S0592, 92310-92317
Description
Fitting of glasses
Frame
Spectacle Lenses (per lens)
Polycarbonate Material (per lens)
Scratch Resistant Coat (per lens)
Repair and refitting of glasses
Contact Lenses
Fitting of Contact Lenses
Dispensing Requirements:
• Provider may employ their lab of choice or take advantage of OptiCare’s designated lab, Select Optical.
• If employing the lab of their choice, providers should report dispense and eyewear HCPCS codes.
• If employing the lab of their choice, providers must offer materials of high quality, variety, and
ophthalmic standards and include manufacturer warranties and provider guarantees.
• Correct coding should be employed e.g. report both underlying lens code as well as add-on polycarbonate
and scratch coat codes.
• For replacements and repair claims, providers should include HCPCS modifiers RA (replacement of a
DME item) and RB (replacement of a part of DME furnished as part of a repair).
• If utilizing Select Optical, providers will receive a kit of covered frames on consignment from Select
Optical (no cost to Provider).
• For Select Optical fulfillment, orders are placed directly with Select Optical (providers are responsible
for checking Member eligibility).
• For orders fulfilled by Select Optical, Select Optical will submit a claim to OptiCare for eyewear (no
provider cost of goods). Provider will report the fitting of the glasses.
• For more information regarding the services of Select Optical, a “frequently asked question” fact sheet
and Welcome Kit order form are attached to the bottom of this document
Minimum Prescription:
Visual conditions requiring prescriptions for correction shall contain power in the stronger lens no weaker
than the following:
(1) ± 0.50 diopter sphere or cylinder
(2) 0.50 diopter of vertical prism
(3) total of two (2) diopters of lateral prism
Eyeglass Material Requirements:
•
•
Unless contraindicated (poor patient visual acceptance, etc.) lens material should be polycarbonate with
scratch resistant treatment.
Tints, photochromics, anti-reflective coatings and other lens options that are not medically necessary are
non-covered and may be paid by the Member. In such cases, the Member must agree in advance and in
writing to pay for the non-Medicaid covered service. An acknowledgement form must explicitly state
the services or procedures that are not covered by Medicaid.
Contact Lenses In Lieu of Eyeglasses
In lieu of eyeglasses, Members may elect to employ a $50 allowance towards the fitting and/or supply of
contact lenses. Charges beyond the $50 allowance are a Member responsibility. Providers should report codes
S0592, 92310-92317 for fitting services and/or S0500, V2500-V2599 for the contact lenses themselves,
accompanied by a refractive diagnosis. Contact lens benefits may not be used as replacements.
Account Name:
Medically Necessary
Optical Services
Optical services that are medically necessary and meet OptiCare’s guidelines are covered and must be billed
in accordance with OptiCare’s guidelines, which incorporate the coverage limitations outlined by the State
Medicaid Program. A copy of OptiCare’s policies and guidelines may be found at www.opticare.com or by
contacting Medical Management at (800) 368-4345.
Post-cataract Eyewear:
Members who have undergone cataract surgery are entitled to one pair of the standard frames and lenses, or
conventional contact lenses when medically necessary. This benefit is allowed once per eye, per lifetime.
Prior notification is not required. Eyewear must meet the same requirements as those listed under the Routine
Optical Requirements and Services Section. Eligible diagnosis for post cataract optical services is V43.1.
Medically Necessary Contact Lenses & Fitting:
Procedure code 92070 is covered and shall be used to bill for the therapeutic bandage lens used in the
treatment of diseases, (e.g., bullous keratopathy, or non-healing corneal ulcers). Prior notification is not
required.
Description
92070
Code
Fitting for Treatment of Disease (includes lens)
Medically necessary contact lenses are covered and payable when any of the following criteria is met:
(a) The CORRECTED acuity in the recipient's best eye is 20/50 and is improved with use of contact lenses;
(b) The visual prescription of ± 8.00 diopter or greater;
(c) ≥ 4.00 diopter anisometropia (difference in power between eyes) exists; or
(d) Documentation is maintained in the recipient's medical record to substantiate why this method of
correction was medically necessary.
Prior notification is not required. A medical diagnosis should be used when submitting claims for medically
necessary contact lenses.
Contacting OptiCare Managed Vision
Customer Relations:
Member Eligibility and Claims Inquiries
(877) 615-7734
Utilization Management:
Prior Notification and Pre-Certification Inquiries
(800) 465-6972
Network Management:
Provider Participation and Credentialing Inquiries
(800) 531-2818
Preferred/Optional Lab Information
Select Optical
6510 Huntley Road
Columbus, OH 43229
Local: (614) 846-5750
(800) 282-6960
Fax: (800) 553-1435
Account Name:
Member Identification Card(s)
Front
Back
Claims Submission
All claims should be submitted within 365 days of the date of service or six (6) months from the adjudication date of the Medicare
payment date or other primary insurance. No reimbursement will be made for claims received beyond this date. Claims received after
the filing deadlines will be considered a Provider liability and Members may not be billed for services.
Electronic Claims Submission
emdeon/WebMD:
Payer ID# 56190
Eye Health Manager
Member Benefits and Eligibility Verification
Claims Entry
Claims Status Review
Audit Tools
Download, Research, & Reprint EOB’s
Please contact Customer Relations if you have misplaced your
username/password or if you would like to have access to the Eye
Health Manager.
To access Eye Health Manager:
1.
2.
3.
4.
Go to www.opticare.com
Click on Providers
Click on Eye Health Manager Login
Log in with your user name and password
Attn: Claims
PO Box 7548
Rocky Mount, NC 27804
Mailing Address:
Paper Claims Submission
Non-Covered Services
*For coverage of
these items, please
contact Kentucky
Spirit Health Plan,
Inc. directly at (866)
643-3153
•
•
•
•
•
Artificial eyes*
Tints, photochromics, anti-reflective coatings and other lens options, unless medically necessary
Plano safety glasses, unless medically necessary
Prisms, unless medically necessary
Low-vision services
KentuckySpirit/OptiCareMedicaid
FrequentlyAskedQuestions
Select Optical, an Essilor Partner Laboratory, has been chosen as the preferred independent eye care
professional laboratory supplier for your Kentucky Spirit / OptiCare Medicaid eyewear. We are pleased to
offer your practice excellent, laboratory service and superior ophthalmic products. Our primary goal is to
meet your professional expectations and provide the quality our customers rely on, time after time.
To help introduce you to the Kentucky Spirit / OptiCare Medicaid arrangement, read below answers to
frequently asked questions.
We look forward to working with you to meet your needs. Welcome!
Q: Who is Essilor Laboratories?
A: Essilor Laboratories is the U.S. leading manufacturer of optical lenses. We are a full-service provider
bringing you extensive lens offerings, superior manufacturing quality, and technologically advanced
processing. Through Essilor laboratories, you gain access to premium brands like Varilux®, Crizal®,
Thin&Lite® and DEFINITY™. Beyond your OptiCare Medicaid work, we offer services including
accredited online and in-office staff training, business consulting, pricing analysis, and programs designed to
build practice profitability.
Q: What does the Kentucky Spirit / OptiCare Medicaid arrangement bring?
A: Through the Kentucky Spirit / OptiCare Medicaid arrangement, you have access to excellent laboratory
service, backed by Essilor’s commitment to meet your needs and help your practice grow. As the leading U.S.
manufacturer of optical lenses, Essilor brings talent, technology, and a reputation for premium quality and
service. We are committed to your satisfaction, supported by superior quality and excellent laboratory service.
Q: Are independent providers required to send their Kentucky Spirit / OptiCare Medicaid work to this
laboratory?
A: No. Select Optical is the preferred laboratory that OptiCare has selected to handle its Medicaid work in
Kentucky. To confirm, you are not required to send Kentucky Spirit / OptiCare Medicaid work to Select
Optical for processing. However, sending Kentucky Spirit / OptiCare Medicaid work to Select Optical will
help save you money, time, and effort in obtaining frames for your member. Providers who choose Select
Optical for their Kentucky Spirit / OptiCare Medicaid work are entitled to receive an OptiCare approved
frame kit at no charge to use on consignment while providing Medicaid services to Kentucky Medicaid
members.
Q: When does the Kentucky Spirit / OptiCare Medicaid arrangement begin?
A: As a Kentucky Spirit / OptiCare Medicaid provider, you can begin placing these orders beginning October
1, 2011. You must establish a Kentucky Spirit / OptiCare Medicaid account number with Select Optical in
order to process your OptiCare orders at Select Optical. You must have a Kentucky Spirit /OptiCare Medicaid
account number (with Select) to avoid any delay in processing.
Notice: This is to provide you with formal notice that as a standard of practice of OMV, a provider candidate has the right to review information submitted in support of his/her
credentialing application. A provider candidate also has the right to correct erroneous information submitted or information obtained by a primary source agency. Any and all
questions pertaining to this notice should be directed to OMV’s Credentialing Unit.
Q: How will I be billed for laboratory services?
A: All covered lab bills for Kentucky Spirit / OptiCare Medicaid members will be directed by Select Optical
to OptiCare. Providers will not be responsible for lab bills generated for covered eyewear for Kentucky Spirit
/ OptiCare Medicaid members. However, if you choose not to use Select Optical as your laboratory for
Kentucky OptiCare Medicaid orders, providers will be responsible for paying their own laboratory invoices
and will need to submit a claim to OptiCare for reimbursement. Providers are responsible for checking a
member’s eligibility before placing an eyeglass order. If a member is not eligible, OptiCare will not pay the
lab and the lab may bill you, the ordering provider, directly for the eyeglasses. In addition, you may be billed
for ordered, but non-covered program items. Providers may collect unpaid charges from ineligible members.
Any questions concerning your reimbursement or member coverage should be directed to OptiCare’s
Customer Relations Department at (877) 615-7734.
Q: What if I wish to cancel an order or have an Rx change or remake request.
A: Cancellations or Rx changes made to an order before the manufacturing process has begun will be
processed at no charge. For any changes made to an Rx already in the manufacturing process, but which
requires a remake, the remake invoice will be billed to the provider with a 50% lens discount. Remakes due to
lab error will be processed at no charge with a specific reason.
Q: What laboratories are available for Kentucky Spirit / OptiCare Medicaid work and how quickly are
lab orders completed?
A: You are not required to send your work to any one specific laboratory. However, OptiCare has contracted
with Select Optical, an Essilor Laboratory as the preferred laboratory whose contact information is referenced
below.
Select Optical
6510 Huntley Road
Columbus, OH 43229
Local: (614) 846-5750
(800) 282-6960
Fax: (800) 553-1435
Once Select Optical receives your order, it will take on average, three (3) business days to complete and ship
the order back to your address. Please note that high Rx’s and/or special materials may take longer to
manufacture.
Q: What’s the process if I already have an account with Select Optical?
A: If you are already an account holder at Select Optical, thank you! You may still use your existing account
number with Select Optical to place both non-OptiCare Rx orders and Kentucky Spirit /OptiCare Medicaid
orders.
Q: What’s the process if I do not have an account with Select Optical?
A: It’s easy! Select Optical will send you an information packet upon your enrollment with OptiCare.
However, if you would like to get started right away, simply complete the attached fax form and send it to
Select Optical. Select Optical will send you a welcome packet which will include a New Accounts
Application and a Zimco Consignment Frame Kit Requisition form. Once you complete and fax the New
Account Application form, you will be contacted by Select Optical with your new account number within a
few business days. Once you have your new account number, you can begin placing your Kentucky Spirit /
OptiCare Medicaid orders. If you need help along the way, please call Select Optical at (800) 282-6960.
Q: Which frame kits will be needed to participate in this program and how do I obtain one?
A: As part of the Kentucky Spirit / OptiCare Medicaid program, frames must be of first quality and free of
defects. For your convenience, when you place your orders at Select Optical, you will be entitled to receive an
OptiCare approved Zimco frame kit on consignment from Essilor to display in your practice. By faxing the
form attached to Select Optical, you will receive a Zimco Consignment Frame Kit Requisition Form. Once
your form has been received and you have established a Kentucky Spirit / OptiCare Medicaid shipping
account with Select Optical, your kit will be shipped.
Information about each frame and instructions on proper use of the frame kit will be included. When you
place your orders, we will have these frames in stock, so there is no need to send in a frame with your order.
You can always call Select Optical with any frame-related questions.
Q: What do I have to do to begin placing my Kentucky Spirit / OptiCare Medicaid orders electronically
through Select Optical?
A: Once your account with Select Optical is set up, there are two online ordering options. You may go
directly to Select Optical’s web site, www.selectoptical.com to access on-line ordering, or you can go to
OptiCare’s website, www.opticare.com and access the on-line ordering website from there. Either way, your
order will be immediately in the hands of Select Optical for processing. Select Optical employs a userfriendly on-line ordering form which includes an order tracking system. You may also use a paper order form,
which will be included in your welcome packet.
Q: Who should I contact with questions about orders as they are being processed or any other lab
questions or concerns?
A: Select Optical’s lab customer service team at (800) 282-6960 will be able to answer all questions related to
your order.
Q: Who should I call with any non-lab related questions or concerns?
A: For all non-lab related questions including member coverage, please call OptiCare’s Customer Relations
Department at (877) 615-7734.
Q: Can I use Select Optical for non-OptiCare work?
A: Absolutely. Select Optical can provide a full range of products and services to assist you in delivering the
best possible vision care to your members. With your Select Optical account number, you are already set up
for private-pay or other third-party paid work. Please contact Select Optical for private pay ordering processes
and pricing.
Q: Which products are available through Essilor laboratories?
A: A full-range of ophthalmic products is available to fit any practice need – from progressives to coatings
and lens materials including premium Essilor brands such as Varilux®, Crizal®, Thin&Lite® and
DEFINITY™.
ABOUT ESSILOR
Essilor is the leading manufacturer of optical lenses in the United States and is the market leader in
progressive, high-index and anti-reflective coated lenses. A pioneer in the development and production of
ophthalmic lenses, Essilor employs over 6,100 people in more than 100 facilities throughout the 50 states.
Essilor manufactures optical lenses under the Varilux®, Crizal®, Thin&Lite®, DEFINITY™ and other
Essilor brand names. Essilor Laboratories of America (ELOA) is the largest, and most trusted, optical lab
network in the U.S. and offers a wide choice of services and lens brands, including Essilor premium lenses, to
eye care professionals across the nation. Essilor of America, Inc. (Essilor) is a subsidiary of Paris-based
Essilor International, S.A., a publicly held company traded on the Euronext Paris stock exchange (Reuters:
ESSI.PA).
Next Steps
To get started today, simply complete the information on the
fax form attached and fax it directly to Select Optical at (800)
553-1435. Once your program participation has been
confirmed by OptiCare, you will be sent a Welcome Kit
directly from Select Optical that contains all of the information
necessary to set up your account and receive your Zimco
consignment frame kit.
Return Fax Sheet
(Select Optical Information)
To:
Select Optical
From:
Fax:
(800) 553-1435
Pages________, including cover
Phone: (800) 282-6960
RE:
Kentucky Spirit /OptiCare Lab Services
Yes, I am interested in using Select Optical laboratory services for my Kentucky Spirit
/ OptiCare Medicaid members.
Please send me the Select Optical Welcome Packet which includes information to set
up an account with Select Optical.
Documents:
New Account Application
Zimco Consignment Frame Kit Requisition Form
My Practice Information:
Practice Name: ______________________________________________________
Practice Address: ____________________________________________________
City: _________________________ State: ______________ Zip: _____________
Should you have any additional questions or need additional information to complete
this process, please contact ________________________ at (______) _____-______.
Please enter your e-mail address if you would like to have the Welcome Packet
e-mailed to you.
_____________________________________________________________________
Section III: Routine Eye Care
The Routine Eye Examination
Each routine eye examination shall be a complete analysis of the member’s visual functions and
shall include the following components:
•
•
•
•
•
•
•
•
Medical history
Visual acuities with correction for distance and near (if applicable)
External examination of the eye and adnexa
Determination of neurological integrity including test of pupillary response
Slit-lamp examination with tension
Dilated fundus examination as per OptiCare’s dilation protocol
Tonometry
Summary, diagnosis and treatment plan including prescribing of corrective lenses.
