cal mediconnect plan provider manual

Transcription

CAL MEDICONNECT PLAN
PROVIDER MANUAL
Effective January 1, 2015
Los Angeles County
California
Table of Contents
CareMore Health Plan of California
Cal MediConnect
Table of Contents
CHAPTER 1: INTRODUCTION .............................................................. 12
Welcome to the Provider Manual ............................................................................................... 12
CareMore Service Area ................................................................................................................ 12
Using This Manual ........................................................................................................................ 12
Provider Portal Access and Training ............................................................................................ 13
How to Access Information and Forms on the Provider Portal Website .................................... 13
Legal and Administrative Requirements...................................................................................... 13
Disclaimer................................................................................................................................. 13
Third Party Websites ................................................................................................................ 14
Privacy and Security Statements ............................................................................................. 14
Confidentiality and Disclosure of Medical Information............................................................... 15
Collection of Personal and Clinical Information ...................................................................... 15
Maintenance of Confidential Information ............................................................................... 15
Member Consent ..................................................................................................................... 16
Member Access to Medical Records ........................................................................................ 16
Disease Management Organizations ....................................................................................... 16
Release of Confidential Information ............................................................................................ 17
Archived Files/Medical Records ............................................................................................... 20
Misrouted Protected Health Information ................................................................................ 20
CHAPTER 2: IMPORTANT CONTACT INFORMATION ........................... 21
CareMore Care Centers Contact Information, Services and Programs ....................................... 21
Other CareMore Contact Information ......................................................................................... 22
State of California Contacts ......................................................................................................... 24
CHAPTER 3: MEMBER BENEFITS......................................................... 26
CareMore Cal Medi-Connect Health Plan Overview ................................................................... 26
Covered Medicare and Medi-Cal Services ................................................................................... 27
Benefits Matrix for Members ...................................................................................................... 27
Outpatient Ancillary Services ....................................................................................................... 31
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Pharmacy Services ....................................................................................................................... 31
Overview .................................................................................................................................. 31
Formulary ................................................................................................................................. 32
Requests for Formulary Changes ............................................................................................. 32
Notification of FDA Recalls ....................................................................................................... 32
Preferred Diabetic Supplies ..................................................................................................... 32
Scripts Provider Newsletter ..................................................................................................... 33
Vision Services ............................................................................................................................. 33
CHAPTER 4: LONG TERM SERVICES AND SUPPORTS (LTSS) ................. 34
Overview ...................................................................................................................................... 34
In-Home Support Services (IHSS) ................................................................................................. 34
Eligibility ................................................................................................................................... 34
County Public Authority ........................................................................................................... 34
Who is Eligible for In-Home Supportive Services (IHSS) .......................................................... 35
IHSS- Referral Process .............................................................................................................. 35
Member Control ...................................................................................................................... 35
Community Based Adult Services (CBAS) .................................................................................... 35
Multipurpose Senior Services Program (MSSP) ........................................................................... 36
MSSP – Referral........................................................................................................................ 37
MSSP Waiver Services .............................................................................................................. 37
Long-Term Services and Supports ............................................................................................... 38
Responsibilities of the LTSS Provider ........................................................................................... 38
Interactive Voice Response Requirements of Providers ............................................................. 39
Identifying and Verifying the Long-Term Care Member.............................................................. 39
Nursing Home Eligibility ............................................................................................................... 39
Covered Health Services .............................................................................................................. 39
Home and Community Services ............................................................................................... 39
CareMore Coordinator................................................................................................................. 40
Consumer Direction ..................................................................................................................... 41
Discharge Planning....................................................................................................................... 41
Medical and Nonmedical Absences ............................................................................................. 42
Member Liability (Share of Cost) ................................................................................................. 42
Our Approach to Skilled Nursing Facility Member Liability/Share of Cost .................................. 44
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Long-Term Care Ethics and Quality Committee .......................................................................... 46
Claims and Reimbursement Procedures ..................................................................................... 46
Precertification Requirements ................................................................................................. 46
Reimbursement to Multipurpose Senior Services Program Providers ........................................ 47
CHAPTER 5: MEMBER SERVICES ......................................................... 48
Member Services ......................................................................................................................... 48
Health Risk Assessments.............................................................................................................. 48
Appointment Scheduling ............................................................................................................. 49
Routine Podiatry Services Appointment Line .......................................................................... 49
Transportation Scheduling ....................................................................................................... 49
Nurse Helpline ............................................................................................................................. 50
Translation, Interpreter and Sign Language Services .................................................................. 50
CHAPTER 6: MEMBER ENROLLMENT AND ELIGIBILITY ........................ 52
Member Enrollment .................................................................................................................... 52
Member Eligibility ........................................................................................................................ 52
Eligibility Verification Process .................................................................................................. 52
Eligibility/Discrepancy .............................................................................................................. 52
Dual Eligible Population ........................................................................................................... 53
Member Identification Cards ....................................................................................................... 53
Overview .................................................................................................................................. 53
Health Plan Identification Card ................................................................................................ 54
CHAPTER 7: CLAIMS PROCESSING ...................................................... 56
Claims Submission Guidelines ..................................................................................................... 56
Overview .................................................................................................................................. 56
Electronic Claims .......................................................................................................................... 56
Paper Claims ................................................................................................................................ 56
Paper Claims Processing .......................................................................................................... 57
CMS-1500 Form ........................................................................................................................... 58
Claims Processing Timelines ........................................................................................................ 59
National Provider Identifier ......................................................................................................... 59
No NPI Required for Atypical Providers ................................................................................... 60
Coding .......................................................................................................................................... 60
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Clinical Submissions Categories ................................................................................................... 61
Claim Forms and Filing Limits ...................................................................................................... 62
Filing and Reimbursement Limits for Medi-Cal Claims ................................................................ 62
Other Filing Limits ........................................................................................................................ 64
Claims Returned for Additional Information ............................................................................... 65
Common Reasons for Rejected and Returned Claims ................................................................. 65
Claims and Encounter Data Inquiries........................................................................................... 66
Encounter Data ........................................................................................................................ 66
Claims Status Inquires .............................................................................................................. 67
Clean Claims Payment.................................................................................................................. 67
Payment of Claims ................................................................................................................... 67
Electronic Remittance Advice .................................................................................................. 68
Electronic Funds Transfer ........................................................................................................ 68
Procedure for Processing Overpayments .................................................................................... 68
Provider Payment Disputes ......................................................................................................... 68
Required Information for an Appeal ........................................................................................ 69
Submission of Provider Appeals .................................................................................................. 69
Hold Harmless .............................................................................................................................. 70
Coordination of Benefits .............................................................................................................. 70
Claims Filed With Wrong Plan ..................................................................................................... 71
Claims Follow-Up/Resubmissions ................................................................................................ 71
CHAPTER 8: BILLING PROFESSIONAL AND ANCILLARY CLAIMS ............ 72
Overview ...................................................................................................................................... 72
Anesthesia ................................................................................................................................ 73
Behavioral Health ..................................................................................................................... 73
Emergency Services ................................................................................................................. 73
E/M Coding – Consultations and Follow up Visits ....................................................................... 74
Ancillary Billing Requirements by Service Category .................................................................... 74
Disposable and Incontinence Medical Supplies....................................................................... 74
Durable Medical Equipment ........................................................................................................ 74
DME Rentals ............................................................................................................................. 75
DME Purchase .......................................................................................................................... 75
DME Wheelchairs/Scooters ..................................................................................................... 75
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DME Modifiers ......................................................................................................................... 76
Laboratory, Radiology and Diagnostic Services ........................................................................... 76
CMS-1500 Claim Form ................................................................................................................. 77
CMS-1500 Claim Form Fields ....................................................................................................... 77
CHAPTER 9: BILLING INSTITUTIONAL CLAIMS ..................................... 80
Overview ...................................................................................................................................... 80
Institutional Inpatient Coding ...................................................................................................... 80
Institutional Outpatient Coding ................................................................................................... 80
Emergency Room Visits ............................................................................................................... 81
Recommended Fields for CMS-1450 ........................................................................................... 81
CHAPTER 10: UTILIZATION MANAGEMENT ........................................ 85
Utilization Management Program ............................................................................................... 85
Medical Review Criteria ............................................................................................................... 85
The Referral Process .................................................................................................................... 86
Self-Referral Services ................................................................................................................... 87
Service Requests .......................................................................................................................... 87
Service Request and Service Request Form............................................................................. 87
Services Requiring Pre-service Review .................................................................................... 87
Services That Do Not Require Pre-service Review................................................................... 88
Service Request Function ......................................................................................................... 88
Determination Definitions ....................................................................................................... 89
Medical Necessity .................................................................................................................... 90
Authorization Expiration Time Frame ...................................................................................... 90
Unauthorized Care ................................................................................................................... 90
Retrospective Review............................................................................................................... 91
Utilization Management Contact Information ........................................................................ 91
Information for Specialists Only .................................................................................................. 91
Additional Services ................................................................................................................... 91
Current Procedure Terminology (CPT) Codes .......................................................................... 92
New Medical Problem.............................................................................................................. 92
Written Report to PCP ............................................................................................................. 92
Utilization Management Contact Information ........................................................................ 92
Durable Medical Equipment ........................................................................................................ 93
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Medically Necessary Services ...................................................................................................... 96
Emergency Room Utilization ....................................................................................................... 96
Pharmacy Formulary .................................................................................................................... 97
Prior Authorization/ Exception Requests ................................................................................ 97
Second Opinions .......................................................................................................................... 97
UM Committee ............................................................................................................................ 98
CHAPTER 11: CASE MANAGEMENT .................................................. 100
Model of Care ............................................................................................................................ 100
Case Management ..................................................................................................................... 101
Overview ................................................................................................................................ 101
Case Management Components............................................................................................ 102
Interdisciplinary Care Team (ICT)............................................................................................... 103
Role of Case Managers .............................................................................................................. 103
Case Management Interventions........................................................................................... 104
Hospitalist Program ................................................................................................................... 104
Communicable Disease Services ................................................................................................ 104
CHAPTER 12: HEALTH PROGRAMS AND EDUCATION ........................ 105
CareMore Programs & Services ................................................................................................. 105
Anti-Coagulation Center ........................................................................................................ 105
Chronic Kidney Disease Care Program ................................................................................... 105
Chronic Obstructive Pulmonary Disease Program ................................................................. 105
CareMore Care Center ........................................................................................................... 105
Congestive Heart Failure Care Program................................................................................. 105
Diabetes Management Program ............................................................................................ 106
Exercise and Strength-Training Program ............................................................................... 106
Fall Prevention Center ........................................................................................................... 106
Foot Center ............................................................................................................................ 106
Healthy Start .......................................................................................................................... 106
Hospitalist Program................................................................................................................ 106
Hypertension Program ........................................................................................................... 107
House Call Program ................................................................................................................ 107
Pre-Op Center ........................................................................................................................ 107
Touch Management Program ................................................................................................ 107
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Wound Care Center ............................................................................................................... 107
Health Education........................................................................................................................ 108
Health Education Services...................................................................................................... 108
Health Education Materials ....................................................................................................... 109
Newsletters ............................................................................................................................ 109
Individual Health Education and Behavioral Assessment (IHEBA) ............................................ 110
Health Education Compliance - Facility Site Reviews ................................................................ 110
CHAPTER 13: PROVIDER ROLES AND RESPONSIBILITIES .................... 111
The Primary Care Provider (PCP) ............................................................................................... 111
Primary Care Provider Role ........................................................................................................ 111
Provider Specialties.................................................................................................................... 112
Responsibilities of the Primary Care Provider ........................................................................... 112
Provider Access and Availability ................................................................................................ 114
Member Missed Appointments ................................................................................................. 115
Noncompliant Members ............................................................................................................ 116
Primary Care Provider Transfers ................................................................................................ 116
Provider Disenrollment Process ................................................................................................ 116
Covering Physicians.................................................................................................................... 117
Continuity of Care ...................................................................................................................... 117
Delivery of Primary Care ........................................................................................................ 119
Coordination of Services ........................................................................................................ 119
Specialty Care Providers ............................................................................................................ 120
Behavioral Health Providers ...................................................................................................... 120
Roles and Responsibilities ...................................................................................................... 120
Transition after Acute Psychiatric Care.................................................................................. 121
Reporting Changes in Address and/or Practice Status .............................................................. 121
Provider Termination Notification ............................................................................................. 121
Americans with Disabilities Act Requirements .......................................................................... 121
For more information visit http://www.ada.gov/. .................................................................... 121
Disclosure of Ownership and Exclusion from Federal Health Care Programs ........................... 121
Health Insurance Portability and Accountability Act (HIPAA) ................................................... 122
Medical Records......................................................................................................................... 123
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Confidentiality of Information ............................................................................................... 123
Misrouted Protected Health Information .............................................................................. 124
Security................................................................................................................................... 124
Storage and Maintenance ...................................................................................................... 124
Availability of Medical Records .............................................................................................. 124
Medical Record Documentation Standards ............................................................................... 125
Clinical Practice Guidelines ........................................................................................................ 126
Advance Directives..................................................................................................................... 127
Prohibited Activities ................................................................................................................... 127
Healthcare Effectiveness Data Information Set (HEDIS) Requirements .................................... 127
CHAPTER 14: PROVIDER GRIEVANCES AND APPEALS ....................... 129
Overview .................................................................................................................................... 129
Provider Grievances Relating to the Operation of the Plan ...................................................... 129
When to Expect Resolution for a Grievance or Appeal ............................................................. 130
Provider Dispute ........................................................................................................................ 130
Provider Appeals: Arbitration .................................................................................................... 131
CHAPTER 15: CREDENTIALING AND RE-CREDENTIALING ................... 132
Overview .................................................................................................................................... 132
Credentialing .............................................................................................................................. 132
Council for Affordable Quality Healthcare (CAQH) ................................................................... 133
Initial Credentialing .................................................................................................................... 135
Behavioral Health Provider Credentialing ................................................................................. 135
Long-Term Care Provider Credentialing .................................................................................... 136
Recredentialing .......................................................................................................................... 138
Providers Responsibilities & Rights during Credentialing/Recredentialing .............................. 138
Provider Rights to Review Credentialing Information ............................................................... 139
Groups Delegated for Credentialing .......................................................................................... 140
Facility Site Reviews ................................................................................................................... 141
CHAPTER 16: MEMBER RIGHTS AND RESPONSIBILITIES .................... 142
Member Rights and Responsibilities ......................................................................................... 142
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CHAPTER 17: MEMBER GRIEVANCE AND APPEALS ........................... 145
Member Grievances................................................................................................................... 145
Member Grievances: Filing a Grievance .................................................................................... 145
Timelines for the Member Grievance and Appeal Process: ...................................................... 146
Member Grievances and Appeals: Acknowledgement ............................................................. 147
Member Grievances: Resolution ............................................................................................... 147
Member Appeals........................................................................................................................ 148
Member Appeals: Standard Appeals ......................................................................................... 148
Member Appeals: Response to Standard Appeals .................................................................... 148
Member Appeals: Resolution of Standard Appeals................................................................... 148
Member Appeals: Expedited ..................................................................................................... 149
Member Appeals: Response to Expedited Appeals ................................................................... 149
Member Appeals: Resolution of Expedited Appeals ................................................................. 149
Member Appeals: Other Options for Filing Grievances ............................................................ 149
Office of the Ombudsman ..................................................................................................... 149
Medi-Cal Member Appeals & Grievances: State Fair Hearing................................................... 150
Medi-Cal Member Appeals: Independent Medical Review ....................................................... 151
Independent Medical Review ................................................................................................ 151
Medicare Member Appeals: Independent Review Entity ......................................................... 151
Member Appeals: Confidentiality .............................................................................................. 151
Member Appeals: Discrimination .............................................................................................. 152
Member Appeals: Continuation of Benefits during an Appeal ................................................. 152
CHAPTER 18: MEMBER TRANSFERS AND DISENROLLMENT .............. 153
Provider-Initiated Member Disenrollment ................................................................................ 153
CHAPTER 19: FRAUD, ABUSE AND WASTE ........................................ 154
First Line of Defense against Fraud, Abuse and Waste ............................................................. 154
Examples of Provider Fraud, Abuse and Waste ..................................................................... 154
Examples of Member Fraud, Abuse and Waste .................................................................... 154
Reporting Provider or Recipient Fraud, Abuse or Waste .......................................................... 155
Anonymous Reporting of Suspected Fraud, Abuse and Waste ............................................. 156
Investigation Process ................................................................................................................. 156
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Acting on Investigative Findings ............................................................................................ 156
False Claims Act ......................................................................................................................... 157
Code of Conduct ........................................................................................................................ 158
CHAPTER 20: QUALITY MANAGEMENT ............................................ 159
Quality Management Program .................................................................................................. 159
Quality Management Committee .............................................................................................. 160
CHAPTER 21: CULTURAL AND LINGUISTIC SERVICES ......................... 162
Overview .................................................................................................................................... 162
24-Hour Access to Interpreter Services ..................................................................................... 162
Facility Signage ....................................................................................................................... 163
Materials in Other Languages and Alternative Formats ........................................................ 163
Disability Access ......................................................................................................................... 164
Referrals to Multi-Ethnic Community-Based Services ........................................................... 164
Cultural Competency Trainings and Resources ......................................................................... 164
APPENDICES
APPENDIX A ...................................................................................................................... 166
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CHAPTER 1: INTRODUCTION
Welcome to the Provider Manual
Welcome to the CareMore Health Plan California (CareMore) family of dedicated physicians.
CareMore has been selected by the California Department of Health Care Services (DHCS) to
participate in the three-year pilot program called Cal MediConnect. The goal of this program is to
integrate care for those dual-eligible individuals who are enrolled in both the Medicare and
Medi-Cal managed care health plans.
At CareMore, our goals are to assist you in providing unequaled care to your patients while
making the practice of medicine more rewarding in terms of better patient outcomes, better
practice economics and diminished practice difficulties. By furnishing the means to accomplish
these ends and by helping you and your patients to access them, we are confident you will be
proud to have joined us.
CareMore Service Area
The definition of a service area, as described by the Member Handbook, is the geographic area
approved by the Centers for Medicare and Medicaid Services (CMS) in which a person must live
to become or remain a member of CareMore. Members who temporarily (as defined by CMS as
six months or less) move outside of the service area are eligible to receive emergency and
urgently-needed services outside the service area.
CareMore is in the following CMS-approved service area:
California:
Los Angeles County
(partial county)
Using This Manual
Designed for CareMore physicians, hospitals and ancillary Providers who are participating with
CareMore under the Cal MediConnect program, this manual is a useful reference guide for you
and your office staff. We recognize that managing our Members’ health can be a complex
undertaking. It requires familiarity with the rules and requirements of a system that
encompasses a wide array of health care services and responsibilities. We want to help you
navigate our managed health care plan to find the most reliable, responsible, timely and costeffective ways to deliver quality health care to our Members.
This manual is available to view or download on our secure Provider Portal, accessible through
our website, Providers.caremore.com. Providers may view it online, download it to their
desktop or print it out from the site. If you are unable to print a copy from the website, please
contact our Provider Relations team at 1-888-291-1358 (select Option 3 > Option 5) to request
that a printed copy be mailed to you.
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There are many advantages to accessing this manual at our website, including the ability to link
to any section by clicking on the topic in the Table of Contents. Each section may also contain
important phone numbers, as well as cross-links to other sections, our website or outside
websites containing additional information. Bold type may draw attention to important
information.
Providers with questions about the content of this manual should contact their Regional
Performance Manager or call our Provider Relations team at 1-888-291-1358 (select Option 3 >
Option 5).
Provider Portal Access and Training
Access Express, CareMore’s Provider Portal, is an easy-to-use Internet based system
that was developed to improve the flow of information between providers and CareMore.
The Provider Relations Department hosts portal trainings via webinar once a month.
Invitations are faxed to providers’ offices along with an RSVP form. If you
already have access and currently use the Provider Portal, we encourage you to
participate for a refresher training to ensure you are utilizing all of the functionalities the
portal has to offer.
Should you need access to the portal, whether it is a new account set up or a password
reset, the Provider Relations team is available to assist.
Please refer to CareMore Contact Information (Chapter 2) for phone number and hours of
operation.
How to Access Information and Forms on the Provider Portal Website
A wide array of valuable tools, information and forms are available on the secure Provider Portal
page of our website, Providers.caremore.com. Throughout this manual, we will refer you to
items located on the Provider Portal page. To access this page, please follow these websteps:
1. Go to Providers.caremore.com
2. Enter your user name and password.
3. Under the Main Menu, go to “Support” and select “User Manual”.
If you have questions about Provider Portal access or training, please contact Provider Relations
at 1-888-291-1358 (select Option 3 > Option 5).
Legal and Administrative Requirements
Disclaimer
The information provided in this manual is intended to be informative and to assist Providers in
navigating the various aspects of participation with CareMore programs. Unless otherwise
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specified in the Provider contract, the information contained in this manual is not binding upon
CareMore and is subject to change. CareMore will make reasonable efforts to notify Providers
of changes to the content of this manual.
This manual, as part of your Provider Agreement and related Addendums, may be updated at
any time and is subject to change. In the event of an inconsistency between information
contained in this manual and the Agreement between you or your facility and CareMore, the
Agreement shall govern.
In the event of a material change to the Provider manual, CareMore will make all reasonable
efforts to notify you in advance of such changes through fax communications and other
mailings. In such cases, the most recently-published information shall supersede all previous
information and be considered the current directive.
The manual is not intended to be a complete statement of all CareMore Cal MediConnect Plan
policies or procedures. Other policies and procedure, not included in this manual may be posted
on our website or published in specially-targeted communications. These communications
include, but are not limited to, letters, bulletins and newsletters.
Throughout this manual, there are instances where information is provided as a sample or
example. This information is meant to illustrate only, and is not intended to be used or relied
upon in any circumstance or instance.
This manual does not contain legal, tax or medical advice. Please consult other advisors for such
advice.
Third Party Websites
The CareMore website and this manual may contain links and references to internet sites owned
and maintained by third party entities. Neither CareMore nor its related affiliated companies
operate or control, in any respect, any information, products or services on these third party
sites. Such information, products, services and related materials are provided “as is” without
warranties of any kind, either express or implied, to the fullest extent permitted under applicable
laws. CareMore disclaims all warranties, express or implied, including, but not limited to, implied
warranties of merchantability and fitness. CareMore does not warrant or make any
representations regarding the use or results of the use of third party materials in terms of their
correctness, accuracy, timeliness, reliability or otherwise.
Privacy and Security Statements
CareMore’s latest privacy policy can be found on the CareMore website. To find these
statements, go to www.caremore.com, scroll down to the bottom of the page and select
Privacy Policy.
Please be aware that when you travel from the CareMore website to another website, whether
through links provided by CareMore or otherwise, you will be subject to the privacy policies (or
lack thereof) of the other sites. We caution you to determine the privacy policy of such websites
before providing any personal information.
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Confidentiality and Disclosure of Medical Information
Collection of Personal and Clinical Information
CareMore will collect and release all personal and clinical information related to Members in
keeping with California and Federal laws, including HIPAA, court orders or subpoenas. Release of
records according to valid court orders or subpoenas are subject to the provisions of that court
order or subpoena.
The person or entity that is seeking to obtain medical information must obtain the authorization
from the Member and is to use that information only for the purpose it was requested and
retains it only for the duration needed.
The individual physician or provider may not intentionally share, sell or otherwise use any
medical information for any purpose not necessary to provide health care services to the
Member.
Only necessary information shall be collected and maintained. Reasons for collecting medical
information may include but are not limited to:

To review for medical necessity of care;

To perform quality management, utilization management and credentialing/re-credentialing
functions;

To determine the appropriate payment under the benefit for covered services;

To analyze aggregate data for benefit rating, quality improvement, chronic disease
management programs, and oversight activities, etc.; and

To comply with statutory and regulatory requirements.
Maintenance of Confidential Information
CareMore maintains confidential information as follows:

Clinical information received verbally may be documented in CareMore’s database. This
database includes a secured system restricting access to only those with authorized entry.
Computers are protected by a password known only to the computer user assigned to that
computer. Computers with any computer screen displaying Member or Provider information
shall not be left on and unattended.

Electronic, facsimile, or written clinical information received is secured, with limited access to
employees to facilitate appropriate Member care and reimbursement for such care. No
confidential information or documents is left unattended (i.e. open carts, bins or trays at any
time). Hard copies of all documents are not visible at any workstation during the employee’s
breaks, lunch or time spent away from desks.

Written clinical information is stamped “Confidential,” with a warning that its release is
subject to California and Federal law.
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
Confidential information is stored in a secure area with access limited to specified employees,
and medical information is disposed of in a manner that maintains confidentiality (i.e. paper
shredding and destroying of recycle bin materials).

Any confidential information used in reporting to other departments or to conduct training
activities, which may include unauthorized staff, will be “sanitized” (i.e., all identifying
information blacked out), to prevent the disclosure of confidential medical information.

Any records related to quality of care, unexpected incidence investigations, or other peer
review matters are privileged communications under California Health & Safety Code section
1370 and California Evidence Code section 1157. As such, these records are maintained as
confidential. All such written information is stamped “Confidential”, with a warning that its
release is subject to state and federal law. Information is maintained in locked files.
Member Consent
Member authorization is not required for treatment, payment and healthcare operations. Direct
treatment relationships (i.e., the provision and/or coordination of health care by providers)
require Member consent.
When a member is enrolled in more than one Managed Care Organization (MCO) (i.e., employer
group and Medicare or Medicare and Medical) all such MCOs are not considered third parties for
the purposes of sharing information. So as to ensure continuity and coordination of care,
individual, identifiable health personal information pertaining to Members’ health and health
care may be released, to the extent allowed under California and Federal law, without the prior
consent of the beneficiary, to any other MCO.
Member Access to Medical Records
Members may access their medical records upon proper request. Upon reviewed and approved
requests to their health care provider, the Member may request a written amendment to their
records if they believe that the records are incomplete or inaccurate.
No written request is required for information/documents to which a Member would normally
have access, such as copies of claims, etc. CareMore substantiates the identity of the individual
Member (i.e., subscriber number, date of service, etc.) before releasing any information.
A written request signed by a Member or the Member’s authorized representative is required to
release medical records. An initial “consent to treat” may be signed at the point of entry into
services prior to the provision of those services, but does not allow records to be released for any
reasons other than those delineated in that original consent (i.e., payment and specialty referral
authorization processes)
CareMore will assist the Member who has difficulty obtaining requested medical records.
Disease Management Organizations
CareMore and its contractors/vendors that administer disease management programs for
conditions such as asthma, diabetes, chronic obstructive pulmonary disease and cardiovascular
disease are prohibited from disclosing a Member’s medical information without physician
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authorization, except as expressly permitted by law. Disease management organizations are
restrained from soliciting or offering for sale any products or services to a health plan Member
while providing disease management services unless, as specified, he or she elects to receive
such information. CareMore staff may contact the Member as needed with information
regarding the disease management program(s).
Release of confidential member information to disease management organizations may be given
for the purpose of providing disease management services, without the authorization of the
treating physician, as long as the following is done:

The disease management organization otherwise maintains the information as confidential as
required by law.

The disease management organization does not attempt to sell its services to members.

Notice of the disease management program (description of the disease management
services) must be given to the treating physician for members whom information will be
provided to the disease management organization.

The disease management organization obtains the treating physician’s authorization prior to
providing home health care services or prior to the dispensing, administering or prescribing
of medication.
Release of Confidential Information
Members Considered Incompetent or Lacking the Legal Capacity
to Give Consent to Medical Treatment
Incompetent members include:

A Member/conservatee who has been declared incompetent to consent to treatment by a
court;

A Member/conservatee who has not been declared incompetent to consent to treatment,
but whom the treating physician determines lacks the capacity to consent;

A Member who is not capable of understanding the nature and effect of the proposed
treatment, and/or
CareMore will consult with legal counsel, as appropriate. The Durable Power of Attorney or
Letters of Conservatorship may need to be reviewed by legal counsel to determine who may
consent to the release of Member information.
Release to Employers
CareMore and its contracted/delegated medical groups/IPAs do not share Member-identifiable
information with any employer without the Member’s written authorization. The member must
identify himself/herself by providing key information such as: subscriber number, provider name
and date of service, etc.
Detailed claims reports will be encrypted or all individually identifiable information blanked out.
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Requests for reports for individual information may be forwarded to legal counsel for review to
ensure employers protect the data from internal disclosure for any use that would affect the
individual in compliance with Health and Safety Code Section 1374.8.
Release to Providers
Provider requests may be honored if the request pertains to that provider’s services. All other
requests require the Member’s or Member representative’s signed release for the information.
Electronic, facsimile, or written clinical information sent is secured with limited access to those
employees who are facilitating appropriate patient care and reimbursement for such care.
Release to Disease Management Organizations
Release of confidential Member information to disease management organizations may be given
for the purpose of providing disease management services, without the authorization of the
treating physician, as long as the following is done:

The disease management organization maintains the information as confidential as required
by law.

The disease management organization does not attempt to sell its services to members.

Notice of the disease management program (description of the disease management
services) is given to the treating physician for members whom information will be provided to
the disease management organization.

The disease management organization obtains the treating physician’s authorization prior to
providing home health care services or prior to the dispensing, administering or prescribing
of medication.
All other requests require the treating physician’s authorization for release of Member
information to a disease management organization for provision of disease management
services.
Electronic, facsimile, or written clinical information sent is secured with limited access to those
employees who are facilitating appropriate Patient care and reimbursement for such care.
Release of Outpatient Psychotherapy Records
Anyone requesting Member outpatient psychotherapy records must submit a written request,
except when the patient has signed a written letter or form waiving notification to the Member
and treating provider. The request must be sent to the Member within 30 days of the receipt of
the records except when the Member has signed a written letter or form waiving notification.
The written request must be signed by the requestor and must identify:

What information is requested,

The purpose of the request, and

The length of time the information will be kept.
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Cal MediConnect
A person or entity may extend the timeframe, provided that the person or entity notifies the
practitioner of the extension. Any notification of the extension will include:
o The specific reason for the extension,
o The intended use or uses of the information during the extended time, and
o The expected date of the destruction of the information.
The request will include a statement that:

The information will not be used for any purpose other than its intended use, and

That the requestor will destroy the information when it is no longer needed (including how
the documents will be destroyed).
The request must specifically include the following:

Statement that the information will not be used for any purpose other than its intended use;

Statement that the person or entity requesting the information will destroy the information
when it is no longer needed;

Specifics on how the information will be destroyed, or specify that the person or entity will
return the information and all copies of it before or immediately after the length of time
indicated in the request; and
Specific criteria and process for confidentially fazing and copying outpatient psychotherapy
records.

Release of Records Pursuant to a Subpoena
Member information will only be released in compliance with a subpoena duces tecum by an
authorized designee in Administration as follows:

The subpoena is to be accepted, dated and timed, by the above person or designee.

The subpoena should give CareMore at least 20 days from the date the subpoena is issued to
allow a reasonable time for the Member to object to the subpoena and/or preparation and
travel to the designated stated location.

All subpoenas must be accompanied by either a written authorization for the release of
medical records or a “proof of service” demonstrating the Member has been “served” with a
copy of the subpoena.

Alcohol or substance abuse records are protected by both Federal and State law (42 USC
§290dd-2;42C, CR§§2.1 et. seq.; and Health and Safety Code §1182 and §11977), and may
not be released unless there is also a court order for release which complies with the specific
requirements.

Only the requested information will be submitted, (HIV and AIDS information is excluded).
HIV and AIDS or AIDS related information require a specific subpoena (Health & Safety Code
§120980).
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Should a notice contesting the subpoena be received prior to the required date, records will not
be released without a court order requiring so. If no notice is received, records will be released at
the end of the 20 day period.
The record will be sent through the US Postal Service by registered receipt or certified mail.
Archived Files/Medical Records
All medical records are retained by CareMore and/or the delegated/contracted medical groups
as well as individual practitioner offices, according to the following criteria:


Adult patient charts – 10 years
X-Rays – 10 years
Misrouted Protected Health Information
Providers and facilities are required to review all Member information received from CareMore
Health Plan to ensure no misrouted protected health information (PHI) is included. Misrouted
PHI includes information about Members that a Provider or facility is not treating. PHI can be
misrouted to Providers and facilities by mail, fax, email, or electronic remittance advice.
Providers and facilities are required to destroy immediately any misrouted PHI or safeguard the
PHI for as long as it is retained. In no event are Providers or facilities permitted to misuse or redisclose misrouted PHI. If Providers or facilities cannot destroy or safeguard misrouted PHI,
please contact Provider Relations at 1-888-291-1358 (select Option 3, Option 5).
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CHAPTER 2: IMPORTANT CONTACT INFORMATION
CareMore Care Centers Contact Information, Services and Programs
CareMore Care Centers are an integral part of our care model and offer various services and
specialized programs for our Members that are not usually available or covered by other medical
groups or health plans. A list of these programs and services can be found below and Chapter 12:
Health Programs and Education has more information on each.
Please contact your local CareMore Care Center to find out which services and programs are
offered there or reference a current list of CareMore Care Centers and their services and
programs available on our portal under the User Manual/Form section.
CareMore Programs and Services

Anti-coagulation Clinic

Fall Prevention Center

Back Pain Program

Healthy Journey

Cardiology

Healthy Start

Cardiac Imaging Center

Hypertension Clinic

Congestive Health Failure Care Program

Nutrition Counseling

Chronic Kidney Disease Program

Pre-Op Clinic

Chronic Obstructive Pulmonary Disease Program

Pulmonology

Dermatology

Smoking Cessation

Diabetes Management Program

Touch Management Program

End Stage Renal Disease Program

Wound Care
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Chapter 2
Chapter 2: Important Contact Information
Cal MediConnect
Other CareMore Contact Information
Name and Address
Phone/Fax
Hours of Operation and
Website Info
CareMore Health Plan
12900 Park Plaza Drive, # 150
Cerritos, CA 90703
Ph: 1-888-291-1358
8 a.m. – 6 p.m.
Monday through Friday
Provider Relations
Ph: 1-888-291-1358
(Select Option3,
Option 5)
www.caremore.com
8 a.m. – 6 p.m.
Ph: 1-562-622-2950
Fax: 1-562-977-6141
Member Services
Ph: 1-888-350-3447
Ph: 1-562-677-3554
8 a.m. – 8 p.m.
Fax: 1-562-741-4406
TTY 711
Member Eligibility
Ph: 1-888-250-5800
(Option 5)
Fax: 1-562-741-4412
5 a.m. – 5 p.m.
Beacon Behavioral Health
Ph: 1-855-371-8092
8 a.m.-8 p.m.
CareMore Compliance
Officer Hotline
Ph: 1-562-741-4552
24 hours a day, 7 days a week
Case Management
Ph: 1-888-291-1385
After Hours (Nights and
Weekends) Case Manager:
Ph:
Claims/ Encounter Data
Attn. Claims Dept – Duals
MS-6110
P.O. Box 366
Artesia, CA 90702
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Name and Address
Phone/Fax
Website Info
Electronic Claims Submission
Ph: 1-866-575-4120
Fax 1-360-896-2151
www.officeally.com
Electronic Fund Transfer/
Electronic Remittance
Advice
Ph: 1-866-506-2830
www.emdeon.com/eft/
CareMore Payer #: CAREMO
Fraud Hotline
(CareMore Ethics &
Compliance Helpline)
Ph: 1-877-725-2702
Nurse Advice Line
Ph: 1-800-224-0336
TTY: 711 or
English:
1-800-735-2929
Spanish:
1-800-855-3000
Pharmacy Department
Ph: 1-800-965-1235
7 a.m. -6 p.m.
Fax: 1-800-589-3149
Sales Managers
Ph: 1-562-207-3614
Nelly De Risio
8:30 a.m.-5:30 p.m.
Ph: 1-562-207-3643
John Ramirez
Telesales West
Ph: 1-877-211-6614
5 a.m. to 8 p.m.
Transportation
Ph: 1-888-325-1024
7 a.m. - 6 p.m.
Fax: 1-888-426-5087
TTY: 711
Utilization Management
Ph: 1-888-291-1358
(Option 3,3,2)
5 a.m. - 5 p.m.
Fax: 1-888-371-3206
TTY: 1-800-577-5586
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Name and Address
Phone/Fax
Website Info
Vision Services:
Vision Service Plan (VSP)
Ph: 1-800-877-7195
Fax: 1-800-405-6451
TTY: 1-800-428-4833
5 a.m-8 p.m.
Saturday 7 a.m. - 8 p.m.
Sunday 7 a.m. – 7 p.m.
www.vsp.com
Disease Management
Programs
Ph: 1-800-589-3148
After Hours Line with Nurse
Practitioner
5 p.m. to 8 p.m. Monday
through Friday
8 a.m. - 5 p.m. Saturday - Sunday
Telehealth Wireless
Monitoring Program
Ph: 1-844-256-0022
State of California Contacts
STATE SERVICES CONTACTS
PHONE/FAX
NUMBERS
Automated Eligibility
Verification System (AEVS)
1-800-456-2387
Community-Based Adult
Services (CBAS)
Disability Rights
California:
www.dhcs.ca.gov/services/medical/Pages/ADHC/ADHC.aspx
1-800-776-5746
www.aging.ca.gov/ProgramsProviders/AD
HC-CBAS/
L.A. Care:
1-888-839-9909
Cal MediConnect
Ombuds Program
1-855-501-3077
Department of Health Care
Services Medi-Cal
Managed Care
Ombudsman
1-888-452-8609
Department of Social
Services Public Inquiry and
Response Unit
1-800-952-5253
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OTHER CONTACT INFORMATION
www.dhcs.ca.gov/services/medical/Pages/MMCDOfficeoftheOmbudsman.a
spx
Email:
[email protected]
TTY:
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STATE SERVICES CONTACTS
PHONE/FAX
NUMBERS
Cal MediConnect
OTHER CONTACT INFORMATION
1-800-952-8349
Department of Managed
Health Care
1-800-400-0815
www.dmhc.ca.gov/
Indian Health Services
1-916-930-3927
www.ihs.gov/Calfornia
Medi-Cal Telephone
Service Center
1-800-541-5555
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CHAPTER 3: MEMBER BENEFITS
CareMore Cal Medi-Connect Health Plan Overview
The Centers for Medicare and Medicaid Services (CMS) and the California Department of Health
Care Services (DHCS) have developed a voluntary, three-year program designed to coordinate
medical, mental and substance abuse care, long-term care, and home- and community-based
services under one plan for people eligible for both Medicare and Medi-Cal (“Duals” or “Dual
Eligibles”).
The CareMore Cal MediConnect Plan is open to certain Dual Eligible beneficiaries who have been
confirmed as eligible for both Medicare and Medi-Cal benefits by the federal Centers for
Medicaid and Medicare (CMS) as well as the State of California’s Department of Health Care
Services (DHCS). Enrolling Members must meet all of the applicable eligibility requirements for
membership and have voluntarily elected to enroll in the Cal MediConnect program.
Certain beneficiaries who are confirmed as Dual Eligible by CMS and DHCS are excluded from
participation in the Cal MediConnect program. Per DHCS, these participant populations excluded
from enrollment in Cal MediConnect include, but are not limited to:

Beneficiaries under age 21

Beneficiaries in rural zip codes excluded from managed care

Beneficiaries who are residents of Intermediate Care Facilities for the Developmentally
Disabled
For a detailed chart outlining the CareMore Cal MediConnect Plan participating populations,
please go to the Coordinated Care Initiative section of the DHCS website at
www.dhcs.ca.gov/provgovpart/Pages/CoordinatedCareIntiatiave.aspx. The CCI Population
Chart is located underneath the CCI Fact Sheets heading.
CareMore Cal Medi-Connect provides comprehensive, coordinated medical services to Members
on a prepaid basis through an established Provider network. Cal MediConnect Members must
choose a Primary Care Provider (or PCP) and have all their care coordinated through this
physician-Provider.
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Chapter 3: Member Benefits
Cal MediConnect
Covered Medicare and Medi-Cal Services
Benefits Matrix for Members
Please note: At no time may a Member be billed for any balance due.
CAL MEDICONNECT BENEFITS
Benefits/Services
Acupuncture and Other Alternative Therapies
Coverage
Not Covered
Ambulance Services

Medically necessary ambulance services
Covered, preauthorization may be required
Audiology Services

Supplemental routine hearing exams and hearing
aids are not covered
Assisted Living
Diagnostic hearing exams
Covered, preauthorization required
Some services may be limited to beneficiaries enrolled in
Medi-Cal Long Term Services and Supports of Home- and
Community-Based Waiver programs
Behavioral Health





Individual or group therapy visit
Individual or group therapy visit with psychiatrist
Partial hospitalization program services
Individual or group substance abuse outpatient visit
Lifetime limit of 190 days of inpatient psychiatric
hospital care—limit does not apply to inpatient
psychiatric care in general hospital
Blood and Blood Products
Covered
Cancer Screening (Refer to Member Handbook)
Covered
Cataract Spectacles and Lenses
Covered when medically necessary
Prior Authorization required
Chemical Dependency Rehabilitation
Administered by the state
Chemotherapy Drugs
Covered
If under 21 years of age, CCS
Chiropractic Services
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Benefits/Services
Coverage
Colostomy Supplies



Inpatient Facility
Outpatient Dispensing
In Conjunction with Home Health
Dental Services


Accidental Injury, Inpatient Facility
Professional Component (Anesthesia)
Covered
Covered
Covered
Covered in cases where the benefit is required to treat the
emergency. Preauthorization required
Diabetic Services


Diabetic supplies and services are limited to specific
manufacturers, products and/or brands. Contact Provider
Relations for a list of covered supplies.
Diabetes Monitoring Supplies
Therapeutic shoes or inserts
Dialysis
Durable Medical Equipment
Not covered:
 Items used only for comfort or hygiene
 Items used only for exercise
 Air conditioners, filters or purifiers
 Spas, swimming pools
Wheelchairs, Canes, Crutches, Walkers, Oxygen
Prostheses
Post-colostomy supplies
Diabetes supplies: Blood sugar monitors, blood and urine
testing strips, insulin pumps and all supplied needed for pump
GMC and Mainstream: Covered, preauthorization required for
specific equipment
Emergency Room (Inside and outside of California)

Outpatient
Covered

Professional
Covered
Endoscopic Studies
Covered
Health Education
Covered
Hemodialysis Chronic Renal Failure
Covered, CCS if under 21 years of age
Hepatitis B Vaccine/Gamma Globulin
Covered
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Benefits/Services
Coverage
Home Services

Meal delivery

Cleaning or housekeeping
Some services are limited to Members enrolled in Medi-Cal
Long Term Services and Supports or Home- and CommunityBased Waiver Programs.

