section g – use of ancillary providers

Transcription

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Care Improvement Plus
Contact Information
PROVIDER SELF-SERVICE CENTER…………………https://providerportal.careimprovementplus.com
For eligibility verification, claims status and payment information
GENERAL PROVIDER INFORMATION………………………...http://www.careimprovementplus.com/
PROVIDER RELATIONS……………………………………………………………………1-866-679-3119
Claims Questions………………………………………………………... [email protected]
Credentialing……………………………………………………….. [email protected]
Contract/Address Updates
Provider updates [email protected]
Delegated updates [email protected]
Provider Relations General requests [email protected]
ELIGIBILITY VERIFICATION………………………………………………….……….....1-866-679-3119
Secure Provider Portal………………………………..https://providerportal.careimprovementplus.com
UTILIZATION MANAGEMENT……………………….…………………………………...1-888-625-2204
For services requiring authorization or prior authorization
MEDICAL CLAIMS…………………………………………………………………………. 1-866-679-3119
Non-Par Provider Dispute Resolution……..www.careimprovementplus.com/providers/nonparpayment.aspx
EDI claims via Availity, Emdeon, or Xerox EDI Direct: Payor ID 77082
Paper Medical Claims:
P.O. Box 488
Linthicum, MD 21090-0488
Attention: Claims Department
[email protected]
Medical Claim Appeals....................................................................................................1-800-204-1002
PHARMACY BENEFITS SERVICES……………………………………………………….1-800-204-1002
Provided by OptumRx
Pharmacy Claims:
OptumRx
P.O. Box 29045
Hot Springs, AR 71903
Pharmacy Appeals……....................................................................................................1-800-204-1002
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Vision and Dental Claims…..…………………………………...........................................................................
United Healthcare Vision
1-800-638-3120
www.spectera.com
United Healthcare Dental
1-844-275-8750
UnitedHealthcare (CIP)
PO Box 2064
Milwaukee, WI 53201
www.uhcproviders.com
Mental Health Claims………………………………………………………………………….1-888-751-1235
Optum
P.O. Box 30760
Salt Lake City, UT 84130-0760
or electronically: payor ID is 87726
CASE MANAGEMENT………………………………………………………………………1-866-460-8699
TELEPHONE FOR HEARING IMPAIRED (TTY)……………………………………………………..711
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Table of Contents
SECTION A – INTRODUCTION ..................................................................................................................... 7
Welcome .................................................................................................................................................................................. 7
Overview of Care Improvement Plus ................................................................................................................................... 7
Care Improvement Plus Programs ....................................................................................................................................... 8
SECTION B – ELIGIBILITY & PLAN DESCRIPTION............................................................................ 9
Eligibility Verification Procedure ......................................................................................................................................... 9
Plan Description ..................................................................................................................................................................... 9
SECTION C – PROVIDER REQUIREMENTS .......................................................................................... 10
Standards of Care ................................................................................................................................................................. 10
Discrimination ...................................................................................................................................................................... 11
Accessibility ........................................................................................................................................................................... 11
Medical Records ................................................................................................................................................................... 11
License, Certifications and Privileges ................................................................................................................................. 11
Compliance with Medicare Requirements and Care Improvement Plus Policies and Procedures ............................... 12
Network Providers................................................................................................................................................................ 12
Pharmaceutical Prescriptions .............................................................................................................................................. 12
Advance Directives ............................................................................................................................................................... 12
Reporting and Disclosure/Encounter Data ........................................................................................................................ 12
Billing of Members ............................................................................................................................................................... 13
Annual Model of Care Training .......................................................................................................................................... 14
SECTION D – PROVIDER RIGHTS AND RESPONSIBILITIES ........................................................ 14
Primary Care Physician ....................................................................................................................................................... 14
Specialty Care Physicians .................................................................................................................................................... 15
Facility Providers.................................................................................................................................................................. 15
Ancillary Providers .............................................................................................................................................................. 15
Updates to Pertinent Information ....................................................................................................................................... 15
Appeals .................................................................................................................................................................................. 16
Member Solicitation ............................................................................................................................................................. 17
Provider Based Activities ..................................................................................................................................................... 18
Suspension or Termination of Contract ............................................................................................................................. 18
SECTION E – BILLING & CLAIMS PAYMENT ..................................................................................... 19
Billing..................................................................................................................................................................................... 19
Claims Payment .................................................................................................................................................................... 19
Dual Advantage Provider Reimbursement ........................................................................................................................ 20
Explanation of Payment ....................................................................................................................................................... 21
Provider Refunds .................................................................................................................................................................. 21
SECTION F – CREDENTIALING PROGRAM ......................................................................................... 22
Program Overview ............................................................................................................................................................... 22
Re-Credentialing .................................................................................................................................................................. 22
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SECTION G – USE OF ANCILLARY PROVIDERS ................................................................................ 22
Ancillary Services ................................................................................................................................................................. 22
SECTION H – BEHAVORIAL HEALTH SERVICES.............................................................................. 23
Program Overview ............................................................................................................................................................... 23
SECTION I – PHARMACY .............................................................................................................................. 24
List of Prescriptions/Medications ........................................................................................................................................ 24
Preauthorization ................................................................................................................................................................... 24
Exceptions ............................................................................................................................................................................. 24
Transition .............................................................................................................................................................................. 24
Five-Tier Copay Structure ................................................................................................................................................... 24
SECTION J – VISION AND DENTAL COVERAGE ................................................................................ 26
SECTION K– UTILIZATION AND CASE MANAGEMENT (UM) ..................................................... 27
Case Management ................................................................................................................................................................ 27
Chronic Care Management ................................................................................................................................................. 27
Utilization Review ................................................................................................................................................................. 27
Services Requiring Prior Authorization ............................................................................................................................. 27
SECTION L – QUALITY IMPROVEMENT (QI) ...................................................................................... 28
QI Program Overview .......................................................................................................................................................... 28
Clinical Practice Guidelines ................................................................................................................................................. 28
Preventive Services Guidelines ............................................................................................................................................ 28
Health Plan Employer Data and Information Set (HEDIS) ............................................................................................. 28
Medical Records ................................................................................................................................................................... 29
Model of Care Training ....................................................................................................................................................... 29
SECTION M – MEMBER RIGHTS AND RESPONSIBILITIES........................................................... 29
Member Rights ..................................................................................................................................................................... 29
Member Responsibilities ...................................................................................................................................................... 29
Out of Area Services ............................................................................................................................................................. 30
Primary Care Physician Selection ....................................................................................................................................... 30
Provider Terminations ......................................................................................................................................................... 30
Grievance Procedures .......................................................................................................................................................... 30
Member Appeals ................................................................................................................................................................... 30
SECTION N – ADVANCED DIRECTIVE ................................................................................................... 31
SECTION O – HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA) RESPONSIBILITIES ....................................................................................................................... 32
Privacy Rule .......................................................................................................................................................................... 32
Security Rule ......................................................................................................................................................................... 33
Breach Notification Rule ...................................................................................................................................................... 33
Transactions and Code Sets Regulations ............................................................................................................................ 34
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HIPAA Required Code Sets................................................................................................................................................. 34
SECTION P – LEGAL NOTICES ................................................................................................................... 36
Subrogation ........................................................................................................................................................................... 36
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SECTION A – INTRODUCTION
Welcome
Welcome to Care Improvement Plus! This provider manual was developed as a guide to assist you and
your office staff with providing services to our members, your patients. We are confident that this
provider manual will be an important resource for your office. The provider manual contains essential
information, and will be updated on a regular basis as policies and procedures are created and/or are
modified and placed online. We encourage you to utilize other tools and information available on our
website www.careimprovementplus.com through our provider services center, specifically designed to
make working with Care Improvement Plus easy for our providers.
Your review and understanding of the provider manual is essential. Any questions, issues, and/or
suggestions concerning the provider manual or our website are encouraged and should be directed to the
Care Improvement Plus Provider Relations department at 1-866-679-3119 or via email at
[email protected].
Once again, thank you for your participation with Care Improvement Plus.
Overview of Care Improvement Plus
Care Improvement Plus, a subsidiary of UnitedHealthcare, is an industry leader in improving the
quality of care for chronically ill and underserved Medicare beneficiaries. Using a combination of
specifically designed coverage options, benefits, services and Care Management programs, our
Medicare Advantage plans are focused on delivering quality healthcare. And our collaborative “team”
approach to healthcare works for members and healthcare providers to achieve better patient outcomes.
The Plan is available to Medicare beneficiaries who are enrolled in Medicare Part A and Medicare
Part B, who reside in our service area, and meet all other eligibility criteria.
We offer a broad range of Medicare Advantage plans including:
 Chronic Conditions Special Needs Plans for Medicare beneficiaries with diabetes and/or heart
failure
 Dual Special Needs plans for beneficiaries who receive both Medicare and full Medicaid
 Medicare Advantage Prescription Drug plans for Medicare beneficiaries who are not eligible for
our Special Needs or Dual Advantage Plans, such as caregivers or spouses of members
In addition to Hospital (Part A), Medical (Part B), and Prescription Drug (Part D) coverage, our plans
feature additional services, including:
 Open-access provider network; no referral required for Medicare-covered services. Members can
go to any Medicare-approved provider who accepts payment from the plan
 Care management support including a 24/7 nurse hotline
 Health education
 A HouseCalls program which enables members to receive a yearly in-home visit from a
physician or a nurse practitioner who will perform an annual health risk assessment and report
back to the primary care doctor
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A PharmAssist program which Members receive personalized, private counseling sessions with
specially-trained plan pharmacists.
Tools to help the member manage and monitor their care
As a sponsor of Medicare Advantage plans, Care Improvement Plus abides by all CMS requirements,
which includes ensuring that payment and incentive arrangements with providers are specified in a
contract, ensuring providers meet all the downstream Medicare Advantage and Medicare Part D
requirements, and ensuring that the plan and its providers follow all laws subject to federal funds,
including fraud, waste, abuse and anti-kickback statutes.
Secure Messaging
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic
communications that contain Protected Health Information (PHI) to be secure. To comply with this
important and practical security measure, we use ZixCorp to protect our email and ensure all PHI remains
confidential.
When a Care Improvement Plus employee sends you an email that contains PHI, ZixCorp detects the PHI
and protects the email. You will receive an email notification that you have been sent a ZixMail secure
message. The notification tells you who the secure message is from and includes a link to retrieve the
email message. The first time you use the ZixMail message service to retrieve a message, you must create
a password. Thereafter, you can use the same password each time you log into the ZixMessage Center to
retrieve an encrypted email.
Please note – ZixMail secure messages are posted and available for 30 calendar days. If the message is
not opened during that timeframe, the message is removed and the sender is notified.
If you would like more information about ZixCorp, visit their website at www.zixcorp.com.
Care Improvement Plus Programs
With every plan we offer, our members have access to special programs in which they are encouraged to
take advantage of. These personalized programs were created to serve our member’s unique needs and
are at no cost to the member.
HouseCalls
This program allows the member to receive one-on-one services without having to leave his/her home. A
physician or nurse practitioner visits the member annually and evaluates the member’s health. The
physician or nurse practitioner is also available to answer any questions the member might have. The
information collected from this visit is summarized and sent to the member’s primary care provider.
PharmAssist
A pharmacist will review member’s medications to ensure no drug interactions or side effects will occur
if taken all together. The pharmacist is also able to answer any questions the member has regarding their
prescriptions.
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My Advocate (formerly known as Social Service Coordinators)
Care Improvement Plus has partnered with My Advocate to help our members see if they qualify for
programs that they may be entitled to. These programs can include: local, state, and federal assistance
programs.
SECTION B – ELIGIBILITY & PLAN DESCRIPTION
Eligibility Verification Procedure
Members should present their Care Improvement Plus ID card (or temporary proof of coverage if they
have not yet received their ID card) upon arrival for services. If a member is enrolled in our Dual
Advantage plan, they will also need to present their State Medicaid card. Providers are encouraged to
validate the identity of the person presenting an ID card by requesting some form of photo
identification, such as a driver’s license, in addition to the ID card. Please see Appendix A for an
example of our ID cards.
Member eligibility may be confirmed by visiting the secure provider self-service center at
www.careimprovementplus.com, or by calling a provider service representative at 1-866-679-3119,
Monday through Friday from 8:00 a.m. to 8:00 p.m. EST.
The ID card does not guarantee eligibility. Member eligibility must be verified at each visit. Failure
to verify eligibility may result in delay or non-payment of claims.
Disease State Verification
Members that wish to enroll in a Care Improvement Plus Chronic Special Needs Plan must have their
disease state verified by a provider within 30 days of enrollment. A Chronic Condition Verification form
will be faxed to your office at the time of the beneficiary enrollment for your completion. See
APPENDIX G – Chronic Condition Disease State Verification Form for a sample of this form. If we
do not receive a completed form we will make an attempt to contact your office via telephone.
Secure Provider Portal
The secure provider portal serves as a resource for providers. The portal allows providers to check
member eligibility and claims status as well as other services. To access the provider portal, visit our
website at https://www.careimprovementplus.com/providers/Default.aspx.
The provider portal user guide can be found at
https://providerportal.careimprovementplus.com/pdf/CIP_Provider_Portal_User_Guide.pdf.
Plan Description
Care Improvement Plus:
 Has an open access network, which means members may use any Medicare-approved provider
that will accept payment from Care Improvement Plus, however;
o Members that use an out-of-network provider may have higher costs for covered services
o Members in our Dual Advantage plan should use a provider that accepts Medicare and
Medicaid
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Because our Plan is a Regional/Local Preferred Provider Organization, if no contracted
network provider is readily available members can access care at in-network cost-sharing
from an out-of-network provider.
o Members that use an out of network provider for home health care services, DME, dental
or vision may have additional out-of-pocket expenses