Billing for Routine Eye Exams
Regardless of final diagnosis, a patient who presents for eye examination with no complaint must
be reported as a routine eye examination (initial visit only) listing ICD-9 codes V72.0 or 367.0
through 367.9 as the primary diagnosis in Box 21 and the diagnosis reference point in Box 24E
of Form CMS-1500. Any medical diagnosis may be listed as secondary. The coverage of
services rendered by an eye care provider is dependent on the purpose of the examination (as
reflected in the chief complaint) rather than on the ultimate diagnosis of the patient’s condition.
Therefore, if a patient presents to a provider’s office for a routine examination, and during the
course of the examination a medical diagnosis is discovered, the examination is still reported as
routine. However, subsequent services to treat the medical diagnosis may be covered as medical
visits.
Some plans administered by OptiCare require a Primary Care Physician (PCP) referral prior to
the treatment of medical eye conditions. Please refer to Section 2, Plan Specifics, of this Manual
for details regarding referral requirements.
Diabetic Eye Examinations
Diabetes is the most frequent cause of new blindness among adults in the United States. It is
important that all diabetics receive an annual dilated eye examination. Because of the
importance of this examination, HEDIS (Health Employer Data Information Set) includes this
data as a measure of how well a health plan performs. HEDIS scores are a significant measure
of quality used by the National Committee for Quality Assurance (NCQA) in order to evaluate
health plans.
Dilation Protocol
Dilation of the pupil is generally required for thorough evaluation of the ocular media and
posterior segment. The results of the initial examination may indicate the appropriate timing for
subsequent pupillary dilation. The health of the anterior structure of the eye and the intraocular
Fax: 252-451-2945
1
pressure level are typically assessed prior to pupillary dilation. However, dilation may facilitate
examination of anterior segment structures when certain conditions are present or suspected.
Dilation is recommended as follows:
Pediatric Eye Evaluation
Refractive errors in infants and preschool children are determined primarily to detect
physical anomalies of the eye that if uncorrected lead to amblyopia. Defining refractive
status can be critical, particularly when there is uncertainty about vision, horizontal
strabismus is present, or amblyopia is (or may be) present. Refractive status is determined
by means of retinoscopy and is a fundamental part of the medical and anatomic
examination of the infant or young child. Because the child may be difficult to examine
and is capable of high levels of accommodation, cycloplegia is recommended.
Pediatric eye care is defined as care to any person 18 years old or younger.
Diabetes Mellitus
The frequency of the exams is based on the types of diabetes and the progression of the eye
disease.
The development of vision-threatening retinopathy is rare in children prior to puberty.
When diabetes is diagnosed between the ages of 10 and 30, significant retinopathy may
become apparent after six to seven years of disease. Exams beginning five years after the
diagnosis of Type I diabetes will discover the vast majority of Type I patients who require
therapy at that time.
Patients first diagnosed after the age of 30 may have high-risk characteristics at the time of
the initial diagnosis of diabetes. Therefore, the patient should have an ophthalmologic
examination when first diagnosed.
Diabetic retinopathy can become particularly progressive during pregnancy. Diabetic
women should be examined for retinopathy when they are planning to become pregnant.
After conception they should be examined in the first trimester and thereafter at the
discretion of the physician, but at least every three months until parturition.
Exams for diabetic patients are recommended as follows:
¾ Diet control of diabetes - every two years
¾ Oral medications control - every year
Fax: 252-451-2945
2
¾ Oral medications control and retinopathy - every six months
¾ Juvenile onset of diabetes - every six to 12 months, as indicated
¾ Pregnancy - as defined above
Examination of the iris for neovascularization should be done prior to dilation, since it may
be missed when the pupil is dilated. In addition to the regular components of the
comprehensive adult eye evaluation, special attention should be paid to pupillary dilation
and examination of the retinal periphery; slit lamp fundus biomicroscopy and gonioscopic
examination are often indicated.
A dilated pupil is necessary to ensure optimal examination of the retina. Unless the retinal
periphery is examined, a substantial proportion of diabetic retinopathy may be missed. This
examination is best performed with indirect ophthalmology or mirrored contact lens.
Retinal Tears
The preferred method to rule out symptoms of and/or to diagnose retinal breaks is prompt
examination with a binocular indirect ophthalmoscope through dilated pupils.
Age-Related Macular Degeneration
Macular degeneration is more common in people over 60 years of age, but it is possible to
develop symptoms in one’s 40’s or 50’s. Macular degeneration often runs in families.
Symptoms can include:
•
•
•
blurry vision
straight lines that appear wavy
dark or empty area appearing in the center of vision
Pupillary dilation is recommended to achieve maximum stereoscopic visualization of the
macular and surrounding retina. Examination of the macular should also involve the use of
the direct and the binocular indirect ophthalmoscopes. All fundus-related procedures
should be done through a maximally dilated pupil, unless the use of mydriatics is
contraindicated.
Glaucoma & Glaucoma Suspect
The preferred technique for examining the optic nerve head involves magnified
stereoscopic visualization through a dilated pupil whenever feasible.
For patients being evaluated for angle-closure glaucoma who are not in the midst of an
acute attack, pupillary dilation may be deferred until after iridotomies or iridectomies are
performed.
Amblyopia
Fax: 252-451-2945
3
A patient’s refractive condition should be evaluated under both noncycloplegic and
cycloplegic conditions to determine whether the amblyopia has a refractive etiology.
Reassessment of visual acuity with best refractive correction is needed to avoid
misdiagnosis of amblyopia. Subjective refraction is typically unreliable in patients with
amblyopia and should only be used in conjunction with objective techniques.
Other Systemic Diseases
Pupillary dilation may be required if the patient has a history of systemic diseases that may
affect the posterior segment of the eye.
Ocular Trauma/Post-Surgical
Pupillary dilation is often required to visually inspect the internal integrity of the lens,
media, retina and optic nerve head.
Initial Visit
An initial visit is without history of a dilated exam within previous two years.
Other Dilation Protocols
Dilation for any reasons other than those listed above may require prior approval.
This protocol constitutes a framework of minimum recommended guidelines for
dilation of the pupil. The final determination as to when dilation of the pupil is
required for a thorough eye evaluation must be based on the doctor’s professional
judgment.
This protocol has been established in part from recommendations and guidelines
from the American Optometric Association’s Optometric Clinical Practice Guideline
and the American Academy of Ophthalmology Preferred Practice Patterns.
Low Vision Exams (not routinely covered)
Low vision exams are reviewed on a case-by-case basis and covered when deemed medically
necessary. The determination of medical necessity is based on a review of the underlying
medical or visual condition. The provider should code the visit using the 99201-03 or 99211-14
series based on provider/patient face-to-face time. 92354-55 codes should be used for the fitting
of low vision aids along with, if appropriate, the supply code of 92392. Coverage is subject to the
member's vision benefit. All services must be clearly documented in the medical record. Low
vision exams require prior approval from OptiCare’s UM Department.
Fax: 252-451-2945
4
Section IV: Utilization Management
Overview:
OptiCare Managed Vision (OptiCare) endeavors to minimize administrative requirements
allowing providers to determine how to best treat their patients. However, certain eye care
services are vulnerable to abuse and require prior authorization. Authorization provisions vary
according to full-service carrier terms. Please contact the OptiCare Utilization Management
Department at 1-800-465-6972 for details pertaining to pre-certification requirements for
individual plans or see Plan Specific information in Section 2.
All clinical criteria are evaluated annually by the Medical Directors. The Medical Directors
make recommended changes and the revised criteria are approved at the Quality Management
Committee Annual Review meeting in early February. The new criterion is published on
OptiCare’s website, www.opticare.com. Providers with appropriate security may access and
download the criteria for their file. Copies of clinical criteria may also be requested via
telephone (800) 465-6972 or written correspondence addressed to the OptiCare UM Department.
Copies will be faxed or sent via U.S. Postal Service.
OptiCare utilizes the following references to annually re-evaluate all clinical criteria:
¾ St. Anthony’s Coding Companion, St. Anthony Publishing, Inc.
¾ American Medical Association’s CPT Manual
¾ National Correct Policy Manual for Part B Medicare Carriers, Centers for Medicare and
Medicaid Services(CMS) (formerly HCFA), US Department of Commerce
¾ Medicare RBRVS: The Physician’s Guide, published by the American Medical
Association
¾ CMS information published at http://www.cms.hhs.gov/
¾ American Academy of Ophthalmology (AAO) Preferred Practice Patterns
¾ Input from board certified doctors of ophthalmology
¾ National Ophthalmology Council recommendations
¾ Local carrier determination policies published (among other locations) at
http://www.cms.hhs.gov/mcd
Surgical services requiring pre-certification, but performed without authorization, will be denied
and the member will be held harmless for payment of benefits normally covered under their
benefit plan. Please follow local carrier, CMS and OptiCare coding policies when requesting
pre-certification of services. OptiCare is not obligated to provide benefits for services that are
not medically necessary or for reported services that do not conform to local carrier, CMS and
OptiCare coding policies. Pre-certification requests for procedures that require authorization
must include any multiple procedures to be performed during the surgical session. Providers
must take care to assure that all procedures are performed at participating facilities. Any
inpatient procedure, procedure to be performed at a non-participating facility, AMA CPT Manual
unlisted procedure (CPT codes xxx99), new technology or new application of existing
technology must also be pre-certified. OptiCare reserves the right to modify pre-certification
requirements for any procedure or any provider. Pre-certification requests that are not approved
may be appealed by following the appeals process outlined in each non-covered service letter.
Fax: 252-451-2945
1
Authorized services may be changed prior to submitting a claim. Following claim submission,
authorized services may be modified by claim appeal only.
OMV shall not permit or provide compensation or any thing of value to OMV employees or
agents, condition employment of its employee or agent evaluations, or set its employee or agent
performance standards, based on the amount or volume of adverse determinations, reductions or
limitations on lengths of stay, benefits, services, or charges or on the number or frequency of
telephone calls or other contacts with health care providers or patients. OMV compensates
utilization review employees on a salary basis, which is in no way connected to utilization
review decisions. UM decision-making is based only on appropriateness of care and service.
OMV does not specifically reward practitioners or other individuals conducting utilization
review for issuing denials of coverage or service. Financial incentives for UM decision-makers
do not encourage decisions that result in under-utilization.
Emergency Care:
Pre-certification is not required in event of an emergency. OptiCare’s standard definition of
emergency care is (this definition may vary, refer to your Provider Participation Agreement) any
health care service provided in a hospital emergency facility (or comparable facility) in order to
evaluate and stabilize medical conditions of recent onset and severity (including severe pain), if
such condition would lead a prudent layperson (possessing an average knowledge of medicine
and health) to believe that failure to get immediate medical care might result in:
¾
¾
¾
¾
¾
Placing the person’s health in serious jeopardy
Serious impairment to bodily functions
Serious dysfunction of any bodily organ or part
Serious disfigurement
In the case of a pregnant woman, serious jeopardy to the health of the fetus
The following guidelines are used for emergency services:
¾
¾
¾
¾
Pre-certification is not required in event of an emergency
Emergency claims will be reviewed on a retrospective basis
All inpatient admissions or outpatient surgeries require pre-certification within 72 hours
Cases that are identified as not medically necessary will be referred to the Utilization
Management (UM) Committee for review
¾ If a deviant pattern(s) are identified, the UM Committee will make a decision on the
appropriate plan of action
¾ No prospective, concurrent or any retrospective denial for emergency health care services
can be made unless an appropriately qualified and licensed practitioner, with at least the
same licensure status as the ordering practitioner, has spoken with the patient’s attending
practitioner
¾ OptiCare covers emergency services if an authorized representative acting for OptiCare
has authorized the provision of emergency services
Fax: 252-451-2945
2
¾ All concurrent, prospective and emergent denials are made, signed and documented by a
licensed practitioner of the same licensure status as the ordering provider
Services Not Typically Performed by Eye Care Providers:
OptiCare does not authorize or reimburse providers for services that are not typically performed
by eye care providers. OptiCare refers to American Medical Association’s CPT Manual, St.
Anthony’s Coding Companion, the opinions of OptiCare Medical Directors and OptiCare local
and national utilization management committees in order to determine what services are typically
performed by eye care providers. Providers asking that a code be considered for addition to the
list of services typically performed by eye care providers may submit their request in writing to:
VP of Provider Relations
OptiCare
PO Box 7548
Excluded Services:
Services that are specifically excluded from an agreement between OptiCare and a full-service
carrier are subject to the policies of the full-service carrier. A list of such services may be
obtained by contacting the OptiCare Utilization Management Department at 1-800-465-6972 and
are plan specific. OptiCare is generally responsible for eye care services only. Pharmaceuticals
and facilities are generally obligations of full-service carriers. A list of participating providers
and facilities may be obtained by contacting OptiCare’s Provider Relations Department at 1-800840-7032.
Assistant Surgeons:
OptiCare allows assistant surgeon services for procedures identified by CMS as potentially
requiring an assistant surgeon. Providers must submit pre-certification requests for both the
primary surgeon and the assistant surgeon for all services that require pre-certification.
Out-of-network eye care services:
Out-of-network care may be approved if there are no in-plan providers to render the necessary
care or if it is in the best interest of the member to continue with care already in progress.
Requests are considered for the following situations:
¾ Prior surgery was performed and continuing care is medically necessary for continuity
¾ Interruption in the treatment plan would jeopardize the member’s recovery time
¾ Any condition that may be approved by an OptiCare Medical Director
Fax: 252-451-2945
3
Continuity of Care:
OptiCare will provide continuity of care within the boundaries of OptiCare’s medical necessity
criteria. The member (or the member’s physician) must submit a request for continuity of care
(including all documentation supporting the request) to the Medical Director for evaluation.
How to obtain an authorization or pre-certification:
Providers should contact OptiCare’s Utilization Management Department at 1-800-465-6972 for
details pertaining to pre-certification requirements for individual plans. Providers can fax an
OptiCare pre-certification request form (attached) to OptiCare at (252) 451-2133 or 1-888-2990712. Providers must supply all the requested information. If a provider is requesting
blepharoplasty or ptosis repair services, the provider is to send (by mail) original photos (front
and side view) showing lid margin reflex along with visual fields and supporting medical
records. If the provider is requesting a cataract surgery, include BCVAs, subjective complaint
and date of previous cataract surgery (if applicable).
Approval for Facility Use – if applicable
OptiCare utilizes a simple process for obtaining facility approval for non-emergency procedures.
All non-emergency services should be reported to OptiCare in advance using the “Medical Precertification Request” form. The “Facility Name & Address” field of the form should be
completed in full by rendering provider’s personnel and faxed directly to the OptiCare
Utilization Management department at (252) 451-2133. OptiCare Health Specialists will review
the request and notify the contact person listed on the form with a response. The telephone
response will include the determination and the reference number. A hardcopy approval will be
faxed upon request. If you have any questions concerning the completion of the form, please
contact the Utilization Management department at (800) 465-6972.
Please Note:
Facility services will be approved only if the professional service being rendered is determined to
be medically necessary in accordance with OptiCare’s clinical criteria and being performed by a
participating provider.
Services performed in a facility on an emergency basis do not require pre-approval and the
professional services are not required to be performed by a participating provider. Please followup with OptiCare within 72 hours of the service to ensure timely clam payment.
Referrals:
If a member presents for a routine eye exam and a medical condition is discovered, the provider,
if not contracted to provide medical eye exams with OptiCare, the member should be referred to
their PCP or the plans Member Services department for direction regarding the applicable
referral process. Because the referral process is plan specific, offices should refer to the Plan
Fax: 252-451-2945
4
Specifics portion of this Office Staff Manual for details regarding referral requirements in
Section 2.
UM Appeals:
(The definitions and examples in this section are OptiCare’s Standard UM Appeals process. The process may
differ depending on the plan specifics. All providers will receive specific instructions within their denial letter
on how, when and where to file an appeal.)
A member or provider may appeal any utilization review adverse determination. Depending on
the level of utilization management appeal delegation provided by each carrier (summary
below), the following steps are followed in order to perform and/or coordinate the appeal
process.