Ramps and Wheelchair Access

Personal care assistant

Job Training

Adult Day Services
Hospital Base Physicians (in lieu of acute inpatient or SNF) Covered
Hospitalization





No limit to number of days covered in each stay
Inpatient
Outpatient
Intensive Care Services
Supplies and Testing
Covered
Covered
Covered
Private room covered only if medically necessary
Immunizations
Covered
Injectable Medications (Outpatient)
Covered
Inpatient Alcohol and Drug Abuse
Covered
Interpreter Services
Covered
Lab and Pathology Services





Lab services
Diagnostic procedures
X-Rays
Diagnostic radiology services
Therapeutic radiology services
Major Organ Transplants
Mammography
Covered
Mastectomy
Office Visit Supplies, including splints, casts, bandages
and dressings
Covered
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Benefits/Services
Coverage
Physical, Occupational and Speech Therapy




Medically necessary
Inpatient or SNF
Outpatient
Professional
Physician Office Visits
Covered
Podiatry Services
Preadmission Testing
Covered
Prosthetics and Orthotics (including artificial limbs and
eyes)
Radiation Therapy
Covered
Radiology Services



Inpatient Facility Component
Outpatient Facility Component
Professional Component
Covered
Covered
Reconstructive Surgery (not cosmetic)
Rehabilitation Services




Medically necessary
Inpatient or SNF
Outpatient
Professional
Routine Physical Examinations

During first 12 months of coverage, Member may
have a single Welcome to Medicare Preventative
Visit or an Annual Wellness Visit. After first 12
months of coverage, Member may have a single
Annual Wellness Visit every 12 months.
Skilled Nursing Facility (SNF)

In-network: No limit to the number of days covered
by the plan each SNF stay
Specialist Care

Covered
Referral required
Surgical Supplies
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Benefits/Services
Coverage
Transfusions (blood and blood products)
Covered
Transportation

In-Network: Up to 30 one-way trip(s) to planapproved locations per year
Urgent Care Center
Covered
Vision Care



Medically Necessary
One pair of eyeglasses (lenses and frames) every
two years
One pair of contact lenses every two years
Vision Screening

Covered
Covered
One supplemental routine eye exam annually
Outpatient Ancillary Services
All laboratory, radiology, therapy, DME and medical soft goods services must be performed at a
contracted facility.
Pharmacy Services
Overview
Our pharmacy benefit provides coverage for medically necessary medications from licensed
prescribers for the purpose of saving lives in emergency situations during short-term illness,
sustaining life in chronic illness, or limiting the need for hospitalization. Members have access to
most national pharmacy chains and many independent retail pharmacies.
Monthly Limits
All prescriptions are limited to a maximum 30-day supply per fill. For Long Term Care
prescriptions are limited to a maximum of 31-day supply per fill.
Medicare Part D covers most of the pharmacy benefits for Members who are dual-eligible for
Medicare and Medi-Cal. There are, however, additional categories of drugs and supplies that are
covered under our program for Cal MediConnect Members:





Barbiturates
Cough and Cold Medications
Over-The-Counter Medications, except for insulin and syringes
Prescription Vitamins and Minerals
Weight Loss Medications, if medically necessary
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Cal MediConnect
Formulary
CareMore’s formulary for Cal MediConnect Members has been reviewed and approved by CMS
as well as our Pharmacy and Therapeutics Committee. The formulary consists of generic and
brand Medicare and Medi-Cal covered medications that may be prescribed for CareMore Cal
MediConnect Plan Members. As noted in the formulary, some of these medications may require
a prior authorization. Throughout the year, there may be additions and deletions to the
CareMore Cal MediConnect Plan formulary. Your office will be notified when these changes take
place.
Please note: The formulary in use for CareMore Cal MediConnect Plan Members is different than
the formularies in use by other CareMore Health Plan programs. For detailed information about
the CareMore Cal MediConnect Plan-specific formulary, please contact CareMore Pharmacy
department at 1-800-965-1235.
Requests for Formulary Changes
Providers are encouraged to submit requests for formulary changes if you feel that a drug is not
covered but is needed for a particular reason. To request these formulary changes, please submit
the following information in writing to the Pharmacy Department address listed in
Chapter 3: Other CareMore Contact Information:

Name of Drug

Drug Class

Dosage (if more than one available, cite the one you are requesting)

Justification for your request

Your Name

Your Contact Number

Medical Group affiliation, if appropriate
Our Pharmacy and Therapeutics Committee will review your request and the pharmacy
department will notify you of the results.
Notification of FDA Recalls
CareMore Health Plan will notify you and any affected Members of any Food and Drug
Administration recalls that may impact Members.
Preferred Diabetic Supplies
The following are CareMore’s Cal MediConnect preferred diabetic supplies:

Freestyle monitors (Lite,Freedom, Insulinx)

Freestyle lancets and test strips

Precision XTRA monitors and test strips
CareMore Health Plan covers 100 test strips and lancets per month (for testing three times a
day). Prior authorization is necessary for Members who require more than 100 items per month
of supplies.
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Scripts Provider Newsletter
Scripts is a newsletter directed to all our providers. The newsletter contains updates on brand
and generic drugs, formulary changes, and pertinent clinical articles. If you have any
suggestions or comments related to our newsletter, please call 800-965-1235.
Vision Services
Vision benefits are offered to all CareMore Cal MediConnect Plan Members through the Vision
Service Plan (VSP). Search for a VSP Provider at www.vsp.com > Find a VSP Doctor.
For questions about vision benefits, please call the Vision Service Plan at: 1-800-877-7195 or
1-800-428-4833 (TTY).
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CHAPTER 4: LONG TERM SERVICES AND SUPPORTS (LTSS)
Overview
CareMore Health Plan (CareMore) covers a wide variety of long term services and supports (LTSS)
that help elderly people and/or individuals with disabilities with their daily needs for assistance
and improve the quality of their lives.
Examples include assistance with bathing, dressing and other basic activities of daily life and self-care,
as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are
provided over an extended period, predominantly in the homes and communities, but also in facilitybased settings such as nursing facilities.
These services fall into four categories and are defined as follows:
 In Home Support Services (IHSS)
 Community-Based Adult Services (CBAS)
 Multipurpose Senior Services Program (MSSP)
 Long Term Services and Supports/Skilled Nursing Facility
Instructions on how to submit a request to have a Member evaluated for LTSS services through
the Provider Portal can be found in Appendix A located in the back of this manual.
In-Home Support Services (IHSS)
This California state program provides in-home care to the elderly and persons with disabilities,
thereby allowing them to safely remain in their homes.
Eligibility
To qualify for IHSS, an enrollee must be aged, blind or disabled and in most cases, have income
below the level to qualify for SSI/State Supplementary Program.
County Public Authority
The County Public Authority social worker is responsible for assessing, approving and authorizing
hours, services and tasks based on the needs of the beneficiary. They are responsible for
screening and enrolling service providers, conducting criminal background checks, conducting
Provider orientation and retaining enrollment documentation. In addition, they maintain a
Provider registry and can provide assistance in finding eligible Providers and perform quality
assurance activities.
Types of services provided include:


Domestic and Related Services (house cleaning/chores, meal preparation & clean-up,
laundry, grocery shopping, heavy cleaning)
Personal Care (i.e. bathing and grooming, dressing, feeding)
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

Cal MediConnect
Paramedical Services (i.e., administration of medication, puncturing skin, range of motion
exercises)
Other Services (i.e., accompaniment to medical appointments, yard hazard abatement,
protective supervision)
Who is Eligible for In-Home Supportive Services (IHSS)
All IHSS beneficiaries must:

be a California resident and a U.S. citizen/legal resident, and be living in their own home

receive of be eligible to receive Supplemental Security Income/State Supplemental
Payment (SSI/SSP) or Medi-Cal benefits

be 65 years of age or older, legally blind, or disabled by Social Security standards

submit a healthcare certification form (SOC 873) from a licensed health care professional
indicating that they need assistance to stay living at home.
IHSS- Referral Process
The county department of Public Social Services (DPSS) determines eligibility and hours of
service. The beneficiary can apply to IHSS by calling 1-888-944-IHSS (inside LA County) or
1-213-744-4477 (outside LA County).
The Personal Assistance Service Council (PASC) assists beneficiaries with finding homecare
workers, and providers other support services for IHSS beneficiaries. 1-877-565-4477
Providers can also call our Care Coordinators for assistance with the referral process by calling
1-855-871-4899. CareMore will be financially responsible for IHSS, and will coordinate with the
Department of Public Social Service (DPSS) to make sure beneficiaries are getting the care they
need.
Member Control
IHSS allows the Member to self direct their care by being able to hire, fire and manage their
homecare workers. A trusted friend or family member could become screened, qualified and
compensated as a Member’s IHSS Provider. The Member could also elect to involve the IHSS
Provider as a member of their Care Team.
County agencies administering the IHSS program will maintain their current roles and CareMore
will not be able to reduce the IHSS hours authorized by the county.
Community Based Adult Services (CBAS)
Facility-based outpatient program serving individuals 18 years old and over who have functional
impairment which puts them at risk for institutional care. The program delivers the following
adult day care services:


Skilled nursing care
Social services
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Physical and Occupational Therapies
Personal care
Family/caregiver training and support
Meals
Transportation
The primary objectives of the CBAS program are to : restore and maintain optimal capacity for
self-care to the elderly or other adults with physical and mental disabilities. Delay or prevent
inappropriate or personally undesirable institutionalization in long-term care facilities.
CBAS- Eligibility
CBAS services may be provided to Medi-Cal beneficiaries over 18 years of age who:
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Meet Nursing Facility A or B Requirements
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Have organic/Acquired or Traumatic Brain Injury and/or Chronic Mental Health conditions
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Have Alzheimer’s disease or other dementia
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Have Mild Cognitive Impairment
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Have a Developmental Disability
CareMore will do face-to-face assessment to determine final program eligibility.
CBAS Centers still determine levels of service after authorization. Those currently enrolled in the
CBAS program will remain in the program as long as they are enrolled in a Medi-Cal health plan.
CBAS- Referral
To receive CBAS services, a beneficiary must first be enrolled in a Medi-Cal health plan. To begin
the referral process please contact CareMore’s Member Services Department at 1-888-350-3447.
CBAS providers must obtain an authorization from CareMore.
Multipurpose Senior Services Program (MSSP)
A California 1915c Home and Community-Based Services (HCBS) waiver program that operates as
an alternative to nursing home placement for those 65 years of age and over with disabilities.
The MSSP is an intensive case management program that coordinates social and health care
services in the community for those wishing to remain in the community and delay or prevent
institutional placement.
Types of services provided:
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Case Management
Personal Care services
Respite Care (in –home and out-of-home)
Environmental Accessibility Adaptations
Housing Assistance/Minor Home Repair
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Transportation
Chore Services
Personal Emergency Response System (PERS)/Communication Device
Adult Day Care/Support Center/Health Care
Protective Supervision
Meal Services (Congregate/Home Delivered)
Social Reassurance/Therapeutic Counseling
Money Management
Translation/Interpretation
MSSPs work closely with local organizations and agencies that provide Long Term Services &
Supports (LTSS) and home and community based services.
MSSP – Referral
After the CCI begins, in order to receive MSSP services, a beneficiary must first be enrolled in a
Medi-Cal health plan. To begin the referral process for a beneficiary, please contact our Care
Coordinators for assistance or Member Services Department.
MSSP Waiver Services
An MSSP provider may purchase MSSP Waiver Services when necessary to support the wellbeing of a CareMore member who is an MSSP Waiver Participant.
Prior to purchasing these services, MSSP providers must verify, and document all efforts to
determine the availability of alternative resources (e.g. family, friends and other community
resources) for the member.
Approved Purchased Waiver Services are listed and defined in the MSSP Provider Site Manual
located on the California Department of Aging website at www.aging.ca.gov. To access the MSSP
manual on this site, select Providers and Partners > Multipurpose Senior Services Program >
MSSP Site Manual and Appendices.
MSSP providers may either enter into contract with subcontractors and vendors to provide
Purchased Waiver Services or directly purchase items through the use of a purchase order.
CareMore requires MSSP providers to maintain written subcontractor/vendor agreements for
the following minimum array of Purchased Waiver Services:
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Adult Day Support Center (ADSC) and Adult Day Care (ADC)
Housing Assistance
Supplemental Personal Care Services
Care Management
Respite Care
Transportation
Meal Services
Protective Services
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Special Communications
MSSP subcontractors and vendors are bound by the following:
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All MSSP subcontractors and vendors must have the proper license, credentials, qualifications
or experience to provide services to any CareMore member receiving MSSP services.
All reimbursements must come from the MSSP provider with whom the subcontractor or
vendor has a signed agreement.
No MSSP subcontractor or vendor may seek any payment for MSSP services from any
CareMore member or from CareMore itself.
MSSP providers are responsible for coordinating and tracking MSSP purchased Waiver Services
for any CareMore member receiving MSSP services.
For information about how to submit claims for MSSP services, please see Reimbursement to
Multipurpose Senior Services Program Providers at the end of this chapter.
For members that are under the MSSP waiver and the MSSP is receiving a monthly payment
then an authorization is not required. For members on the waiting list in need of services,
please contact CareMore for an authorization.
Long-Term Services and Supports
When long-term services and supports are necessary, CareMore works with the Provider and
Member (or their designated representative) to plan the transition/discharge to an appropriate
setting for extended services. These services can be delivered in a nonhospital facility such as:
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Nursing Facilities, Subacute Care Facilities (NF/SCF)
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Respite Care – In Home or Out of Home
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Home and Community-Based Services HCBS
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Home health care program (i.e. home I.V. antibiotics)
When the Member and family together with the Provider identifies medically necessary and
appropriate services for the Member, then CareMore will assist in providing a timely and
effective plan that meets the Member’s needs and goals.
Responsibilities of the LTSS Provider
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Assisted living facilities and nursing homes must retain a copy of the Member’s CareMore
plan of care on file.
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Assisted living facilities are required to promote and maintain a homelike environment and
facilitate community integration
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All facility-based Providers and home health agencies must notify a CareMore case manager
within 24 hours when a Member dies, leaves the facility or moves to a new residence.
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LTSS Providers will participate in the Member’s Interdisciplinary Care Team (ICT) dependent on
the Member’s need and preference
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Interactive Voice Response Requirements of Providers
The following Providers are required to have 24-hour service:
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Assisted living facilities/services
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Emergency response systems
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Nursing homes/Skilled nursing facilities
Such Providers will provide advice and assess care as appropriate for each Member’s medical
condition. Emergent conditions will be referred to the nearest emergency room.
Identifying and Verifying the Long-Term Care Member
Upon enrollment, we will send a welcome package to the Member. This package includes an
introductory letter, a Member ID card and a Member Handbook. Each CareMore Member will
identify himself or herself prior to receiving services by presenting a CareMore ID card, which
includes a Member number. You can check Member eligibility by calling us at 1-888-250-5800
(Option 5).
For more information covering Member eligibility verification, please see Chapter 6: Member
Eligibility.
Nursing Home Eligibility
CareMore will review the member’s eligibility and benefits to determine if a member qualifies for
Nursing Facility placement. This review will include the initial Level of Care (LOC) (including
custodial nursing home vs. Skilled Nursing Facility) is determined by the Authorization/Case
Manager/Care Coordinator.
For members that reside in a nursing home, the care coordinator will complete the Health Risk
Assessment within 60 days of plan enrollment via a face-to-face meeting. During this process, the
care coordinator will ensure to incorporate Minimum Data Set 2.0 (MDS 2.0) into the Plan of
Care. MDS 2.0 is located online at on the CMS website at www.CMS.gov at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/downloads/MDS20MDSAllForms.pdf.
Covered Health Services
CareMore provides the covered services listed below and will authorize these covered services.
Any modification to covered services will be communicated through a Provider newsletter,
Provider manual update and/or contractual amendment. The scope of benefits includes the
following:
Home and Community Services
Adult companion services
Adult day health center services
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Assisted living services
Care management services
Chore services
Consumable medical supply services
Environmental accessibility adaptation services
Escort services
Family training services
Financial assessment/risk reduction services
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Nursing facility services
Nutritional assessment/risk reduction services
Occupational therapy
Personal care services
Personal emergency response system services
Physical therapy
Respiratory therapy
Respite care services
Speech therapy
CareMore Coordinator
The CareMore Coordination model promotes cross-functional collaboration in the development
of Member service strategies. Members identified as waiver Members, high risk and/or with
complex needs are enrolled into the service coordination program and are provided
individualized services to support their behavioral, social, environmental, and functional and
health needs. Service Coordinators accomplish this by screening, assessing, and developing
targeted and tailored Member interventions while working collaboratively with the Member,
practitioner, provider, caregiver and natural supports.
Since many CareMore Members have complex needs that require services from multiple
Providers and systems, gaps may occur in the delivery system serving these Members. These
gaps can create barriers to Members receiving optimal care. The CareMore service coordination
model helps reduce these barriers by identifying the unmet needs of Members and assisting
them to find solutions to those needs. This may involve coordination of care, assisting Members
in accessing community-based resources or any of a broad range of interventions designed to
improve the quality of life and functionality of Members and to make efficient use of available
healthcare and community-based resources.
The scope of the Service Coordination Model includes but is not limited to:
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Annual assessments of characteristic and needs of Member populations and relevant subpopulations
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Initial and ongoing assessment
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Problem-based, comprehensive service planning, to include measurable prioritized goals and
interventions tailored to the complexity level of the Member as determined by the initial and
ongoing assessments.
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Coordination of care with PCPs and specialty Providers
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Providing a service coordination approach that is “Member-centric” and provide support,
access, and education along the continuum of care
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Establishing a plan that is personalized to meet a Member’s specific needs and identifies:
prioritized goals, time frames for reevaluation, resources to be utilized including the
appropriate level of care, planning for continuity of care, and family participation
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Obtaining Member/family/caregiver input and level of participation in the creation of a
service plan that includes the development of self- management strategies to increase the
likelihood of improved health outcomes that may result in improved quality of life.
Consumer Direction
Consumer direction is a process by which eligible home and community-based services (HCBS)
are delivered; it is not a service.
Consumer direction affords Members the opportunity to have choice and control over how
eligible HCBS are provided. The program also allows Members to have choice and control over
who provides the services and how much workers are paid for providing care--up to a specified
maximum amount established by California’s DHCS. Member participation in consumer direction
of HCBS is voluntary. Members may elect to participate in or withdraw from consumer direction
of HCBS at any time without affecting their enrollment.
Consumer direction is offered for Members who, through the needs assessment/reassessment
process, are determined by Care Coordinators to need any service specified in DHCS rules and
regulations as available for consumer direction. These services include, but are not limited to:
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attendant care
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personal care
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in-home respite care
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companion care service
A service that is not specified in DHCS rules and regulations as available for consumer direction
shall not be consumer-directed.
If a Member chooses not to direct his or her care, he or she will receive authorized HCBS through
contract Providers. Members who participate in consumer direction of HCBS choose either to
serve as the employer of record for their workers or to designate a representative to serve as the
employer of record on his or her behalf. The Member must arrange for the provision of needed
personal care and does not have the option of going without needed services.
Discharge Planning
CareMore assists with discharge planning, either to the community or through a transfer to
another facility, if the Member or responsible party so requests. If the Member or responsible
party requests a discharge to the community, the Care/Service Coordinator will:
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Collaborate with the skilled nursing facility (SNF) Social Worker to convene a planning
conference with the SNF staff to identify all potential needs in the community
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Facilitate a home visit to the residence where the Member intends to move to assess
environment, durable medical equipment (DME) and other needs upon discharge
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Convene a discharge planning meeting with the Member and family, using the data complied
through discussion with the SNF staff as well as home visit, to identify Member preferences
and goals
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Involve and collaborate with community originations such as Community Developmental
Disability Organizations (CDDOs), Centers for Independent Living (CILs) or Area Agencies on
Aging (AAAs) in this process to assist Members as they transition to the community
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Finalize and initiate execution of the transition plan
Although our Member-centric approach is driven by the Member, the transition implementation
is a joint effort between the SNF Social Worker and the CareMore Service Coordinator.
Medical and Nonmedical Absences
Members are allowed up to ten days per confinement for reservation of a bed when a SNF,
SNF/MH, or ICF/MR beneficiary leaves a facility and is admitted to an acute care facility when
conditions under the reserve day regulations are met. To ensure accurate payment, the SNF,
SNF/MH, or ICF/MR must bill hospital leave days consecutively beginning with the date of
admission.
Members are allowed up to 21 days per admission for reservation of a bed when an SNF/MH
resident leaves a facility and is admitted to one of the state mental hospitals, a private
psychiatric hospital, or a psychiatric ward in an acute care hospital. To ensure accurate payment,
the SNF/MH must bill psychiatric leave days consecutively, beginning with the date of admission.
If a beneficiary is not admitted to a hospital but goes to a hospital for observation purposes only,
it is considered an approved nursing facility day and not a hospital or therapeutic reserve day.
In the event of a nonmedical absence from a SNF, providers will obtain an authorization with the
status changes on the nursing home member and should bill the end hold/leave of absence
Revenue code and accommodation code. A maximum of 18 home-leave days for SNFs and 21
days for SNF/MHs are allowed per calendar year. Additional days require precertification. The
number of nonmedical reserve days is restricted to 21 days per year for ICF/MR residents.
Providers will not be reimbursed for days a bed is held for a resident beyond the limits set forth
above and will not reimburse for medical absences without precertification.
Member Liability (Share of Cost)
Medi-Cal should be the payer of last resort. CareMore will ensure Medicare SNF benefits are
exhausted prior to utilizing Medi-Cal benefits. CareMore will assist the facility in convening a
discussion with the Member and/or responsible party and/or state staff, Adult Protective Service,
law enforcement or others as needed.
The SNF is responsible for collecting the Member liability/Share of Cost amount each month and
should represent the liability in box 39 on each claim. Please indicate the Share of Cost by billing
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the value code 23 with $0.00 or greater amount on the claim when submitting to CareMore. The
payment remitted by CareMore will be reduced by the Member liability amount.
The SNF should also complete and send an MS-2126 to the case worker/care coordinator so the
level of care is updated appropriately in the state’s system.
For circumstances in which the Member or responsible party fails to remit payment of the
Member’s liability to the SNF, CareMore Care Coordinators will assist the facility in convening a
discussion with the Member and/or responsible party and/or state staff, Adult Protective Service,
law enforcement or others as needed. The facility administrator or manager should contact the
CareMore service coordinator with details regarding the lack of payment of Member liability.
Details should include:
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The date the last payment was made
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Discussions held with the Member/family to date
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Correspondence with the Member/family to date
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History of late and/or missed payments, if applicable, and
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Any knowledge of family dynamics, concerns regarding the responsible party, or other
considerations
Upon approval of SNF eligibility, the state’s eligibility office will issue a notice of action that will
identify the patient liability for the first month of eligibility and for the subsequent months.
The Provider should then collect the patient liability consistent with the notice of action.
The following situations and responses are provided to assist you with addressing Member
liability collection.
Example 1: The Member is approved for institutional SNF eligibility as of the 15th of the month.
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State issues notice of action for the month for the amount of $500 and for the following
month forward of $1000 per month
The facility per diem is $150: 150 x 15 = $2,250
The facility collects the $500 patient liability, represents the amount on the claim form in box
39, and bills CareMore for $2250
CareMore will reduce the $2250 by $500 and remit $1750
If a Member is discharged to home or expires mid-month, the Provider may retain the patient
liability up to the total charges incurred for the month before discharge.
Example 2: The Member is approved for institutional nursing facility eligibility as of the first of
the month and is discharged during the month.
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Patient liability is $1000
Per diem is $150
Member is discharged on day 7: 7 x $150 = $1050
Provider retains all of the patient liability and represents the amount on the claim to the
MCO.
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Member is discharged on day 3: 3x$150 = $450
Provider refunds $550 to the Member/family or estate
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Provider submits a claim to MCO for 3 days representing the patient liability collected and
MCO reduces the payment by the patient liability and issues a $0 claim payment
If a Member transfers facilities mid-month:
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Eligibility office is contacted regarding impending transfer and expected dates.
Eligibility office issues a notice of action to the discharging facility for the patient liability it is
to collect for the discharge month.
Eligibility office issues a notice of action to the receiving facility as to the patient liability it is
to collect in the first month and for subsequent months.
Our Approach to Skilled Nursing Facility Member Liability/Share of Cost
CareMore recognizes the unique challenges faced by skilled nursing facility (SNF) Providers.
CareMore has developed intensive training for nursing facilities to address a Member/family that
is noncompliant in paying the Member liability; including facilitating a transfer if the issue cannot
be resolved.
The paragraphs below outline our plan for working with the SNF and the Member/family to
resolve such issues.
1. The SNF administrator or office manager contacts the CareMore Care Coordinator with
details regarding the lack of payment of the Member liability including:
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The date the last payment was made
Discussions held with the Member/family to date
Correspondence between the Member/family to date
History of late and/or missed payments, if applicable
Any knowledge of family dynamics, concerns regarding the responsible party, or other
considerations
2. A CareMore Care Coordinator and the Nursing Home Social Worker, if applicable, discuss the
issue with the Member, determine the barrier to payment, and elicit cooperation:
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The CareMore Care Coordinator guides the discussion using pre-determined talking
points, including review of the obligation, potential impact to ongoing eligibility, and
potential threat to continued residence at the current SNF
CareMore talking points will be provided to the State for review and approval as may be
applicable
The CareMore Service Coordinator screens for any potential misappropriation of funds
by family or representative payee
3. The CareMore Care Coordinator will discuss the issue with the identified responsible party if
the Member is unable to engage in a discussion regarding payment of the Member liability
due to cognitive impairment or other disabilities.
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4. The CareMore Care Coordinator or SNF Social Worker will take action if concerns related to
misappropriation of funds are raised or suspected, and may:
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Refer the Member to Adult Protective Services and/or law enforcement
Submit request to the Social Security Administration to change the representative payee
status to the person of the Member’s choosing or the SNF
Engage additional family Members
Engage the Guardianship Program to establish a conservator or guardian
5. The CareMore Care Coordinator will request copies of the cancelled check or other bank
document and/or request copy of receipt issued by the SNF for payment of liability if the
Member or responsible party asserts that the required liability has been paid. The Care
Coordinator will present evidence of payment to the SNF business office and request
confirmation that the issue is resolved. The CareMore Care Coordinator will also engage the
assigned CareMore Provider Relations Representative to work with the SNF to improve its
processes.
6. CareMore will send correspondence that outlines the obligation to pay the Member liability,
potential impact to ongoing eligibility, and potential threat to continued residence at the
current SNF if the responsible party is unresponsive and/or living out of the area.
The correspondence will be submitted to the State for review and approval as required
The correspondence will provide the responsible party with an opportunity to dispute the
allegation and provide evidence of payment
7. CareMore will take the following actions in conjunction with the SNF Social Worker if
Member liability remains unsatisfied after the first rounds of discussion or correspondence:
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Convene a formal meeting with the SNF leadership, Member and/or responsible party,
Long-term Support Services Ombudsman, Adult Protective Services representative, other
representative of the State as applicable, and other parties key to the discussion
Review the patient liability obligation and potential consequences of continued
nonpayment
Attempt to resolve the payment gap with a mutually agreed-upon plan
Explain options if the Member or responsible party wishes to pursue transfer to another
facility or discharge to the community
CareMore, together with the SNF, will engage in any of the following, as may be applicable if the
Member liability continues to go unsatisfied:
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Update and escalate intervention by Adult Protective Services or law enforcement
Refer to State Medicaid Fraud Control Unit or other eligibility of fraud management staff that
the State may designate
Escalate engagement to facilitate a change to representative payee, Power of Attorney, or
Guardian
Escalate appointment of a volunteer guardian or conservator
Initiate discharge planning
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Long-Term Care Ethics and Quality Committee
The Long-Term Care Ethics and Quality Committee addresses quality-of-care issues, ethical issues
and standards of care. The committee reports to the Quality Management Committee.
The CareMore Quality Management program is a positive one. Our focus is on identification,
improvement, education and support so Providers understand and comply with standards that
impact the quality of care provided to our Members.
Claims and Reimbursement Procedures
Precertification Requirements
Precertification, sometimes referred to as Prior Authorization (PA), is required for all SNF services
for which Medicaid is the primary payer, including all levels of care, medical and nonmedical
absences and Reserve Days (leaves of absence). The Provider is responsible for obtaining
precertification and is required to pay the SNF room and board charges.
Provider must submit precertification requests with all supporting documentation immediately
upon identifying a SNF admission or at least 72 hours prior to the scheduled admission.
So we can ensure appropriate discharge planning, you must provide notice to CareMore via our
precertification process when a member is admitted to an acute care or behavioral health care
facility. For Members that enter the facility as “Medicaid Pending”, please request a
precertification as soon as the state approves the Medicaid eligibility and the Member’s eligibility
is reflected on the CareMore website.
The CareMore website and your Provider Manual list those services that require precertification
and notification. Our Provider website also houses evidence-based criteria we use to complete
precertification and concurrent reviews.
CareMore will follow the criteria established by DHCS authorizing short term or long term SNF
stays.
The certification request can be submitted by:
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Fax the request to 1-866-333-4818
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Calling Care Management at 1-888-831-2246 (Select Option 2)
Member Liability (Share of Cost) should be reported on the CMS-1450/UB-04 claim form, Box 39.
Your claim may be rejected if Box 39 is not populated. Please make sure to bill Value code 23
with $0.00 or greater amount. Even if multiple claims are submitted monthly and the Member
Liability is met with the first claim, subsequent claims should indicate $0 liability with the value
code 23.
Retroactive adjustments: CareMore understands the unique requirements of nursing facilities to
accept residents as Medicaid pending. As soon as the facility receives notice from the state of the
Medicaid approval, the facility should verify eligibility on the CareMore website and then request
an authorization back to the date of eligibility as established by the state. Please note that it may
take the state 24 to 48 hours to transmit an updated eligibility to the CareMore.
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Crossover Claims Procedures: In most cases, when a resident has met the criteria for a Medicare
qualified stay in a certified Medicare bed, the Medicare cost share will be relayed to CareMore
via a crossover file provided to CareMore. We will then process and adjudicate the crossover
claim. No further action should be necessary by the Provider.
Corrected Claims Procedures: A corrected claim Code XX7 or a replacement claim Code XX8 may
be submitted within 60 calendar days of the original claim’s Explanation of Payment (EOP) date.
When submitting a corrected claim, ensure that the applicable claim code is indicated on the
claim form. Also ensure that corrected claims contain all applicable dates of service and/or
Revenue Codes for processing.
Reimbursement to Multipurpose Senior Services Program Providers
MSSP Providers must submit monthly invoice/report to CareMore no later than the fifth day of
each month for all members for the reimbursement of the PMPM payment. The invoice/report
shall be for each CareMore member enrolled in the MSSP as of the first day of the month for
which the report is submitted. CareMore will pay the MSSP provider no later than thirty days
after receipt of an undisputed claim. The report submitted must include the following:
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The name of the CareMore member receiving the MSSP services
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The member’s Client Index Number (CIN)
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The MSSP Provider’s ID number.
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Other items as identified by both the health plan and the MSSP.
CareMore pays MSSP Providers a fixed monthly amount for each CareMore member receiving
MSSP Waiver Services. This amount is equal to one twelfth (1/12th) of the annual amount
budgeted per MSSP Waiver slot allotment in the MSSP Waiver. This amount is provided by the
state to CareMore.
MSSP Providers must accept CareMore’s payment as payment in full and final satisfaction of
CareMore’s payment obligation for MSSP Waiver Services for each MSSP Waiver Participant
enrolled in CareMore.
MSSP Providers may not submit separate claims to different plans for the same MSSP Waiver
Participant within the same invoice period.
MSSP Providers must make timely payments to their subcontractors and/or vendors.
The MSSP would then submit an encounter claim to CareMore within 60 days from the date of
services. The encounter claim would then be processed as zero payment to the MSSP.
Any questions can be directed to your LTSS provider relations representative.
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CHAPTER 5: MEMBER SERVICES
Member Services
Member Services Department:
Hours of Operation:
1-888-350-3447 (toll free)
8 a.m. to 8 p.m.
Monday through Friday (except holidays)
The CareMore Health Plan (CareMore) Member Services Department is designed to assist
Members with all of our value-added services and health plan benefit coordination. The
department’s friendly, knowledgeable and bilingual representatives are available to answer
Member questions regarding, but not limited to
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General benefits
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Assigned physician
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Hospital information
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Pharmacy locations
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Status of referrals and authorizations
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Billing questions
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Hospital services
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Community resources and support groups
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Pharmacy benefits and coverage
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Grievances and appeals process
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ID card replacements
Health Risk Assessments
Within 60 days of enrollment in Cal MediConnect, Members are encouraged to come into a
CareMore Care Center to receive an initial “Healthy Start” health risk assessment (HRA). For
those enrolled in a SNP Plan, they will then receive a “Healthy Journey” HRA on an annual basis
thereafter. These face-to-face assessments include:
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A complete medical history
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A head-to-toe physical examination
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An assessment of health behaviors
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On-site lab testing with a complete metabolic panel, additional tests may include A1C,
PT/INR, random urine microalbumin, if needed
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Depression Screening to identify Members requiring treatment for depression.
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Mini-Cognitive or Mini-Mental State Exam (MMSE) to identify if the Member suffers from
dementia.
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Community Assessment Risk Screening (CARS) to identify those Members at an increased
risk of hospitalization.
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A fall risk screen to identify Members at risk of falling.
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Pain assessment screening to identify if the Member requires additional treatment.
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Functional screening to identify the Member’s ability to perform daily activities, such as
bathing, dressing and preparing meals.
These HRAs are fundamental to understanding and improving our Members’ health status,
access to care, health outcomes and utilization. Information gained in the HRA process is used by
the Interdisciplinary Team (ICT), which includes the Member and family Member(s) when
appropriate, to develop the Member’s plan of care.
Appointment Scheduling
Routine Podiatry Services Appointment Line
As part of their benefit package, Members may self-refer to the CareMore Foot Centers for
routine foot care such as toenail clipping. To schedule an appointment for routine foot care,
Members or the physician office staff may call the nearest Foot Center-equipped CareMore Care
Center. For CareMore Care Center contact information, please see Chapter 2: Important Contact
Information – Care Centers.
Transportation Scheduling
The Member Services Department coordinates the transportation benefit for Members. The
transportation benefit does not apply to medical transportation services, such as ambulance
service.
Transportation services must be scheduled one business day in advance of a Member’s medical
appointment and may only be used to travel to and from scheduled medical appointments at
CareMore-approved locations. Transportation must be coordinated through CareMore.
Members must notify CareMore of any cancellation one business day prior to the scheduled trip.
Same-day cancellations may count as a one-way trip taken toward their annual transportation
benefit limit. In order to receive covered transportation services, Members must be able to use
standard means of transportation, such as buses, vans, or taxicabs, and must be able to ride with
others.
Our drivers are scheduled to meet Members 30 to 60 minutes prior to their appointment time.
When the Member is ready to return home, the Provider’s office staff will call CareMore Health
Plan so that a ride may be arranged. Standard wait time for pick-up upon completion of
Member’s medical appointment is approximately 60 minutes.
Transportation may be scheduled by the Member or by the Provider’s office. To schedule
transportation or to contact us for more information, please call:
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CareMore Transportation:
Hours of operation:
Cal MediConnect
1-888-325-1024
7 a.m. to 6 p.m. Monday through Friday, except holidays.
Nurse Helpline
Members seeking medical information after hours may call our 24/7 NurseLine, a 24 hours a day,
7 days a week information phone line, any time of the day or night, to speak to a registered
nurse. Members can also call our 24/7 NurseLine information line, 24 hours a day, seven days a
week, to speak to a registered nurse. These nurses provide health information regarding illness
and options for accessing care, as well as information on the following:

Authorization requests

Emergency instructions

Health concerns

Local health care services

Medical conditions

Prescription drugs

Transportation needs
24/7 NurseLine:
1-800-224-0336 (24 hours a day, 7 days a week)
(TTY):
711, or 1-800-735-2929 (English) / 1-800-855-3000 (Spanish)
Translation, Interpreter and Sign Language Services
CareMore recognizes that some Members may experience communication barriers when
accessing benefits and services. We do the following to help remove those barriers:

Ensure Members with limited English proficiency (LEP) have meaningful access to services

Make available (upon request) written Member materials in large print, Braille, audio and
in languages other than English.