Requires preauthorization for elective inpatient hospital admissions, skilled nursing facilities,
home health services, and select DME items. Please see Appendix B for the current list of
services requiring preauthorization, or visit our website at www.careimprovementplus.com to
access the Provider Authorization Requirements fact sheet
o No preauthorization is required for emergency services. However, all inpatient admissions
require authorization.
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Does not require a qualifying three (3) day hospital stay before admission to a Skilled Nursing
Facility (as does traditional fee-for-service Medicare). This allows the physician to admit to this
level of care if that is the most appropriate care for the patient
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Covers emergency and urgently-needed services, regardless if the member is in or outside of the
plan service area (as further described in the members Evidence of Coverage)

Encourages the use of preventive services, including an annual physical exam

Offers additional benefits, such as transportation, routine vision and routine dental
services
SECTION C – PROVIDER REQUIREMENTS
Providers may include physicians, facilities, and ancillary providers that provide services to Care
Improvement Plus members. In some instances, providers may include Physician Hospital Organizations
and Independent Physician Associations who may subcontract with other Care Improvement Plus
approved Providers to render care to Care Improvement Plus members as well. In all cases, Care
Improvement Plus providers are required to acknowledge and adhere to the following:
Standards of Care

Providers are required to render medically necessary covered services to members in an
appropriate, timely, and cost effective manner and in accordance with Care Improvement Plus’s
policies and procedures, including adherence to Care Improvement Plus’s appointment wait time
standards. Refer to Appendix F for maximum expected wait times.

Providers are required to support an open communication relationship with members regarding
appropriate treatment alternatives without regard to cost or benefit coverage.
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Providers are required to accept and render service to members at the same level, scope, and
quality of care rendered to all members and other patients.
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Providers must accept responsibility for the advice and treatment given to members and for the
performance of all medical services in accordance with accepted professional standards.
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Providers must render service as applicable within the scope of their specialty.
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Providers should make a concerted effort to educate and instruct members about the proper
utilization of the practitioner’s office in lieu of hospital emergency rooms.
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Providers shall not refer or direct members to hospital emergency rooms for non-emergent
medical services at any time.
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Providers must meet all applicable requirements of the Americans with Disabilities Act (ADA),
the Civil Rights Act of 1974, the Age Discrimination Act of 1975 and any other applicable
laws or rules when rendering services to members with disabilities who may request special
accommodations such as interpreters, alternative formats, or assistance with physician
accessibility. Providers must remain professional and keep the member’s needs in mind at all
times.
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Providers shall provide services in a culturally competent manner.
Discrimination
Providers are required to refrain from discriminating against any member on any basis prohibited by law,
by the frequency or extent of services; Providers shall not discriminate because of member’s religion,
race, color, national origin, age, sex, weight, height, marital status, economic status, health status, sexual
preference, or physical handicaps as further prohibited by law. Providers are further required to refrain
from segregating a member or treating a member in a location or manner different from other members or
other patients.
Accessibility
Physician providers are required to provide or arrange for urgent care, including emergency medical
services on a 24-hour per day basis, 7 days per week. Providers are required to have an answering
service set up for after hours to meet these needs.
Medical Records
Every provider is required to create and maintain, consistent with all federal and state laws (including
Medicare Advantage and Medicare Part D laws) and standards of any organization to which the provider
is subject, a health record-keeping system through which a complete and accurate set of all pertinent
information relating to the health care of members is maintained and is readily available to persons
authorized to review these records, including Care Improvement Plus and its designee.
Providers shall maintain confidential medical records consistent with HIPAA regulations and state laws
governing the use and disclosure of Care Improvement Plus members’ information. HIPAA limits the use
and disclosure of Protected Health Information without the individual’s authorization. Providers also
must maintain and safeguard member personal health information and records (including, without
limitation, medical records), consistent with state and federal laws and other standards applicable to
Providers.
License, Certifications and Privileges
Providers are required to maintain all licenses, certifications, permits, and other prerequisites required by
law to render services pursuant to their contracts with Care Improvement Plus, and submitting evidence
that each is current and in good standing upon the request by Care Improvement Plus, including but not
limited to eligibility and participation in the Medicare Program. Providers are further required, as
applicable, to maintain staff membership and admission privileges in good standing at the network
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hospital stipulated in Provider’s credentialed approval.
Any changes in hospital privileges should be reported to Care Improvement Plus’s Credentialing
Department in writing at:
4350 Lockhill-Selma Road, Suite 300
Shavano Park, TX 78249
Attention: Credentialing Department
[email protected]
Compliance with Medicare Requirements and Care Improvement Plus Policies and
Procedures
Providers must comply with all applicable Medicare Advantage and Medicare Part D laws and
regulations, guidance and instructions issued by the Centers for Medicare and Medicaid Services (CMS),
Care Improvement Plus’s contract with CMS to sponsor MA-PD plans, and applicable written policies
and procedures as established and modified by Care Improvement Plus from time to time, which are
available online through our Provider Portal at www.careimprovementplus.com.
Network Providers
Providers are encouraged to utilize Care Improvement Plus’ network hospitals, physicians, and ancillary
providers. A network directory may be found at www.careimprovementplus.com. However, providers
may refer members to any Medicare-approved provider as long as the provider agrees to accept payment
from Care Improvement Plus.
Pharmaceutical Prescriptions
Providers are encouraged to prescribe and authorize the substitution of generic pharmaceuticals and
otherwise abide by the Care Improvement Plus Formulary available upon request and found online
at www.careimprovementplus.com.
Advance Directives
Institutional providers are required to give adult members (age 21 and older) written information
about their right to have an advance directive; advance directives are oral or written statements
either outlining a member’s choice for medical treatment or naming a person who should make
choices if the member loses the ability to make decisions.
Non-institutional providers that choose to provide information on Advance Directives should follow the
same provisions listed above. For more information reference Section N.
Reporting and Disclosure/Encounter Data
Providers are required to submit data and other information, including medical records, as needed when
necessary to characterize the content and purpose of each encounter with a member. Providers are
required to certify to the completeness, truthfulness and accuracy of such information. This information
and data may be submitted to CMS.
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Billing of Members
Providers may not bill, charge, collect a deposit from, seek compensation, remuneration, or
reimbursement from or have any recourse against any member for any amount owed by Care
Improvement Plus to Providers. The foregoing does not affect Provider’s obligation to collect
applicable coinsurance, copayments and deductibles as applicable, from members.
Every provider shall indemnify and hold members harmless for any and all debts of provider, amounts
owed to provider by Care Improvement Plus, and any coinsurance, copayments and deductibles owed to
provider by the applicable state Medicaid program.
In order to bill a Care Improvement Plus member for a non-covered service, the Provider must obtain
the member’s written consent and the following must occur:

If you know or have reason to know that a service or item you are providing or referring
may not be covered (as described below), you must request a pre-service organization
determination from Care Improvement Plus prior to providing or referring for the service
or item in order to seek and collect payment from the member for the service or item.
Care Improvement Plus must issue a determination before you render or refer for the
non-covered service or item. A pre-service organization determination is not required in
order to seek and collect payment from the member where the Medicare Advantage
Member’s Evidence of Coverage (EOC) or other related materials are clear that a service
or item is never covered.

If after you request a pre-service organization determination, Care Improvement Plus
determines that the service or item is not covered, Care Improvement Plus will issue an
Integrated Denial Notice (IDN) to you and the member. The IDN informs the member of
his or her liability for the non-covered service or item and appeal rights. You must make
sure the member has received the IDN prior to rendering or referring for non-covered
services or items in order to collect payment. Please be aware that when a Medicare
Advantage member wishes to receive a non-covered service or item, the Centers for
Medicare and Medicaid Services (CMS) requires that the member be provided an IDN in
order for the member to be financially liable for the non-covered service or item unless
the service or item is clearly excluded in the EOC or other related materials.
You should know or have reason to know that a service or item may not be covered if:
 We have provided general notice through an article in a newsletter or bulletin, or
information provided on www.careimprovementplus.com or
https://providerportal.careimprovementplus.com
(including clinical protocols, medical and drug policies) either that we will not cover a
particular service or item, or that a particular service or item will be covered only under
certain circumstances not present with the member; or
 We have made a determination that the planned service or item is not covered and have
communicated that determination to you on this or a previous occasion.
 For Medicare Advantage benefit plans, CMS has published guidance, through National
Coverage Determinations, Local Coverage Determinations, or other CMS guidance,
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indicating that the service or item may not be covered in certain circumstances. You are
required to review the Medicare Coverage Center. You must not bill our member for a
non-covered service or item in cases in which you do not comply with this Protocol.
You must not bill a member for non-covered services in cases in which you do not comply with the
terms of the Protocol outlined above. Failure to comply with the terms of the Protocol, including but
not limited to failure to request a pre-service organization determination for a Medicare Advantage
member or rendering the service to a Medicare Advantage member before Care Improvement Plus
issues the pre-service organization determination, will result in an administrative claim denial. You
cannot bill the member for claims that are administratively denied.
Annual Model of Care Training
As required by CMS, Care Improvement Plus must conduct initial and annual Model of Care training for
our provider network to keep everyone informed about the care management structure and revisions
made based on performance improvement activities. Instructions are distributed annually to providers in
order to satisfy this requirement.
SECTION D – PROVIDER RIGHTS AND RESPONSIBILITIES
Primary Care Physician
Care Improvement Plus recognizes the important role that specialists have in the health care needs of our
members. We also recognize the need for a Primary Health Care Provider to coordinate and monitor the
overall clinical care needs of the patient (the physician primarily focuses on clinical aspects related to
their chronic illness). As such, we encourage the member to identify a Primary Care Physician who will
be willing to act in that capacity.
A Primary Care Physician (PCP) is defined as a physician with a specialty of: family practice, general
practice, internal medicine, or gerontology. When a Provider consents to act as Primary Care Physician
for a member, it is the role of the Primary Care Physician to coordinate all health care and when
medically necessary, refer Care Improvement Plus members to other specialists if needed.
Primary Care Physicians responsibilities include, but are not limited to:
 Notify Care Improvement Plus of all hospital admissions, if aware.
 Discuss and consider requests from members who have chosen that physician as their Primary
Care Physician
 Perform services normally in his or her scope of practice
 Coordinate the provision of covered services to members by: (1) counseling members and their
families regarding members’ medical care needs, including family planning and advance
directives; (2) initiating medically necessary referrals; and (3) monitoring progress, care, and
managing utilization of specialty services
 Render preventive health services; such services shall include, but are not limited to, periodic
health assessments, immunizations, and other measures for the prevention and detection of
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disease
Render immunization services without assessing a co-pay
Participate and abide by all decisions regarding member complaints, peer reviews, quality
improvement and utilization management
Give direction and follow-up care to those members who have received emergency services
Accept and participate in peer review
Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) medical care
Provide clinical documentation as requested
Specialty Care Physicians
All specialty care physicians have responsibilities that include, but are not limited to:
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Providing covered specialty care services to members (referrals are not required)
Facility Providers
All facility providers have responsibilities that include, but are not limited to:

Providing covered services to members
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Obtain authorizations as appropriate
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Ancillary Providers
All ancillary providers have responsibilities that include, but are not limited to:
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Providing covered services to members
Obtain authorizations as appropriate
*Note: There is an out-of-network cost differential for dental, vision, home health services and DME in
some Care Improvement Plus plans.
Updates to Pertinent Information
Providers must give Care Improvement Plus written notification thirty (30) days prior to any change in:
 Address
 Telephone number
 Tax identification number (including a W-9 form)
 License status
 Certification status
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Medicare certification status
Professional liability coverage
National Provider Identifier (NPI)
Specialties (Primary Taxonomy Code)
Other information supplied in the credentialing application.
All updates should be directed to:
 Provider updates [email protected]
 Delegated updates [email protected]
 Provider Relations General requests [email protected]
or by mail:
4350 Lockhill-Selma Road, Suite 300
Shavano Park, TX 78249
Attention: Credentialing Department
Failure to notify Care Improvement Plus may result in delay of or denial of payment for services
rendered and the provider must hold the member harmless.
Appeals
Providers may appeal claims where Care Improvement Plus has denied all or part of a claim following an
uphold decision of the reconsideration process. All appeals must be submitted within sixty (60) days, or
as stipulated in the provider’s contract, from the date that the provider’s payment was denied in whole or
in part.

Re-openings – For contracted providers, if the denial was made for inadequate records to support
medical necessity and the provider, with the appeal request submits additional documentation, the
plan may make the decision to re-open its original determination rather than go through the
appeals process. If the decision to re-open qualifies, the additional documentation will be
reviewed. The provider will be notified if the original denial will stand and receive appeal rights
based on this decision. If the decision is overturned, the provider will receive an adjusted
payment and Explanation of Payment. For non-contracted providers, the receipt of additional
documentation will be treated as an appeal or reconsideration.

Appeals- The appeal case will undergo investigation and review by an appeals staff clinician who
works with a licensed physician or specialist to evaluate medical necessity and appropriateness of
care. A non-contracted provider is required to submit a Waiver of Liability for each claim
appealed in order for the appeal to be accepted and processed. (The most recent CMS Approved
Waiver of Liability form can be found at the following link: Waiver of Liability). Refer to
Appendix H for additional information for non-contracted providers. A contracted provider is not
required to complete the Waiver of Liability and should reference the current contract. The
provider must cooperate in sending all necessary medical documentation to support the case for
the Plan’s review. Care Improvement Plus will send a written decision within sixty (60) days. If
the initial decision is overturned, in whole or in part, a check will be sent following the decision.
In making the determination for medical necessity, Care Improvement Plus follows Medicare
coverage requirements, the benefit package applicable to the member, and Milliman Guidelines.
If Care Improvement Plus upholds the initial denial, then the contracted provider is notified. If
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Care Improvement Plus upholds the initial denial for a non-contracted provider, the provider is
notified and the case is automatically submitted to CMS’ contracted Independent Review Entity
(IRE), Maximus for an additional review. If Maximus overturns the decision, in whole or in part,
the plan will send a check within 30 days of the Maximus decision. If Maximus upholds the
decision, the plan will notify the provider of the decision and provide the provider a copy of
Maximus’ written decision with the providers’ next level appeals rights.
Provider and Member Appeals: Members have appeal rights that begin with plan-level
reconsideration and extend through four (4) additional levels of external review. Providers may
appeal on behalf of a member, but only in the limited circumstances as allowed by federal law, as
follows:
Expedited Appeals: Physicians may request an expedited appeal on behalf of the member.
Expedited appeals (also known as reconsiderations) are cases where denied medical services or
prescription drug(s) are of an urgent nature. That is, a delay in obtaining the medical services or
prescription drug(s) could jeopardize the member’s health, life, or ability to regain maximum
function. Expedited appeals do not have to be in writing and may be initiated by calling 1-877-2629203 for medical and 1-800-204-1002 for prescription drug appeals.
Authorized Representative: Providers may serve as the “official” representative of the member by
signing, along with the member, a CMS Form 1696. A letter that includes the same designation of
authority and co-signed with the member may also be used. Once activated, an authorized
representative has the same rights as a member in the Medicare member appeals process.
Except for expedited appeals, all appeals should be in writing and mailed to the following address:
6514 Meadowridge Rd. 1st Floor
Elkridge, MD 21075
Attention: Appeals Department
For more information on how to file an appeal, please call the Compliance Department at
1-800-213-0672; TTY users should call 711.
For prescription drug appeals, please call 1-800-204-1002, or fax to 1-866-308-6294 (for
expedited use 866-308-6296), or send to the following address:
United Healthcare Part D Appeal and Grievance Department
PO Box 6106
Mail Stop CA124-0197
Cypress, CA 90630
Member Solicitation
Providers may announce new affiliations and repeat affiliation announcements for specific plan sponsors
through general advertising (e.g., publicity, radio, television). An announcement to patients of a new
affiliation which names only one plan sponsor may occur only once when such announcement is
conveyed through direct mail and/or email. Additional direct mail and/or email communications from
17
providers to their patients regarding affiliations must include all plans with which the provider contracts.
Provider affiliation banners, displays, brochures, and/or posters located on the premises of the provider
must include all plan sponsors with which the provider contracts. Any affiliation communication
materials that describe plans in any way (e.g., benefits, formularies) must be approved by CMS.
Providers may feature Special Needs Plans (SNPs) in a mailing announcing an ongoing affiliation. This
mailing may highlight the providers’ affiliation or arrangement by placing the SNP affiliations at the
beginning of the announcement and may include specific information about the SNP. This includes
providing information on special plan features, the population the SNP serves or specific benefits for
each SNP. The announcement must list all other plans with which the provider is affiliated.
Provider Based Activities
Providers contracted with Care Improvement Plus may:
 Provide the names of plan sponsors with which they contract and/or participate;
 Provide information and assistance in applying for the low income subsidy;
 Provide objective information on ALL plan sponsors’ specific plan formularies, based on a
particular patient’s medications and health care needs;
 Provide objective information regarding ALL plan sponsors’ specific plans being offered, such as
covered benefits, cost sharing, and utilization management tools;
 Make available and/or distribute plan marketing materials for all plans with which the provider
participates (including PDP enrollment applications, but not MA or MA-PD enrollment
applications);
 Refer their patients to other sources of information, such as the SHIPS, plan marketing
representatives, their State Medicaid Office, local Social Security Office, CMS’s website at
http://www.medicare.gov/ or calling 1-800-MEDICARE; and
 Print out and share information with patients from CMS’s website.
Providers contracted with Care Improvement Plus may not:
 Direct, urge or attempt to persuade, any prospective enrollee to enroll in a particular Plan or to
insure with a particular company based on financial or any other interest of the provider;
 Offer sales/appointment forms;
 Collect enrollment applications;
 Mail marketing materials on behalf of plan sponsors;
 Offer inducements to persuade beneficiaries to enroll in a particular plan or organization;
 Offer anything of value to induce Plan enrollees to select them as their provider;
 Expect compensation in consideration for the enrollment of a beneficiary; or
 Expect compensation directly or indirectly from the Plan for beneficiary enrollment activities.
Suspension or Termination of Contract
In the event Care Improvement Plus suspends or terminates a Provider’s contract to provide health care
services to members, Care Improvement Plus will provide the Provider written notice of the suspension
or termination, including the basis for Care Improvement Plus’ action, the right to appeal the action, and
the process and timing for requesting a hearing regarding Care Improvement Plus’ action. Suspensions
and terminations resulting from deficiencies in the quality of care furnished by the Provider will be
reported to the applicable licensing or disciplinary bodies or other appropriate authorities as required by
Medicare Advantage regulation.
18
Termination without cause of a Provider’s contract with Care Improvement Plus, if permitted by the
terms of the contract, may be effective no earlier than sixty (60) calendar days after notice of termination
is provided.
SECTION E – BILLING & CLAIMS PAYMENT
Billing
Care Improvement Plus follows Medicare payment policies and guidelines as directed in the
Medicare Advantage Payment Guide. Providers must submit their claim on the current and
appropriate Medicare billing form, with all required fields and documentation complete.
Claims Payment
Care Improvement Plus accepts both paper and electronically submitted claim forms from providers.
Care Improvement Plus encourages providers to submit claims electronically whenever possible. There
are many advantages to submitting claims electronically. Elimination of paper and associated expenses,
more timely claims payment by Care Improvement Plus, and the ability to track submitted claims are just
a few of the benefits. Care Improvement Plus coordinates benefits with State Medicaid for members in
the Dual Advantage plan. All claims and encounter data must be submitted on either a form CMS 1500 or
UB-04, or on electronic media in an approved HIPAA compliant format.
Care Improvement Plus utilizes Availity, Emdeon and Xerox EDI Direct as our clearinghouse options.
The unique Electronic Payor ID is: 77082. Call 1-866-679-3119 for assistance or more information.
For more detailed information regarding Care Improvement Plus claims payment policies, please go online to
www.careimprovementplus.com to our provider self-service center and access the quick links for more
information.
In the event that a provider does not agree with the payment of a specific claim, our secure provider
portal has a “dispute” option. Providers may submit claims specific information online via the “dispute”
option for review of a claim. Additional information for non-contracted providers is included in
Appendix H.
For claims status information, you can visit us at www.careimprovementplus.com and log into the
secure provider self-service center, or call Provider Relations at 1-866-679-3119.
Medical Claims may also be submitted via paper to:
P.O. Box 488 Linthicum, MD 21090-0488
Attention: Claims Department
or
Electronic payor ID is 77082
19
Dual Advantage Provider Reimbursement
The Dual Advantage plan is a Dual Special Needs plan designed for beneficiaries that have their A/B cost
sharing covered by State Medicaid. Members are not responsible for paying any Medicare Part A or Part
B cost sharing in this plan. Refer to www.careimprovementplus.com and
https://providerportal.careimprovementplus.com/ for additional, state specific claims information.
Arkansas-Department of Human Services
1.800.482.5431 or (local) (501) 682.8501
P.O. Box 1437, Slot S410, 112 W. Main Street
Little Rock, AR 72203
http://www.arkansas.gov/dhs/homepage.html
Georgia-Department of Human Resources Division of Family & Children Services
1-800-869-1150
2 Peachtree Street, NW Suite 18-486
Atlanta, GA 30303
http://dfcs.dhr.georgia.gov/portal/site/DHS-DFCS/
Missouri Department of Social Services
1-800-392-2161
615 Howerton Court, P.O. Box 6500
Jefferson City, MO 65102
http://www.dss.mo.gov/
New Mexico Human Services Department
1-888-997-2583
P.O. Box 2348
Santa Fe, NM 87504-2348
http://www.hsd.state.nm.us/mad/
South Carolina-Department of Health and Human Services
1-888-549-0820
P.O. Box 8206
Columbia, SC 29202
http://www.dhhs.state.sc.us/medicaid.asp
Texas Health and Human Services Commission
1-800-252-8263
4900 N. Lamar Blvd.
Austin, TX 78751-2316
http://www.hhsc.state.tx.us/medicaid/index.html
Wisconsin ForwardHealth
1-800-362-3002
PO Box 7190
Madison, WI 53707
https://www.forwardhealth.wi.gov/WIPortal/Default.aspx
Mental Health and Substance Abuse Claims via paper to:
Optum
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P.O. Box 30760
or
Pharmacy Claims may be submitted via paper to:
OptumRx
PO BOX 29045
Dental and Vision Claims may be submitted to:
www.spectera.com
PO Box 2064
Milwaukee, WI 53201
Explanation of Payment
An explanation of payment (EOP) will be generated for all claims processed by Care Improvement Plus.
The EOP will be mailed regardless of payment amount, and will be accompanied by a claim check when
applicable. For questions or concerns about the EOP, visit the provider self-service center at
www.careimprovementplus.com or contact Provider Relations at 1-866-679-3119; TTY users should call
711. A sample of the EOP can be found in Appendix C.
Provider Refunds
Georgia and South Carolina
Care Improvement Plus of the Southeast Inc
P.O. Box 822657
Philadelphia, PA 19182-2657
Missouri and Arkansas
Care Improvement Plus South-central Insurance Company Inc
P.O. Box 822660
Texas, New Mexico, Illinois, Iowa, Indiana, North Carolina and Nebraska
Care Improvement Plus of Texas Insurance Company Inc
P.O. Box 822663
21
Wisconsin
Care Improvement Plus Wisconsin Insurance Company
P.O. Box 824460
SECTION F – CREDENTIALING PROGRAM
Program Overview
Care Improvement Plus maintains a comprehensive credentialing program; developed in accordance
with CMS and the National Committee for Quality Assurance (NCQA) standards. The credentialing
process involves several steps including application, primary source verification, Credentialing
Committee review and provider notification.
All providers applying to the Care Improvement Plus network have the right to:




Review information obtained in support of their credentialing application except for
references, recommendations or other information peer review protected by law.
Respond to information obtained during the credentialing process that is discrepant with
the information submitted on their credentialing application.
Correct erroneous information that may have been submitted.
Be informed of the status of their credentialing or re-credentialing application upon
request.
The credentialing program is periodically reviewed by the Credentialing Committee and revised
when necessary. All information obtained during the credentialing process is held in the strictest
confidence. All providers shall be notified in writing of any denial, suspension or termination.
Re-Credentialing
Providers are re-credentialed every three (3) years of the date of their last credentialing cycle. The basic
process is the same as the initial credentialing process. Additional criteria that may be used during the recredentialing process include, but are not limited to:





Compliance with health plan policies and procedures.
Sanctions related to utilization management, administrative or quality of care issues.
Member complaints
Member satisfaction survey results
Participation in quality improvement activities
SECTION G – USE OF ANCILLARY PROVIDERS
Ancillary Services
Laboratory Services
22
Any Medicare certified laboratory provider may be used. Physicians may do limited lab work in their
offices – some services will be considered “bundled charges” and will not be paid in addition to an office
visit. For a listing of contracted laboratory facilities in your area, search our online provider directory or
contact our Provider Relations department.
Radiology Services
Any Medicare certified radiology provider may be used. For a listing of contracted radiology
facilities in your area, search our online provider directory or contact our Provider Relations
department.
Physical Therapy
Any Medicare certified therapy provider may be used. For a listing of contracted physical therapy
facilities in your area, search our online provider directory or contact our Provider Relations
department.
Home Health and Durable Medical Equipment
Any Medicare certified licensed Home Health and/or DME supplier may be used; however Care
Improvement Plus members may have additional out-of-pocket expenses if an out-of-network provider is
used. Select DME items require preauthorization. For a listing of contracted Home Health and DME
suppliers in your area, search our online provider directory or contact our Provider Relations department.
Please refer to Appendix B for the specific DME which require prior authorization.
SECTION H – BEHAVIORAL HEALTH SERVICES
Program Overview
Care Improvement Plus recognizes that members with chronic medical illness may also have
symptoms requiring behavioral health services for psychiatric or substance abuse treatment. Clinical
staff will assist in accessing providers and facilities for treatment (both inpatient and outpatient)
when these needs are identified.
Members and providers can make requests for this assistance by calling Optum at 1-888-751-1235.
Emergency care needs should always be directed to the nearest Emergency Department or Local
Hospital.
Mental Health and Substance Abuse Claims may be submitted via paper to:
Optum
PO Box 30760
or
23
SECTION I – PHARMACY
List of Prescriptions/Medications
The Care Improvement Plus Formulary:





Contains at least two (2) drugs from each class;
Provides a framework and relative cost information for the management of drug costs;
Requires generic drug prescription usage whenever possible. These drugs are listed with the
generic name on the Formulary. If a member requests a brand name drug when a generic drug is
available, the member may be responsible for additional charges;
Includes quantity, form, dosage and preauthorization restrictions for certain drugs
(Clinical and/or coverage determinations); and
Will be updated, reprinted and distributed to physician offices upon request.
Physician offices needing additional copies of the list should contact Care Improvement Plus Provider
Relations at 1-866-679-3119. The formulary and any recent changes are also available online at
www.careimprovementplus.com.
Preauthorization
Some medications as noted on the Care Improvement Plus Formulary require preauthorization from
Care Improvement Plus. Clinical Prior Authorizations and Part B/D Coverage Determinations require
a decision within 72 hours for Standard requests, and within 24 hours for Expedited requests.
Prescriptions requiring preauthorization should be called in to 1-800-711-4555.
Exceptions
Members may request an exception when they wish to receive a drug that is not on the formulary (NonFormulary Exception), a Step Therapy exception (ST), a Quantity Limit exception (QL) or a Tiering
exception in order to lower the coinsurance/copay/tier of a medication. The OptumRx Prior
Authorization department reviews the request and may contact the prescriber to obtain information
necessary to approve or deny the request. The decision to approve or deny the request will be made
within seventy-two (72) hours of receiving a supporting statement from the doctor for a standard request
or within twenty-four (24) hours of receiving a supporting statement for an expedited request. Members
may request a re-determination of any denial of coverage (See Section M- Members Rights and
Responsibilities, for more detailed information on pharmacy appeals, including the right to an expedited
appeal). More information on requesting an exception (including provider and member forms to request
an exception) is available online at www.careimprovementplus.com.
Transition
At the time an individual joins a Medicare Part D plan, a new Member may be taking a Drug Product that
is either not on the Benefit Plan’s Formulary or is subject to Benefit Plan requirements or restrictions.
The Member may be eligible to receive a temporary transition supply of the Drug Product. The maximum
days’ supply allowed is a thirty-one (31) day supply (unless the prescription was written for fewer days)
at any time during the first ninety (90) days of Membership in the Member’s Medicare Part D Plan.
24
The Medicare Part D Sponsor provides notice to its Members and their Prescriber who receive a
transitional supply of a Drug Product. This notice is sent by U.S. mail within three (3) business days of
the temporary fill. It includes:
• An explanation of the temporary nature of the transitional supply.
• Instructions for working with the Benefit Plan Sponsor and the Prescriber to identify appropriate
Formulary alternatives.
• An explanation of the Member’s right to request an exception.
• A description of the procedures for requesting an exception.
After the initial temporary transition supply of up to thirty-one (31) days, the Benefit Plan Sponsor may
not continue to pay for these Drug Products under the transition policy. The Member should discuss
appropriate alternative therapies on the Formulary with the Prescribing Physician. If there are no
alternatives, the Member and Prescriber may request a PA.
Five-Tier Copay Structure
Care Improvement Plus has a five-tier formulary. Most drugs are covered (with the exception of
exclusions as listed in the member’s Certificate of Insurance). Copayments vary depending on the tier in
which the prescription drug falls.
To access a copy of our formulary or to access our online formulary search tool, go to
www.careimprovementplus.com, For Providers section and select “Formulary” under Quick Links.
Tiers include:
Tier 1- Preferred
Generic
Tier 2- Non-Preferred
Generic
Tier 3- Preferred Brand
Includes lower-cost, commonly used generic drugs.
Tier 4 -Non-Preferred
Brand
Tier 5- Specialty Drugs
Preauthorization
Includes non-preferred generic and non-preferred brand name
drugs.
Includes unique and/or very high-cost drugs.
Some medications as noted on the Care Improvement Plus
Formulary require pre-authorization from Care Improvement Plus
Clinical Prior Authorizations and Part B/D Coverage
Determinations require a decision within 72 hours for Standard
requests, and within 24 hours for Expedited requests.
Preauthorization may be requested by calling Member Services at
1-800-711-4555.
Members may request an exception when they wish to receive a
drug that is not on the formulary Non-Formulary), a Step Therapy
Exception (ST), a Quantity Limit Exception (QL) and to receive a
drug at a lower coinsurance/co-pay/tier or Tier Exception. The
OptumRx Authorization department reviews the request and may
Exceptions
Includes most generic drugs.
Includes many common brand name drugs, called preferred
brands and some higher-cost generic drugs.
25
Transition
contact the prescriber (as necessary) to obtain information
necessary to make a coverage decision. The decision to approve
or deny the request will be made within seventy-two (72) hours of
receiving a supporting statement from the doctor for a standard
request or within twenty-four (24) hours of receiving a supporting
statement for an expedited request. Members may request a redetermination of any denial of coverage (See Section MMembers Rights and Responsibilities, for more detailed
information on pharmacy appeals, including the right to an
expedited appeal). More information on requesting an exception
(including provider and member forms to request an exception) is
available at www.careimprovementplus.com.
All new enrollees may receive a one-time refill of any nonformulary medication for up to a ninety (90) day period after
enrollment. This includes formulary medications requiring prior
authorization and step therapy under Care Improvement Plus’
utilization management rules. Medications that are excluded by
Medicare and those that require a Part B/D coverage
determination are not eligible for a transition fill. Providers and
patients should consider switching to a formulary option in
advance of the next refill of the non-formulary medication. A
notification will be sent to the member regarding the need to
transition to a formulary medication. Members who are
experiencing a level of care change to or from a long term care
facility may be eligible for additional transition supplies after the
initial ninety (90) day period.
SECTION J – VISION AND DENTAL COVERAGE
Care Improvement Plus covers medical services for vision care as well as routine vision screening services
that are typically not covered by Medicare. Care Improvement Plus offers routine eye exams and a materials
benefit to purchase frames, lenses or contacts. A list of contracted routine vision service providers is located
in the provider directory. Care Improvement Plus also offers a routine dental benefit, which includes cleaning,
exam, x-rays, and denture adjustments. Some plans offer comprehensive coverage as well. A list of contracted
routine dental service providers is located in the provider directory. This is a general description only. Please
refer to the members’ Evidence of Coverage and summary of benefits for benefit information. In the event of
any conflict between the Evidence of Coverage and this provider manual, the Evidence of Coverage shall
prevail.
For assistance, Providers may call United Healthcare Vision at 1-800-638-3120.
For assistance, Providers may call United Healthcare Dental at 1-844-275-8750.
Providers may also submit Dental and Vision Claims to:
www.spectera.com
26
PO Box 2064
Milwaukee, WI 53201
SECTION K– UTILIZATION AND CASE MANAGEMENT (UM)
Note: Authorization is based on a determination that services are medically necessary but is not a
guarantee of payment. Payment for services is subject to member eligibility and benefits limitations.
Case Management
Care Improvement Plus’ Case Management program is a customized/case-specific approach to
managing complex, resource-intensive cases, and provides education and counseling for our members.
Our Case Managers develop and implement proactive care plans designed to reduce or eliminate barriers
to care, especially those in the realm of psychosocial or socioeconomic barriers. Our goal is to maximize
participation with the chronic care management approaches proven to be successful in enhancing health
outcomes. Care Managers collaborate with Primary Care Physicians, discharge planners, social
workers, community outreach programs, family and caregivers. We encourage providers to make
referrals to our Case Management Department at 1-866-460-8699, Monday -Friday, 8:00 a.m. - 5:00
p.m. EST. To make referrals after hours, Providers can leave a message at 1-866-460-8699.
Chronic Care Management
Care Improvement Plus offers fully integrated chronic care management programs for high
prevalence, high cost conditions that encompass the full continuum of disease management
interventions from low-risk through high-risk. We take a comprehensive focus on care issues
surrounding diabetes, heart failure, cardiovascular disease and end stage renal disease. The programs
are proactive, criteria and risk-based with targeted clinical outcomes, focused on meeting the health
needs of members.
Utilization Review
Utilization Management staff will perform review services telephonically and/or onsite and review the
member’s admissions, services and continued stays for medical necessity and appropriateness of the level
of care. Utilization Management staff may also screen for quality and/or risk management issues,
participate in and coordinate the discharge planning process, and identify member’s post-discharge
needs. Care Improvement Plus’ Medical Director may, from time to time, ask to speak with a member’s
provider to discuss a plan of care or institutional stay.
Services Requiring Prior Authorization
Services requiring preauthorization can be found in Appendix B of this manual.
27
SECTION L – QUALITY IMPROVEMENT (QI)
QI Program Overview
Care Improvement Plus’s Quality Improvement program aims to ensure that timely, efficient and quality
clinical care and services are rendered to our members. We participate in all CMS reporting and survey
requirements, including the annual HEDIS, NCQA, CAHPS, and HOS surveys. The program seeks to
demonstrate value and improve quality through the elimination of over, under, and misuse of services by:




Measuring, assessing, and coordinating the quality of clinical care across Care Improvement Plus’
delivery system.
Promoting members’ health through health promotion, disease management, and condition
pathways.
Assisting members to engage in healthy behaviors and encourage active self-management.
Implementing interventions to improve the safety, quality, availability and accessibility of, and
member satisfaction with, care and services.
Care Improvement Plus has a long-term commitment to quality improvement initiatives that encompass the
full spectrum of care and services provided to our members. The Quality Improvement Program is dedicated
to fulfilling that commitment by working with the provider community to establish evidence-based clinical
guidelines and service standards. The guidelines and measures are used to develop tools for the purpose of
providing feedback to members and providers, to encourage improvement.
Care Improvement Plus will disclose to CMS as required, from time to time, information and data relating to
efforts and initiatives to achieve satisfactory health outcomes and other performance indicators.
Clinical Practice Guidelines
The Medical Advisory Board and clinical leadership team are responsible for identifying appropriate
nationally recognized clinical guidelines for use in Care Improvement Plus clinical programs. All guidelines
are evidence-based so as to achieve optimum, high-quality health outcomes. The complete set of guidelines
is reviewed annually by the Medical Advisory Board comprised of community based physicians and clinical
experts.
Preventive Services Guidelines
When providers consistently offer preventive services, patients are able to maintain or improve their health,
while avoiding more costly and invasive medical procedures. With prevention, everybody wins. These
guidelines are evidence-based, offering only recommendations that are well supported in the medical
literature. Every year the guidelines are reviewed and updated as needed.
Health Plan Employer Data and Information Set (HEDIS)
Care Improvement Plus is required by CMS to submit data annually for HEDIS reporting that measures the
quality of clinical care provided to our members and health plan performance. At various times throughout
the year and especially during annual HEDIS preparation, Care Improvement Plus may request medical
files, including lab results, blood pressures and other clinical data which will be reviewed for adherence
with HEDIS clinical performance indicators. The HEDIS quality indicators may be viewed on the National
Committee for Quality Assurance website at: www.ncqa.org.
28
Medical Records
Care Improvement Plus requires all affiliated providers to abide by the medical record standards established
by Care Improvement Plus policy as well as state and federal regulations. These standards are based on the
requirements of NCQA, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and other
regulatory bodies. Care Improvement Plus’s Quality Improvement department routinely audits provider
documentation for medical record-keeping practices during the credentialing process and re-credentialing
process, when applicable.
Model of Care Training
As a Special Needs Plan, Care Improvement Plus must implement a model of care consistent with CMS
standards. Requirements include conducting initial and annual Model of Care training for employees,
contracted personnel and the provider network to keep everyone informed about the care management
structure and revisions made based on performance improvement activities. Instructions are distributed
annually to providers in order to satisfy this requirement
SECTION M – MEMBER RIGHTS AND RESPONSIBILITIES
Member Rights
Care Improvement Plus members have the right to understand their health conditions and to
participate in health care decisions. To ensure that members attain the maximum benefits, we
encourage members to exercise their rights, including but not limited to:









Receive considerate and respectful care, regardless of nationality, race, creed, color, age,
economic status, sex, lifestyle or severity of illness
Be treated with respect and to have their dignity and personal privacy recognized
Obtain complete and current information about their treatment alternatives without regard to cost
or benefit coverage
Understand their health conditions and to participate in health care decisions
Receive all information needed to give informed consent prior to the start of any procedure or
treatment including an explanation of procedures and any potential risks
Be informed of the Care Improvement Plus affiliated providers available to deliver medical care
Access to complete and current information about Care Improvement Plus, its services,
practitioners and providers
Receive prompt treatment in an emergency
Voice an opinion or to file a grievance or appeal
Member Responsibilities
Care Improvement Plus is committed to treating its members in a manner that respects their rights and
addresses their responsibility for cooperating with Care Improvement Plus staff and Care Improvement
Plus affiliated practitioners and providers. Member responsibilities include but are not limited to:

Make a full and complete disclosure of their medical history and symptoms before and during the
course of treatment
29



Follow the agreed upon plan and instruction from their health care provider
Treat Care Improvement Plus staff, Care Improvement Plus affiliated providers and their
personnel, and other Care Improvement Plus members or patients respectfully and courteously
Keep scheduled appointments or give adequate notice of delay or cancellation of appointments.
Notify their health care provider of any unexpected health changes. Understand and follow Care
Improvement Plus policies and procedures. Provide pertinent information to Care Improvement
Plus and its affiliated providers in order to render health care benefits and health care services.
Out of Area Services
Emergency and urgently needed services are covered regardless of whether a member is within or
outside the applicable Care Improvement Plus plan service area. Renal dialysis services are covered
when a member is out of the applicable Care Improvement Plus plan service area temporarily. Care
Improvement Plus also covers ambulance services for medical emergencies.
Additional coverage for members who permanently move from the applicable Care Improvement Plus
plan service area into a designated continuation area may be available. More information is available by
contacting Care Improvement Plus.
Primary Care Physician Selection
All members are encouraged to identify a Primary Care Physician (PCP), and Care Improvement Plus’
Member Services department will assist with that process if needed. The process begins with a new
member’s enrollment application. A member may identify their PCP at enrollment into Care
Improvement Plus, or Members can also select a PCP by contacting Care Improvement Plus’ telephone
line, or going online at www.careimprovementplus.com.
Provider Terminations
While Care Improvement Plus does not require members to be assigned to a Primary Care Physician
(PCP), when known, we will notify affected members thirty (30) days before the effective date of a
Primary Care Physician termination. The notification will include information that will assist the
member in selecting a new PCP, if requested. It will also identify resources for additional physician
selection assistance. Reasons for terminations will remain confidential.
Grievance Procedures
The purpose of the member grievance process is to provide a mechanism by which a Care Improvement
Plus member who is dissatisfied with any aspect of the health plan may file a formal grievance and have
the complaint investigated. A grievance is any complaint other than an adverse decision with regard to a
service or claim (e.g., denied authorizations and denied claims are appeals, not grievances). Timeframes
for responding to grievances are as follows:


Thirty (30) days for regular grievance, but may extend fourteen (14) calendar days if additional
information is required
Twenty-four (24) hours for an expedited grievance
Member Appeals
Members or their authorized representatives may request in writing an appeal of a denied service, such as
30
a disapproved authorization or admission, or a denied claim. The member has sixty (60) days from the
date of the denial to file an appeal. Care Improvement Plus conducts these reconsiderations, or first level
appeals, according to Medicare Advantage and Medicare Part D requirements. There are standard
timeframes for medical appeals and claims appeals. There also are expedited appeals for medical
services. The timeframes are as follows:




Standard medical reconsiderations: Up to thirty (30) calendar days, with a possible extension of
fourteen (14) calendar days
Expedited reconsiderations: seventy-two (72) hours or less based on need, with a possible
extension of fourteen (14) calendar days
Medical claim reconsiderations: No more than sixty (60) days
Post Service Appeals cannot be expedited
With the prescription drug benefit, there are also appeals, or “redeterminations.” Appeals related to the
drug benefit may occur when a formulary drug is denied, a member’s drug claim is denied, a request for
an exception to the tiering structure of the formulary is rejected, a request for an exception to a drug
utilization management tool is rejected, or a request for a non-formulary drug is denied (See Section I:
Pharmacy Services). As with medical services, there are expedited appeals in addition to the standard
timeframes:
 Standard drug redeterminations: Up to seven (7) days
 Expedited drug redeterminations: Seventy-two (72) hours or less
There are several sources of information on how an enrollee may file an appeal, such as in their
Evidence of Coverage, on the plan website, and on denial notices. Additional questions may be directed
to Provider Relations at 1-866-679-3119.
If Care Improvement Plus upholds Part C denial, the case is then sent to an external, Independent Review
Organization (Maximus). The enrollee may keep appealing through two (2) additional levels of federal
review and ultimately seek Judicial Review.
Providers are expected to participate in member appeals.
SECTION N – ADVANCED DIRECTIVE
Every competent adult and emancipated minor has the right to execute an Advance Directive. The
Patient Self-Determination Act requires that “a provider of services” must document in the individual’s
medical record whether or not the individual has executed an Advance Directive. Institutional
participating providers must demonstrate compliance with all applicable state and federal laws and
regulations. If a non-institutional provider chooses to discuss advance directives, they must document it
in their patient’s medical charts.
Care Improvement Plus routinely provides information on Advance Directives to members upon
enrollment. Provider Relations may conduct provider staff education on Advance Directives along with
regular updates and reminders. Providers seeking information on Advance Directives and/or forms can
contact the Provider Relations Department at Care Improvement Plus.
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SECTION O – HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT (HIPAA) RESPONSIBILITIES
To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification
provisions that required the United States Health and Human Services Department (HHS) to adopt
national standards for electronic health care transaction code sets, unique health identifiers, and security.
At the same time, Congress recognized that advances in electronic technology could erode the privacy of
health information. Consequently, Congress incorporated HIPAA provisions that mandated the adoption
of Federal privacy protections for individually identifiable health information.
HHS published a final Privacy Rule in December 2000, which was last modified in January 2013. This
Rule set national standards for the protection of individually identifiable health information by three
types of covered entities: health plans, health care clearinghouses, and health care providers who conduct
the standard health care transactions electronically. Compliance with the Privacy Rule was required as of
April 14, 2003 (April 14, 2004, for small health plans).
HHS published a final Security Rule in February 2003. This Rule sets national standards for protecting
the confidentiality, integrity, and availability of electronic protected health information (ePHI).
Compliance with the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health
plans).
The Office of Civil Rights administers and enforces the Privacy Rule and Security Rule.
Other HIPAA Administrative Simplification Rules are administered and enforced by the Centers for
Medicare & Medicaid Services (CMS), and include:
Electronic Transactions and Code Sets Standards
Employer Identifier Standard
National Provider Identifier Standard
The Enforcement Rule provides standards for the enforcement of all the Administrative Simplification
Rules.
All of the HIPAA Administrative Simplification Rules are located at 45 CFR Parts 160, 162, and 164.
HIPAA Privacy and Security Standards and information can be found at:
https://www.cms.gov/HIPAAGenInfo/ and Office of Civil Rights (OCR) at:
http://www.hhs.gov/ocr/hipaa/
Care Improvement Plus has processes, policies and procedures to comply with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
Privacy Rule
The Privacy Rule regulates who has access to a Member’s/Patient’s protected health information (PHI),
32
whether in written, verbal or electronic form. In addition, this regulation affords individuals the right to
keep their PHI confidential, and in some instances, from being disclosed.
The Office for Civil Rights enforces the HIPAA Privacy and Security Rules, which sets national
standards for the security of electronic protected health information; and the confidentiality provisions of
the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events
and improve patient safety.
In compliance with the Privacy Regulations, Care Improvement Plus (CIP) has provided each CIP
Member with a Notice of Privacy Practices, which describes how Care Improvement Plus can use and
disclose a Member’s health records, and how the Member can get access to the information. In addition,
the Notice of Privacy Practice informs the Member of their health care privacy rights, and explains how
these rights can be exercised.
A copy of Care Improvement Plus’s Notice of Privacy Practices is included as Attachment D.
As a Provider, if you have any questions about Care Improvement Plus’s privacy practices, please contact
the Compliance and HIPAA Department at 1-800-210-3312.
Members should be directed to Care Improvement Plus Member Services with any questions about the
Privacy Regulations at 1-800-204-1002.
Security Rule
The HIPAA Security Rule establishes national standards to protect individuals’ electronic protected
health information (ePHI) that is created, received, used or maintained by Care Improvement Plus. The
Security Rule requires appropriate administrative, physical and technical safeguards to ensure
confidentiality, integrity, and security of electronic protected health information.
The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164.
Breach Notification Rule
Final breach notification regulations, issued January 17, 2013, found at 45 CFR 164.400, et seq (Subpart
D – Notification in Case of Breach of Unsecured Protected Health Information), implement section
13402 of the Health Information Technology for Economic and Clinical Health (HITECH) Act by
requiring Care Improvement Plus and their business associates to provide notification following a breach
of unsecured protected health information. Care Improvement Plus will provide notice of any breach of
unsecured protected health information to affected individuals, the Secretary and, in certain
circumstances, the news media.
Similar breach notification provisions implemented and enforced by the Federal Trade Commission
(FTC), apply to vendors of personal health records and their third party service providers, pursuant to
section 13407 of the HITECH Act.
Care Improvement Plus has additional obligations to notify CMS of security incidents. Those obligations
are in addition to the HITECH requirements and include additional incidents not reportable under
HITECH.
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Transactions and Code Sets Regulations
Transactions are activities involving the transfer of health care information for specific purposes. Under
HIPAA, if Care Improvement Plus or a health care provider engages in one of the identified transactions,
they must comply with the standard for it, which includes using a standard code set to identify diagnoses
and procedures. The Standards for Electronic Transactions and Code Sets, published August 17, 2000
and since modified, adopted standards for several transactions, including claims and encounter
information, payment and remittance advice, and claims status. Any health care provider that conducts a
standard transaction also must comply with the Privacy Rule.
HIPAA Required Code Sets
The HIPAA Code Sets regulation requires that all codes utilized in electronic transactions are
standardized, utilizing national standard coding.
Only national standard codes can be used for electronic claims and/or authorization services.
Code Sets
The HIPAA final rule also named standards for code sets used to encode data that is sent in the HIPAAnamed transactions. Code sets are identified as “medical” or “non-medical”. Medical code sets include
the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-10), Current
Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS). “Nonmedical” code sets are administrative code sets and include ZIP code, state abbreviations, and
administrative billing code sets (e.g. place of service).
HIPAA Designated Medical Code Sets
Standard Code Set Name
Code Set Functionality
Maintained or Established
by:
International Classification of
Diseases, 9th revision, Clinical
Modification (ICD-9-CM)
Volumes 1 & 2
Diagnosis
International Classification of
Diseases, 9th revision, Clinical
Modification (ICD-9-CM)
Volume 3
Current Procedure Terminology
(CPT) codes
Health Care Common Procedure
Coding System (HCPCS)
Inpatient hospital procedures
National Center for Health
Statistics, Centers for Disease
Control (CDC) within the
Department of Health and
Human Services (HHS)
Center for Medicare and
Medicaid Services (CMS)
Code of Dental Procedures and
Nomenclature (CDT)
National Drug Codes (NDC)
Physician services/other health
services
Physician services/other health
services and medical supplies,
orthotics and durable medical
equipment
Dental Services
American Medical Association
Drugs/biologics
FDA
Center for Medicare and
Medicaid Services (CMS)
American Dental Association
34
1.
HCPCS can be purchased from the American Medical Association at 1-800-621-8335. For more
information and resources from the American Medical Association go to: http://www.amaassn.org/
2. To access the complete NDC code set go to:
http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm
International Classification of Diseases, 10th revision, Clinical Modification ICD-10-CM is the new
diagnosis coding system that was developed as a replacement for ICD-9-CM, Volume 1 & 2.
International Classification of Diseases, 10th revision, Procedure Coding System ICD-10-PCS is the new
procedure coding system that was developed as a replacement for ICD-9-CM, volume 3. The
compliance date for implementing and adopting ICD-10-CM for diagnosis and ICD-10-PCS for
inpatient hospital procedures was October 1, 2013.
HIPAA Electronic Transactions
There are currently eight electronic standardized transactions that are mandated by HIPAA regulations
(listed below). Updates to these transactions (270/271 and 276/277) will take place during the first
quarter of 2014 and be posted on the Provider Portal.
If you have questions or would like to utilize the HIPAA standard transactions please contact
[email protected].
Transaction
Transaction Number
Health claims or equivalent
encounter information
Enrollment and disenrollment in a
health plan
Health plan eligibility solicitations
and response
837 Professional, 837 Institutional
Y
834
N
Health care payment and
remittance advice
Health plan premium payment
Health claim status
835
Coordination of benefits
Referral certification and
authorization
837 Professional and Institutional Claims
278
270 (Request)/ 271 (Response)
820
276 (Request)/277 (Response)
Utilized by CIP
N
Alternative
Method
Y
N
N
Alternative
Method
Y
N
Though it is standard operating process, Care Improvement Plus does not currently utilize all standard
transaction sets. Functionality equivalent to that which is offered by these transaction sets is made
available to Care Improvement Plus Members and Providers such as online tools.
Care Improvement Plus currently offers an alternative through the online web tool using Care
Improvement Plus’s secure Provider Portal for the following transactions:
ASC X12 270 Health Plan Eligibility Solicitations
ASC X12 271 Response
ASC X12 276 Health Claim Status Request
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ASC X12 277 Health Claim Status Response
National Provider Identifier (NPI)
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA)
Administrative Simplification Standard. The NPI is a unique identification number for covered health
care providers. Covered health care providers and all health plans and health care clearinghouses must
use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry
other information about health care providers, such as the state in which they live or their medical
specialty. The NPI must be used in lieu of legacy provider identifiers in all electronic HIPAA standards
transactions.
As outlined in the Federal Regulation, covered providers must also share their NPI with other providers,
health plans, clearinghouses, and any entity that may need it for billing purposes.
All Care Improvement Plus providers must attest a valid NPI upon application for network participation.
For any questions about NPI, please contact Provider Relations at: 1-866-679-3119.
SECTION P – LEGAL NOTICES
Subrogation
If we make any payment to you or on your behalf for covered services, we are entitled to be fully
subrogated to any and all rights you have against any person, entity, or insurer that may be responsible
for payment of medical expenses and/or benefits related to your injury, illness, or condition. We are
entitled to exercise the same rights of subrogation and recovery that are accorded to the Medicare
Program under the Medicare Secondary Payer rules.
Once we have made a payment for covered services, we shall have a lien on the proceeds of any
judgment, settlement, or other award or recovery you receive, including but not limited to the following:
1. Any award, settlement, benefits, or other amounts paid under any workers’ compensation law or
award;
2. Any and all payments made directly by or on behalf of a third-party tortfeasor or person, entity, or
insurer responsible for indemnifying the third-party tortfeasor;
3. Any arbitration awards, payments, settlements, structured settlements, or other benefits or
amounts paid under an uninsured or underinsured motorist coverage policy;
4. Any other payments designated, earmarked, or otherwise intended to be paid to you as
compensation, restitution, or remuneration for your injury, illness, or condition suffered as a result
of the negligence or liability of a third party.
You agree to cooperate with us and any of our representatives and to take any actions or steps necessary
to secure our lien, including but not limited to:
1. Responding to requests for information about any accidents or injuries;
36
2. Responding to our requests for information and providing any relevant information that we have
requested; and
3. Participating in all phases of any legal action we commence in order to protect our rights,
including, but not limited to, participating in discovery, attending depositions, and appearing and
testifying at trial.
In addition, you agree not to do anything to prejudice our rights, including, but not limited to, assigning
any rights or causes of action that you may have against any person or entity relating to your injury,
illness, or condition without our prior express written consent. Your failure to cooperate shall be deemed
a breach of your obligations, and we may institute a legal action against you to protect our rights.
Reimbursement
We are also entitled to be fully reimbursed for any and all benefit payments we make to you or on your
behalf that are the responsibility of any person, organization, or insurer. Our right of reimbursement is
separate and apart from our subrogation right, and is limited only by the amount of actual benefits paid
under our plan. You must immediately pay to us any amounts you recover by judgment, settlement,
award, recovery, or otherwise from any liable third party, his or her insurer, to the extent that we paid out
or provided benefits for your injury, illness, or condition during your enrollment in our plan.
Antisubrogation rules do not apply
Our subrogation and reimbursement rights shall have first priority, to be paid before any of your other
claims are paid. Our subrogation and reimbursement rights will not be affected, reduced, or eliminated by
the "made whole" doctrine or any other equitable doctrine. We are not obligated to pursue subrogation or
reimbursement either for our own benefit or on your behalf. Our rights under Medicare law and this
Evidence of Coverage shall not be affected, reduced, or eliminated by our failure to intervene in any legal
action you commence relating to your injury, illness, or condition.
37
Appendix
38
APPENDIX A – Sample Care Improvement Plus Member Identification Cards
39
APPENDIX B
– Care Improvement Plus UM Provider Fact Sheet of Auth Rules- 2015
*These rules are designed to promote effective and efficient care management for the benefit of CIP members, and will be applied consistent with CMS and contractual requirements.
*All services are subject to member eligibility and benefits limitations. An authorization does not guarantee payment. Medical necessity will need to be established.
*Failure to obtain authorizations beyond emergency and post-stabilization services may result in delays or denials of payment or additional administrative requirements.
* The Care Improvement Plus Utilization Management office is closed on weekends/holidays for routine requests. Clinical information is due on the next business day.
* Providers must be Medicare certified to provide services.
Inpatient Hospital Admissions all require
notification
No preauthorization is required for emergency services. However, all inpatient admissions require notification. Consistent with
NCQA guidelines, the plan must have a report of all admissions within 1 business day of the admission, Discharge planning
coordination is required. Please fax the admission face sheet, admitting H&P, diagnosis with ICD-9 diagnosis codes. Once the
CIP beneficiary is admitted, the facility is expected to fax all supporting clinical documentation, including but not limited to the
inpatient admission order.
Behavioral Health Services
For all behavioral health services (inpatient and outpatient), please call 1-888-751-1235
Skilled Nursing Facility, Inpatient Rehab
Facilities (Acute Rehab) and Long Term Acute
Care (LTAC)
All skilled nursing facility, inpatient rehab facility, and long term acute care facility admissions require preauthorization in
advance of the admission. An updated authorization is required in advance of a continued inpatient stay beyond the initial
authorization period. Initial requests must include discharge summary MD Order from hospital and PT/OT evaluations. The Plan
will notify the provider of the determination within 2 business days of receipt of all necessary/requested information.
All home health services require Pre-authorization during the first week of services. Requests must include number of visits
and services requested (skilled nsg, PT/OT, SW), ICD-9 codes, CPT codes, start of care date and MD order and/or 485 POC.
For all RECERTIFICATIONS we will require the 485 plan of care, the previous certification SIGNED 485 POC, documentation of
face to face, specific services requested, nursing and therapy progress notes. Information should be received within 72 hours of
expiration of previous episode. Plan will notify provider of determination within 14 business days of receipt of all clinical
information.
Home Health Services (physical therapy,
occupational therapy, speech therapy,
medical social worker, etc.)
Home Infusion Services
ALL HOME INFUSION services require PRIOR AUTHORIZATION BEFORE initiating care.
Elective Hospital Services: Transplant (Organ
and Bone Marrow), Blepharoplasty, Bariatric
(Weight Loss), LVAD Procedures, Elective
Permanent Pacers and ICD’s
Require preauthorization. Requests should be submitted at least 14 calendar days prior to the scheduled procedure/service
with the supporting clinical information. Experimental procedures (without FDA approval) are not generally covered.
Power Operated Vehicles and Power
Wheelchairs (rental and purchase)
Require preauthorization in advance. Submit MD order, completed physical therapy eval (if applicable), face to face exam,
applicable physician office notes, and any other clinical information supporting the request. Include HCPCS codes, and ICD-9
codes.
Prosthetics (lower limb)
Negative Pressure Wound Therapy
(Wound Vac)
Bone Growth Stimulators (long bone and
spine)
Require preauthorization in advance. Submit MD order, clinical documentation denoting the member’s past medical history,
reason for amputation, current condition, and status of residual limb, desire to ambulate, and clinical assessment of rehabilitation
potential. Include HCPCS codes, and ICD-9 codes.
Require preauthorization in advance. Submit MD order, clinical documentation of wound history including measurements,
staging, and complete description of wounds and past treatment plans. Include HCPCS codes, and ICD-9 codes.
Require preauthorization in advance. Submit MD order, clinical documentation which details prior treatment plan, diagnostic
result which confirms non-union of fracture (for long bones) or for spinal devices documentation of failed fusion surgeries and/or
recent multilevel fusion procedures (for spinal devices). For pain management devices, include previous medical management
treatments, psychological/physical evaluations. Include HCPCS, diagnoses, and ICD-9 codes.
Pain Management Devices (spinal cord)
Air Fluidized Beds (at home)
Lymphedema Pumps (Pneumatic
Compression Devices)
Require preauthorization in advance. Submit MD order, clinical documentation of wound history including measurements,
staging, complete description of wounds, past treatment plans, neuro status, mobility status, nutritional status. Include HCPCS,
and ICD-9 codes.
Require preauthorization in advance. Submit MD order, H&P, diagnostic test results. Include HCPCS, and ICD-9 codes.
IMPORTANT PHONE NUMBERS
Phone: 1-888-625-2204
Fax: HOME HEALTH = 866-219-2923
Preauthorization for, SNF, Home Health, Acute
Rehab, LTAC, DME and elective hospital
admissions.
Notification for emergency inpatient hospital
admissions (medical/surgical) and inpatient
hospital admissions
Fax: SNF/LTAC/IRF = 866-304-2382
Fax: INPATIENT HOSPITALADMISSION NOTIFICATIONS/Blepharoplasty/Bariatric/LVAD/Electives = 800-211-6490
Fax: DME/ELECTIVE HOSPITAL SERVICES = 866-224-1151
Fax: EXPEDITED = 888-579-9899
Expedited Fax line: Please utilize this fax line only if the physician ordering the service indicates that applying the
standard time for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to
regain maximum function. Expedited requests determinations are rendered in 72 hours. CIP determinations for LTACH, SNF
and IRF requests are processed within 2 business days of submission of complete information.
Transplants
Phone 1-866-460-8699 option 3, Fax: 443-853-2771
Member Services
Transportation Services
UHC Vision/Dental Services
1-800-204-1002
1-855-693-2897
1-800-638-3120 (Vision) 1-844-275-8750 (Dental)
Provider Services/Claims Inquiries
1-866-679-3119
Pharmacy Services/OptumRx
Appeals and Retrospective Review
1-800-204-1002
1-877-262-9203
1-866-683-2073
1- 800-204-1002
MEDICAL CLAIMS ADDRESS:CARE IMPROVEMENT PLUS, PO BOX 488 Linthicum, MD 210900488
EDI Claims: payer ID 77082
40
PHARMACY CLAIMS ADDRESS: OptumRx, PO Box 29045
Expedited and Medical Necessity Appeals (for denied medical claims)
UM Retrospective Review for Pended Claims
Pharmacy Appeals
APPENDIX C– Sample Explanation of Payment (EOP)
41
APPENDIX D-Notice of Privacy Practices
HEALTH PLAN NOTICES OF PRIVACY PRACTICES
NOTICE FOR MEDICAL INFORMATION: Pages 1-6.
NOTICE FOR FINANCIAL INFORMATION: Pages 7-8.
MEDICAL INFORMATION PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Effective September 23, 2013
We1 are required by law to protect the privacy of your health information. We are also required to send you this notice,
which explains how we may use information about you and when we can give out or "disclose" that information to others.
You also have rights regarding your health information that are described in this notice. We are required by law to abide
by the terms of this notice.
The terms “information” or “health information” in this notice include any information we maintain that reasonably can
be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or
the payment for such health care. We will comply with the requirements of applicable privacy laws related to notifying
you in the event of a breach of your health information.
We have the right to change our privacy practices and the terms of this notice. If we make a material change to our
privacy practices, we will provide to you, in our next annual distribution, either a revised notice or information about the
material change and how to obtain a revised notice. We will provide you with this information either by direct mail or
electronically, in accordance with applicable law. In all cases, we will post the revised notice on your health plan website,
such as www.careimprovementplus.com. We reserve the right to make any revised or changed notice effective for
information we already have and for information that we receive in the future.
UnitedHealth Group collects and maintains oral, written and electronic information to administer our business and to
provide products, services and information of importance to our enrollees. We maintain physical, electronic and
procedural security safeguards in the handling and maintenance of our enrollees’ information, in accordance with
applicable state and federal standards, to protect against risks such as loss, destruction or misuse.
How We Use or Disclose Information
We must use and disclose your health information to provide that information:


To you or someone who has the legal right to act for you (your personal representative) in order to administer your
rights as described in this notice; and
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected.
We have the right to use and disclose health information for your treatment, to pay for your health care and to operate
our business. For example, we may use or disclose your health information:
42
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




For Payment of premiums due us, to determine your coverage, and to process claims for health care services you
receive, including for subrogation or coordination of other benefits you may have. For example, we may tell a doctor
whether you are eligible for coverage and what percentage of the bill may be covered.
For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care.
For example, we may disclose information to your physicians or hospitals to help them provide medical care to you.
For Health Care Operations. We may use or disclose health information as necessary to operate and manage our
business activities related to providing and managing your health care coverage. For example, we might talk to your
physician to suggest a disease management or wellness program that could help improve your health or we may
analyze data to determine how we can improve our services.
To Provide You Information on Health Related Programs or Products such as alternative medical treatments and
programs or about health-related products and services, subject to limits imposed by law.
For Plan Sponsors. If your coverage is through an employer sponsored group health plan, we may share summary
health information and enrollment and disenrollment information with the plan sponsor. In addition, we may share
other health information with the plan sponsor for plan administration purposes if the plan sponsor agrees to special
restrictions on its use and disclosure of the information in accordance with federal law.
For Underwriting Purposes. We may use or disclose your health information for underwriting purposes; however,
we will not use or disclose your genetic information for such purposes.
For Reminders. We may use or disclose health information to send you reminders about your benefits or care, such
as appointment reminders with providers who provide medical care to you.
We may use or disclose your health information for the following purposes under limited circumstances:












As Required by Law. We may disclose information when required to do so by law.
To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your
care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or
when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, we will use
our best judgment to decide if the disclosure is in your best interests. Special rules apply regarding when we may
disclose health information to family members and others involved in a deceased individual’s care. We may disclose
health information to any persons involved, prior to the death, in the care or payment for care of a deceased
individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the
deceased.
For Public Health Activities such as reporting or preventing disease outbreaks to a public health authority.
For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by
law to receive such information, including a social service or protective service agency.
For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure,
governmental audits and fraud and abuse investigations.
For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena.
For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for
purposes such as providing limited information to locate a missing person or report a crime.
To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing
information to public health agencies or law enforcement authorities, or in the event of an emergency or natural
disaster.
For Specialized Government Functions such as military and veteran activities, national security and intelligence
activities, and the protective services for the President and others.
For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers
compensation laws that govern job-related injuries or illness.
For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or
disability, if the research study meets federal privacy law requirements.
To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to
identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to
funeral directors as necessary to carry out their duties.
43




For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking
or transplantation of organs, eyes or tissue to facilitate donation and transplantation.
To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or
under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the
correctional institution.
To Business Associates that perform functions on our behalf or provide us with services if the information is
necessary for such functions or services. Our business associates are required, under contract with us and pursuant to
federal law, to protect the privacy of your information and are not allowed to use or disclose any information other
than as specified in our contract and as permitted by federal law.
Additional Restrictions on Use and Disclosure. Certain federal and state laws may require special privacy
protections that restrict the use and disclosure of certain health information, including highly confidential information
about you. “Highly confidential information” may include confidential information under Federal laws governing
alcohol and drug abuse information and genetic information as well as state laws that often protect the following types
of information:
1. HIV/AIDS;
2. Mental health;
3. Genetic tests;
4. Alcohol and drug abuse;
5. Sexually transmitted diseases and reproductive health information; and
6. Child or adult abuse or neglect, including sexual assault.
If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws
that apply to us, it is our intent to meet the requirements of the more stringent law. Attached to this notice is a “Federal
and State Amendments” document.
Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health
information only with a written authorization from you. This includes, except for limited circumstances allowed by
federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others, or
using or disclosing your health information for certain promotional communications that are prohibited marketing
communications under federal law, without your written authorization. Once you give us authorization to release your
health information, we cannot guarantee that the recipient to whom the information is provided will not disclose the
information. You may take back or "revoke" your written authorization at anytime in writing, except if we have already
acted based on your authorization. To find out where to mail your written authorization and how to revoke an
authorization, contact the phone number listed on the back of your ID card.
What Are Your Rights
The following are your rights with respect to your health information:


You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care
operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in
your health care or payment for your health care. We may also have policies on dependent access that authorize your
dependents to request certain restrictions. Please note that while we will try to honor your request and will permit
requests consistent with our policies, we are not required to agree to any restriction.
You have the right to ask to receive confidential communications of information in a different manner or at a
different place (for example, by sending information to a P.O. Box instead of your home address). We will
44




accommodate reasonable requests where a disclosure of all or part of your health information otherwise could
endanger you. In certain circumstances, we will accept your verbal request to receive confidential communications,
however, we may also require you confirm your request in writing. In addition, any requests to modify or cancel a
previous confidential communication request must be made in writing. Mail your request to the address listed below.
You have the right to see and obtain a copy of certain health information we maintain about you such as claims and
case or medical management records. If we maintain your health information electronically, you will have the right to
request that we send a copy of your health information in an electronic format to you. You can also request that we
provide a copy of your information to a third party that you identify. In some cases you may receive a summary of
this health information. You must make a written request to inspect and copy your health information or have your
information sent to a third party. Mail your request to the address listed below. In certain limited circumstances, we
may deny your request to inspect and copy your health information. If we deny your request, you may have the right
to have the denial reviewed. We may charge a reasonable fee for any copies.
You have the right to ask to amend certain health information we maintain about you such as claims and case or
medical management records, if you believe the health information about you is wrong or incomplete. Your request
must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed
below. If we deny your request, you may have a statement of your disagreement added to your health information.
You have the right to receive an accounting of certain disclosures of your information made by us during the six
years prior to your request. This accounting will not include disclosures of information made: (i) for treatment,
payment, and health care operations purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional
institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to
provide an accounting.
You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you
have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You also may also
obtain a copy of this notice on your health plan website, such as www.careimprovementplus.com.
Exercising Your Rights

Contacting your Health Plan. If you have any questions about this notice or want information about exercising your
rights, please call the toll-free member phone number on the back of your health plan ID card or you may
contact a Care Improvement Plus at 800-204-1002.