The Standard Appeals Process:
1. Level I Appeal (Reconsideration)
OMV accepts written requests for standard reconsiderations filed within 60-calendar days of the
notice of the organization determination or, if good cause is shown, accepts written requests for
standard reconsideration after 60-calendar days. Members covered under ERISA governed
Health plans have 180 days to file an appeal for non-urgent pre-service, urgent pre-service,
concurrent care, and post service adverse benefit determinations. An appeal acknowledgement
letter will be mailed to member/provider within 5 working days after receipt of the appeal. The
letter will contain the appeal received date along with a list of any additional information needed
to complete the review as applicable. An OMV Medical Director not involved in the prior
review will evaluate the request based on clinical information in the member’s medical records
and any additional information submitted to Utilization Management department. The OMV
Medical Director will review all documentation submitted by all parties which may include:
new, previously unknown information, further "reasonable" documentation related to this case
but not previously received, medical records, or patient interview (at Medical Director's
discretion). The review will include consideration of the availability or non-availability for
optional health care services proposed, and the hardship imposed by the optional health care on
the patient and his/her immediate family. After completion of the review, the Medical Director
will either approve or deny the appeal. All resolution letters will contain the contractual reason,
the clinical rationale for the resolution, and the specialty of the provider rendering the decision.
If OMV makes a fully favorable decision, a decision is issued to the member and/or provider as
expeditiously as the member’s health condition requires, but not later than 30-calendar days from
the date OMV receives the request for a standard reconsideration. Member will be notified by
the 15th calendar day if additional information is needed and shall have 45 calendar days to
provide additional information. For plans with two levels of appeals, 15 days for each level is
granted, not to exceed a maximum of 30 days. Appeals for adverse benefit determinations for
urgent pre-service authorizations will be responded to within 72 hours. Member will be notified
within 24 hours if there is insufficient information to make a decision. Member will have 48
hours to provide information. Requests for appeal of post-service (retrospective UR requests)
will be processed and a decision reached within 60 days. If plan has a two level appeal structure,
each level will have 30 days, not to exceed a total of 30 days. If additional information is
needed, OMV will advise member within 30 days. Member will then have 45 calendar days to
Fax: 252-451-2945
5
provide additional information. For appeals of concurrent care reductions or extensions, OMV
will make a decision within 72 hours for urgent requests or within 30 days for non-urgent
requests.
If OMV is unable to make a fully favorable decision, OMV forwards the case to Centers for
Medicare and Medicaid Services' (CMS) independent contractor as expeditiously as the
member’s health condition requires, but not later than 30-calendar days for standard service
denials (or if it is an expedited reconsideration within 24 hours of its decision) from date of
receipt of the reconsideration request. OMV concurrently notifies the member and/or provider of
this action. OMV makes reasonable and diligent efforts to assist in gathering and forwarding
information to CMS’ contractor.
Reversals by the independent outside entity:
Requests for service: If on reconsideration OMV's organization determination is reversed in
whole or in part by the independent outside entity, OMV authorizes the service within 72 hours
from the date it receives the notice reversing the determination, or as quickly as the member's
health condition requires (but no later than 14 calendar days from that date). OMV informs the
independent outside entity that the organization has effectuated the decision.
Requests for payment: If on reconsideration OMV's organization determination is reversed in
whole or in part by the independent outside entity, OMV pays for the service no later than 30calendar days from the date it receives notice reversing the organization determination. OMV
informs the independent outside entity that the organization has effectuated the decision.
Reversals other than by the OMV or the independent outside entity:
If the independent review entity's expedited determination is reversed in whole or in part at a
higher level of appeal, OMV authorizes the service under dispute as expeditiously as the
member’s health condition requires, but no later than 60-calender days from the date it receives
the notice reversing the organization determination. OMV informs the independent outside
entity that the organization has effectuated the decision.
EXPEDITED RECONSIDERED DETERMINATIONS:
Reversals by OMV:
If on reconsideration of an expedited request for service OMV completely reverses its
organization determination, OMV authorizes the service under dispute as expeditiously as the
member's health condition requires, but no later than 72 hours after the date OMV receives the
request for reconsideration. If the member requests an extension or if OMV justifies a need for
additional information, OMV may extend the timeframe by up to 14 calendar days. When OMV
extends the timeframe, it notifies the member and/or provider in writing of the reasons for the
delay and informs the member and/or provider of the right to file a grievance if they disagree
with OMV’s decision to grant itself an extension.
Fax: 252-451-2945
6
Reversal by the independent outside entity:
If OMV's determination is reversed in whole or in part by the independent outside entity, OMV
authorizes the service under dispute as expeditiously as the member's health condition requires,
but no later than 72 hours from the date OMV receives notice reversing the determination. OMV
informs the independent outside entity that it has effectuated the decision.
Reversal other than by the OMV or the independent outside entity:
If the independent review entity's expedited determination is reversed in whole or in part by the
ALJ or at a higher level of appeal, OMV authorizes the service under dispute as expeditiously as
the member's health condition requires, but no later than 60 days from the date OMV receives
notice reversing the determination. OMV informs the independent outside entity that the
organization has effectuated the decision.
OMV provides an expedited review when any physician (either contracting or non-contracting)
requests an expedited review or supports the member’s request, if the physician indicates that
applying the standard timeframe could seriously jeopardize the life or health of the member.
OMV maintains written documentation in the Risk Manager database case file of any and all oral
request(s) for an expedited organization determination or reconsideration. If a First Level review
results in a denial, the letter will further advise the member of the process for filing an appeal to
the next level.
If the reconsidered determination overturns OMV’s initial adverse organization determination,
OMV authorizes and pays for the service according to the following requirements:
Requests for service: If OMV’s reconsideration decision for a service request is completely in
favor of the member, OMV authorizes the service as expeditiously as the member’s health
condition requires, but no later than 30-calendar days from the date OMV receives the
reconsideration request.
Requests for payment: If OMV’s reconsideration decision is completely in favor of the
member for a claims issue, then OMV must effectuate the payment no later than 60-calender
days from the date it receives the request.
2. Level II Appeal
If OptiCare is not delegated Level II Appeals by the health plan and the provider and /or the
member are dissatisfied with the outcome of the appeal, they may appeal directly to the full
service carrier’s Utilization Management Committee. If OptiCare is delegated Level II Provider
Appeals by the health plan and the provider is dissatisfied with the outcome of the appeal, the
provider may appeal directly to OptiCare’s Utilization Management department. Physicians of
similar specialty as the requesting physician will make review decisions with 15 working days.
After careful review of all documentation and consultation with sub-specialist(s), as needed, the
committee will vote on the appeal decision. The majority vote of the committee is required to
Fax: 252-451-2945
7
reverse the original decisions of the Medical Directors. Written notification of the UM
Committee’s decision will be submitted to all parties involved within five (5) working days of
the decision. All resolution letters will contain the contractual reason, the clinical rationale for
the resolution, the specialty of the provider rendering the decision, and the procedure for
appealing to the next level. If not totally satisfied with the decision of the UM Committee, the
provider and/or member may request a third level appeal by submitting such appeal in writing to
the full-service carrier’s Utilization Review Medical Director. Rationale for review should be
documented in the request.
3. Level III Appeal
A provider or member has the right to request an external appeal of any adverse determination
directly to an independent third party managed care appeals organization. This is the final level
of appeal.
Expedited Pre-Service Appeals
If a delay in the decision making process might seriously jeopardize the life or health of the
member, an expedited appeal may be requested. An expedited appeal will be conducted and
communicated to the member and provider as expeditiously as the medical condition requires,
but no later than 72 hours after the request is made. If additional information is needed, the
information will be requested within 24 hours. Member has 48 hours to provide the additional
information. The decision shall be communicated to the provider(s) and member within one (1)
business day following the decision or within the 72 hours, whichever is earlier. A written
decision of the appeal results will be mailed within two (2) working days of the decision. All
resolution letters will contain the contractual reason and the clinical rationale for the resolution.
If the expedited appeal involves concurrent review determination, the decisions that are based on
medical appropriateness should be continued without liability to the patient until the patient is
notified of the decision, unless it is related to an initial unauthorized admission. Emergency
services necessary to screen and stabilize the member will be covered without authorization,
where the patient, acting reasonably, feels a true medical emergency existed.
Complete documentation for all levels of appeal including resolutions will be filed and
maintained for three (3) years in the Utilization Management department. Failure by OMV to
make a determination within applicable time periods shall be deemed to be a reversal of the
utilization management denial.
OMV documents and replies to oral and written first-level appeals of non-covered services
according to the following guidelines. OMV:
• notifies the member of the appeal process within five (5) working days of receiving a request
for a first-level appeal
• documents the substance of the appeal and the actions taken
• fully researches the substance of the appeal, including any aspects of clinical care involved
Fax: 252-451-2945
8
•
•
•
appoints reviewers who were not involved in the initial determination
resolves the appeal within 30 working days
notifies the member of the disposition of the appeal and the right to further appeal
If OMV does not make a decision within 30 working days due to circumstances beyond its
control, OMV issues a written decision within 15 additional working days and provides notice to
the member with the reasons for the delay before the 30th working day.
OMV documents and replies to expedited first-level appeals that may be initiated by a member
or by a practitioner acting on behalf of a member. In the case of an expedited first-level appeal,
OMV:
• makes an expedited appeal decision and notifies the member and practitioner(s) as
expeditiously as the medical condition requires, but no later than three (3) calendar days after
the request is made.
• provides written confirmation of its decisions within two (2) working days of providing
notification of that decision, if the initial decision was not in writing.
OMV documents and replies to oral and written second-level appeals according to the following
guidelines. OMV:
• documents the substance of the appeal and the actions taken
• fully researches the substance of the appeal, including any aspects of clinical care involved
• appoints second-level reviewers who were not involved in any previous decisions regarding
the appeal
• informs the member that they have a right to appear before the panel and if they cannot
appear in person at the panel hearing, they may communicate with the panel by conference
call or other appropriate technology
• resolves the second-level reviews within 30 working days of receiving the request
• provides written notification to the member within five (5) working days of completing the
review of the disposition of the appeal
• provides written notification of the potential right to appeal to an independent review
organization
OMV documents and replies to expedited second-level appeals that may be initiated by a
member or by a practitioner acting on behalf of a member. In the case of an expedited secondlevel appeal, OMV:
• makes an expedited appeal decision and notifies the member and practitioner(s) as
expeditiously as the medical condition requires, but no later than three (3) calendar days after
the request is made
• provides written confirmation of the decision within two (2) working days of providing
notification of that decision, if the initial decision was not in writing
OMV allows a practitioner or member representative to act on behalf of a member at any level of
appeal. OMV affirms that in at least one level of internal appeal, at least one of the people
appointed to review an appeal involving clinical issues is an actively practicing practitioner in
the same or a similar specialty who typically treats the medical condition, performs the
Fax: 252-451-2945
9
procedure or provides the treatment. This individual must not have participated in any of
OMV’s prior decisions on the case. If requested, OMV allows for independent, external review
of final determinations if:
• a member is appealing an adverse determination that is based on medical necessity, as
defined by NCQA
• OMV has completed two levels of internal reviews and its decision is unfavorable to the
member, or has elected to bypass one or both levels of internal review and proceed to the
independent review or has exceeded its time limit for internal reviews, without good cause
and without reaching a decision and a member has not withdrawn their appeal request,
agreed to another dispute resolution proceeding, or submitted to an external dispute
resolution proceeding required by law
OMV notifies members about the independent appeals program as follows:
• general communications to members announce the availability of the right to independent
review
• letters informing members and practitioners of the upholding of a non-covered service
covered by this standard include notice of independent appeal rights and processes, contact
information for the independent review organization, and a statement that the member does
not bear any costs of the independent review organization.
• letters inform members of the time and procedure for claim payment or approval of service in
the event the independent review organization overturns OMV’s decision
For all independent, external reviews of final determinations, OMV contracts with independent
review organizations that:
• conduct a thorough review in which it considers anew all previously determined facts, allows
the introduction of new information, considers and assesses sound medical evidence, and
makes a decision that is not bound by the decisions or conclusions of the internal appeal
• has no material professional, familial, or financial conflicts of interest with OMV
With the exception of exercising its rights as party to the appeal, OMV does not attempt to
interfere with the independent review organization’s proceeding or appeal decision. In addition,
a member is not required to bear costs of the independent review organization, including any
filing fees. Any member, or his or her legal guardian, may designate in writing a representative
to act on his or her behalf. OMV implements the independent review organization decision
within the timeframe specified by the independent review organization. OMV obtains from the
independent review organization, or maintains, data on each appeal case, including descriptions
of the denied item(s), reasons for denial, independent review organization decisions, and reasons
for decisions. OMV uses this information in evaluating its medical necessity decision-making
process. OMV adjudicates members’ appeals in a thorough, appropriate, and timely manner and
meets all the requirements of NCQA standard UM 7 and its own standards for handling first- and
second-level appeals as well as independent, external appeals.
Fax: 252-451-2945
10
Medical Pre-certification Request
Fax (252) 451-2133 Phone Toll Free (800) 465-6972
Date
_________EMERGENT
_________URGENT
_________ROUTINE
Office Contact
Phone
Referring Physician
Fax
Referred to Physician
Prov ID
Co-Management: Please specify Co-managing________________________________________________________________
Provider__________________________________________________________Provider______________________________
(Middle)
DOB
Patient Name (Last)
(First)
HMO (Plan)
ID #
Group #
Other Insurer (if any)
Date of Surgery
Date of Admit
IP/OP (Circle One) Anticipated LOS
Facility Name & Address
Diagnosis : (must be provided)-
Procedure:(must be provided)
ICD 9
Description
CPT
Description____________________ RT LT 50
ICD 9
Description_______________ CPT___________ Description_____________________ RT LT 50
ICD-9
Description_______________ CPT___________ Description_____________________ RT LT 50
PCP Referral Number: ____________________________ Effective date _____________________ Expiration date________
Medical Reason for
Request_________________________________________________________________________________________________
Attach additional pages if necessary
Patient’s Subjective Complaint: _______________________________________________________________________
Patient’s BCVA: OD_______________________
OS________________________________
Signature of Attending Physician:______________________________
Date________________________
Office Location:___________________
________________________________________________________________________________________________
PRE CERTIFICATION/AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT. COVERED SERVICES ARE BASED
ON MEMBER ELIGILIBITY AND BENEFIT LIMITATIONS AT THE TIME SERVICE(S) ARE RENDERED.
DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY
Reviewing Physician
Denied:
Approve
Approved LOS
Rationale for Denial:
Recommendation for alternative treatment(s)
Date
Reviewing Physician Signature
or Denial Reference #
Authorization #
Date
Medical Claims Administrator Signature
If Denied: Please refer to your Provider Manual or call 1-800-465-6972 to be informed of your appeal rights.
Fax: 252-451-2945
11
Section V: Payment for Services
Methods for Filing Claims:
Currently, OptiCare offers three ways to submit claims: via the OptiCare web site at
www.opticare.com, electronically via Emdeon or by mail. Faxed claims are generally not an
acceptable form of claim submission. Handwritten claims are not accepted. If your office
is unable to meet this standard, contact Provider Relations at 800-840-7032. Please refer to
the last page of the Plan Specifics Section (2) for information on where claims should be filed.
OptiCare Web Site:
OptiCare is extremely pleased to offer its complete Online Eye Health Manager, which will
allow your office to take full advantage of OptiCare’s web site. The site offers the following:
¾ Direct claims filing with immediate confirmation of receipt
¾ 24-hour claim status checks
¾ Member eligibility verification
¾ Pre-certification request and/or checks
¾ OptiCare’s Office Staff Manual (coming soon)
¾ OptiCare Medical Management Clinical Criteria
¾ OptiCare Claims Policies & Procedures
¾ Printing of Explanation of Benefits
¾ A Provider Locator for referral purposes
OptiCare takes very seriously the privacy of its member and provider information. To respect
the privacy of claims and eligibility information, access to the site is restricted and passwordprotected.
To obtain access to OptiCare’s web site, please contact OptiCare’s Provider Relations
Department (1-800-840-7032) to enroll.