Provide Member materials written at the appropriate reading and/or grade level

Provide interpreter services to communicate with a limited-English proficiency Member
Call Member Services at the numbers listed at the beginning of this chapter to access interpreter
services for more than 150 languages (including American Sign Language).
CareMore has contracted with several language services companies to assist both Members and
Providers in those instances where interpreter services, including American Sign Language, are
needed to ensure adequate health care communication.
These interpreter services, which include over-the-phone and face-to-face interpreters, are
available at no cost to both Provider and Member. Providers must notify Members of the
availability of interpreter services and strongly discourage the use of friends and family,
particularly minors, to act as interpreters. It is important that you or your office staff document
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the Member’s language, any refusal of interpreter services, and requests to use a family Member
or friend as an interpreter in the Member’s medical record.
When Language Services or Sign Language Services are required by the Member at their assigned
Primary Care Physician or Specialist office, the office must contact the Member Services at the
numbers listed at the beginning of this chapter to request those services.
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CHAPTER 6: MEMBER ENROLLMENT AND ELIGIBILITY
Member Enrollment
Certain Los Angeles County residents who are eligible for the state-funded Medi-Cal and
federally-funded Medicare programs are passively enrolled into CareMore Health Plan’s Cal
Medi-Connect program by California’s Department of Health Care Services (DHCS). Individuals
who choose not to enroll in Cal Medi-Connect and wish to keep their Medicare benefits separate
may ‘opt out’ of the plan at any time by notifying DHCS of their choice.
Please note: Opting out applies only to Medicare benefits. Beneficiaries must still get their MediCal benefits, including Long Term Services and Supports (LTSS) benefits, through a managed care
health plan.
Member Eligibility
Eligibility Department:
Hours of Operation:
1-888-250-5800 (Option 5)
5 a.m. to 5 p.m., Monday through Friday
Eligibility Verification Process
All primary care physicians (PCPs), specialists, ancillary providers, and facilities must verify
eligibility prior to rendering services to Members. Providers may verify a Member’s eligibility by
logging onto CareMore’s online Provider Portal or by calling CareMore’s Eligibility Department.
On-Line: Providers who have been trained on CareMore’s On-Line Provider Portal may verify a
Member’s eligibility by using this site: Providers.caremore.com. For additional information
regarding the Provider Portal please contact Provider Relations at 1-888-291-1358 (Select Option
3, then Option 5).
By telephone: When contacting the Eligibility Department to verify a Member’s eligibility, please
be prepared to give the following information:

Member’s name

Member’s date of birth

Member's ID number
Eligibility/Discrepancy
In the event that eligibility is not accurate, please contact Provider Relations at 1-888-291-1358
(Select Option 3, then Option 5) for investigation and resolution. Please include:

Member’s Name

ID Number

Date of Birth

Primary Care Provider (Name and NPI)
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Explanation of discrepancies to include the months in question.
In cases where members change PCP assignment on or around the 15th of the month
retroactively, members may be omitted from the eligibility webpage or capitation report for that
particular PCP. The retroactivity will appear on the following month’s eligibility/capitation
reports. The Capitation Department will work with your Regional Performance Manager on any
capitation related issues Medicare has specific rules in place for Hospice and although the
member is still technically assigned to CareMore, all payments for medical services related to
their condition are handled thru Hospice. CareMore will not issue Capitation payment on
members who have elected Hospice.
Please contact the Eligibility Department if one or more of the following discrepancies occur
based on eligibility information available on CareMore’s Provider Portal:

The patient is eligible with the health plan but is not listed as eligible

The patient is not eligible with the health plan but is listed as eligible

The PCP assignment is not accurate
 The identification information is not accurate
If the patient is listed as eligible on CareMore’s Provider Portal but is not listed on the capitation
report, please contact Provider Relations at 1-888-291-1358 (Select Option 3, then Option 5) for
investigation and resolution.
Once the Eligibility Department is contacted and made aware of the discrepancy, the Eligibility
staff conducts its internal investigation of the discrepancy and submits a response and corrective
action plan to the Provider within two (2) business days.
You may contact the Eligibility Department directly to check on the status of your discrepancy or
if you require additional information. The Eligibility Department may be reached at
1-888-250-5800 (Option 5).
Dual Eligible Population
In order to enroll in CareMore Cal MediConnect Plan, an individual must be eligible for Medicare
(Part A and B) as well as Medi-Cal Managed Care (Medi-Cal). To learn more about
CalMediConnect eligibility restrictions and to view a detailed chart outlining the demonstration
program’s participating populations, please go to the Coordinated Care Initiative section of the
DHCS website at www.dhcs.ca.gov/provgovpart/Pages/CoordinatedCareIntiatiave.aspx. The
CCI Population Chart is located underneath the CCI Fact Sheets heading.
Member Identification Cards
Overview
Primary care physicians, specialists, ancillary providers, and facilities are responsible for verifying
each Member’s eligibility prior to rendering services, unless it is an emergency. All Members
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have a health plan identification card, which must be presented each time services are
requested.
Health Plan Identification Card
The Health Plan Identification Card should contain, but not be limited to, the following
information:

Health Plan

Member Name/Subscriber Name

Member Health Plan Identification Number

Primary Care Physician - name and phone number*

Pharmacy Information, including Pharmacy Benefit Manager (PBM) help desk and phone
number, PCN ID, BIN#, Group#, Pharmacy ID

Member Services - toll-free number
Copayments for PCP office visits and Specialist office visit

*For some service areas, the card may also include the name and phone number of the assigned Ophthalmology
Provider. For more information, contact your Regional Performance Manager or Provider Relations.
MEMBER IDENTIFICATION CARD SAMPLE
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CHAPTER 7: CLAIMS PROCESSING
Claims Submission Guidelines
Overview
Having a fast and accurate system for processing claims allows Providers to manage their
practices, and our Members’ care, more efficiently.
With that in mind, CareMore Health Plan (CareMore) has made claims processing as streamlined
as possible. The following guidelines should be shared with your office staff, billing service and
electronic data processing agents, if you use them.



Submit “clean” claims, making sure that the right information is on the right form.
Submit claims as soon as possible after providing service.
Submit claims within the contract filing time limit.
All claims information must be accurate, complete, and truthful based upon the Provider’s best
knowledge, information and belief.
Electronic Claims
We encourage the submission of claims electronically through Office Ally™. All Providers must
submit claims within the timeframes listed in their agreement or contract with CareMore.
The advantages of electronic claims submission are as follows:








Facilitates timely claims adjudication
Acknowledges receipt and rejection notification of claims electronically
Improves claims tracking
Improves claims status reporting
Reduces adjudication turnaround
Eliminates paper
Improves cost-effectiveness
Allows for automatic adjudication of claims
For electronic submission, please contact Office Ally™ at 1-866-575-4120 or online at
www.officeally.com to set up an account.
Paper Claims
Paper claims are scanned for clean and clear data recording. To get the best results, paper claims
must be legible and submitted in the proper format. Follow these requirements to speed
processing and prevent delays:

Use the correct form and be sure the form meets Centers for Medicare and Medicaid Services
standards.
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
Use black or blue ink (do not use red ink, as the scanner may not be able to read it).

Use the “Remarks” field for messages.

Do not stamp or write over boxes on the claim form.

Send the original claim form to CareMore, and retain a copy for your records.

Separate each individual claim form. Do NOT staple original claims together; CareMore will
consider the second claim as an attachment and not an original claim to be processed
separately.

Remove all perforated sides from the form; leave a ¼-inch border on the left and right side of
the form after removing perforated sides. This helps our scanning vendor scan accurately.

Type information within the designated field. Be sure the type falls completely within the text
space and is properly aligned.

Don't highlight any fields on the claim forms or attachments; doing so makes it more difficult
to create a clear electronic copy when scanned.

If using a dot matrix printer, do not use “draft mode” since the characters generally do not
have enough distinction and clarity for the optical scanner to read accurately.
If you submit paper claims, you must include the following Provider information:

Provider name

Rendering Provider Group or Billing Provider

Federal Provider Tax Identification Number (TIN)

The CareMore Health Plan Payer Identification Number

National Provider Identifier (NPI)

Medicare number
Please Note: Some claims may require additional attachments. Be sure to include all supporting
documentation when submitting your claim. Claims with attachments should be submitted on
paper.
Mail paper claims to:
Attn: Claims Dept MS-6110
P.O. Box 366
Artesia, CA 90702
Paper Claims Processing
All submitted paper claims are assigned a unique document control number (DCN). The DCN
identifies and tracks claims as they move through the claims processing system. This number
contains the Julian date, which indicates the date the claim was received.
Claims entering the system are processed on a line-by-line basis except for inpatient claims,
which are processed on a whole-claim basis. Each claim is subjected to a comprehensive series of
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checkpoints called “edits.” These edits verify and validate all claim information to determine if
the claim should be paid, denied or pended for manual review.
The Provider is responsible for all claims submitted with the Provider number, regardless of who
completed the claim. If you use a billing service you must help ensure that your claims are
submitted properly.
Please note: We cannot accept claims with alterations to billing information. Claims that have
been altered will be returned with an explanation for the return. We will not accept claims from
those providers who submit entirely handwritten claims.
CMS-1500 Form
Professional claims must be submitted on a CMS-1500 (version 08/05) form. If you are
submitting through OfficeAlly, as of April 1,2014 the CMS-1500 (version 02/12) form must be
used. Doing so will expedite processing of your claim. Incomplete claims and/or illegible claims
will be returned. Claims must be itemized to include CPT codes with modifiers and correlating
ICD-9 codes. Billed services may be denied for correction of coding. Upon the anticipated
transition deadline / effective date , ICD-10 codes must be used and must be billed on the CMS1500(version 02/12) form as mandated by the Centers for Medicare & Medicaid Services (CMS).
To expedite the processing of claims, it is important to include the following information:

Member Name

Enrollee ID Number

Physician’s Name

ICD-9 Code(s)

Date of Service

CPT Code(s)

Charge

Place of Service

Authorization Number, when applicable

Copies of reports when billing by report procedures
Copies of operative/pathology/consultative and referral/authorization forms should be
submitted with the claim for processing. Paper authorizations do not need to be submitted with
inpatient claims.
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Claims Processing Timelines
Claims are processed from the date of receipt. Medicare Member claims are processed within 60
calendar days. Per your agreement and/or contract with CareMore.
Additional Payer
A determination should be made as to whether an additional payer has primary responsibility for
the payment of a claim. If CareMore finds that another payer is responsible for payment, we will
coordinate benefits with that payer. With the payment from the primary carrier and CareMore,
you will be paid up to the amount allowed in your Agreement with CareMore.
Claims can/will be denied based on the timely submissions of claims provision in the Provider
Health Services Agreement.
National Provider Identifier
The National Provider Identifier (NPI) is a 10-digit, all numeric identifier. NPIs are only issued to
Providers of health services and supplies. As one provision of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), the NPI is intended to improve efficiency and reduce
fraud and abuse.
There are several advantages to using the Provider NPI for claims and billing:



It allows Providers to bill with only one number
It simplifies the billing process since it is no longer necessary to maintain and use legacy
identifiers for each health care plan
It simplifies making changes to addresses or locations
NPIs are divided into two types:


Type 1: Individual Providers, which includes but is not limited to physicians, dentists and
chiropractors
Type 2: Hospitals and medical groups, which includes but is not limited to hospitals,
residential treatment centers, laboratories and group practices
For billing purposes, claims must be filed with the appropriate NPI for billing, rendering and
referring Providers. Providers may apply for an NPI online at the National Plan and Provider
Enumeration System (NPPES) website: https://nppes.cms.hhs.gov. Or, you can get a paper
application by calling NPPES at:
NPPES:
1-800-465-3203
The following websites offer additional NPI information:

Centers for Medicare and Medicaid Services:
https://www.cms.gov/Regulations-and-Guidance/HIPAA-AdministrativeSimplification/NationalProvIdentStand/index.html?redirect=/nationalprovidentstand/

National Plan and Provider Enumeration System (NPPES):
https: //nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
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National Uniform Claims Committee:
www.nucc.org
No NPI Required for Atypical Providers
Some LTSS providers are atypical providers and are not eligible to apply for an NPI. Such
providers do not need to submit an NPI when billing for services.
An atypical provider is an individual or organization that provides non-traditional services that
are indirectly healthcare related. An atypical provider is not a healthcare provider and does not
provide any healthcare services. Examples include those who provide:

non-emergency transportation or vehicle modifications

housekeeping services

physical alterations to living quarters for purposes of accommodating disabilities
Coding
The Coding Department’s goal is to achieve correct coding in order to accurately report the
comprehensive health status of every CareMore member. Providers and their office staff are
educated on current coding and documentation guidelines.
Medicare Risk Adjustment
Medicare Risk Adjustment determines reimbursement to all Medicare Advantage (MA) health
plans based upon a patient’s individual health status. Reimbursement to the health plan is only
provided for conditions that are documented and reported to Medicare at least annually. These
illnesses are reported to CMS by way of ICD-9-CM diagnoses codes. There are more than 3,000
risk adjusting codes that are broken into 70 HCC’s or hierarchical condition categories. Chronic
conditions must be documented, coded, and submitted at least yearly for every member for
payment. CMS validates this data by auditing “one best” progress note for each condition. They
do not audit complete charts.
Concurrent Review
Concurrent Review is conducted on a daily basis for a large portion of the encounter data that is
submitted to CareMore. Encounter forms, submitted by the providers, are reviewed along with
the corresponding documentation (progress note) to verify that all appropriately documented
diagnoses are coded correctly. Any diagnoses marked by the provider on the encounter form
that are not supported in the documentation are removed. Concurrent Review provides the
coding department the ability to quickly identify any coding or documentation issues so that
education can be given to the provider.
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Assessment Form (PAHAF) Note: Applies to PCPs in their 2nd year with CareMore
Patient Annual Health Assessment Forms (PAHAF’s) are generated at the beginning of each year
for each currently eligible member that has at least one HCC and/or one potential HCC
documented in the previous calendar year. These forms are given to all contracted Primary Care
Physicians. The Primary Care Physicians are asked to schedule their members for a face-to-face
office visit during the current calendar year so that all of their patient’s current chronic illnesses
can be assessed & documented in a progress note. The Coding Department then reviews the
PAHAF along with the documentation and validates the diagnoses coded for the encounter. Any
coding or documentation issues are noted and education is then given to the provider.
Chart Reviews
Chart Reviews are scheduled periodically. These chart reviews are conducted with the intention
of validating encounter data submitted by the provider’s offices. Depending on the
documentation reviewed, existing claims may be amended in the claims system. Encounters are
created if they were not already submitted by the provider. Any coding or documentation issues
are noted and education may be given to the provider.
Education and Training
Education and training are given to the providers on an on-going basis. All new providers are
contacted and trained on correct Risk Adjustment/HCC documentation and coding. Coding and
documentation issues are identified through Concurrent Review, the PAHAF process, and/or
Chart Reviews. Providers that need education and feedback regarding their documentation and
coding are contacted for refresher training.
Clinical Submissions Categories
The following is a list of claims categories for which we may routinely require submission of
clinical information before or after payment of a claim:





Claims involving precertification/prior authorization/pre-determination (or some other
form of utilization review) including but not limited to:
o Claims pending for lack of precertification or Prior Authorization
o Claims involving medical necessity or experimental/investigative determinations
o Claims for pharmaceuticals requiring Prior Authorization
Claims requiring certain modifiers, including, but not limited to, Modifier 22
Claims involving unlisted codes
Claims for which we cannot determine from the face of the claim whether it involves a
covered service; thus, benefit determination cannot be made without reviewing medical
records, including but not limited to pre-existing condition issues, emergency serviceprudent layperson reviews, and specific benefit exclusions
Claims that we have reason to believe involve inappropriate (including fraudulent) billing
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



Cal MediConnect
Claims that are the subject of an audit (internal or external), including high-dollar claims
Claims for individuals involved in case management or disease management
Claims that have been appealed (or that are otherwise the subject of a dispute, including
claims being mediated, arbitrated or litigated)
Bundling and unbundling of services
Other situations in which clinical information might routinely be requested:







Billing services at a higher level of care than what has been authorized
Accreditation activities
Coordination of benefits
Credentialing
Quality improvement/assurance efforts
Recovery/subrogation
Requests relating to underwriting (including but not limited to Member or Provider
misrepresentation/fraud reviews and Stop Loss coverage issues)
Examples provided in each category are for illustrative purposes only and are not meant to
represent an exhaustive list within the category.
Claim Forms and Filing Limits
Claims must be submitted within the contracted filing limit to be considered for payment.
Claims submitted after that time period will be denied.
Determine filing limits as follows:
 If CareMore is the primary payer, use the length of time between the last date of service on
the claim and CareMore’s receipt date.
 If CareMore is the secondary payer, use the length of time between the other payer’s notice
or Remittance Advice (RA) date and CareMore’s receipt date.
Please Note: CareMore is not responsible for a claim never received. Additionally, if a claim is
submitted inaccurately, prolonged periods before resubmission may cause you to miss the filing
deadline. Claims must pass basic edits in order to be considered received. To avoid missing
deadlines, submit “clean” claims as soon as possible after delivery of service.
Filing and Reimbursement Limits for Medi-Cal Claims
In order for Providers to be reimbursed fully for professional Medi-Cal claims, those claims must
be submitted within 180 days of the date of service. Because this is a regulatory requirement,
this timeline supersedes any conflicting timelines that may be in your Agreement with CareMore.
Reimbursement for claims submitted between 180 and 365 days of date of service will be
reduced by the following amounts:
 25 percent for claims submitted seven through nine months after the month of service, or
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 50 percent for claims submitted 10 through 12 months after the month of service.=9876543Pursuant to the California Welfare and Institutions Code (W & I) Section 14115,
DHCS allows for the following four exceptions to the six-month billing limit:
 If the patient has failed to identify himself or herself as a Medi-Cal beneficiary within four
months after the month of service.
 If a Provider has submitted a bill to a liable third party, the Provider has one year after the
month of service to submit the bill for payment.
 If a legal proceeding has commenced in which the Provider is attempting to obtain payment
from a third party, the Provider has one year to submit the bill after the month in which the
services have been rendered.
 If CareMore finds that the delay in submission of the bill was caused by circumstances
beyond the control of the Provider.
CareMore does not reimburse claims submitted more than one year after the date of service.
Providers who have questions about claims submittal timelines should call Provider Relations at
1-888-291-1358 (option 3, then option 5).
Form
Type of Service to be Billed
Time Limit to File
CMS-1500
Professional services,
including physician services.
For services provided to Cal MediConnect
Members, file a clean claim subject to the
terms as described in your Agreement with
CareMore, not to exceed 365 days of the
service date per regulations.
CMS-1500
Specific ancillary services,
including physical and
occupational therapy, skilled
nursing facilities (SNF) and
speech therapy.
Members, file a clean claim subject to the
terms as described in your Agreement with
CareMore, not to exceed 365 days of the
service date per regulations.
CMS-1500
Ancillary services, including:
Members, file a clean claim within 365 days of
the service date.
Audiologists, ambulance,
ambulatory surgical center,
dialysis, durable medical
equipment, diagnostic
imaging centers, hearing aid
dispensers, home infusion,
home health, laboratories,
prosthetics and orthotics
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Form
Type of Service to be Billed
Time Limit to File
CMS-1450
(UB-04)
Hospitals and Institutions;
therapy services conducted
Members, file a clean claim within 365 days of
in the skilled nursing faciliites the service date or otherwise described in the
Hospital Services Agreement.
Other Filing Limits
Action
Description
Time Limit to File
Third Party
Liability (TPL)
or
Coordination
of Benefits
(COB)
If the claim has TPL or COB and
requires submission to a third party
before submitting to us, the filing limit
starts from the date on the notice or
Remittance Advice (RA) from the third
party.
From the date of notice or RA from
the third party, follow the
applicable claim filing limits.
Checking Claim
Status
Claim status may be checked any time
on Providers.caremore.com, or by
calling the Claims Department at
1-877-211-6553.
After 60 business days from the
Plan's receipt of a clean claim,
Providers can stamp the original
claim with “TRACER” and resubmit.
Claim
Resubmittal
To submit a corrected claim following
the Plan's request for more
information, correction to a claim, or
to follow up a claim that has not been
paid, denied or contested.
Provider must return request
information to the Plan within 45
days from the date of the Plan's
request for correction.
Provider
Dispute
Providers may request claim
reconsideration in writing. Please refer
to Chapter 2 Important Contact
Information for claims mailing
address.
The request for claim
reconsideration must be received
within 365 days from the receipt of
the Plan's RA.
Plan Response
to Provider
Dispute
Resolution
Request
The Plan's response time to investigate Determination is made within 45
and make a determination based on
business days from the Plan's
guidelines.
receipt of dispute or amended
dispute.
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Claims Returned for Additional Information
CareMore will send you a request for additional or corrected information when the claim cannot
be processed due to incomplete, missing or incorrect information. Providers have 45 days from
the date on the request in which to submit the corrected claim information. If the Provider does
not resubmit within this time frame, the claim is denied.
Common Reasons for Rejected and Returned Claims
Many of the claims returned for further information are returned for common billing errors. The
following grid lists the most common errors.
Problem
Explanation
Resolution
Member ID Number
Incomplete
The state provides ID cards to the Member
in addition to our ID card. The Member's
Plan ID number is called the CIN number. It
includes a 3-digit alpha prefix, followed by
10-14 numerical digits.
Make sure to use the Member's CIN number
from his or her paper ID card, not the number
from the state's card.
Duplicate Claim
Submission
Duplicate claims are submitted before the
applicable processing time frame has
passed.
Wait to resubmit a claim until the
appropriate time frame for processing has
passed.
Overlapping services dates for the same
service create a question about duplication.
Then, look up claim status on the Provider
portal at Providers.caremore.com or use the
IVR phone system to check claim status.
Authorization
Number Missing or
Doesn't Match
Services
The authorization number is missing or the
approved services do not match the services
described in the claim.
Confirm that the authorization number is on
the claim form (CMS-1500 Box 23 and CMS
1450 Box 63) and that the approved services
match the provided services.
Missed Filing Limit
The time frame for submitting a claim for
reimbursement is determined by the
applicable CareMore State Sponsored
Business Provider Agreements and the type
of services provided: Professional, ancillary
or institutional.
Be sure to submit the claim within:
Missing Codes for
Required Service
Categories
Current HCPCS and CPT Manuals must be
used because changes are made quarterly or
annually. Manuals may be purchased at any
technical bookstore or call the American
Medical Association to order them.
Make sure all services are coded with the
correct Medicare codes. Check the
codebooks or ask someone in your office
familiar with coding.
Unlisted Code for
Service
Some procedures/services do not have an
associated Medicare code, so an unlisted
procedure code is used.
CareMore needs a description of the
procedure and medical records when
appropriate in order to calculate
reimbursement. For prosthetic devices, we
require a manufacturer's invoice.
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180 365 days from date of service for
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180 365 days from date of service in
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Problem
Explanation
Resolution
By Report Code for
Service
Procedure or service information is missing.
CareMore needs a description of the
procedure and medical records when
appropriate to calculate reimbursement. For
DME, prosthetic devices, hearing aids or
blood products, we require a manufacturer's
invoice. For drugs and injections, we require
the NDC number.
Unreasonable
Numbers Submitted
Unreasonable numbers, such as "9999," may
appear in the Service Units fields.
Be sure to check your claim for accuracy
before submission.
Submitting Batches
of Claims
Stapling claims together can make the
subsequent claims appear to be
attachments rather than individual claims.
Make sure each individual claim is clearly
identified and not stapled to another claim.
Nursing Care
Nursing charges are included in the hospital
and outpatient care charges. Nursing
charges that are billed separately are
considered unbundled charges and are not
payable. Also, we will not pay claims using
different room rates for the same type of
room to adjust for nursing care.
Do not submit bills for nursing charges.
Hospital Medicare
ID Missing
A Medicare ID number is required for claim
processing.
On the CMS-1450 Form, hospitals must enter
their Medicare ID number in Box 64.
Claims and Encounter Data Inquiries
Encounter Data
PCPs who receive monthly capitation reports for Members are required to submit encounter
data on a monthly basis. All encounter data submitted to CareMore must be accurate, complete,
and truthful based upon the Provider’s best knowledge, information and belief. This data should
be submitted on a CMS-1500 form and should include:

Member name

Member ID number

Date of birth

Date of service

Place of service

CPT code number

ICD-9 code number

Charge
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Please mail encounter data at least once a month to:
Attn: Claims Dept – Duals MS-6110
P.O. Box 366
Artesia, CA 90702
Providers may also submit encounter data electronically through their Office Ally™ account. For
electronic submission, please contact Office Ally™ at 1-866-575-4120 or online at
www.officeally.com.
Claims Status Inquires
Contact us at the telephone or fax number provided in this manual if you have any claims
questions related to, but not limited to, the following topics:

When claim was paid

Amount paid

Status of claim

Timely filing information

Provider appeals
For more information, please refer to CareMore Contact Information (Chapter 2) for phone number
and hours of operation.
Clean Claims Payment
Payment of Claims
Once we receive a claim, the following steps are taken:
1. CareMore processing systems analyze and validate the claim for Member eligibility,
covered services and proper formatting.
2. CareMore processing systems validate billing, rendering and referring Provider
information against CareMore files.
3. CareMore generates a Remittance Advice (RA), summarizing services rendered and payer
action taken.
4. CareMore sends the appropriate payment to the Provider.
CareMore will finalize a clean electronic claim within applicable timeframes or according to your
agreement or contract with CareMore.
Capitation
Capitation is a payment arrangement for health care service providers. A set amount is paid to
the capitated provider/group for each enrolled person assigned to them, per period of time,
whether or not that person seeks care. Capitation is generated on or around the 7th of each
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month and mailed with payment by the 27th of each month. All payments made reflect the
current month and six months retro-activity.
Electronic Remittance Advice
CareMore offers secure electronic delivery of remittance advices, which explain claims in their
final status. This service is offered through Emdeon. For more information, Providers and
vendors may call Emdeon directly at 1-866-506-2830 or go to http://www.emdeon.com/eft/.
CareMore Payer#: CM001.
Electronic Funds Transfer
CareMore allows Electronic Funds Transfer (EFT) for claims payment transactions. This means
that claims payments can be deposited directly into a previously selected bank account.
Providers can enroll in this service by contacting Emdeon, the EFT vendor, at the number
provided above.
Procedure for Processing Overpayments
CareMore seeks recovery of all excess claims payments from the person or entity to whom the
benefit check is made payable. When an overpayment is discovered, CareMore initiates the
overpayment recovery process by sending written notification.
If you are notified by CareMore of an overpayment, or discover that you have been overpaid,
mail the check, along with a copy of the notification or other supporting documentation within
30 days to the following address:
Attn. Claims Recovery MS 6110
P.O. Box 366
Artesia, CA 90702
LTSS Providers, please mail the check, along with a copy of the notification or other supporting
documentation within 30 days to the following address:
P.O. Box 933657
Atlanta, GA 31193-3657
If CareMore does not hear from you or receive payment within 30 days, the overpayment
amount is deducted from future claims payments. In cases CareMore determines that recovery is
not feasible, the overpayment is referred to a collection service.
Provider Payment Disputes
CareMore has established fair, fast and cost-effective procedures to process and resolve Provider
appeals. The following definitions apply to this process:
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Appeal
A written notice to CareMore, submitted to the designated Provider appeal address, challenging,
appealing or requesting reconsideration of a claim, or requesting resolution of billing
determinations, such as bundling/unbundling of claims/procedures codes or allowances. Also, a
written notice to CareMore, submitted to the designated Provider appeal address, disputing
administrative policies & procedures, administrative terminations, retroactive contracting, or any
other contract issue.
Provider Inquiry
A telephone call for information, including questions, regarding the following:

Claim status

Submission of corrected claims

Member eligibility

Payment methodology rules (bundling/unbundling logic, multiple surgery rules)

Medical policy

Coordination of benefits

Third party liability/workers compensation issues submitted by a Provider to CareMore

A telephone discussion or written statement questioning the manner in which CareMore
processed a claim (i.e. wrong units of service, wrong date of service, clarification of
payment calculation)
Required Information for an Appeal
An appeal must be submitted in writing and contain the following information:

Provider name

Provider tax ID or NPI Number

Contact information - mailing address and phone number

Original claim number, when applicable

Member’s name, when applicable

Member’s subscriber number, when applicable

Date of service, when applicable
The appeal must also include a clear explanation of issue the Provider believes to be incorrect,
including supporting medical records when applicable.
Submission of Provider Appeals
All claims appeals must be submitted in writing to the following address:
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Attn: Claims Disputes MS 6110
P.O. Box 366
Artesia, CA 90702
LTSS Providers – All claims appeals must be submitted in writing to the following address:
P.O. Box 61599
Virginia Beach, VA 23466-1599
Filing an appeal falls under the same submission timeframe as filing an original claim. CareMore
will respond to claims appeals within the time frame listed in your CareMore Provider
Agreement.
Hold Harmless
According to federal law, Providers may not bill Cal MediConnect Members for covered services
except for applicable co-payments. Title 42, Section 422.502(g)(1) and (i) states, "...protect its
enrollees from incurring liability ... for payment of any fees that are the legal obligation of the
Medicare Advantage organization.”
This requirement includes any services where the Member is responsible for any co-payment.
There can be no balance billing of the Member for any portion of the billed charges that are in
excess of that co-payment.
Per the Medicare Managed Care Manual, Chapter 6, Section 100;
"Consistent with §1852(a)(2) and §1852(k)(1) of the Social Security Act, noncontract Providers must accept as payment in full, payment amounts
applicable in Original Medicare. Thus, this provision of law imposes a cap on
payment to non-contract Providers of provide payment amounts plus
Member cost-sharing amounts applicable in Original Medicare, and ensures
that non-contract Providers not balance bill Medicare Advantage plan
Members for other than Medicare Advantage cost-sharing amounts."
In addition, under Federal law, non-contracted Providers are subject to penalties if they accept
more than Original Medicare amounts. None of the above precludes Providers from billing
Members for any non-covered services (i.e., travel vaccinations or cosmetic surgery).
Coordination of Benefits
When an individual enrolls with CareMore, we will ask the Member whether he/she has
healthcare insurance other than CareMore. Providers should always inquire whether a Member
has other health insurance coverage. For those Members who are over 65 years of age and
retired, CareMore will generally be the primary payer.
When CareMore is the primary payer, the Provider may bill the secondary carrier for usual and
customary fees and receive reimbursement in addition to that received from CareMore.
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Please note: a Member may not be billed for any balance due.
CareMore Health Plan will be the secondary payer in the following situations:

The Member is age 65 or older and has coverage under an employer group health plan
through an employer with 20 or more employees, either through the Member’s own
employment or the enrollee's spouse's employment.

The Member is under age 65 and is entitled to Medicare due to disability other than ESRD,
and the Member has coverage under a large employer (100 or more employees) group health
plan, either through the Member's own employment or that of their spouse.

The Member is being treated for an accident or illness that is work-related or otherwise
covered under Workers' Compensation.

The Member has End Stage Renal Disease (ESRD) and is covered under an employer group
health plan. In such cases, CareMore Health Plan will be the secondary payer for up to 30
months. After 30 months, Medicare will be the primary payer.

The Member is being treated for an injury, ailment, or disease caused by a third party and
automobile or other liability insurance is available.
Questions regarding COB can be directed to Member Services at 1-888-350-3447.
Claims Filed With Wrong Plan
If you file a claim with the wrong insurance carrier, CareMore will process your claim without
denying it for failure to file within the filing time limits if:


There is documentation verifying that the claim was initially filed in a timely manner
The corrected claim was filed within 90 days of the date of the other carrier’s denial letter
Claims Follow-Up/Resubmissions
Providers can initiate follow-up action to determine claim status if there has been no response
from CareMore within 60 days of the Plan's receipt of the claim. To follow up on a claim, please:
1.
2.
3.
4.
5.
Complete all required fields as originally submitted and mark the change(s) clearly.
Write or stamp "TRACER" across the top of the form.
Attach a copy of the EOB and state the reason for re-submission.
Attach all supporting documentation.
Send to:
Attn: Claims Department MS 6110
P.O. Box 366
Artesia, CA 90702
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CHAPTER 8: BILLING PROFESSIONAL AND ANCILLARY CLAIMS
Overview
This chapter is divided into two sections:

Billing Requirements for Professional Claims

Billing Requirements for Ancillary Claims
When billing for professional or ancillary claims, all Providers and vendors should bill using the
most current version of the CMS-1500 Claim Form.
Standardized code sets must be used. The Healthcare Common Procedure Coding System
(HCPCS), sometimes referred to as the National Codes, provides coding for a variety of services.
HCPCS consists of two principal subsystems, referred to as Level 1 and Level 2:
Level 1: The Current Procedural Terminology (CPT) codes maintained by the American Medical
Association (AMA).
CPT codes are represented by 5 numeric digits.
Level 2: Other codes that identify products, supplies and services not included in the CPT codes,
such as ambulance and Durable Medical Equipment (DME). These are sometimes called the
alphanumeric codes because they consist of a single alphabetical letter followed by 4 numeric
digits.
Products, supplies and services NOT included in the CPT codes are represented by a single
alphabetical letter followed by 4 numeric digits.
In addition to the HCPCS (national) codes, the California Department of Health Care Services
(DHCS) created a separate set of codes and modifiers for its Medi-Cal Program, sometimes called
Local Codes. These codes and modifiers identify services and products specific to Medi-Cal.
Special professional and ancillary billing instructions include the following:
Physician License Number: Indicate the rendering physician's state-issued license number in Box
24J of the CMS-1500 form. Missing or invalid license numbers may result in nonpayment.
Advanced Practice Clinicians: Indicate the name and license number in Box 19 of the CMS-1500
form; the supervising physician's license number should be entered in Box 24J. The following are
defined as mid-level:

Physician Assistants

Nurse Practitioners

Certified Nurse Midwives
Modifier Codes: Use modifier codes when appropriate with the corresponding Local Only, HCPCS
or CPT codes. For paper claims, all modifiers should be billed immediately following the
procedure code in Box 24D of the CMS-1500.
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Prior Authorization Number: Indicate the Prior Authorization number in Box 23 of the CMS-1500
form.
Member ID Number: Use the Member's Client Index Number (CIN) when billing, whether
submitting electronically or on paper. It is important to use the Member's Plan ID card number,
not the number on the identification card issued by the state.
On-Call Services: Insert On-Call for PCP in Box 23 of the CMS-1500 form when the rendering
physician is not the PCP, but is "covering for" or has received permission from the PCP to provide
services that day.
Anesthesia
Providers submitting anesthesia claims via Electronic Data Interchange (EDI) should use the
following guidelines:

Use the appropriate ASA CPT anesthesia code (00100-01999) with the appropriate
modifier.

Indicate the actual time of the service rendered in minutes in the 465A record segment,
using an MJ qualifier. The MJ qualifier equals the minutes billed.

Providers submitting anesthesia claims on paper should use the following guidelines:

Use the appropriate ASA CPT anesthesia code (00100-01999) with the appropriate
modifier.

Indicate the actual time ("hands-on time") of the service rendered in minutes in Field 24G
of the CMS-1500 form. This is particularly important for anesthesia code OB 01967.

Do not report the base units on claims.
Behavioral Health
The Primary Care Provider (PCP) is expected to treat Members with situational behavioral health
problems, the most common of which are depression and anxiety disorders.
For those Members whose behavioral health problems do not respond to treatment in a primary
care setting, referrals must be made to CareMore’s behavioral health vendor, Beacon, for
screening and referrals for additional behavioral health services. Please contact Beacon at
1-855-371-8092 for additional information.
Emergency Services
Emergency services are defined in the Provider's contract and by state and local law. Related
professional services offered by physicians during an emergency visit are reimbursed according
to the Provider's contract. For emergency services billing, indicate the Injury Date in Box 14 of
the CMS 1500 form.
Please Note: Members should be referred back to the Primary Care Provider (PCP) of record for
follow-up care. Unless clinically required, follow-up care should never occur in a hospital
emergency department.
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E/M Coding – Consultations and Follow up Visits
Evaluation/Management services will be reimbursed as authorized at a level 3 (99203, 99213)
When level “4” or “5” E/M coding is requested, Providers may submit appropriate, complete and
legible clinical documentation of the rendered service to support higher level visit.
When requesting a level “4” or “5” reimbursement, records should include Member history,
examination, medical decision making and the level of service provided to the Member during
the encounter.
The medical records will be reviewed by the clinical review team to determine appropriate
coding in accordance with Current Procedural Terminology (CPT) definitions and Medicare
guidelines.
Ancillary Billing Requirements by Service Category
Disposable and Incontinence Medical Supplies
The California Department of Health Care Services (DHCS) has implemented Health Insurance
Portability and Accountability Act (HIPAA)-mandated changes to Medicaid billing requirements
for disposable and incontinence medical supplies. For billing, use the following guidelines:

Providers must bill disposable incontinence and medical supplies with HCPCS Level II
Codes for contracted items using either electronic billing or the CMS-1500 form.

Providers may not use Local “99” Codes for disposable incontinence and medical supplies.
Providers must include the Universal Product Number (UPN) for contracted incontinence and
medical supplies.
Durable Medical Equipment (DME) is a covered service when prescribed to preserve bodily
functions or prevent disability. All custom-made DME, also referred to as By Report, requires
Prior Authorization. Other DME and supplies may also require pre-service review.
For DME, billing guidelines and requirements include the following:

For Medi-Cal, use Local or HCPCS Codes.

Use miscellaneous codes when an HCPCS Code does not exist for a particular item. An
example: Code E1399, which represents customized equipment.

Attach the manufacturer's invoice to the claim if using a miscellaneous or unlisted code.
The invoice must be from the manufacturer, not the office making the purchase.

Unlisted codes will not be accepted if valid HCPCS Codes exist for the DME and supplies.

Catalog pages are not acceptable as manufacturer's invoices.

Procedure Code L9999 is obsolete.
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Many Local Codes are no longer acceptable for submission.
The correct way to bill for DME and DME supplies sales tax is the following:

Bill the code for the service with the appropriate modifier for rental or purchase for the
amount charged, less the sales tax

Bill the S9999 code on a different line with charges only for the sales tax
An example:
PT
Modifier
Amount
E0570
Applicable modifier code to designate a DMR
rental is RR
$100.00
S9999
Sales tax will be paid as billed
$ 8.00
DME Rentals
DME rentals require medical documentation from the prescribing physician. Most DME is
dispensed on a rental basis only, such as oxygen tanks or concentrators. Rented items remain the
property of the DME Provider until the purchase price is reached. Please note the following
guidelines:

DME Providers may use normal equipment collection guidelines. We are not responsible
for equipment not returned by Members.

Charges for rentals exceeding the reasonable charge for a purchase will be rejected.

Rental extensions may be obtained only on approved items.
DME Purchase
DME may be reimbursed on a rent-to-purchase basis over a period of 10 months unless specified
otherwise at the time the review by our Utilization Management department.
DME Wheelchairs/Scooters
All Medi-Cal wheelchair claims undergo claims examination. The claims examiners follow MediCal guidelines when calculating payments for By Report (customized) wheelchair claims. By
Report claims on the CMS-1500 form must be accompanied by one of the following:

Manufacturer's purchase invoice

Manufacturer's suggested retail price (MSRP) from a catalog dated before August 1, 2003
If the item was not available before August 1, 2003, claims must be submitted with a
manufacturer's purchase invoice, the catalog page that first published the item, and the MSRP.
The initial date of availability must be documented in the Reserved for Local Use field (Box 19) of
the claim. Documentation must include:

Catalog Number
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
Item Description

Manufacturer Name

Model Number

Marked Catalog Page(s) or Invoice Line so it can be matched to the claim line

Completion of the Reserved for Local Use field (Box 19) of the CMS-1500 form with the
total MSRP of the wheelchair, including all accessories, modifications, replacement parts
and the name of the employed Rehabilitation and Assistive Technology of America
certified technician
Wheelchair claims from manufacturers billing as Providers must include:
Suggested retail price (MSRP) from a catalog page dated before August 1, 2003. If the item was
not available before then, the manufacturer's invoice must accompany the claim
Initial date of availability must be documented in the Reserve for Local Use field (Box 19) of the
CMS-1500 form
DME Modifiers
For a list of DME Modifier Codes, see Appendix 1 of the HCPCS 2006 publication available from
the American Medical Association (AMA) or log onto the AMA website: www.ama-assn.org.
Laboratory, Radiology and Diagnostic Services
The billing requirements for outpatient laboratory, radiology and diagnostic services include, but
are not limited to:

Clinical Laboratory Tests

Pathology

Radiology
These billing requirements include services rendered in relation to an outpatient visit for these
tests, including, but not limited to:

Equipment Use

Facility Use, including nursing care

Laboratory

Professional Services, if applicable

Supplies
Please Note: Outpatient radiation therapy is excluded from this service category and should be
billed under the requirements of the Other Services category.
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CMS-1500 Claim Form
All professional Providers and vendors should bill us using the most current version of the CMS1500 claim form. Should we document all the fields below or advise providers to refer to CMS
website for billing 1500 claims forms.
CMS-1500 Claim Form Fields
Field #
Title
Explanation
Field 1
Medicaid/Medicare/Other ID
If the claim is for Medi-Cal, put an X in the Medicaid box. If
Member has both Medi-Cal and Medicare, put an X in both
boxes. Attach a copy of the form submitted to Medicare to
the claim.
Field 1a
Insured's ID Number
From the Plan Member's ID card. Be sure to use the
Member's CIN number from the paper ID card, not the
number from the state's card.
Field 2
Patient's Name
Enter last name first, then first name and middle initial (if
known). Do not use nicknames or full middle names.
Field 3
Patient's Birth Date
Enter date of birth as MM/DD/YY. If the full date of birth is
not available, enter the year, preceded by 01/01.
Field 4
Insured's Name
"Same" is acceptable if the insured is the patient.
(Not required by Medi-Cal)
Field 5
Patient's Address/Telephone Number
Enter complete address. Include any unit or apartment
number. Include abbreviations for road, street, avenue,
boulevard, place, etc. Enter patient's phone number,
including area code.
Field 6
Patient Relationship to Insured
The relationship to the Member, such as self, spouse,
children or other.
Field 7
Insured's Address/Phone Number
"Same" is acceptable if the insured is the patient.
Field 8
Patient Status
Check patient's status (single, married, other, employed,
full-time student or part-time student). Check all that apply.
Field 9
Other Insured's Name
If there is other insurance coverage in addition to the
Member's coverage, enter the name of the insured.
Field 9a
Other Insured's Policy or Group
Number
Name of the insurance with the group and policy number.
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Field #
Title
Explanation
Field 9b
Other Insured's Date of Birth
Enter date of birth in the MM/DD/YY format.
Field 9c
Employer's Name or School Name
Name of other insured's employer or school.
Field 9d
Insurance Plan Name or Program
Name
Name of Plan carrier.
Field 10
Patient's Condition Related To
Include any description of injury or accident, including
whether it occurred at work.
Field 10a
Related to Employment?
Y or N. If insurance is related to Workers Compensation,
enter Y.
Field 10b
Related to Auto Accident/Place?
Y or N. Enter the state where the accident occurred.
Field 10c
Related to Other Accident?
Y or N.
Field 10d
Reserved for Local Use
If applicable, use for Member copayment.
Field 11a-b
Insured's Policy Group of FECA
Number, Date of Birth, Sex, Employer
or School Name
Complete information about Insured, even if same as
Patient.
Field 14
Date of Current
Injury, Illness or Pregnancy
Field 21
Diagnosis or Nature of Illness or
Injury
Enter the appropriate diagnosis code or nomenclature.
Check the manual or ask a coding expert.
Field 24a
Date(s) of Service
If dates of service cross over from one year to another,
submit two separate claims: For example, one claim for
services in 2012, one claim for services in 2013.
Field 24b
Place of Service
This is a 2-digit code. Use current coding as indicated in the
CPT manual.
Field 24d
Procedure, Services or Supplies
Enter the appropriate CPT codes or nomenclature. Indicate
appropriate modifier when applicable. Do NOT use NOC
Codes unless there is no specific CPT code available. If using
an NOC code, include a narrative description.
Field 24e
Diagnosis Code
Use the most specific ICD-9 Code available.
Field 24f
Charges
Charge for each single line item.
Field 24g
Days or Units
If applicable.
Field 24h
EPSDT Family Plan
Enter Y for EPSDT or N for non-EPSDT.
Field 25
Federal Tax ID Number
Enter the 9-digit number.
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Field #
Title
Explanation
Field 28
Total Charge
Total of line item charges.
Field 31
Full Name and Title of Physician or
Supplier
Actual signature or typed/printed designation is acceptable.
Field 32
Provider Servicing Address
Include suite or office number. Include abbreviations for
road, street, avenue, boulevard, place or other common
street name endings.
Field 33
Physician's or Supplier's Billing Name
Provider Identification Number (the number CareMore
assigns to the Provider.)
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CHAPTER 9: BILLING INSTITUTIONAL CLAIMS
Overview
All Medicare-approved facilities should bill using the most current version of the CMS-1450 form,
which is the UB-04.
To be sure that claims are processed in an orderly and consistent manner, standardized code sets
must be used. The Healthcare Common Procedure Coding System (HCPCS), sometimes called the
National Codes, provides coding for a variety of services. HCPCS consists of two principal
subsystems, referred to as Level 1 and Level 2:

Level 1: The Current Procedural Terminology (CPT) codes maintained by the American
Medical Association (AMA). CPT codes are represented by 5 numeric digits.