Submitting a Written Request. Mail to us your written requests to exercise any of your rights, including modifying
or cancelling a confidential communication, requesting copies of your records, or requesting amendments to your
record, at the following address:
UnitedHealthcare
Government Programs Privacy Office
MN006-W800
PO Box 1459
Minneapolis, MN 55440

Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the
address listed above.
45
You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We
will not take any action against you for filing a complaint.
1
This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with
UnitedHealth Group: ACN Group of California, Inc.; All Savers Insurance Company; All Savers Life Insurance
Company of California; AmeriChoice of Connecticut, Inc.; AmeriChoice of Georgia, Inc.; AmeriChoice of New Jersey,
Inc.; Arizona Physicians IPA, Inc.; Care Improvement Plus of Maryland, Inc.; Care Improvement Plus of Texas Insurance
Company; Care Improvement Plus South Central Insurance Company; Care Improvement Plus Wisconsin Insurance
Company; Citrus Health Care, Inc.; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.;
Evercare of Arizona, Inc.; Golden Rule Insurance Company; Health Plan of Nevada, Inc.; MAMSI Life and Health
Insurance Company; MD - Individual Practice Association, Inc.; Medical Health Plans of Florida, Inc.; Medica
HealthCare Plans, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.; Neighborhood Health
Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans
(CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; PacifiCare Life and Health Insurance
Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of Colorado, Inc.; PacifiCare of
Nevada, Inc.; Physicians Health Choice of New York, Inc.; Physicians Health Choice of Texas, LLC; Preferred Partners,
Inc.; Sierra Health and Life Insurance Company, Inc.; UHC of California; U.S. Behavioral Health Plan, California;
Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Health Plan of Delaware, Inc.;
Unison Health Plan of the Capital Area, Inc.; United Behavioral Health; UnitedHealthcare Benefits of Texas, Inc.;
UnitedHealthcare Community Plan, Inc.; UnitedHealthcare Community Plan of Texas, L.L.C.; UnitedHealthcare
Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New
York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Life Insurance Company;
UnitedHealthcare of Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.;
UnitedHealthcare of Colorado, Inc.; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.;
UnitedHealthcare of Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of Louisiana, Inc.;
UnitedHealthcare of Mid-Atlantic, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.;
United HealthCare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New Mexico, Inc.;
UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.;
UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.;
UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.; UnitedHealthcare
of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc.
46
FINANCIAL INFORMATION PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW FINANCIAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Effective September 23, 2013
We2 are committed to maintaining the confidentiality of your personal financial information. For the purposes of this
notice, “personal financial information” means information about an enrollee or an applicant for health care coverage that
identifies the individual, is not generally publicly available, and is collected from the individual or is obtained in
connection with providing health care coverage to the individual.
Information We Collect
We collect personal financial information about you from the following sources:



Information we receive from you on applications or other forms, such as name, address, age, medical information and
Social Security number;
Information about your transactions with us, our affiliates or others, such as premium payment and claims history; and
Information from consumer reports.
Disclosure of Information
We do not disclose personal financial information about our enrollees or former enrollees to any third party, except as
required or permitted by law. For example, in the course of our general business practices, we may, as permitted by law,
disclose any of the personal financial information that we collect about you, without your authorization, to the following
types of institutions:



To our corporate affiliates, which include financial service providers, such as other insurers, and non-financial
companies, such as data processors;
To nonaffiliated companies for our everyday business purposes, such as to process your transactions, maintain
your account(s), or respond to court orders and legal investigations; and
To nonaffiliated companies that perform services for us, including sending promotional communications on our
behalf.
Confidentiality and Security
We maintain physical, electronic and procedural safeguards, in accordance with applicable state and federal standards, to
protect your personal financial information against risks such as loss, destruction or misuse. These measures include
computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information.
Questions About this Notice
If you have any questions about this notice, please call the toll-free member phone number on the back of your health
plan ID card or contact 800-204-1002.
For purposes of this Financial Information Privacy Notice, “we” or “us” refers to the entities listed in footnote 1,
beginning on the first page of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates:
AmeriChoice Health Services, Inc.; Dental Benefit Providers, Inc.; HealthAllies, Inc.; MAMSI Insurance Resources,
LLC; Managed Physical Network, Inc.; OneNet PPO, LLC; Oxford Benefit Management, Inc.; Oxford Health Plans LLC;
47
2
ProcessWorks, Inc.; Spectera, Inc.; UMR, Inc.; Unison Administrative Services, LLC; United Behavioral Health of New
York I.P.A., Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC; UnitedHealthcare Service LLC;
UnitedHealthcare Services Company of the River Valley, Inc.; UnitedHealthOne Agency, Inc. This Financial Information
Privacy Notice only applies where required by law. Specifically, it does not apply to (1) health care insurance products
offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life Insurance Company, Inc.; or (2) other
UnitedHealth Group health plans in states that provide exceptions for HIPAA covered entities or health insurance
products.
48
UNITEDHEALTH GROUP
HEALTH PLAN NOTICE OF PRIVACY PRACTICES:
FEDERAL AND STATE AMENDMENTS
Revised: June 30, 2013
The first part of this Notice, which provides our privacy practices for Medical Information (pages 1-6), describes how we
may use and disclose your health information under federal privacy rules. There are other laws that may limit our rights
to use and disclose your health information beyond what we are allowed to do under the federal privacy rules. The
purpose of the charts below is to:
1. show the categories of health information that are subject to these more restrictive laws; and
2. give you a general summary of when we can use and disclose your health information without your consent.
If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the
applicable federal or state law.
Summary of Federal Laws
Alcohol & Drug Abuse Information
We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain
limited circumstances, and/or disclose only (2) to specific recipients.
Genetic Information
We are not allowed to use genetic information for underwriting purposes.
Summary of State Laws
General Health Information
We are allowed to disclose general health information only (1) under
certain limited circumstances, and /or (2) to specific recipients.
CA, NE, PR, RI, VT, WA, WI
HMOs must give enrollees an opportunity to approve or refuse
disclosures, subject to certain exceptions.
KY
You may be able to restrict certain electronic disclosures of health
information.
NC, NV
We are not allowed to use health information for certain purposes.
CA, IA
We will not use and/or disclosure information regarding certain public
assistance programs except for certain purposes
MO, NJ, SD
49
Prescriptions
We are allowed to disclose prescription-related information only (1)
under certain limited circumstances, and /or (2) to specific recipients.
ID, NH, NV
Communicable Diseases
We are allowed to disclose communicable disease information only (1)
under certain limited circumstances, and /or (2) to specific recipients.
AZ, IN, KS, MI, NV, OK
Sexually Transmitted Diseases and Reproductive Health
We are allowed to disclose sexually transmitted disease and/or
reproductive health information only (1) under certain limited
circumstances and/or (2) to specific recipients.
CA, FL, IN, KS, MI, MT, NJ, NV, PR, WA, WY
Alcohol and Drug Abuse
We are allowed to use and disclose alcohol and drug abuse
information (1) under certain limited circumstances, and/or disclose
only (2) to specific recipients.
CT, GA, KY, IL, IN, IA, LA, MN, NC, NH, WA, WI
Disclosures of alcohol and drug abuse information may be restricted
by the individual who is the subject of the information.
WA
Genetic Information
We are not allowed to disclose genetic information without your
written consent.
CA, CO, IL, KS, KY, LA, NY, RI, TN, WY
We are allowed to disclose genetic information only (1) under certain
limited circumstances and/or (2) to specific recipients.
AK, AZ, FL, GA, IA, MD, MA, MO, NJ, NV, NH,
NM, OR, RI, TX, UT, VT
Restrictions apply to (1) the use, and/or (2) the retention of genetic
information.
FL, GA, IA, LA, MD, NM, OH, UT, VA, VT
HIV / AIDS
We are allowed to disclose HIV/AIDS-related information only (1)
under certain limited circumstances and/or (2) to specific recipients.
AZ, AR, CA, CT, DE, FL, GA, IA, IL, IN, KS, KY,
ME, MI, MO, MT, NY, NC, NH, NM, NV, OR, PA,
PR, RI, TX, VT, WV, WA, WI, WY
Certain restrictions apply to oral disclosures of HIV/AIDS-related
information.
CT, FL
Mental Health
We are allowed to disclose mental health information only (1) under
certain limited circumstances and/or (2) to specific recipients.
CA, CT, DC, IA, IL, IN, KY, MA, MI, NC, NM, PR,
TN, WA, WI
50
Disclosures may be restricted by the individual who is the subject of
the information.
WA
Certain restrictions apply to oral disclosures of mental health
information.
CT
Certain restrictions apply to the use of mental health information.
ME
Child or Adult Abuse
We are allowed to use and disclose child and/or adult abuse
information only (1) under certain limited circumstances, and/or
disclose only (2) to specific recipients.
AL, CO, IL, LA, NE, NJ, NM, RI, TN, TX, UT, WI
51
APPENDIX F – Maximum Expected Waiting Times
Maximum Expected Waiting Times:











Appointment/Waiting Time - Usual and customary not to exceed thirty (30) calendar days for regular
appointments and forty eight (48) hours for urgent care
In-Office Waiting Time - Members with appointments shall not routinely be made to wait longer than
one (1) hour
Emergency Care - Emergency care must be provided as the situation dictates. In general, emergency
care must be given in accordance to the time frame dictated by the nature of the emergency, at the
nearest available facility, twenty-four (24) hours a day, seven (7) days a week, regardless of contracts.
All emergency care must be provided on an immediate basis at the nearest facility available, regardless
of contracting arrangements
Urgent Care - Triage and appropriate treatment shall be provided on the same or next day
Non-Urgent Problems and Routine Primary Care - Appointments for non-urgent care and routine
primary care shall be provided within three (3) weeks of participant request
Specialty Care - Referral appointments to specialists, except for specialists providing mental health and
substance abuse services (e.g., specialty physician services, hospice care, home health care and certain
rehabilitation services, etc.), shall not exceed thirty (30) calendar days for routine care or forty eight
(48) hours for urgent care
General Optometry Services - Plan Providers must have a system in place to document compliance
with the following appointment scheduling time frames listed below. PHP monitors compliance with
appointment/waiting time standards as part of the required surveys and monitoring requirements
Transport Time - Transport time will be the usual and customary, not to exceed one (1) hour, except in
areas where community access standards and documentation will apply
Pharmacy Services - Plan Providers must have a system in place to document compliance with the
following appointment scheduling time frames listed below. PHP monitors compliance with
appointment/waiting time standards as part of the required surveys and monitoring requirements
Lab and X-Ray Services - Plan Providers must have a system in place to document compliance with
appointment scheduling time frames. PHP monitors compliance with appointment/waiting time
standards as part of required surveys and monitoring requirements
All Other Services - All other services not specified here shall meet the usual and customary standards
for the community
52
APPENDIX G – Chronic Condition Disease State Verification Form
53
54
APPENDIX H – Non-Contracted Provider Appeals and Dispute Process
Attention Non-Contracted Medicare Providers
Appeals Process for Non-contracted Medicare Providers
Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request
reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a claim denial,
submit a written request within 60 calendar days of the remittance notification date and include at a minimum:





A statement indicating factual or legal basis for appeal
A signed Waiver of Liability form (you may obtain a copy at www.careimprovementplus.com)
A copy of the original claim
A copy of the remittance notice showing the claim denial
Any additional information, clinical records or documentation
Mail the appeal request to:
Elkridge, MD 21075
Payment Dispute Process for Non-contracted Medicare Providers
Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may file a
payment dispute for a Medicare Advantage plan payment determination. A payment dispute may be filed when the
provider disagrees with the amount paid, including issues related to bundling of services. To dispute a claim denial,
submit a written request within 120 calendar days of the remittance notification date and include at a minimum:




A statement indicating factual or legal basis for the dispute
A copy of the original claim
A copy of the remittance notice showing the claim payment
Any additional information, clinical records or documentation to support the dispute
A payment dispute form can be found at: Payment Dispute Form.
Mail the payment dispute to:
Elkridge, MD 21075
For additional information on the dispute process including a payment dispute form, please go to the Payment
Dispute Form.
55

section g – use of ancillary providers

Transcription

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