Emdeon:
OptiCare is contracted with Emdeon to receive claims electronically.
In order to transmit claims electronically to OptiCare through Emdeon, the following
information is required:
Fax: 252-451-2290
1
1.
OptiCare’s Payor ID is currently listed with Emdeon as
“OptiCare/PrimeVision Health”. The Payor ID# is 56190 should be placed
in-2010BB Loop/NM109 Segment—Use “PI” as the ID Code Qualifier in
NM108.
2.
Rendering Provider ID should be placed in 2310B Loop/REF02 segment-Use
“N5” as the Reference Number Qualifier in REF01 must include the provider’s
OptiCare ID#. If a provider has questions about the process of setting up an
account with Emdeon to submit claims electronically, call Emdeon at 1-888-3513309
Frequently Asked Questions (FAQ) regarding E.D.I.:
FAQ:
How does an office that currently submits claims electronically confirm receipt by OptiCare?
Answer:
An office should receive an Emdeon confirmation that OptiCare has received the claim(s).
FAQ:
What is OptiCare’s Payor ID Number?
Answer:
OptiCare’s Payor ID is currently listed with Emdeon as “OptiCare/PrimeVision Health”. The
Payor ID# is 56190.
FAQ:
An office’s claims reject with an error message “Rendering Provider Network ID required”.
How does an office obtain a provider’s ID number?
Answer:
This information is available upon contacting OptiCare’s Provider Relations Department at 1800-840-7032.
FAQ:
How does an office get a confirmation report of the electronic claims after they have been
submitted?
Answer:
Contact Emdeon at 1-888-351-3309 or contact the applicable E.D.I. vendor.
FAQ:
How long does it take for claims to reach OptiCare if submitted electronically through Emdeon?
Answer:
If an office contracts directly with Emdeon, claims may be transmitted to OptiCare within 24
hours. However, the clearinghouse in use may affect an office’s electronic claim submissions.
Fax: 252-451-2290
2
FAQ:
What does an office need to do if interested in submitting claims electronically to OptiCare?
Answer:
OptiCare presently offers two (2) capabilities of accepting electronically submitted claims. An
office can submit in “real time” directly through OptiCare’s Online Eye Health Manager via the
internet. To obtain access to OptiCare’s web site, please contact OptiCare’s Provider Relations
Department (1-800-840-7032) to enroll. An office can also establish an account with Emdeon by
calling 1-888-351-3309.
FAQ:
If a claim is submitted via Emdeon on Friday March 30, 2004, why does OptiCare’s EOB show a
received date of April 2, 2004?
Answer:
All claims received from Emdeon after 2:00PM, on any normal business day are downloaded and
processed on the following business day. Claims are not transmitted or processed on weekends
and holidays.
FAQ:
Why is the address on the OptiCare EOB different than what was submitted through Emdeon
electronically?
Answer:
This information is available upon contacting OptiCare’s Provider Relations using the phone
number in the Plan Specifics section of the Office Staff Manual (Section 2).
Mail:
All claims submitted to OptiCare by mail for payment should be filed on an original CMS 1500
form. Forms must be completed and legible for payment processing. Claims submitted in red ink
will not be processed. Claims should be mailed to OptiCare daily. Handwritten claims are not
accepted. If your office is unable to meet this standard, contact Provider Relations at 800840-7032.
Claims are opened and date stamped with the date the mail is received from the Post Office.
OptiCare’s Clean Claims Mail Cover Sheet may be utilized if you wish to be notified by
OptiCare upon receipt of submitted claims. This cover sheet is the only recognized form of
mailed claims confirmation of receipt. Please complete a form for each submitting provider and
place before each batch of claims in the envelope. OptiCare will fax the confirmation of receipt
to the designated number on the cover sheet the date the claims are received.
Mailing Address:
OptiCare
Fax: 252-451-2290
3
Insert Plan Name
PO Box 7548
Fax: 252-451-2290
4
OptiCare CLEAN CLAIMS MAIL COVER SHEET
PROVIDER NAME: _______________________PROVIDER ID# ____________
PROVIDER ADDRESS: _______________________________________________
_____________________________________________________________________
PROVIDER PHONE: (____) ___________PROVIDER FAX: (____) __________
NAME OF ADDRESSEE: ______________________________________________
ADDRESS TO WHICH CLAIMS WERE MAILED:
_____________________________________________________________________
_____________________________________________________________________
MEMBER
MEMBER ID#
1-_____________________ ___________________
DOS
_______________________
2-_____________________ ___________________
_______________________
3-_____________________ ___________________
_______________________
4-_____________________ ___________________
_______________________
5-_____________________ ___________________
_______________________
6-_____________________ ___________________
_______________________
7-_____________________ ___________________
_______________________
8-_____________________
___________________ _______________________
9-_____________________
___________________ _______________________
10-____________________
___________________ _______________________
11-____________________
___________________ _______________________
12-____________________
___________________
_______________________
FAXED TO: ____________________________________
OptiCare Claim Representative: ____________________DATE: _______________
Fax: 252-451-2290
5
Faxed:
It is the policy of OptiCare not to accept original claims submission via fax. The exceptions
to this policy are defined below, but prior contact and approval by the receiving party at
OptiCare should take place prior to the fax. This approval is required to coordinate the claim
receipt and adjudication.
•
As a courtesy to a provider who has previously submitted a claim multiple times for
processing
•
The claim was omitted from the provider’s request for an appeal
•
The provider is requesting a status check for the claim
•
The provider is submitting a claim to be researched
•
State legislation requirement
General Filing Tips
The use of the following tips will help improve the quality of the claims we receive. Note:
Referral forms do not need to be submitted with the claim, unless it is indicated in the Plan
Specific section (Section 2) of this guide. If the following criteria are not met when submitting a
claim to OptiCare, there is the possibility that the claim may be denied.
All hard copy claims must be submitted on standard CMS 1500 forms.
1. Claims must be typed or computer-printed to be processed by the scanner. Handwritten
claims are not accepted. If your office is unable to meet this standard, contact Provider
Relations at 800-840-7032.)
2. Claim forms must be clear and legible to be processed. If OptiCare cannot read the claim,
OptiCare will be unable to process it, and it will be returned to your office for corrections.
3. Claims must be filed with the correct subscriber ID number, including the correct alpha
prefix or suffix, if applicable.
4. Providers should verify the subscriber’s coverage information with the patient or guardian to
avoid filing claims under an invalid subscriber ID number.
5. Claims must be filed under the subscriber’s name on the ID card, not his or her nickname.
6. Claims must include the Health Plan name (i.e. CIGNA of CO, Medicare Complete, Carolina
Care Plan, etc.) in field 11c of the CMS 1500.
Fax: 252-451-2290
6
7. Claims must include your Tax ID# in Field 25. This number should be the Tax ID number or
Social Security number reported to OptiCare on the provider’s W-9.
8. Claims must contain a pre-certification or referral number in Field 23 of the CMS form or
applicable electronic field if applicable.
9. File current HCPCS health services codes. If there is no suitable HCPCS code or if the
HCPCS code is unlisted, give a complete description in Field 19 or applicable electronic note
field for electronic claims.
10. If multiple modifiers are being billed on the claim, please use modifier 99 in Field 24D and
place the additional modifiers directly after modifier 99.
11. Indicate how many times each service was performed and make sure the units are consistent
with the health service code.
12. When submitting an accident diagnosis, include the date that the accident occurred in Field
14.
13. Claims must have the provider’s signature and location of the office where services were
rendered. If OptiCare is unable to read the Provider’s signature, the claim will be returned.
14. Providers must submit their NPI number in field 24 J of the CMS-1500 form.
15. All claims should be received within your claim filing period defined within your
Provider Participation Agreement (PPA). We strongly encourage the submission as soon
as services are provided. If not received within the filing time period, the claim will be
denied for late submission.
16. To initiate a review of a denied claim, please see Appeal Guidelines on page 29.
17. NO STAPLES OR NO POST-IT NOTES. All attachments must be on a full sheet of paper
and placed directly after the claim. Although all claims are adjudicated within the
appropriate timeframe, this practice will slow the processing of your claim.
18. NO HIGHLIGHTS, LABELS OR STICKERS. Although all claims are adjudicated within
the appropriate timeframe, these adjustments will slow the processing of your claim.
19. NO WHITE OUT OR RED INK. Claims received with white out and/or red ink will be
returned.
Faxed and/or copied claims will not be accepted for an original submission.
Fax: 252-451-2290
7
Claim Attachments
Some claims (initial filings, resubmissions and/or appeals) require additional information that
must accompany the CMS 1500 form to be considered a “clean claim” and appropriately
adjudicate the claim. The following is a listing of attachment/description requirements:
1.
A copy of the primary EOB should accompany the CMS 1500 claims form when filing
for COB.
2.
A description on a full sheet of paper or write a description in field 19 of CMS 1500 form
for 92499, V2599, or any other unlisted procedures.
3.
An invoice for consideration of wastage for botox injections (If applicable).
4.
Copies of previous and current prescriptions for significant changes in vision and when
requesting replacement hardware (if applicable for health plan). This information can
also be placed in field 19 of the CMS-1500 form.
5.
Office notes/medical records signed by the rendering provider for changes in diagnosis,
procedure codes or rendering provider.
6.
A list of supplies if billing 99070 with an office visit.
7.
A copy of invoice and prescription when billing for high-powered index and/or polycarbonate lenses.
8.
A copy of diabetic coupon (if applicable for health plan).
Fax: 252-451-2290
8
Place of Service Codes
The standard place of service codes as defined by CMS should be used when requesting
authorizations and filing claims for payment.
The standard place of service codes are:
11
12
15
21
22
23
24
25
26
31
32
33
34
41
42
51
52
53
54
55
56
61
62
65
71
72
81
99
Doctor’s Office
Patient’s Home
Mobile Unit
Inpatient Hospital
Outpatient Hospital
Emergency Room
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
Skill Nursing Facility
Nursing Facility
Custodial Care
Hospice
Ambulance - Air
Ambulance - Water
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospitalization
Community Mental Health Center
Intermediate Care Facility
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Facility
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End Stage Renal Disease
State or Local Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Unlisted Facility
Fax: 252-451-2290
9
Modifiers and definitions:
24
Unrelated Evaluation and Management service by the same physician during the
postoperative period. The physician may need to indicate that an evaluation and
management service was performed during the postoperative period for a reason(s)
unrelated to the original procedure. This modifier should only be used with office visit
codes.
25
Significant, separately identifiable evaluation and management service by the same
physician on the same day of a procedure or other service. The physician may need
to indicate that on the day a procedure or service identified by a CPT code was
performed, the patient’s condition required a significant, separately identifiable E/M
service above and beyond the other service provided or beyond the usual preoperative
and postoperative care associated with the procedure that was performed. This modifier
should only be used with office visit codes when performing a minor surgery.
57
Decision for surgery. An evaluation and management service that resulted in the initial
decision to perform the surgery on the same day. This modifier should only be used with
office visit codes when performing a major surgery.
26
Professional component. Certain procedures are a combination of a physician
component and a technical component. The professional component (26) is for the
physician’s interpretation of the diagnostic test.
50
Bilateral procedure. Unless otherwise identified in the listings, procedures that are
performed on both eyes at the same operative session. This modifier should be used on
unilateral surgical or diagnostic codes when the same procedure is performed on both
eyes in the same operative/office session. The procedure should be billed as one line
item with one unit and with a modifier of 50.
51
Multiple procedures.
When multiple procedures, other than evaluation and
management services, are performed on the same day or at the same session by the same
provider. This modifier should be used on surgical codes when more that one procedure
is performed on the same eye in the same operative session.
78
Return to the operating room for a related procedure during the postoperative
period. The physician may need to indicate that another procedure was performed
during the postoperative period of the initial procedure. This modifier should be used on
surgical codes when a related procedure is performed in the postoperative period of a
previous procedure.
Fax: 252-451-2290
10
79
Unrelated procedure or service by the same physician during the postoperative
period. The physician may need to indicate that the performance of a procedure or
service during the postoperative period was unrelated to the original procedure. This
modifier should be used on surgical codes when the same physician performs an
unrelated procedure in the postoperative period of a previous procedure.
TC
Technical component. Used to report the technical portion of a diagnostic test. (e.g.
Fluorescein angiography, A-Scan) The technical component (TC) is for the actual test
being performed.
54
Surgical Care Only. When one physician performs a surgical procedure and another
provides preoperative and/or postoperative management. This modifier should be used
with the surgical code to identify the surgical portion of the procedure only.
55
Postoperative Management Only. When one physician performs the postoperative
management and another physician has performed the surgical procedure. This modifier
should be used with the surgical code to identify the postoperative portion of the
procedure only.
56
Preoperative Management Only. When one physician performs the preoperative care
and evaluation and another physician has performs the surgical procedure, the
preoperative component may be identified by adding the modifier 56 to the usual
procedure number or by use of the separate five digit modifier code 09956.
80
Assistant Surgeon. Surgical assistant services. This modifier should be used with the
surgical code to identify the assistant surgeon portion of the procedure.
99
Multiple Modifiers. Under certain circumstances, two or more modifiers may be
necessary to completely describe a service. In these situations, modifier 99 should be
used with the basic service code, and all other applicable modifiers may be listed as part
of the description of the service.
Anesthesia modifiers
•
AA - Anesthesia Services performed personally by the anesthesiologist
•
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;
•
G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly
invasive surgical procedures;
•
G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary
condition
Fax: 252-451-2290
11
•
QK - Medical direction of two, three or four concurrent anesthesia procedures involving
qualified individuals
•
QS - Monitored anesthesia care service QX - CRNA service; with medical direction by a
physician
•
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist
•
QZ - CRNA service: Without medical direction by a physician.
Filing for Routine Payment
When completing the CMS 1500 claim form for a routine vision exam, the following guidelines
must be utilized:
CPT Codes:
92002 New, Intermediate exam
92004 New, Comprehensive exam
92012 Established, Intermediate exam
92014 Established, Comprehensive exam
in conjunction with a PRIMARY diagnosis (ICD-9) code of:
V72.0 or 367.xx series
**Note: Please check the Plan Specifics (Section 2) for more details on each plan.
Filing for Hardware Payment
For materials, use the appropriate Medicare Level III HCPC “V” codes for Commercial,
Medicaid and Medicare claims as specified in Section 2 of this Manual (Plan Specifics).
To be reimbursed for a routine exam, please separately bill the exam, contact lens fitting and
contact lens.
**Note: Please check the Plan Specifics (Section 2) to determine if contact lens fitting fees
and/or contact lenses are covered.
Filing for Facility Payment
Ambulatory Surgery Centers
Please use the standard CMS 1500 form when submitting the claim to OptiCare. The “SG”
modifier should be applied to the primary surgical procedure code. Placing the OptiCare
approval number on the form is optional. If you choose to place the number on the form, please
place it in box 23 of the CMS 1500 form.
Fax: 252-451-2290
12
Outpatient Hospitals
OptiCare prefers the standard CMS 1500 form when submitting the claim, however will also
accept the UB-92 CMS-1450 claim form. Placing the OptiCare approval number on the form is
optional. If you choose to place the number on the form, please place it in field 63 if the UB-92
form.
Coordination of Benefits
When a Member is covered by more than one plan, OptiCare will Coordinate Benefits (COB)
with other plans to reduce the Member's out-of-pocket expenses. OptiCare adheres to the COB
regulations of the state where the service is rendered.
Order of Benefit Determination is based on rules set forth by the National Association of
Insurance Commissioners (NAIC) and adopted by the state in which the service is rendered.
When OptiCare is considered the Secondary Plan, a clean CMS 1500 claim form and a copy of
the Primary Plan’s Explanation of Benefits (EOB) are required for calculation of the secondary
payment. Provider can also submit an electronic claim form with the appropriate COB filed out.
OptiCare will calculate the payment based on the Allowable Fee under the provider’s contracted
rate. OptiCare will coordinate benefits as outlined below.
Coordinating Benefits for Commercial Plan Claims
When it is determined that OptiCare is the primary plan, OptiCare will calculate and pay the
member's benefit as if no other plan exists. Payment will be based on the "Allowable Fee Under
this Contract" amount. No further payment obligation from OptiCare will be due beyond
Contracted Rates.