Level 2: Other codes that identify products, supplies and services not included in the CPT
codes, such as ambulance and Durable Medical Equipment (DME). These are sometimes
called the alpha-numeric codes because they consist of a single alphabetical letter
followed by 4 numeric digits.
In addition to the HCPCS codes, the California Department of Health Care Services (DHCS)
created a separate set of codes for its Medi-Cal Program, sometimes called Local Codes. These
codes identify services and products specific to Medi-Cal.
Institutional Inpatient Coding
Use the following codes for inpatient billing:

CMS-1450 Revenue Codes: To order the current CMS-1450 Billing Procedures Manual,
call: 1-800-494-2001

ICD-9 Procedure Codes: To order the current ICD-9 Code Book, call: 1-800-633-7467

Modifier Codes: Refer to the current edition of the Physicians' Current Procedural
Terminology Manual published by the American Medical Association (AMA).
Please Note: Surgical supply charges require a modifier. Use UA for procedures without
anesthesia or UB for procedures with anesthesia.
Institutional Outpatient Coding
Use the following codes for outpatient billing:

HCPCS Codes: Refer to the current edition of CMS Common Procedure Coding System
published by the Centers for Medicare and Medicaid Services (CMS). To order, call: 1-800633-7467

CPT Codes: Refer to the current edition of the Physicians' Current Procedural Terminology
manual published by the American Medical Association (AMA). To order a copy of this
manual, please call: 1-800-621-8335
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Cal MediConnect
Please Note: Claims must be submitted with both HCPCS and CPT codes. Use of Revenue Codes
alone on an outpatient claim may result in a claim delay or denial due to lack of information.
Please Note: Use the Member's Client Index Number (CIN) when billing, whether submitting
electronically or on paper.
Emergency Room Visits
The billing requirements for emergency room visits apply to all emergency cases treated in the
hospital emergency room (for patients who do not remain overnight) and cover all diagnostic
and therapeutic services, including, but not limited to, the following:

Equipment Use

Facility Use, including nursing care

Laboratory

Pharmaceuticals

Radiology

Supplies
Reimbursement for emergency room services relates to the emergency diagnosis and can be
based on urgent care rates, depending on the diagnosis. Special billing instructions include:

ICD-9-CM principal diagnosis codes are required for all services provided in an emergency
room setting

Each service date must be billed as a separate line item

Medi-Cal Local Codes are: Z7502 or Z7500 (Z7500 must be billed with Revenue Code 450
to be considered ER)
Please Note: Refer all Members back to the Primary Care Provider for follow-up care. Unless
clinically required, follow-up care should never occur in the hospital's emergency department.
Recommended Fields for CMS-1450
Field
Box Title
Description
1 (R)
Blank
Facility name, address and telephone number
2
Blank
3a
PAT. CNTL #
Member's account number
3b
MED. REC #
Member's record number, which can be up to 20 characters
4(R)
TYPE OF BILL
Enter the Type of Bill
(TOB ) Code
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Field
Box Title
Description
5
FED. TAX NO.
Enter the Provider's Federal Tax ID number
6
STATEMENT COVERS
PERIOD
"From" and "Through" date(s) covered by the claim being
submitted
7
Blank
Leave Blank
8a-b (R)
PATIENT NAME
Member's name
9a-e (R)
PATIENT ADDRESS
Complete address (number, street, city, state, zip code,
telephone number)
10 (R)
BIRTH DATE
Member's date of birth in MM/DD/YY format
11 (R)
SEX
Member's gender
12 (R)
ADMISSION DATE
Member's admission date to the facility in MM/DD/YY
13 (R)
ADMISSION HOUR
Member's admission hour to the facility in military time (00-23)
format
14 (R)
ADMISSION TYPE
Type of admission
15 (R)
ADMISSION SRC
Source of admission
16 (R)
DHR
Member's discharge hour from the facility in military time (0023) format
17 (R)
STAT
Patient status
18-28
CONDITION CODES
Enter Condition Code (81) XO-X9
29
ACDT STATE
Accident State. Leave blank.
30
Blank
Leave blank
31-34 (R)
OCCURRENCE CODE
Occurrence Code (42) and date, if applicable
OCCURRENCE DATE
35-36
OCCURRENCE SPAN (CODE,
FROM AND THROUGH)
Enter dates in MM/DD/YY format
37
Blank
Leave blank
38
Blank
Enter the responsible party name and address, if applicable
39-41
VALUE CODES (CODE AND
AMOUNT)
Enter Value Codes
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Field
Box Title
Description
42 (R)
REV. CD.
Revenue Codes, required for all institutional claims
43 (R)
DESCRIPTION
Description of services rendered
44 (R)
HCPS/RATE/HIPPS CODE
Enter the accommodation rate per day for inpatient services or
HCPS/CPT Code for outpatient services
45 (R)
SERV. DATE
Date of services rendered
46 (R)
SERV. UNITS
Number/units of occurrence for each line or service being billed
47 (R)
TOTAL CHARGES
Total charge for each line of service being billed
48
NON-COVERED CHARGES
Enter any non-covered charges
49
Blank
Leave blank
50
PAYOR NAME
Payer Identification. Enter any third party payers.
51 (R)
HEALTH PLAN ID
Medicare Provider ID Number/unique Provider ID Number. The
billing Provider number is required
52 (R)
REL. INFO
Release of information certification indicator
53
ASG BEN.
Assignment of benefits certification indicator
54
PRIOR PAYMENTS
Prior payments
55
EST. AMOUNT DUE
Estimated amount due
56 (R)
NPI
Enter the NPI number
57 (R)
OTHER PRIV ID
Enter the other Provider ID, if applicable
58 (R)
INSURED'S NAME
Member's name
59 (R)
P. REL
Patient's relationship to insured
60 (R)
INSURED'S UNIQUE ID
Insured's ID Number: Certificate number on the Member's ID
card
61
GROUP NAME
Insured Group Name: Enter the name of any other health plan
62
INSURANCE GROUP NO.
Enter the Policy Number of any other health plan
63
TREATMENT
AUTHORIZATION CODES
Authorization Number or authorization information
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Field
Box Title
Description
64
DOCUMENT CONTROL
NUMBER
The Control Number assigned to the original bill
65
EMPLOYER NAME
Name of organization from which the insured obtained the
other policy
66 (R)
DX/PROC Qualifier
Enter the diagnosis and procedure core qualifier (ICD version
indicator)
67 (R)
DX
Principal Diagnosis Codes. Enter the ICD-9 diagnostic codes, if
applicable
67a-q (R)
DX
Other Diagnosis Codes: Enter the ICD-9 diagnostic codes, if
applicable
68
Blank
Leave blank
69
ADMIT DX
Admission Diagnosis Code: Enter the ICD-9 code
70a-c
PATIENT REASON DX
Enter the Member's reason for this visit, if applicable
71
PPS CODE
Prospective Payment System (PPS) Code: Leave blank
72
ECI
External Cause of Injury Code
73
Blank
Leave blank
74 (R)
PRINCIPAL PROCEDURE
CODE/DATE
ICD-9 principal procedure code and dates, if applicable
74a-e (R)
OTHER PROCEDURE
CODE/DATE
Other Procedure Codes
75
Blank
Leave blank
76 (R)
ATTENDING
Enter the attending physician's ID number
77 (R)
OPERATING
Enter the Provider Number if you use a surgical procedure on
this form
78-79
OTHER
Enter any other Provider numbers, if applicable
80
REMARKS
Use this field to explain special situations
81a-c (R)
CC
Enter additional or external codes, if applicable
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CHAPTER 10: UTILIZATION MANAGEMENT
Utilization Management Program
CareMore Health Plan (CareMore) has a Utilization Management (UM) Program that defines
structures and processes and assigns responsibility to appropriate individuals. The mission of this
program is to:

Ensure consistent delivery of quality health care and optimum Member outcomes; and

Provide and manage coordinated, comprehensive, quality health care, without discrimination
toward any individual and in a culturally competent manner
The purpose of the UM Program is to provide a process in which review of inpatient and
outpatient services are performed in accordance with health plan and regulatory/accreditation
agency. This process helps ensure the delivery of medically necessary and quality Member care
through appropriate utilization of resources in a cost-effective and timely manner.
The UM Program’s focus is to ensure efficiency and continuity of this process by identifying,
evaluating, monitoring and correcting elements which may impact the overall effectiveness of
the UM process. The Program’s activities are developed and approved, through the Quality
Management (QM) Committee, by the CareMore Board of Directors.
The Program is reviewed on an annual basis and revised when appropriate. All revisions are
approved by the QM Committee and the CareMore Board of Directors.
Goals and objectives of the UM Program include, but are not limited to:

Help ensure appropriate levels of care in a timely, effective and efficient manner.

Monitor, evaluate and optimize health care utilization resources, on a continuous basis, by
applying UM policies and procedures to review medical care and services.

Monitor, document and submit for review any potential quality of care concerns, for both
inpatient and outpatient care.

Monitor utilization practice patterns of contracted Providers and/or their practitioners to
identify variations.

Conduct medical review of all potential denials of service for medical necessity.

Identify high-risk Members and help ensure appropriate care is delivered by accessing the
most efficient resources.

Improve utilization criteria, on a continuous basis, based on outcome data and review of the
medical literature.
Medical Review Criteria
The UM team takes a multidisciplinary approach to meet the medical and psychosocial needs of
our Members. Authorizations are based on the following:

Benefit coverage
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

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Established criteria
Community standards of care
The decision-making criteria used by the UM team is evidence-based and consensus-driven. We
periodically update criteria as standards of practice and technology change. These criteria are
available to Members, Physicians and other health care Providers upon request by contacting the
UM Department at 1-888-291-1358 (Option 3, Option 3, Option 2) from 5 a.m. to 5 p.m.,
Monday through Friday, excluding holidays.
Based on sound clinical evidence, the UM team provides the following service reviews:


Prior Authorizations
Post-Service Clinical Claims Reviews
Decisions affecting the coverage or payment for services are made in a fair, impartial, consistent
and timely manner. The decision-making incorporates nationally recognized standards of care
and practice from sources including:











Medicare National Coverage and Local Coverage Determinations (NCD, LCD)
United States Preventative Task Force (USPSTF) Guidelines
CareMore Clinical Guidelines and Medical Policies
Milliman Clinical Guidelines
Centers for Disease Control (CDC)
American College of Physicians (ACP)
Federal Food and Drug Administration (FDA)
American Hospital Formulary Services Drug Information
United States Pharmacopeia-Drug Information
National Comprehensive Cancer Network (NCCN)
DRUGDEX Information System (for prescription drugs)
Please Note: We do not reward practitioners and other individuals conducting utilization reviews
for issuing denials of coverage or care. There are no financial incentives for UM decision-makers
that encourage decisions resulting in under-utilization.
If you disagree with a UM decision and want to discuss the decision with the physician reviewer,
you can call the UM Department at 1-888-291-1358 (Options 3, Option 3, Option 2).
The Referral Process
CareMore has two methods for referring patients to specialists and ancillary facilities:

Self-Referral

Service Request
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Referrals to Long Term Services Support (LTSS):
LTSS service requests may be submitted through our provider portal
https://providers.caremore.com/ or you may contact our CareMore, LLC Member Services
department at 1-800-888-3447. Case Management will coordinate with the LTSS team and then
schedule the necessary assessments to determine which services are most appropriate. Please
see Appendix A
Self-Referral Services
Members do not need prior authorization and may self-refer for the following services provided
by qualified, in-network Providers:

Womens’ Health Services
 Initial gynecological care
 Mammography services

Influenza vaccines
Service Requests
Service Request and Service Request Form
Providers are responsible for verifying eligibility and in ensuring that our Utilization Management
(UM) department has conducted pre-service reviews for elective non-emergency and scheduled
services before rendering those services. Prior Authorization ensures that services are based on
medical necessity, are a covered benefit, and are rendered by the appropriate Providers.
CareMore encourages providers to submit service requests online via the Provider Portal. To
register, please contact Provider Relations at 1-888-291-1358 (Select Option 3, Option 5). If that
is not an option for technical reasons (i.e. lack of internet access), Providers may submit a Service
Request Form to CareMore when requesting pre-service review and may be faxed to 1-888-3713206 upon completion.
Once our UM team has received your request, it will be approved, denied or pended for
additional medical information by the CareMore Utilization Management staff. If the request is
pended, the CareMore Utilization Management staff will contact you by telephone, fax, or via
email through the Provider Portal with a request for the information reasonably needed to
determine medical necessity.
Services Requiring Pre-service Review
Service Requests are required for the following:




Consultation and follow up visit to Specialty Service
Elective procedures or surgeries
All admissions, elective or emergent
Durable Medical Equipment (DME)
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



Cal MediConnect
Home health services including home infusion
Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST)
Certain radiological procedures i.e. magnetic resonance imaging (MRI), positron emission
tomography (PET) scan
Certain laboratory tests i.e. genetic testing
Services That Do Not Require Pre-service Review
Providers no longer need to submit a service request to obtain a referral/authorization for plain
film x-rays or mammograms as long as the service is prescribed/ordered by a treating physician
and the service is directed to one of the preferred CareMore contracted providers.
Please ensure you provide the member with a singed order and that the following information is
included: members name, DOB, requested procedure, providers printed name, and submit to the
preferred provider. For a listing of the approved x-ray codes, radiology and mammography codes
and CareMore contracted preferred provider for your region, please contact Provider Relations.
Please refer to CareMore Contact Information (Chapter 2) for phone number and hours of
operation.
Service Requests are not required for:











Emergency and post-stabilization services, including emergency behavioral health care;
Urgent care;
Crisis stabilization, including mental health;
Urgent support
Family planning services;
Prevention services;
Basic prenatal care;
Communicable disease services, including sexually transmitted infection (STI) and human
immunodeficiency virus (HIV) testing;
Out-of-area renal dialysis services; and
Lab tests (other than above) when performed by contracted laboratory; and
Services that fall under the Self-Referral policy (see above).
Service Request Function
Providers will no longer need to submit a service request for additional service rendered at the
time of a pre-approved office visit/procedure for retrospective review, as log as the CPT code is
listed on our Incidental approval lists for your specialty. For a listing of the approved Incidental
codes, please refer to our provider portal at providers.caremore.com or you may contact
Provider Relations. Please refer to CareMore Contact Information (Chapter 2) for phone number
and hours of operation.
Service Requests, even when automatic approval is granted, support the following functions:

Provide authorization for claims payment
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

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Support progressive care history when additional or more complex care or service is
requested
Support continuity and coordination of care
Determination Definitions
Upon receipt of a completed Service Request form, the Utilization Management Department will
adhere to the following definitions when determining if the requested services are approved,
modified, denied, or pended (see definitions):

Approved: The referral is approved as requested. The Utilization Management (UM)
Department will fax the authorization to the referring physician and the authorized specialist,
facility, or vendor (e.g., DME).The authorization will detail the services approved. Additional
services not included and detailed on the authorization will require prior authorization.

Modified: The authorization determination is changed from what had been requested, such
as place of service requested, Provider requested or even service requested. The modified
authorization is faxed to the referring physician and the authorized specialist or facility.

Pended: The determination of the request is placed on “hold” until additional medical
necessity information is received. The requesting Provider will need to submit any necessary
additional information the UM Department requires in order to make an appropriate
decision. The total timeframe for processing a request that requires additional information is
not to exceed the maximum allotted by Medicare or Medicaid, respectively.

Denied: The services requested are not authorized. A detailed explanation of the denial
decision and an alternative treatment plan are faxed to the referring Provider. The Member is
sent a letter in which we explain why the service was denied. A CareMore Medical Director is
responsible for all denial decisions when the determination is based on medical necessity.
The Medical Director reviews requests on a case-by-case basis and takes into consideration
special circumstances that may deviate from established protocols. Both the referring
Provider and the Member are informed of the appeal process at the time they are notified of
the denial.
Turn-Around-Time
Based on the authorization time frame indicated on the Service Request form, CareMore’s UM
Department will fax a response/authorization within the appropriate time frame listed below.
Both the referring physician and the authorized specialist or facility will receive the faxed
response/authorization from the Utilization Management Department.
CareMore follows the rules for the timing of authorization decisions for Medicaid services and for
Medicare services.