OptiCare’s objective as secondary plan is to limit member's liability by paying the difference
between the allowable expense of the ophthalmologic covered health care service and supplies
provided to the member less whatever the primary plan paid, not to exceed the OptiCare COB
eligible amount (See definitions).
When it is determined that OptiCare is the secondary plan, OptiCare will calculate its payment
based on the Allowable Fee Under this Contract amount. OptiCare will then coordinate benefits
to pay 100% of the member's liability of the Allowable Expense, not to exceed the amount that
OptiCare would have paid in the absence of COB. If the member's liability is not covered in full
by OptiCare’s secondary payment, the member may be billed for any uncovered deductible, coinsurance, or co-pay amounts. The member may not be billed for any amount greater than the
Allowable Fee under this Contract due to the negotiated fee arrangement that exists between the
provider and OptiCare. If the provider believes that the member has accumulated a benefit
reserve amount for the claim determination period, they may submit a request in writing for
Fax: 252-451-2290
13
review by OptiCare. If a benefit reserve does exist, the unpaid member liability will be
supplemented and the benefit reserve reduced accordingly.
When OptiCare is determined to be the Third Payor, OptiCare will calculate its payment based
on the Allowable Fee Under this Agreement amount. OptiCare will then coordinate benefits to
pay 100% of the Members liability of the Allowable Expense, not to exceed the amount that
OptiCare would have paid in the absence of COB amount will be determined by calculating the
payment made by the primary and the secondary payors. OptiCare will only pay up to the
remaining patient liability as calculated by the secondary payor. To calculate the allowed
amount, add the total COB amount to the remaining patient liability.
Coordinating Benefits with Medicare Claims
When a member is entitled to receive payment or benefits from Medicare, OptiCare will
coordinate Benefits with Medicare to reduce the member's out-of-pocket expense. OptiCare
adheres to the COB regulations of the state where the service is rendered.
When it is determined that OptiCare is the primary plan, OptiCare will calculate and pay the
member's benefit as if no other plan exists. Payment will be based on the "Allowable Fee Under
this Contract" amount. No further payment obligation from OptiCare will be due beyond
Contracted Rates.
When it is determined that OptiCare is the secondary plan, OptiCare will use the "Allowable Fee
under this Schedule" to calculate the member's benefit for the service(s) rendered. OptiCare will
reimburse the member's deductible and/or co-insurance amounts up to the Medicare Allowable,
not to exceed the OptiCare COB eligible amount. Any deductible or co-insurance amount that is
not covered by OptiCare may be billed to the member.
For services that are not covered by Medicare, such as routine vision exams, OptiCare will
reimburse the OptiCare contracted rate for the service. Member is responsible for any
deductible, co-insurance, or co-payment amounts only. The member may not be billed for
amounts over the Contracted Rate. Refractive exam, procedure code 92015, is not a covered
service of Medicare, however it may be a covered service by OptiCare. OptiCare considers this
service bundled with the routine vision exam. No reimbursement is made for this service, and
the member may not be billed.
When Medicare denies a claim, the COMB will indicate if the patient is liable for the charges.
Use the following decision table to determine which procedure to follow when Medicare denies
a claim.
If
The Patient is liable (Medicare remark
Then
Follow OMV’s contract benefits and
Fax: 252-451-2290
14
code starts with “PR”)
The patient is not liable (Medicare EOMB
message code starts with CO-XX)
limitations when paying the claim or
service.
Deny the charge with message
“DMEDASSIGN- Denied: Provider
accepts Medicare assignment and this
service was disallowed by Medicare. No
member or Secondary Payor liability on
this service.”
Coordinating Benefits for Medicaid Account Claims
"Under federal regulations, Medicaid must pay for health care only after an individual's other
health care resources have been exhausted." Medicaid is viewed as the payor of last resort.
When it is determined that OptiCare is the payor of last resort, OptiCare will calculate its
payment based on the Allowable Fee Under this Agreement amount. OptiCare will then
coordinate benefits to pay 100% of the member's liability of the Allowable Expense, not to
exceed the amount that OptiCare would have paid in the absence of COB. If the member's
liability is not covered in full by OptiCare’s secondary payment, the member may be billed for
any remaining deductible, co-insurance, or co-pay amounts. The member may not be billed for
any amount greater than the Allowable Fee under the provider’s contract due to the contracted
fee arrangement that exists between the provider and OptiCare. OptiCare will not hold any
claims pending due a COB resolution. Claims must be paid within each state's designated time
frame. If it is determined after a claim has been adjudicated that the member has a Primary
Payor, OptiCare will attempt to recover overpaid monies, if any, from the provider of service.
Coordinating Benefits for Medicare/Medicaid Crossover Claims
When an individual is entitled to Medicare and eligible for Medicaid, Medicare is considered the
Primary Payor. The payment of the Medicare Part B deductible and co-insurance for Medicaid
clients who are Medicare beneficiaries is based on the following:
•
If the Medicaid client is eligible for Medicaid only as a qualified Medicare
beneficiary, Medicaid pays the Medicare Part B co-insurance and deductible on valid
Medicare claims
•
If the Medicaid client is not a qualified Medicare beneficiary, Medicaid pays the
clients Part B:
• Deductible liability on valid assigned Medicare claims
•
Coinsurance liability on valid assigned Medicare claims that are within the
amount, duration, and scope of the Medicaid program, and would be covered
by Medicaid, when the services are provided, if Medicare did not exist.
Fax: 252-451-2290
15
•
Medicaid payment of a client's coinsurance/deductible liabilities satisfies the
Medicaid obligation to provide coverage for services that Medicaid would
have paid in the absence of Medicare. Medicare Part A services are not
covered by OptiCare.
Worker's Compensation
OptiCare does not pay as secondary on Worker's Compensation (WC) claims. That is, OptiCare
does not coordinate or make partial payments on WC claims. OptiCare will pay as primary
payor only when the WC claim has been totally denied by WC carrier or WC benefits have been
exhausted.
Federal Black Lung Program
OptiCare does not pay secondary on Federal Black Lung Program claims. That is, OptiCare
does not coordinate or make partial payments on Black Lung claims. OptiCare will pay as
primary only when the Black Lung claim has been denied.
Definitions:
Allowable Expense
Allowable expense means an ophthalmologic health care service or expense including
deductibles, co-insurance, or co-payments, that is covered in full or in part by the plans covering
the person except as set forth below or where a statute requires a different definition. An
expense or service or a portion of an expense or service that is not covered by any of the plans is
not an allowable expense. The following are examples of expenses that are not an allowable
expense.
a) If a person is covered by two (2) or more plans that compute their benefit payments on the
basis of usual and customary fees, any amount in excess of the highest of the usual and
customary fee for a specified benefit is not an allowable expense.
b) If a person is covered by two (2) or more plans that provide benefits or services on the basis
of negotiated fees, any amount in excess of the highest of the negotiated fees in not an
allowable expense.
c) If a person is covered by one plan that calculates its benefits or services on the basis of usual
and customary fees and another plan that provides its benefits or services on the basis of
negotiated fees, the primary plan's payment arrangement shall be the allowable expense for
all plans.
d) If a service is not a benefit of either plan, then it is not an allowable expense.
Fax: 252-451-2290
16
OptiCare limits the application of COB to vision and/or ophthalmology services only. This
policy means that the definition of allowable expenses is limited only to Covered Services or
expenses that OptiCare provides.
Allowable Fee Under this Contract (Contracted Rate)
The allowable fee under this agreement is the contracted payment amount that exists between
OptiCare and the OptiCare contracting provider.
Benefit Reserve
A Benefit Reserve contains the actual COB savings for each plan participant during the
applicable annual claim determination period. The savings are used to ensure that the member
with duplicate coverage ends up with no out-of-pocket expenses (except, of course, those limited
out-of-pocket expenses that are not allowable expenses).
Claim Determination Period
A period of not less than 12 consecutive months, over which allowable expenses shall be
compared with total benefits payable in the absence of COB, to determine whether over
insurance exists and how much each plan will pay or provide. As each claim is submitted, each
plan determines its liability and pays benefits based upon allowable expenses incurred up to that
point in the claim determination period. That determination is subject to adjustment as later
allowable expenses are incurred in the same claim determination period. This period varies for
OptiCare accounts.
Medicare Allowable
The amount that Medicare assigns as the "Allowable Expense" for services and supplies.
OptiCare COB Eligible Amount
The amount that OptiCare would have paid had OptiCare been the Primary Payor.
Primary Plan/Payor
The plan that is determined to make the first payment as defined by the NAIC "Order of Benefit
Determination" guidelines.
Secondary Plan/Payor
The plan that is determined to make the secondary payment as defined by the NAIC "Order of
Benefit Determination" guidelines.
Global Fees/Surgical Follow-up
OptiCare follows CMS global fee guidelines for all medical/surgical services. The National
Physician Fee Schedule can be obtained at www.CMS.gov. Most minor procedures include
Fax: 252-451-2290
17
preoperative relative values on the day of the procedure and postoperative relative values during
a 10-day postoperative period included in the fee schedule amount; evaluation and management
services on the day of the procedure and during the 10-day postoperative period are generally not
payable. Most major surgeries have a one-day preoperative period and 90-day postoperative
period included in the fee schedule amount. Providers in the same group practice are covered
under a single global fee for pre- and postoperative services.
Global Fees and Surgical Follow-up include the following:
•
Pre- and Postoperative visits
•
Patient’s history and physical
•
Any inpatient visits
•
Complications following surgery
•
Local and topical anesthesia administered by the physician
•
Intraoperative services
•
Supplies
Co-Management of Care
If the pre/postoperative care is to be performed by a provider other than the surgeon, it should be
noted at the time of the pre-certification request. When the surgeon releases the patient to
another provider, the office should call to update the authorization. The surgeon should bill for
the surgery only, and the other providers will bill the pre/postoperative part of the global fee.
Multiple Surgeries
OptiCare will reimburse providers for multiple surgeries in accordance to Centers for Medicare
and Medicaid Services (CMS) guidelines. Multiple surgeries are separate surgical procedures
performed by the same provider on the same member at the same operative session or the same
day and do not require separate preparation and setup. Payment for appropriate multiple surgery
billing combinations is based on CMS payment guidelines of 100% of the Payor allowance for
the major procedure and 50% of the Payor allowance for all subsequent procedures. Procedures
that are also bilateral should have the bilateral rule applied first, and then the multiple surgery
rules applied to the bilateral procedure. There are some surgical procedures that do not meet the
multiple surgical rules.
Fax: 252-451-2290
18
Payment Methodologies:
Covered procedures are subject to OptiCare’s payment
methodologies for both commercial and government sponsored programs based on: The
National Correct Coding Policy Manual for part B Medicare Carriers, Medicare RBRVS:
The Physician’s Guide, and local Medicare Carrier Policies in addition to Company’s
coding guidelines. These guidelines are intended to incorporate and, in specific instances,
include the requirements of the CMS guidelines. Additional resources for payment
methodologies administered by OptiCare include but are not limited to:
•
Medicare Physicians Fee Schedule
•
National Correct Coding Policy Manual for Part B Medicare Carriers
•
American Medical Association’s CPT Manual
•
St. Anthony’s Coding Companion
•
American Academy of Ophthalmology (AAO) Preferred Practice Patterns
•
Input from board-certified doctors of ophthalmology
•
Literature including (but not limited to) current medical journals and textbooks
•
Recommendations from the National Ophthalmology Council any other source deemed
appropriate by OptiCare
Definitions:
Consult:
A consultation is a type of service provided by a physician whose opinion or
advice regarding evaluation and/or management of a specific problem is requested by another
physician or other appropriate source. A physician consultant may initiate diagnostic and/or
therapeutic services at the same or subsequent visit. The written or verbal request for a consult
may be made by a physician or other appropriate source and documented in the patient’s medical
record. The consultant’s opinion and any services that were ordered or performed must also be
documented in the patient’s medical record and communicated by written report to the
requesting physician or other appropriate source.
Covered And Non-Covered Services:
Vision care services or supplies for which a member
is entitled to receive benefits under a Plan directly or indirectly provided, administered, or insured in
whole or in part by the Company. Coverage and non-coverage of eye care CPT codes is
determined by Company and is subject to membership eligibility and applicable benefit coverage
periods. Procedures and supplies must be reported for reimbursement in strict accordance with
coding guidelines established by the CMS, the American Medical Association and OptiCare’s
eye care payment methodologies.
Fax: 252-451-2290
19
Modifiers 24 (unrelated service during post-op), 25 (separately
Global Services:
identifiable service), 59 (distinct procedural service) and 79 (unrelated procedure during post-op)
must be reported with a different ICD-9 code in order to be considered for payment. Providers
in the same group practice are covered under a single global fee for pre- and postoperative
services.
Level One Office Visit:
Includes a minor severity presenting problem, a chief complaint, a
brief history of present illness, one to five examination components, and straightforward medical
decision-making.
Level Two Office Visit:
Includes a moderate severity presenting problem, a chief
complaint, a brief history of present illness, a problem pertinent review of systems, at least six
examination components, and straightforward medical decision-making.
Level Three Office Visit:
Includes a moderate severity presenting problem, a chief
complaint, an extended history of present illness, an extended review of systems, a problem
pertinent past, family and social history, at least nine examination components, and low
complexity medical decision making.
Includes a moderate to high severity presenting problem, a chief
Level Four Office Visit:
complaint, an extended history of present illness, a complete review of systems, a complete past,
family and social history, all twelve examination components and moderate complexity medical
decision making.
Level Five Office Visit:
Includes a high severity presenting problem, a chief complaint, an
extended history of present illness, a complete review of systems, a complete past, family and
social history, all twelve examination components and high complexity medical decision
making.
The coverage of services rendered by an eye
Medical Evaluation & Management Services:
care provider is dependent on the purpose of the examination rather than on the ultimate
diagnosis of the patient’s condition. Therefore, if a patient presents to a provider’s office with a
medical symptom (as reflected in the chief complaint), the examination is reported as a medical
evaluation & management office visit.
Verifying Claim Status
Claims should be at least forty-five (45) days old, from the date of service, before a status is
requested. Claim status can be obtained by calling OptiCare’s Customer Relations Department
Fax: 252-451-2290
20
or by faxing a completed Status Request Form to 252-451-2910. Claim status can also be
obtained by accessing the OptiCare web site at www.opticare.com.
Fax: 252-451-2290
21
Sample CMS 1500 Form
Instructions can be obtained at www.nucc.org
Fax: 252-451-2290
22
Fax: 252-451-2290
23
Sample UB-92 CMS 1450 Form
Fax: 252-451-2290
24
Fax: 252-451-2290
25
Non-Covered Services
After-Hours Office Visit
OptiCare does not reimburse providers for this service, because it is considered by the CMS to
be a “bundled” service. Bundled services are not payable, nor should they be reported, even
when performed incidental to or in combination with another service.
Telephone Consultations
Billing for telephone consultations is not covered.
Billing for Missed Appointments
OptiCare does not cover charges for missed appointments. Commercial and Medicare members
may be billed for missed appointments only if this is the standard office procedure, the member
has previously received a written statement of this procedure, or it is posted in a prominent
location in the office.
Medicaid members may not be billed for missed appointments.
Incomplete Claims
All claims will be entered into the claim system if possible and will be included on your
Explanation of Benefits (EOB). Under certain circumstances, claims may be mailed back to the
provider or member with a “Notice of Incomplete Claim” form. These include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Hand written claims
Inability to determine the name of the provider who rendered the services
Missing name and address of location or facility where services is rendered
Information on the CMS 1500 form is not legible.
Inability to identify the member
Inability to identify the member’s health plan
Date of service is missing
Any claim not submitted on a CMS 1500 claim form
Missing Tax Identification Number
Missing amount billed for the services
Valid place of service is required
Valid ICD9 diagnosis is required
Valid diagnosis pointer is required
Valid CPT procedure code is required
Whiteout is not accepted
Fax: 252-451-2290
26
•
•
•
Units not listed on CMS 1500 form
Information that has been written over
Missing NPI number
Correcting A Claim
When filing a corrected claim, please submit all charges that were on the original claim rather
than just the charge that has changed. If only one charge is resubmitted, it is not clear whether
OptiCare is to remove the charges that were previously processed and a refund might be
requested in error.
When submitting a correction for a diagnosis or procedure code only, submit the change on a
clean CMS 1500 form, indicate “RESUBMISSION” OR “CORRECTED” in field 19 of the
CMS form, web submission or applicable electronic field for Emdeon.
A corrected claim is defined as a claim that is being re-filed with necessary, additional
information that enables the proper adjudication of the claim. In most instances, the original
claim was initially submitted without all of the proper elements necessary to process the claim,
resulting in a denial for additional information.
Responding to an Incorrect Payment When You Notice It:
If you notice that we have made an overpayment to you, please call Customer Relations by using
the telephone number supplied in Section 2 of the Office Staff Manual. You may also write us a
letter giving us the amount of the overpayment, the member’s ID number, date of service,
provider’s ID number, copy of the EOB, and the reason you believe the payment is in error.
Please send written notification with a refund check for the amount overpaid to:
OptiCare/Claim Administration/Refunds
PO Box 7548
Responding to an Incorrect Payment When OptiCare Notices It:
OptiCare will send a written request for reimbursement of the overpayment. If we have not
received the requested refund within 45 days of the date of the request, we will make the
necessary adjustments, and they will be reflected on your next EOB. If you have questions about
adjustments that appear on an EOB, please contact OptiCare by using the telephone number
supplied in Section 2 of the Office Staff Manual.
OptiCare Claim Appeal/Grievance Process
Fax: 252-451-2290
27
OptiCare strives to process all claim appeals/grievances in a systematic and timely fashion for
the benefit of all our contracted Payors, Members, and Providers.
Purpose of the Appeal/Grievance Process:
The purpose of this procedure is to ensure that OMV’s network providers and members have
procedures available to fairly resolve appeals on a timely basis relating to all aspects of OMV’s
administration of health care services including disputes relating to claim payments (excluding
all clinical or medical necessity determinations).
Definitions:
Appeal
Procedures dealing with the review of adverse organization determinations (denials) on health or
vision care services an enrollee believes he or she is entitled to receive. This includes delay in
providing, arranging for, or approving the health care services (such that a delay would adversely
affect the health of the enrollee) or on any amounts the enrollee must pay for a services. The
procedures include reconsideration by organization and if necessary, an independent review
organization, hearings before Administrative Law Judges (ALJ), review by the Departmental
Appeals Board (DAB), and judicial review. An unfavorable determination (denial) may trigger
the appeals process if the enrollee believes that he/she is not receiving what is entitled to receive.
Authorized Representative
Any individual authorized by an enrollee, or a surrogate who is acting in accordance with state
law on behalf of the enrollee, in order to obtain an organization determination or handle any
level of the appeals process.
Effectuation
Effectuation means compliance with a reversal of the organization’s original adverse
organization determination. This includes payment of a claim, authorization for a service, or
provision of services.
Enrollee
An eligible individual who has elected the Medicare plan offered by an M+C or Medicare
Advantage (MA) organization or his/her representative.
Independent Review Entity
An independent entity contracted by CMS to review M+C or MA organization’s denial of
coverage determinations.
Inquiry
Fax: 252-451-2290
28
An inquiry is any oral or written request to an M+C or MA organization, provider, facility,
without expression of dissatisfaction. An example of an inquiry might be a request for
information.
In order for the Appeals/Grievance Committee to review a claim appeal, the following
information must be submitted:
•
A complete CMS 1500 form for claim in question
•
A complete Claim Appeal Request Form (attached)
•
A copy of the EOB in which the claim in question is listed
•
Any other documentation (primary EOB’s, authorizations, referrals, etc.)
The Claim Appeal mailing address is:
OptiCare/Attn: Appeals
PO Box 7548
Once all documentation has been received, a committee consisting of employees from designated
departments within OptiCare will review the claim. This committee meets weekly, and reviews
all provided documentation with the appeal, and renders a decision based upon all available
evidence.
Appeals are reviewed on a case-by-case basis. The following information represents criteria for
the Appeal Committee decisions:
•
Eligibility Concerns
1.
•
The full-service carrier will be contacted to determine the member’s coverage at time of
service.
Timely Filing Guidelines
1. Claims should be filed within stated filing period defined within your Provider
Participation Agreement (PPA) and/or appealed within defined within your Provider
Participation Agreement (PPA) of receipt of the EOB.
2.
OptiCare will not accept office claims system/accounts receivable printouts as proof of
timely filing.
Fax: 252-451-2290
29
Acceptable proof of timely filing includes: certified mail receipts with a log detailing contents
(For example number of claims members included and dates of service), Emdeon confirmations
of Daily Management Summary, Daily Acceptance Report, and Unprocessed Claims Report,
OptiCare web site confirmation, or OptiCare-signed claims batch cover sheet.
Decisions made by the Appeals Committee are based on the supporting documentation received
from your office to support this appeal. Based on the supporting documentation provided to
OptiCare, this appeal decision is final.
Level I Appeal
A Level I Appeal is considered a formal written or oral request for review of a denial or reduced
level of benefits. Members requesting an appeal will receive an “appeal acknowledgement”
letter within five (5) business days of receipt, a decision will be made within 30 calendar days
from the date the written request is received by OptiCare. The Member and/or the Provider must
be notified in writing of the Appeal Committee decision within 30 calendar days of receipt of
written request. The Appeals Committee will meet once a week or more frequently if needed.
All requests for a Level I Appeal should be mailed to:
OptiCare Eye Health Network
PO Box 7548
Attn. Claims Appeal Committee
Level II Appeal
A member, member representative or provider may file a Level II appeal if satisfaction is not
received after a Level I Appeal has been completed. OptiCare does not contract with Payors for
Level II member appeals. All Level I member letters will provide instructions for members who
wish to submit a second level appeal directly to the Payor and/or external review agency if
applicable. A Level II provider appeal is the final level of appeal for the participating provider.
All appeal options will be exhausted upon the second level of appeal determination. Provider
submitting a request for a second level appeal should send the request to the address referenced
above.
Claim Appeal Request Form
(One claim appeal per form)
Fax: 252-451-2290
30
Claim appeals may be filed with OptiCare in order to challenge any adverse determination. Appeals must be filed
within plan specific days. For all claim appeals, please PRINT OR TYPE this form in full; attach the appropriate
documents and mail to:
Attn: Appeals Department
P.O. Box 7548
Today’s Date: _________________________
Provider Name: ________________________________
Practice Name__________________________________
Claim Information:
Patient ID Number: _________________________ Date of Service: ________________
Patient Name: _____________________________
Service(s) Provided (CPT): ________________
HealthPlan Name: __________________________ OptiCare Claim #: _________________________
Request for Review: Indicate the reason(s) this claim should be reconsidered.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________
____________________________________________________________________________________
The below attachments are required, if applicable:
1. Claim specific correspondence from OptiCare (authorizations, referrals, Primary EOB, etc).
2. Documentation supporting the appealed claim (operative reports, medical records, chart notes, etc).
3. A copy of the CMS Form 1500 listing the appealed claim.
4. A copy of the OptiCare EOB in which this claim is listed.
For OptiCare Use Only:
Committee Date: _________________________________ Claim forwarded for Entry:________________
Committee Decision: ______________________________ Adjusted Claim #: ________________________
Fax: 252-451-2290
31
Section VI: Quality Management
Quality Management Program Overview
OptiCare Managed Vision (OptiCare) has a Quality Management Program designed to
objectively and systematically monitor and evaluate the quality of clinical care and the quality of
service.
Quality deficiencies, individual concerns, and patient safety issues are identified and monitored
through regularly scheduled evaluations conducted by the Quality Management (QM)
Department. These include:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Concerns, complaints and grievances of patients, providers, and/or full-service HMO’s.
Delegating payor input (solicited and unsolicited).
High-risk care and service evaluation (e.g. diabetic studies).
High volume care and service evaluation.
Internal audits for Claim, Credentialing, Customer Relations, Network Development,
and UM departments.
Monitoring of established practice guidelines through review of medical records and
utilization indicators (as applicable).
Member satisfaction surveys (quarterly).
Member service evaluations.
Member access evaluations (geographical and appointment time reviewed annually).
Member input (solicited and unsolicited).
Payor satisfaction surveys (annually).
Provider inquiries (inside and outside of panel, solicited and unsolicited).
Provider office procedure review.
Provider satisfaction surveys (annually).
Re-credentialing.
Retrospective chart review (as applicable).
Site visits (where applicable).
Provider profiling
Telephone abandonment rates and delay to answer Statistics (monthly)
Utilization data evaluation (over- and under-utilization)
OptiCare develops performance thresholds and benchmarks for some or all of these indicators,
based on current practice standards and scientific studies. The QM Department develops,
monitors, and carries out these evaluations with the assistance of the Credentialing, Customer
Relations, IS, Medical Management, Operations, Provider Relations, and Utilization
Management departments.
If a quality issue is identified, OptiCare will conduct an investigation. Providers in question
have the right to see all documents related to the case and the right to respond to all of the issues
and have their responses recorded. Providers may appeal decisions pertaining to their cases, and
have their case reviewed by a Peer Review Committee.
Fax: 252-451-2945
1
Provider Complaint/Grievance Process
OptiCare will make every effort to resolve all complaints as soon as possible with minimal
discord in accordance with state regulations and client contracts. OptiCare maintains an internal
system for identifying and promptly resolving both oral and written provider complaints. When
a complaint is received by Opticare from a provider or his/her designated representative, the
following process will be utilized. This includes a process for providers to appeal complaint
determinations.
1. OptiCare receives an oral or written complaint from a provider or his/her designated
representative. (If the complaint refers to an adverse determination, please refer to the UR
Appeals Process in Section 4 of this Guide. If it refers to a claim issue, please refer to the
Claim Appeal/Grievance Process in Section 5 of this Guide).
2. Any written or oral complaints, concerns, or issues will be logged into Task Manager on
the date received for quality and tracking purposes. The initial complaint as well as any
and all subsequent communications will be thoroughly documented in Task Manager,
including the substance of the complaint and action(s) taken. A complaint is defined as
any dissatisfaction expressed orally or in writing regarding any aspect of OptiCare’s
operation. A complaint is not a misunderstanding or misinformation that is promptly
resolved by providing the appropriate information or clarifying and resolving the
misunderstanding.
3. Customer Relations (CR), Utilization Management (UM), or Quality Management (QM)
personnel will make their best effort to resolve the complaint to the satisfaction of all
parties. Best attempts to resolve the complaint should be accomplished within the initial
call or within twenty four (24) hours. If the complaint is resolved at this juncture, the
appropriate staff will update Task Manager with the resolution notes and mark the issue
resolved. The complaint acknowledgement/resolution letter will be sent by the QM
specialist within five business days of receipt of the complaint. If the complaint cannot be
resolved within five (5) business days, a complaint acknowledgement letter will be sent
by the QM specialist within five (5) business days of receipt of the complaint. The letter
will include the date of receipt of the complaint and a description of the complaint
procedures and time frames. If the complaint is received verbally, a complaint form will
be attached to the letter. A verbal complaint will not be processed until the completed
complaint form is received by OptiCare.
4. If the complaint has not been resolved within twenty four (24) hours, the issue will be
forwarded to the Customer Relations (CR) department to coordinate the investigation. CR
will investigate the complaint within the applicable department (QM, UM,
Administrative, or the Medical Director) and arrive at a complaint resolution (Level I). If
the complaint is clinical in nature, at least one physician not involved in prior reviews can
be included in the investigation. This process should take no longer than 30 calendar
days (once all the necessary information is collected with which to make a decision).
Fax: 252-451-2945
2
Upon completion of the investigation, a complaint resolution letter will be mailed to the
complainant. This letter should explain the resolution of the complaint, state specific
medical (clinical) and/or contractual reasons for the resolution, the types (if any) of
physicians or other providers consulted in the decision process, and the internal process
for the appeals process and timeframes for the appeal decision.
5. If the complainant is not satisfied with the complaint resolution, he/she may request an
appeal (Level II). He/she must notify the QM department in writing of the desire to
appeal the resolution offered. OptiCare will send a complaint appeal acknowledgment
letter within five (5) business days of receipt of the notification of appeal. The complaint
appeal acknowledgment letter should acknowledge receipt of the notice of appeal and
date, provide a date and location for the hearing before the Complaint Appeals Panel, and
give the complainant the right of appearance, the right to representation, the right to
present written or oral information, the right to present expert testimony and the right to
question any personnel who were responsible for making the determination that resulted
in the appeal.
6. OptiCare will inform the complainant five (5) days prior to the hearing of the following:
documentation that will be presented at the hearing, specialty area(s) of physicians
involved (if any), and the name and job description of OptiCare representatives on the
Complaint Appeals Panel.
7. The Complaint Appeals Panel hearing will be held within 30 calendar days of receipt of
the request for the complaint appeal. Members of the panel must not have been
previously involved in the disputed resolution.
8. The complainant will be notified of the final resolution by written notification within
three (3) business days. A record of the proceedings shall be kept for a minimum of six
(6) years or as required by state or federal law.
9. If the provider is not satisfied with the resolution(s) of the above listed Complaint Appeal
Panel, the matter shall be submitted to mandatory, binding arbitration (See Provider
Participation Agreement for specifics).
State specific protocols regarding provider complaints can be found in Section 2 (Plan
Specifics) of this Guide.
To initiate a written appeal or grievance, please write OptiCare at:
Standard UM Appeal - Mail to UM Coordinator at OptiCare, 112 Zebulon Court,
Rocky Mount, NC 27804 or Fax to: 252-451-2133
Standard Claims Appeal - Mail to Claim Department at OptiCare, 112 Zebulon Court,
Rocky Mount, NC 27804.
Fax: 252-451-2945
3
Grievance Issues - Mail to Provider Relations regarding contracting and credentialing
issues or Quality Management for issues pertaining to quality of care. Please mail your letter to
the same address as noted above, noting the specific department. Providers may also contact
OptiCare directly at 1-800-840-7032 to report a concern or grievance
Fax: 252-451-2945
4
Section VII: Administrative Information
Provider Credentialing & Recredentialing
To be eligible to become a member of the OptiCare Managed Vision, (OptiCare) Provider
network, a Provider must:
•
Have a state specific Medicaid identification number prior to being credentialed as an
OptiCare participating provider. If you do not have currently your state specific Medicaid
Provider identification number, you may visit the appropriate state Medicaid website for
enrollment information.
•
Be currently licensed to practice their profession in a state within the service area of the
plan. To participate with OptiCare’s medical/surgical panels, Providers must hold a State
therapeutic pharmaceutical agent certification and DEA Certification, if applicable.
•
Have an office in or immediately adjacent to the service area of the plan.
•
Maintain professional liability coverage in the amount required, as stipulated by the
Credentialing Committee Standard Operating Procedures and as required by governing
laws. Currently, the standard minimum liability insurance limits of $1 million per
occurrence and $3 million aggregate are required, unless State minimums are enforced.
•
Agree to meet the standards of care and service as specified by the appropriate quality
committees of OptiCare.
•
Not have any unresolved disciplinary reviews or losses of privileges related to his/her
licensure. Resolved disciplinary reviews or losses of privileges will be assessed by the
Credentialing Committee after reports from the Credentialing Department have been
reviewed from the National Practitioners’ Data Bank, HealthCare Integrated Practitioner
Data Bank, State licensing records or other appropriate sources.
•
Be subject to Agreement with the specific Plan/Full-Service carrier.
To apply for membership in the OptiCare panel, Providers submit a completed Panel
Participation Request Form (this form follows in this Section) to the OptiCare Network
Development Department.
Afterwards, a completed Credentialing Application must be
submitted via the Council for Affordable Quality Health Care’s (CAQH) Universal Credentialing
Datasource to the OptiCare Credentialing Department, along with copies of required
documentation as stated in the application.
OptiCare reviews the application and verifies a Provider's credentials. When the applicant’s file
is complete and OptiCare receives all of the necessary documentation, the credentials are
presented at the next Credentialing Committee Meeting for a decision.
Fax: 252-451-2945
1
Special Notes
1. A Provider, at the time of credentialing or recredentialing, has the right to review information
submitted in support of his or her credentialing process. Information in support of a
Provider’s credentialing application includes, but is not limited to, primary outside sources
such as liability insurance carriers.
2. Each Provider has the right to correct erroneous information submitted by another party,
including primary and secondary information, or to correct information he or she submitted
incorrectly under OptiCare’s credentialing process.
3. Please contact OptiCare’s Credentialing Department at (888) 361-9825 if you wish to initiate
a review or to correct information pertaining to your credentialing file.
4. Each Provider has the right to be informed, upon request, of the status of their credentialing
or recredentialing application.
All Providers are currently recredentialed every three years.
Provider Performance Standards
Active panel membership with OptiCare depends upon maintaining high standards of patient
care, well-documented, legible records and a state-of-the-art routine and/or medical eye care
delivery facility. The Provider should have the ability to ensure patient satisfaction without
generating complaints and avoid over-utilization, unbundling, or upcoding of procedures.
Provider performance is continually monitored through ongoing quality assessment, physician
profiling and utilization review.
If patient satisfaction surveys, and chart audit, if applicable, results, or utilization study results
reveal negative deviations from established norms or quality standards, the Provider may be
placed on review status, sanctioned or terminated, depending on the significance of the
deviation. If OptiCare determines that there is a possibility of a health risk to a plan member, the
Plan has the undisputed right to place the participation privileges of the Provider’s office
involved on a “temporary” suspension status while the appropriate OptiCare personnel collect
additional information. Quality of patient care issues are referred to the Peer Review
Committee.
Inability to meet established quality standards of care or service, to achieve cost norms, or to
satisfy members within 30 days of notification may result in the termination of membership in
the Provider panel.
Fax: 252-451-2945
2
Access to Care Standards
The following Access to Care Standards have been established for optometrists and
ophthalmologists by OptiCare’s Quality Management Committee:
1. Waiting time for appointment (number of days):
(A) Regular
Routine Eye Examination
Within two (2) weeks
Sub-Acute Problem (of short duration) Within two (2) weeks
Chronic Problem (needs long time for Within four (4) weeks
consultation)
(or as referenced in the Plan
Specifics in Section II)
(B) Urgent
Not life-threatening, but a problem Within the same office day
needing care within 24 hours
2. Time in waiting room (minutes):
(A) Scheduled
after 30 minutes, patient
must be given an update on
waiting time with an option
of waiting or rescheduling
appointment;
maximum
waiting time = 60 minutes
after 45 minutes, patient
must be given an update on
waiting time with an option
of waiting or rescheduling;
maximum waiting time = 90
minutes
(B) Work-ins
(called that day prior to coming)
3. Response time returning call after-hours (minutes):
(A) Urgent
20 minutes
(B) Other
One (1) hour or next working
day based on circumstances
4. Office hours:
(A) Daytime
hours/week
15 hours/week minimum
covering at least four (4)
days
Fax: 252-451-2945
3
Access to Care Standards Continued
5. Availability of Office hours:
(A) Daytime
hours/week
(B) Night
hours/weekend
40 hours/week
24 hour/day coverage of
some sort (should be
medical/surgical
only
stipulation)
Notify OptiCare if…
As a member of the OptiCare Provider network, you are required to notify OptiCare when any of
the following occur:
•
You add or delete practitioners in your office. Generally all vision care practitioners in
any one office must be members of the OptiCare network. If you add an associate,
please make sure he or she completes and submits an application for inclusion in the
OptiCare network. OptiCare requires you to have a state specific Medicaid
identification number prior to your becoming credentialed as an OptiCare
participating Provider.
•
You move your office location. Please send OptiCare a change of address notice so that
our records can be kept up to date, you continue to receive payments promptly, and our
Provider databases are accurate. The OptiCare Claims Department must enter your
new location before claims can be adjudicated for payment.
•
You add or open a second office. Complete and send a Provider Address Information
Form if you begin to practice in more than one location. A sample Provider Address
Information Form appears on the following page. To request additional forms, contact
Customer Relations at (800) 840-7032. The OptiCare Claims Department must
enter your new location before claims can be adjudicated for payment.
•
Your business name and/or Tax ID number changes. The OptiCare Medical
Management Department must update your Provider(s)’s records to reflect your
updated tax information.
OptiCare must receive all applicable changes 30 days in advance of the change's effective
date.
Fax: 252-451-2945
4
Reporting Fraud and Abuse:
Providers and recipients may report potential or suspected cases of fraud and abuse to OptiCare
Managed Vision by calling the National Provider Relations toll-free number at 1-800-840-7032.
OptiCare in conjunction with the health plan will report this information to the appropriate State
Medicaid Fraud Division/Unit.
Fax: 252-451-2945
5
Copy of Panel Participation Request Form
Fax: 252-451-2945
6
Copy of Office Address Information Form
Fax: 252-451-2945
7
Copy of Office Address Information Form Page 2
Fax: 252-451-2945
8
Discounts on Prescription Eye Wear
Providers under contract with OptiCare to provide a prescription eyewear discount from their
usual and customary pricing are required to:
1. Provide the discount, as designated on the applicable Fee Schedule on any
prescription eyewear purchased by an eligible member during his or her covered
benefit period. There should not be a limit to the number of purchases made by the
member when utilizing their eyewear discount.
2. Honor hardware discounts for a prescription written by another participating eye care
Provider.
3. Not apply eyewear discounts on Provider eyewear sales or promotional items if
applicable. See Plan Specifics in Section II.
4. Not apply discounts on prescription eyewear related to disposable contact lenses if
applicable. See Plan Specifics in Section II.
OptiCare Standard Provider Research Procedures
Providers, members and anyone within the managed care organization that has cause can initiate
a research request. Request for research is generated as a result of a payment or non-payment of
a claim. The function begins with the request and ends with the response going back to the
requestor.
Process:
Requests for research should be sent directly to OptiCare’s Customer Relations Department in
evaluating an issue, to that individual’s attention.
Upon receipt of claim information to be researched via fax or mail, the information is logged into
OptiCare’s system. Research will be completed within five business days. Each claim is
individually reviewed, and the research results of each claim are documented on a spreadsheet.
The OptiCare representative in receipt of the original request for research will follow up with the
Provider/office for review of the research results.
Fax: 252-451-2945
9
Copy of Appeal Form
within plan specific days. Please consult your Office Staff Guide (Section 6). For all claim appeals, please PRINT
OR TYPE this form in full; attach the appropriate documents and mail to:
P.O. Box 7548
Today’s Date: _________________________
Provider Name: ________________________________
Practice Name__________________________________
Claim Information:
Patient Name: _____________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________
____________________________________________________________________________________
3. A copy of the CMS Form 1500 listing the appealed claim.
4. A copy of the OPTICARE EOB in which this claim is listed.
Fax: 252-451-2945
10
Member Complaints
Respond Promptly to Member Complaints
Occasionally Providers may be asked to review a member complaint and respond to the
problem. In complying with your Provider Participation Agreement (PPA), we ask that
you place a high priority on reviewing and responding to requests for comments in these
cases. Promptness is the most effective method of minimizing dissatisfaction and
preventing more complex problems.
Cultural Competency Program
OptiCare Managed Vision, (OptiCare) commits to arranging quality eye care services to
all members regardless of age, gender, ethnicity, socioeconomic status, or sexual
orientation. OptiCare provides cultural diversity and sensitivity educational information
to panel Providers and their staffs to foster equitable treatment of all members.
OptiCare employs bilingual Customer Relations Representatives to handle Spanish
members in addition to contracting with AT&T language line for members speaking
other languages. The following information represents the cultural diversity and
sensitivity concepts presented to Providers.
Cultural Competency Information
Culture within a Culture
Keep in mind…
1. “Family” has many definitions. Definitions depend on individual experiences and ethnic
backgrounds.
2. Parenting styles differ across cultures. Discipline and expressions of affection vary
within different family structures.
3. The importance of the family as a source of support and encouragement during health
education.
4. Children may experience different roles and expectations as a part of growing male or
female in their families, their culture, and the larger culture in which they interact.
Cultural background can affect the perception and experience of being male or female.
5. Families may experience intergenerational stress and value conflicts among members if
grandparents, parents, and children are integrating into mainstream society at different
levels.
6. Encourage communication to help overcome barriers whether those barriers include
language variances, attitudinal barriers, transportation, etc.
Fax: 252-451-2945
11
7. Support active involvement of the family as the primary values educators of their
children.
Triple Discrimination
In our society people who are low-income, of minority status, and labeled as having a
disability are often at a disadvantage within the health care delivery system. It has been
suggested that when these elements intersect, families and people with disabilities are
more vulnerable to discrimination.
Disability has existed since the beginning of time. The ways in which people with
disabilities have been treated and represented, for example, in art and media varies
dramatically throughout history and among different cultures. Disabled people have been
revered or ascribed with superhuman characteristics in some cases and disparaged,
tortured, and even systematically murdered in others. People with disabilities also have a
long history of attempting to better their situation through self-advocacy and selfdetermination.
Ethnicity
Though there are many aspects that shape a person, ethnicity has a major influence on
how a child understands him/herself. Often it is the cultural patterns that a child learns
from his/her family that form his/her view of many things including disability.
How disability is constructed within a specific culture plays a key role in understanding
the meaning of disability for that person or family. The cultural context within which
disability is perceived is important in knowing the kinds of services to be provided to
families and people with disabilities. This notion brings up the question of how a label is
defined and to who is it important. What is imposed on a family or person may be treated
very differently within their cultural context. This difference is not only true in relation
to labels but also in relation to parenting practices within a family.
One African-American mother may talk about sending her child to her mother in the
south when she felt she needed a break. What she perceived as good parenting and love,
workers entering her home see as her inability to care for her child.
When the perceived difference is seen as a deficit that needs to be worked on, people
often experience a cadre of workers involved in their lives, and a new specialist for each
difference identified. A number of additional conflicts emerge when services are
provided based on values of the dominant culture. Often support agencies are located
outside of a community and transportation becomes a problem. This development, in
addition to a lack of trust in the system outside of their culture, often leads to people
being labeled as unconcerned, non-compliant or uncaring about their children. It is clear
Fax: 252-451-2945
12
that to some families the issue of disability is secondary to health issues or day to day
getting by based on the overall needs of the family or person.
Culture of the Child
America is very health-conscious. More than 11 percent (11%) of the gross national
product is spent on health. Yet many of America's children suffer from health problems
related to poverty. One out of five children under six live in poverty, and their health
status is worse than that of non-poor children.
Children in poverty experience more of many types of health problems than do children
in families with more adequate incomes. A particular problem's incidence, prevalence, or
severity may be higher among low-income children. Rates of infant mortality (under age
one) and overall childhood mortality are higher among low-income children, and certain
causes of death are higher: sudden infant death syndrome (SIDS), unintended injuries,
child abuse, and infectious diseases including AIDS.
Rates of morbidity are also higher. Conditions that the low-income suffer
disproportionately include low birth weight, HIV infection, asthma, dental decay,
measles, nutritional problems, lead poisoning, learning disabilities, unintentional injuries,
and child abuse and neglect. Low-income infants and children have higher rates of
hospitalization, and their health status as reported by their parents is lower than that of
the non-poor.
For some low-income children, unstable or dangerous physical environments compound
the difficulties created by their economic circumstances. These environments include
children without permanent homes because low-cost housing is unavailable; children
whose parents are migrants; and children who are in foster care. Some Native American
children and children who live in rural areas or central-city urban areas also experience
special health problems.
Impact of Poverty on Health
The reasons for higher rates of health problems among low-income infants and children
are complex and difficult to analyze. A family's low-income, relative to its size, is
associated with several demographic and psychological factors that may lead to poor
health--independent of the receipt of personal health services. These factors include less
than a high school education, limited English proficiency, single-parent household,
teenage motherhood, and feelings of stress and depression. Poverty also makes it
difficult to purchase some of the commodities conducive to good health. These
commodities include adequate housing, nutritious food, transportation, drugs, medical
Fax: 252-451-2945
13
equipment, and safety devices. In addition, low-income families frequently have little
time available for health-promoting activities.
For economic, educational, and other reasons, low-income families are less likely to have
healthy life-styles or to engage in health-promoting behaviors. Finally, low-income
families may seem unmotivated to seek personal health services when the problem is
actually lack of information, ability to communicate, fear, or different priorities regarding
the use of time and money. When financial barriers are removed, the care-seeking
behavior of many of the poor closely resembles that of the non-poor.
The Personal Health Care Patterns of Families in Poverty
Even though many of the health problems experienced by low-income children are the
direct or indirect consequences of poverty and related factors, health-related services can
play an important role in preventing and ameliorating these problems. Low-income
families have different patterns of health service utilization than do non-poor families,
but these differences may be largely a function of financial constraints.
Low-income families participate less in activities that reduce injuries and poisonings.
Low-income women are more likely to have unwanted or mistimed births, and they are
less likely to use contraceptives. Low-income pregnant women are less likely to begin
prenatal care in the first trimester and more likely to receive no care at all.
The number of physician visits per year is lower for low-income children than non-poor
children. The source of medical care also differs, with non-poor children less likely to be
seen in a physician's office and more likely to be seen in an emergency room, a clinic, or
a hospital outpatient department. Children of color are less likely to be fully immunized
than white children.
1. All staff and subcontractors should have a baseline knowledge for:
• Ensuring effective communication through the provision of linguistic services
following Title VI of the Civil Rights Act guidelines; and
• Ensuring the provision of auxiliary aids and services, in compliance with the
Americans with Disabilities Act, Title III, Department of Justice Regulation 36.303.
2. In general, the Americans with Disabilities Act requires a public accommodation to take
such steps as may be necessary to ensure that no individual with a disability is excluded,
denied services, segregated or otherwise treated differently than other individuals
because of the absence of auxiliary aids and services, unless the public accommodation
can demonstrate that taking such steps would fundamentally alter then nature of the
goods, services, facilities, advantages, or accommodations being offered or would result
in undue burden. Auxiliary aids may include, offering materials in alternative formats
Fax: 252-451-2945
14
(i.e. large print, tape or Braille), and interpreters or real-time captioning to accommodate
the needs of persons with disabilities that affect communication.
3. Staff and subcontractors will be educated about the regulations during their regular
training related to the Cultural Competency Plan. Refresher training will also be offered
periodically.
Both Acts may be reviewed on the Internet. Title VI of the American Civil Rights Act can
be found at www.access.gpo.gov/nara/cfr/waisidx_99/34cfr100_99.html. Americans with
Disabilities Act, Title III, is located at www.usdoj.gov/crt/ada/adahom1.html. Americans
with Disabilities Act, Title III, is located at www.usdoj.gov/crt/ada/adahom1.html.
Notice of Privacy Practices
OptiCare Managed Vision (OptiCare) takes seriously the privacy interests of our membership, as
we know you do. As an eye health managed care organization, we want you to understand how
we protect members’ confidential information.
We protect all confidential information we have about our members and disclose only the
information that is legally and contractually appropriate. Our membership has the right to expect
its legally protected privacy interests will be respected and protected by OptiCare.
Our Member Confidentiality Policy is intended to comply with applicable state and federal laws
and regulations, and the accreditation standards of the National Committee for Quality
Assurance. If these requirements and standards change, we will review and revise our policy. We
also may change our policy (as allowed by law) as necessary to better serve our membership.
To make sure that our policy is effective, we have designated a Corporate Compliance Officer
who is charged with approving and reviewing OptiCare’s privacy and confidentiality standard
operations procedures. This officer is responsible for the oversight, implementation, and
monitoring of our policy.
OptiCare’s Core Privacy Principles:
•
We will protect Member confidential information and will not disclose any personal
information to any external party except as we describe in our policy or as permitted or
required by law or regulation.
•
Members have a right to request restrictions in writing on the uses and disclosures of
their confidential member information. However, OptiCare is not required to agree with a
requested restriction.
•
Each of our employees must sign a confidentiality statement when they begin
employment with us, asserting they will abide by our policy. Only employees who have
Fax: 252-451-2945
15
legitimate business needs to use Member confidential information will have access to
such information.
•
When we use outside parties to perform work for us, we require these contractors to sign
their own confidentiality agreements, stating they will protect member confidential
information.
•
We also require the same kind of confidentiality agreement with our contracted
Providers.
•
We disclose member confidential information only where: required or permitted by law;
or we obtain a separate authorization from the Member for specific purposes. All
disclosures we make are permitted or required by law. These disclosures include those
for health care treatment and payment, our company’s health care operations, various
areas where the Member’s consent is not needed for certain public purposes (such as
public health emergencies), and certain other health care purposes such as coordination
of medical care, quality assessment and measurement, and accreditation. In a limited
number of situations beyond these areas, we will seek a Member’s separate authorization
for a specific purpose.
•
Members have the right to review certain records held in our possession. If Members
wish to review records containing confidential information about them from the previous
six years, they must submit a written request for copies of the information (we may
charge a fee to obtain these copies).
•
Members have the right to request an amendment to their confidential information. Such
requests must be made in writing.
•
If members have questions or concerns about the accuracy or completeness of
information we have about them, Members should contact us in writing to tell us about
their concerns. We will make the appropriate changes, as may be required by law. If a
Provider or someone other than us created the information, then we will direct the
Member to that person to make the corrections.
•
Prior to responding to a phone request for Member confidential information, the caller
will be asked to provide identifying information to reduce the possibility of a disclosure
of Member confidential information to an unauthorized individual.
•
Individuals seeking Member confidential information will be required to submit Consent
for Release of Medical Information form signed by the Member or his/her
parent/guardian.
Fax: 252-451-2945
16
•
A person who believes OptiCare is not complying with these requirements may file a
complaint with the OptiCare Corporate Compliance Officer, in accordance with the
following protocol:
1. A complaint must be filed in writing, either on paper or electronically.
2. A complaint must name the entity that is the subject of the complaint and describe
what is believed to be the violation.
3. A complaint must be filed within 180 days of when the complainant knew or
should have known that the act or omission complained of occurred, unless the
HHS Secretary, for good cause shown, waives this time limit.
4. OptiCare Corporate Compliance Officer may be contacted at the following
address:
Corporate Compliance Officer
P.O. Box 7548
112 Zebulon Court
Rocky Mount NC 27804
•
A person who believes OptiCare is not complying with these requirements may file a
complaint with the HHS Secretary, in accordance with the following protocol:
1. A complaint must be filed in writing, either on paper or electronically.
2. A complaint must name the entity that is the subject of the complaint and describe
what is believed to be the violation.
3. A complaint must be filed within 180 days of when the complainant knew or
should have known that the act or omission complained of occurred, unless the
HHS Secretary, for good cause shown, waives this time limit.
4. HHS Secretary may be contacted at the following address and phone number:
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775
Providers are welcome to view any of OptiCare’s policies on administering privacy and security
practices. For further information, call Provider Relations at 800-840-7032.
Fax: 252-451-2945
17
Section VIII: Glossary of Terms
ADJUDICATE: The processing and finalization of a claim, which results in payment, denial or
deferral.
ADJUSTMENT: The process of reopening a processed claim for re-adjudication.
ALLOWABLE CHARGE: The Usual, Customary, and Reasonable (UCR) fee the Plan will
pay for a particular procedure.
APPEAL: The process of disagreement about a Plan decision, usually related to denial of
authorizations or claims, or claims payment
AUTHORIZATION: The approval in advance to a provider for services to be delivered to a
member and paid to the provider at the negotiated fee.
CAPITATION: A payment method by which providers are paid a flat rate in advance for a
predetermined set of services, for a given number of members of a Plan.
CLAIM (HCFA 1500 Form): The standard form the provider submits to the Plan for
reimbursement of services rendered to a covered member.
CONCURRENT REVIEW: Utilization review of inpatient services and patient medical
condition to ensure that patients continue to meet criteria for a continued stay.
COORDINATION OF BENEFITS: The process of coordinating payable benefits when a
member is covered by two or more benefit plans.
COPAYMENT: Charges or fees which patients pay directly to the provider for covered
services. The Schedule of Copayments is contained in the Fee Schedule.
COSMETIC SERVICES: Services not deemed medically necessary.
COVERED SERVICES: Those benefits, services, and hardware for which the Plan must pay.
CREDENTIALING: The process of reviewing the education, training, background and
experience of a provider who seeks to contract with the Plan.
CREDENTIALING APPLICATION: The formal document provider completes when seeking
to contract with the Plan, and which the Plan uses as the foundation for approving or rejecting
credentialing.
CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES: A listing of descriptive
terms and identifying codes for reporting health care services and procedures rendered by
providers.
Fax: 252-451-2945
1
DEFERRED CLAIM: A claim the Plan is unable to process for payment due to incomplete or
inaccurate information submitted.
DEPENDENT: A member of a subscriber’s family who is eligible for coverage, who is enrolled
in the Plan and for whom the premium has been paid.
DIAGNOSIS CODES (ICD-9): The International Classification of Diseases which lists
diagnoses and assigns identifying codes for provider reporting use.
DIRECT REIMBURSEMENT: Payment to the member from the Plan for covered services
rendered and previously paid for by the member.
DISENROLLMENT: The process of ending membership in the Plan.
EFFECTIVE DATE: The date shown in the Plan’s records on which coverage begins for
members.
EMERGENCY SERVICES: Emergency health care services are covered inpatient and
outpatient services which are furnished inside or outside the service area and 1) are needed
immediately because of an injury or sudden illness, 2) are needed because the time required to
reach Plan providers (or providers authorized by the Plan) would have meant risk of permanent
damage to the member’s health.
EXCLUSION: Items or services that are not covered under this contract.
EXPLANATION OF BENEFIT (EOB): A document that accompanies payment to a provider
that explains the payments made for covered services included in that check.
HCFA 1500: The standard form providers submit to the Plan for payment of services provided
to a member.
IN-NETWORK: Refers to providers who have contracts with the Plan.
MAXIMUM ALLOWABLE CHARGE: An amount established by the Plan as the maximum
amount payable for particular covered services.
MEDICAL DIRECTOR: A duly licensed physician or designee who is employed by the Plan
to monitor the quality and delivery of health care to members in accordance with the Plan
contract and the accepted medical standards of this community.
MEDICALLY NECESSARY: The use of services or supplies as provided by a Plan provider
to identify or treat illness or injury and which, as determined by the provider and the Plan, are:
Fax: 252-451-2945
2
(1) consistent with the symptoms, diagnosis and treatment of the member’s condition, disease,
ailment or injury; (2) in accordance with recognized standards of care for the member’s disease,
ailment or injury; (3) appropriate with regard to standards of good medical clinical practice; (4)
not solely for the convenience of members or providers; and (5) the most appropriate supply or
level of service which can be safely provided. When specifically applied to an inpatient, it
further means that the member’s medical symptoms or condition requires that the diagnosis,
treatment or service cannot be safely provided as an outpatient.
MEDICARE: The federal government health insurance program established by Title XVIII of
the Social Security Act.
MEMBER: A subscriber and or eligible dependent who is eligible for and enrolled in the Plan,
and for whom all appropriate premiums have been paid.
PARTICIPATING PROVIDER OR CONTRACTING PROVIDER: A physician, hospital,
or other facility, or any other duly licensed institution or health professional under contract to
provide professional services to members. A list of Plan providers and their locations is available
to each subscriber upon enrollment.
PRE-AUTHORIZATION: A system whereby a provider must receive approval from the Plan
before the member can receive certain health care services.
PRE-ADMISSION CERTIFICATION: The written prior authorization by the Plan and
administrators or the facility to be used for services.
PREMIUM: The money prepaid to the Plan by the Subscribing Group.
PCP/PRIMARY MEDICAL DOCTOR: The HMO physician responsible for providing or
authorizing the health services covered under the HMO contract.
REFERRAL: The occasion when a provider directs a member to seek or obtain covered
services from another provider in accordance with the policies and procedures of the Plan.
RETROSPECTIVE REVIEW: The review of the member’s medical records and other
supporting documentation by the Plan after services have been rendered to determine the Plan’s
liability for payment.
SUBSCRIBER: An eligible person whose Enrollment Application is accepted by the Plan and
for whom the premium is paid, and who is the policyholder.
URGENT CARE: Services provided for a condition that occurs suddenly and unexpectedly,
requiring prompt diagnosis or treatment, such that in the absence of immediate care, the
individual could reasonably be expected to suffer an extended illness, or prolonged impairment.
Fax: 252-451-2945
3
UTILIZATION REVIEW: A system that reviews the necessity and appropriateness of covered
services provided or available to members.
VISION HARDWARE: Eyeglasses or contact lenses.
Fax: 252-451-2945
4
Section IX: Forms
Web Security Letter
Provider Affairs
P.O. Box 7548
Rocky Mount, NC
Dear Provider Affairs,
Please accept this letter as a request to set up an account to access the secure areas of the OptiCare Managed Vision
(OptiCare) web site at www.opticare.com. This access is only available to providers currently contracted with
OptiCare.
I hereby attest that the information given in this letter of application is accurate and complete. By signing this
document I fully understand and agree to the following terms and conditions:
1.
2.
3.
4.
5.
6.
7.
8.
It is my responsibility to ensure that the security code provided to me by OptiCare to gain access to confidential
information maintained on OptiCare’s web site will be maintained in confidence and only used by me and/or by
my employed staff.
In the event my provider security code is compromised in any way, I will immediately notify OptiCare’s
Provider Relations Department to report such incident and to request a new security code.
I acknowledge that OptiCare’s provider security access code can only be communicated in writing and sent by
first-class mail to my designated primary office location.
My provider security access code to OptiCare’s website can be terminated at any time without notice at the sole
discretion of OptiCare.
Unauthorized use of my provider security code may be grounds for provider termination from OptiCare.
All information on this form will be verified and must match the information on the provider’s credentialing
application that OptiCare has on file.
If any provider that shares the same tax ID number or any staff member in my office that accesses the web site
terminates employment, it is my responsibility to notify OptiCare’s Provider Relations Department of this
termination so that a new security code can be issued for the office.
Should my contract terminate with OptiCare, I acknowledge that my access to the web site will be terminated
the date my contract termination becomes effective.
Signature:
________________________________________________ Date Signed:
______________
Full Name:
(Print)
Office Addr.:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Tax ID No.:
___________________________
Office Ph. No.:
___________________________
Office Fax No.:
____________________________
Office Email address:___________________________________________________
(needed for system announcements)
Please be sure that all providers in your practice have signed and completed a form before returning this letter to the
above address.
APPROVED
OR DENIED
PA Name
PA Date
MIS Date
User ID
Password
Fax: 252-451-2805
1
Section IX: Forms
PROVIDER NAME: _______________________PROVIDER ID# ____________
PROVIDER ADDRESS: _______________________________________________
_____________________________________________________________________
PROVIDER PHONE: (____) ___________PROVIDER FAX: (____) __________
NAME OF ADDRESSEE: ______________________________________________
ADDRESS TO WHICH CLAIMS WERE MAILED:
_____________________________________________________________________
_____________________________________________________________________
MEMBER
MEMBER ID#
1-_____________________ ___________________
DOS
_______________________
2-_____________________ ___________________
_______________________
3-_____________________ ___________________
_______________________
4-_____________________ ___________________
_______________________
5-_____________________ ___________________
_______________________
6-_____________________ ___________________
_______________________
7-_____________________ ___________________
_______________________
8-_____________________
___________________ _______________________
9-_____________________
___________________ _______________________
10-____________________
___________________ _______________________
11-____________________
___________________ _______________________
12-____________________
___________________
_______________________
FAXED TO: ____________________________________
OptiCare Claim Representative: ____________________DATE: _______________
Faxed:
Fax: 252-451-2805
2
Section IX: Forms
Claims Status Check Form
Fax: 252-451-2805
3
Section IX: Forms
Claims Appeal Form
within plan specific days. Please consult your Office Staff Guide (Section 6). For all claim appeals, please PRINT
OR TYPE this form in full; attach the appropriate documents and mail to:
P.O. Box 7548
Today’s Date: _________________________
Provider Name: ________________________________
Practice Name__________________________________
Claim Information:
Patient Name: _____________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________
____________________________________________________________________________________
3. A copy of the HCFA Form 1500 listing the appealed claim.
4. A copy of the OptiCare EOB in which this claim is listed.
Fax: 252-451-2805
4
Section IX: Forms
Medical Pre-certification Request
Fax (252) 451-2133 Phone Toll Free (800) 465-6972
Date
Office Contact
Referring Physician
_________EMERGENT
_________URGENT
_________ROUTINE
Fax
Phone
Prov ID
Referred to Physician
Co-Management: Please specify Co-managing Provider__________________________________________________
Patient Name (Last)
(First)
(Middle)
DOB
ID #
HMO (Plan)
Group #
Other Insurer (if any)
Date of Surgery
Date of Admit
IP/OP (Circle One) Anticipated LOS
_______
Facility Name & Address
Diagnosis : (must be provided)-
Procedure:(must be provided)
ICD 9
Description
CPT
Description____________________ OU OD OS
ICD 9
Description_______________ CPT___________ Description_____________________ OU OD OS
ICD-9
Description_______________ CPT___________ Description_____________________ OU OD OS
PCP Referral Number: ___________________ Effective date ________________ Expiration date_____________________
Medical Reason for Request_______________________________________________________________________________
Attach additional pages if necessary
Patient’s Subjective Complaint: ____________________________________________________________________________
Patient’s BCVA: OD___________________________
OS____________________________________________________
Signature of Attending Physician: ________________________________
Date___________________________
Office Location: _________________________________________________________________________________________
PRE CERTIFICATION/AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT. COVERED SERVICES ARE BASED ON
MEMBER ELIGILIBITY AND BENEFIT LIMITATIONS AT THE TIME SERVICE(S) ARE RENDERED.
DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY
Reviewing Physician
Denied:
Approve
Approved LOS
Rationale for Denial:
Recommendation for alternative treatment(s)
_______
Reviewing Physician Signature
Authorization #
Date
or Denial Reference #
Date
Medical Claims Administrator Signature
If Denied: Please refer to your Provider Manual or call 1-800-465-6972 to be informed of your appeal rights
Fax: 252-451-2805
5
Section IX: Forms
Notice of Facility Use
Fax To: OptiCare Managed Vision
Attention: UM Department
Fax Number: (252) 451-2133
Re: Notice of Facility
Number of Pages: _________
Facility Information
Facility Name: ______________________________________________________
Facility Location: ____________________________________________________
Date of Procedure: __________________ Diagnosis Code(s): ___________________
Primary Procedure Code: _____________ or Description: ____________________
Contact Name: ___________________________________
Contact Phone #: ________________________ Fax #: _______________________
Member Information
Member Name: __________________________________________________
Member ID: ___________________________
OptiCare Use Only
Approved: _______ Denied: ________
Date Notified: _________________
Reference Number: ________________
Person Notified:___________________
OptiCare will not approve services for ancillary providers unless the service is deemed to be medically
necessary.
Eligibility is based on current information in our system and does not guarantee claims payment. If you have any questions or concerns regarding
the information above, please contact OptiCare Managed Vision’s Utilization Management department.
The information contained in this transmission is intended only for the use of the individual or entity to whom it is addressed and may contain
information that is confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient
or the employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination
distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us
immediately by telephone and return the original message to us at the above address via the United States Postal Service. We apologize for any
inconvenience this may have caused you. Thank you.
P.O. Box 7548
Rocky Mount, North Carolina, 27804
Fax: 252-451-2805
6
Section IX: Forms
Fax: 252-451-2805
7

OptiCare - Kentucky Spirit Health

Transcription

Similar documents

- AmeriHealth Administrators

Scanned Document

SPECIALTY GLASS - OBSCURE glaztech.com - Glaz

View Full Brochure - Rocky Mount Home Builders Association

Skibox - PistenBully

PRINT the Sell Sheet PDF

Brotoloc South Brochure

Welcome To The 26th Annual - BECKLEYREGISTER

Halloween flyer

Rocky - Cafe Bernardo (20140409)