Standard: within 14 calendar days from receipt of request (Medicare), within five business
days from receipt of request (Medicaid)
Expedited: within 72 hours from receipt of request (Medicare and Medicaid)
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Average turn-around-time of service requests is approximately four business days. However, as
per Centers for Medicaid and Medicare Services (CMS) guidelines, the health plan may take up to
14 days to make a decision.
Expedited Referrals
The Expedited Referral Request may be used for cases involving an imminent and serious threat
to the patient's health, including, but not limited to, severe pain, potential loss of life, limb, or
major bodily function.
Expedited requests must meet the definition of ‘expedited’ as listed above and are reviewed and
completed within 72 hours of receipt.
If the request is urgent and you need to speak to a CareMore Utilization Management staff
Member to discuss the request, please contact our CareMore Utilization Management at
1-888-291-1358 (Option 3, Option 3, Option 2). However, if the physician’s medical opinion is
that 24 hours is an adequate amount of time to receive a response from UM, there is no need to
call. Simply mark the request “Expedited” and also indicate that the request is “Expedited” in the
Special Instructions section of the Service Request form.
Provider is Notified of Determination
Upon review of the request, the UM Department will fax a response to the requesting Provider
and specialist or facility. Copies of all authorization determinations are faxed to the patient’s PCP
to ensure that the Provider is apprised of the services the Member is receiving from other
Providers. Auto-approval of many services is done instantly and, when the request is submitted
electronically, the ordering Provider receives an immediate approval notice to give to the
Member.
Medical Necessity
Utilization decisions are based on medical necessity as indicated by the supporting clinical
documentation, approved practice guidelines and the Member’s health plan benefits. These
guidelines are available to contracted Providers and assigned Members upon request. Providers
may contact the UM department at 1-888-291-1358 (Option 3, Option 3, Option 2) Members
may contact Members Services department at 1-888-350-3447.
Authorization Expiration Time Frame
Approved authorizations are valid for 120 days from the date the approval was given. The
authorized care provided by a specialist must occur within the 120-day period. If the Member is
unable to see the specialist within the 120-day period, the referring physician may call the UM
Department at 1-888-291-1358 (Option 3, Option 3, Option 2) to request an authorization
extension. They may also submit a new Service Request Form or send an email request to extend
the expired authorization via the Provider portal at Providers.caremore.com.
Unauthorized Care
The UM Department retrospectively reviews all services that have been rendered without prior
authorization only when submitted within 30 days from rendered date of service. Reviews for
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retrospective services after 30 days from rendered date of service will need to be submitted thru
CareMore Claims department.
During the retrospective review, rendered services are compared to the Evidence of Coverage
(EOC) as well as CMS guidelines for medical necessity. The review process may result in
disallowing inappropriate services and the Member may be financially responsible for the cost of
the unauthorized service when rendered from a non-contracted provider.
The Member is not financially liable for any administrative denial related to Provider contract
issues and cannot be balance billed.
Retrospective Review
The UM Department may review authorized services retrospectively in order to match the
preauthorized information with the clinical findings and the services performed. If any
discrepancies are discovered during the retrospective review process, UM staff may recommend
for non-payment for unauthorized services. Please refer to our Incidental Code lists for a listing of
additional services that will not require a pre-approved request at the time of visit/procedure and not subject to a
retrospective review.
Extended/Standing Referrals
If a Member’s condition is complex and requires specialist care, the Member may receive
authorization for ongoing services by that specialist. The specialist is required to:


submit a plan of treatment to the UM Department
communicate Member’s progress to their PCP on a regular basis
Utilization Management Contact Information
Providers may contact UM staff at the numbers below from 8 a.m. to 5 p.m. Monday through
Friday to submit telephone requests for verification and to request authorization determinations.
After hours, weekends, and holidays, the on-call UM nurse is available by calling 1-562-299-2668.
CareMore UM Department:
Toll-free:
1- 888-291-1358 (Option 3, Option 3, Option 2)
Information for Specialists Only
Additional Services
If additional care or diagnostic testing is required, the specialist must submit a Service Request to
the UM Department. (See Chapter 10: Utilization Management - The Referral Process for more
information.) Providers should submit a Service Request using the Provider Portal. In the event
internet access is not available, complete and return the Service Request form via fax to 1-888371-3206. The request for authorization will be reviewed by UM staff and the specialist will be
notified of the approval to perform the services. If the time frame of that authorization is
exhausted and the specialist determines that additional care is required, a subsequent Service
Request must be submitted to UM staff via the online Provider Portal.
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Current Procedure Terminology (CPT) Codes
The CPT code for a follow-up visit is 99213. Please note: If the services provided exceed a 99213,
the specialist must include his notes and supporting documentation when submitting the claim
for reimbursement. The Medical Director reviews all requests for CPT codes 99214 and 99215
using the evaluation and management (E & M) guidelines to determine appropriate and accurate
coding.
New Medical Problem
If the Member presents with a new medical problem while undergoing treatment, the specialist
must submit a Service Request for authorization prior to treating the new problem. There is no
need to direct the Member back to his or her PCP for an initial referral. However, if three
months or more have passed since the Member’s last visit to the specialist, please refer the
Member back to his or her PCP. The PCP will then submit a Service Request Form requesting a
referral to the specialist, if appropriate. The service request for evaluation and treatment of a
new medical problem will be reviewed by UM staff for medical necessity based on established
clinical criteria.
Written Report to PCP
After treating the Member, the specialist MUST submit a written report to the Member’s PCP
regarding the results of all care provided and the proposed treatment plan. This report must
include any plans for hospitalization or surgery and should be submitted to the PCP within 14
days of treatment or earlier if the medical condition of the Member is of a more urgent nature.
This information should also be included on the Service Request Form that is submitted to the
UM Department.
Utilization Management Contact Information
Specialists may contact UM staff at the numbers below from 8 am to 5pm Pacific Time Monday
through Friday to submit telephone requests for verification and to request authorization
determinations. After hours, weekends, and holidays, the on-call UM nurse is available by calling
1-562-299-2668.
CareMore UM Department:
Toll-free:
1- 888-291-1358 (Option 3, Option 3, Option 2)
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Below is a table with useful information regarding proper durable medical equipment (DME)
request procedures. This table is available online on CareMore’s Provider Portal.
DME Request Procedures
Oxygen Equipment and Set-Up
Description
HCPCs
Information Required in DME Request Notes
Oxygen concentrator
E1390-RR

Current pulse ox on room air

ABG Report, if available

Liter flow & Continuous or PRN






Oxygen, portable
(E-tank)
Oxygen, portable
(Gas)
E0431-RR
E0443-NU
Back Pack
M6 Conserving Device
E1399
Please enter “back pack” or “conserving devise” in notes
Nebulizer
E0570-NU & A7003-NU x 2
(kits include mouthpiece and tubing)
DME Request Procedures
Mobility Items
Description
HCPCs
Lightweight Wheelchair
K0003-RR
Companion Wheelchair
Only for Members unable to
self-propel
E1038-RR
Heavy-duty Wheelchair
(250+ lbs.)
K0006-RR
Standard Wheelchair
K0001-RR
Elevated Leg Rests (ELR)
K0195-RR
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
Member’s height and weight

Can the Member self-propel?

How long will Member require usage of the item?
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Front-wheeled walker (FWW)
E0143-NU
Quad cane
E0105-NU
Single cane
E0100-NU
3-in-1 commode
E0163-NU

Hospital Beds and Accessories
Description
HCPCs
Hospital bed
E0260-RR
Alternating pressure pad
mattress (for pressure sores
and to alleviate pressure)
E0181-RR
Low air loss mattress (for
pressure ulcers Stage II and
above)
E0277-RR


How long will Member require usage of the item?
C-PAP and BI-PAP
Description
HCPCs
C-PAP
Applies continuous pressure to
the airways; has only one level
of pressure
E0601-RR
BI-PAP
Applies two different pressures;
higher pressure when the
E0470-RR
Member is breathing in, lower
pressure when breathing out
Standard mask
A7034-NU
Headgear
A7035-NU
Tubing
A7037-NU
Filters
A7038-NU

Copy of Sleep Study

Machine Settings
C-PAP and BI-PAP
Heated humidifier
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Cool humidifier
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E0561-NU
Medical Supplies
To order medical supplies, please contact Edgepark Customer Service Department:
Phone: 1-800-321-0591
Fax: 1-330-963-6172
Website: www.edgepark.com
IMPORTANT: Please indicate manufacturer name and item # for all items. (May be obtained from
packing on Member’s current supplies.) Due to different manufacturers and type of supplies, this
information is required to maintain accuracy and timeliness of medical supply orders.
Information required in notes for Medical Supply requests
Wound care supplies

Type of wound

Size of wound

# of dressing changes per day

Specific type of supplies

Specific # of each item needed for 1 month supply
Information required in notes for Medical Supply requests
Ostomy supplies
Catheter supplies

Size of stoma opening

Specific type of bags (Drainable, closed pouch) and supplies
needed

Manufacturer and brand of bags and related supplies

Re-order #, if available


Size of catheter (e.g. 14 French)

Type of catheter and related supplies

Manufacturer and brand of catheters, bags and related supplies

Re-order #, if available

DME Modifiers
RR: rental item
NU: new item
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Medically Necessary Services
Medically necessary behavioral health services:





Are reasonable and necessary for the diagnosis or treatment of a mental health or chemical
dependency disorder or to improve, maintain or prevent deterioration of functioning
resulting from such a disorder
Are acceptable clinical guidelines and standards of practice in behavioral health care
Are available in the most appropriate and least restrictive setting in which services can be
safely provided
Are at the appropriate level or supply of service that can safely be provided
If omitted, would adversely affect the Member’s mental and/or physical health or the quality
of care rendered
Medically necessary health services mean health services other than behavioral health services
that are:





Reasonable and necessary to prevent illness or medical conditions or provide early screening,
interventions and/or treatments for conditions that cause suffering or pain, cause physical
deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or
infirmity of a Member or endanger life
Available at appropriate facilities and at the appropriate levels of care for the treatment of
the Member’s health condition(s)
Consistent with health care practice guidelines and standards endorsed by professionally
recognized health care organizations or governmental agencies
Consistent with the diagnosis of the conditions
No more intrusive or restrictive than necessary to provide a proper balance of safety,
effectiveness and efficiency
Note: We do not cover the use of any experimental procedures or experimental medications
except under certain circumstances.
Emergency Room Utilization
Prior authorization is not required for treatment of emergency medical conditions. In the event
of an emergency, Members can access emergency services 24 hours a day, 7 days a week.
Emergency services coverage includes services that are needed to evaluate or stabilize an
emergency medical condition. Criteria used to define an emergency medical condition are
consistent with the prudent layperson standard and comply with federal and state requirements.
Emergency medical condition is defined as a physical or behavioral condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) that a prudent layperson who
possesses an average knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in the following:
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
The health of the individual (or, with respect to a pregnant woman, the health of the woman
or her unborn child) is placed in serious jeopardy.

The Member will suffer serious impairment to bodily functions

The Member will suffer serious dysfunction of any bodily organ or part.
Emergency service claims are retrospectively reviewed, after all pertinent clinical information is
obtained, by the ER Claims Coder and/or Medical Director of Quality Management or Utilization
Management for coding appropriateness.
All reviews are performed in accordance with the established emergent diagnosis criteria and as
interpreted by a “prudent layperson.” While ER claims are not denied, claims are monitored for
physician and Member education relative to emergency services. All patients admitted to noncontracted hospitals will be transferred to contracted hospitals as soon as medically stable.
CareMore’s Utilization Management Department must be notified of any ER authorizations by
the morning of the next business day. Utilization Management may be contacted at
1-888-291-1358 [Option 3, Option 3, Option 2].
Pharmacy Formulary
Prior Authorization/ Exception Requests
Prior authorization/Exception Requests are used for formulary drugs that require prior
authorization or to request non-formulary drug coverage. National Pharmaceutical Services
(NPS) serves as the Pharmacy Benefit Manager to review the drug requests.
Please fully complete and sign the Prior Authorization form available on the CareMore On-Line
Provider Portal to include the 1) diagnosis; 2) previously tried and failed formulary
medications; and 3) why other formulary options are not acceptable or would be less effective
or harmful to the patient’s medical condition.
Second Opinions
A Member, parent and/or legally appointed representative or the Member’s PCP may request a
second opinion in any situation where there is a question concerning a diagnosis or the options
for surgery or other treatment of a health condition. The second opinion shall be provided at no
cost to the Member.
The second opinion must be obtained from a network Provider (see Provider Referral Directory)
or a non-network Provider if there is not a network Provider with the expertise required for the
condition.
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We may also request a second opinion at our own discretion. This may occur under the following
circumstances:

If there is a concern about care expressed by the Member or the Provider

If potential risks or outcomes of recommended or requested care are discovered by the
health plan during its regular course of business

Before initiating a denial of coverage of service

If denied coverage is appealed

If an experimental or investigational service is requested
UM Committee
The CareMore Board of Directors has granted the UM Committee the authority to:

Develop and monitor the UM Program.

Oversee the activities to develop clinical criteria.

Serve as an expedited and standard appeals panel, if necessary.

Communicate with participating physicians, as necessary.
The UM Committee reports to the QM Committee and submits a quarterly report of all activities
to the QM Committee for presentation to and approval by the CareMore Board of Directors. The
Medical Director serves as the chairperson of the UM Committee and presides over the
meetings.
The UM Committee is composed of:

Physician Members, who serve a two-year term on the committee and are either primary or
specialty care physicians. There is also a panel of advisors, consisting of board certified
physicians in many specialty areas, (i.e., behavioral health) that is available to the Medical
Director for consultation, if needed.

Non-physician Members from Health Care Services, Pharmacy, Member Services and
Provider Relations.
This committee meets on a regularly scheduled basis, no less than quarterly to:

Develop, evaluate and implement the UM Program.

Assist the QM Committee to develop, implement and monitor clinical guidelines relating to
quality of care.

Investigate, resolve and monitor daily operations relating to UM activities.

Monitor appropriate levels of healthcare and timeliness of the delivery of healthcare services.

Review proposed UM policies and procedures for utilization by the clinical and non-clinical
staff.
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
Review clinical appeals.

Monitor inpatient services.

Evaluate new and existing technology.

Coordinate quality issues with the QM Department/Committee.

Monitor effectiveness of the UM process through Member and practitioner satisfaction
survey results.

Provide information for inclusion in the annual QM Work-plan.

Review the annual evaluation of the QM Program for accuracy concerning UM and UM
Committee function.

Monitor practice patterns of practitioners and Providers from Medical Groups
(MG)/Independent Physician Associations (IPAs).

Assist the MG/IPA in providing continuing education programs for their practitioners.

Assess pharmacy utilization.
In order to hold a meeting, there must be at least three physicians present. Minutes are
maintained for the meeting and all discussions are considered confidential.
The Health Care Services Department develops and the UM Committee approves a work-plan for
the year, which outlines the Program activities and corresponding time frames for progress and
completion dates. This work-plan, along with quarterly reports which focus on measuring
progress toward the goals, is then presented, along with the UM Program, to the QM Committee
and the CareMore Board of Directors for review and approval.
On an annual basis, the UM Committee performs a retrospective evaluation of its activities to
measure the performance achievements and activities for the year. If goals and objectives are
not met, changes are recommended to the subsequent UM Program/ Work-plan. This annual
evaluation is also presented to the QM Committee and the CareMore Board of Directors for
review and approval.
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CHAPTER 11: CASE MANAGEMENT
Model of Care
The goals of California’s Coordinated Care Initiative (CCI), which includes Cal MediConnect, are
to:

Improve the quality of care for members

Maximize the ability of members to remain safely in their homes and communities with
appropriate services and supports, in lieu of institutional care.

Coordinate Medi-Cal and Medicare benefits across health care settings and improve
continuity of care across acute care, long-term care, behavioral health, and home and
community-based services settings by using a person-centered approach.

Promote a system that is both sustainable, person- and family-centered, and enables
members to attain or maintain personal health goals by providing timely access to
appropriate, coordinated health care services and community resources, including home
and community-based services and mental health and substance use disorder services.

Increase the availability and access to Long Term Services and Supports (LTSS) including
Home and Community-Based Services (HCBS).

Improve transitions of care across health care settings, providers and HCBS.

Maximize the ability of dual eligible members to remain in their homes and communitybased settings with appropriate services and supports in lieu of institutional care.

Preserve and enhance the ability for members to self-direct their care and receive high
quality care.

Optimize the use of Medicare, Medi-Cal and other State/County resources.
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Interdisciplinary
Care Team
Member, PCP Doctors,
Specialists, Case
Managers, Behavioral
Health, Nutritionists,
Social Workers, other
providers including
LTSS Providers
The figure above demonstrates the person-centricity of the model. Depending on member
conditions, needs and desires, a team comprised of experts in physical health, behavioral health,
LTSS, and social work works with the member, their representative (if desired) and the PCP and
Specialists as required. Communication among all the constituents is critical and is supported by
CareMore systems.
Case Management
Overview
CareMore Case Management is an integral part of the Model of Care outlined above as it
supports the social and medical needs of CareMore’s most vulnerable Members. The CareMore
Case Management Program is designed to ensure Members receive personalized care
coordination that is focused on clinical, behavioral and social needs.
The CareMore Case Management Program works with Providers, Members, families and
caregivers to provide long-term, comprehensive care coordination to identified Members who
are at risk of less than optimal outcomes in any setting. The Case Management Team does this by
establishing and coordinating care plans, performing on-going evaluations, and providing
education to Members, their families, and/or caregivers. In doing so, the team is able to decrease
fragmentation of care across the continuum, and ensure appropriate provision of cost-effective
quality care. This is accomplished by ongoing communication to all involved clinicians, including
the PCP, Specialists, and Extensivists*.
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* Extensivist: a hospitalist that follows a Member across the medical continuum i.e. from
inpatient care to skilled nursing to the ambulatory setting.
CareMore Case Management can be involved with Members for short term needs, such as
identifying community resources or assistance with transportation needs. Or, the Case
Management Team can be involved on a long–term basis to support Members through a difficult
course of treatment or prolonged disease progression.
Case Management Components
There are several different components within the CareMore Case Management Program. Each
component focuses on different aspects of Member care needs but all are focused on support
and assistance to Members, families and care givers to maintain Members at the optimal level of
health and wellbeing. The Care More Case Management components include, but are not limited
to:

Education and management of disease processes in the ambulatory setting.

Coordination of care across the care delivery, such as direct admits to acute inpatient or
skilled nursing facilities if warranted or arranging for home health services if indicated.

Support and management at the time of transition from an acute admission to another level
of care, whether skilled or home.

Follow-up with Members in the CareMore Care Centers at the time of their first postdischarge appointment after a hospital stay.

Outreach after an ER visit to support Member care in the PCP office or Care Center to prevent
or reduce further ER visits

Management of Members admitted to non-contracted hospitals and coordination of care
back within the CareMore network.

Pre-op discussion about–post surgery and discharge plans for complex cases or Members
with multiple comorbid conditions that may have poor outcomes.

Support and management of Members undergoing dialysis.

End of life support to enhance comfort and improve the quality of Member’s life.
CareMore also has several programs to help support the high risk population. In these programs,
the Case Manager and Providers (such as a Social Worker and Nurse Practitioner) work with the
high risk physician to ensure Members at greatest risk are identified and managed through the
end of care.
If you need assistance with any CareMore Member, contact the CareMore Case Management
Team at 1-888-291-1385.
For information regarding any of CareMore’s Care Programs, please contact Provider Relations at
1-888-291-1358 (Option 3 > Option 5). If CareMore Members have questions regarding
CareMore’s Care Programs, please direct them to call Member Services at 1-888-350-3447.
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Interdisciplinary Care Team (ICT)
Every CareMore Member enrolled in Cal MediConnect is offered Case Management and an
Interdisciplinary Care Team (ICT) to coordinate the delivery of services and benefits in support of
the Care Plan. Each ICT consists of the Member, their PCP, a CareMore clinician, a social worker
and other Member-designated individuals including but not limited to:

Family Members

Caregivers

Legal representatives

Extensivists

Behavioral Health Specialists

Other specialists, such as pulmonologists, cardiologists, podiatrists
Each designates a team leader. In most instances, this will be the Case Manager. The ICT Case
Manager helps implement the Member’s plan of care and addressees those needs of the
Member that may arise on a regular or frequent basis, such as the scheduling of in-home services
and medical appointments.
Role of Case Managers
CareMore Case Managers are responsible for long-term care planning and for developing and
carrying out strategies to coordinate and integrate the delivery of medical and long-term care
services. Our Case Management department is dedicated to helping Members obtain needed
services. Each Member is assigned to a case manager.
Case Managers will:

Collaborate with Primary Care Provider and other Providers

Help Members obtain needed services

Develop individual care plans

Coordinate and integrate acute and long-term care services

Evaluate and coordinate community resources and issue authorizations to Providers for
covered services

Promote improvement in the Member’s quality of life

Allocate appropriate health plan resources to the care and treatment of Members with
chronic diseases
Please contact a Case Manager for changes in a Member’s status or questions regarding services,
authorization for service or other issues pertaining to Member needs.
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Case Management Interventions
Case Management interventions can be performed by:

Face-to-face visits with the Member and/or family at a local CareMore Care Center

Telephonic follow-up with the Member by a Case Manager

Educational materials

Communication with service Providers

Coordination and integration of acute and long-term care services
Hospitalist Program
CareMore has a Hospitalist Program that serves as the admitting and attending physicians for
health plan Members. The hospitalists are on-call 24 hours a day, seven days a week.
If you need to reach a hospitalist, call the CareMore Care Center and ask for the hospitalist oncall for the specific hospital.
Please discuss any potential hospital admission with the hospitalist prior to that admission if the
clinical situation allows. If the clinical situation is emergent, send the patient to the ER by the
appropriate means and, when time permits, call the hospitalist to inform him or her of the
admission.
If a hospital ER contacts you regarding a CareMore patient, please ask the ER staff to notify the
CareMore hospitalist directly.
Communicable Disease Services
We make communicable disease services available to our Members through their primary care
provider. Communicable disease services help control and prevent diseases such as Tuberculosis
(TB), Sexually Transmitted Diseases (STDs) and Human Immunodeficiency Virus/Acquired
Immune Deficiency Syndrome (HIV/AIDS) infection. Providers should encourage Members to
receive TB, STD and HIV/AIDS services through CareMore to ensure continuity and coordination
of a Member’s total care.
Please report all cases of TB, STD and HIV/AIDS infection to the state public health agency within
24 hours of notification by Provider or from date of service. You also must report all diseases
reportable by health care workers regardless of whether the case is also reportable by
laboratories.
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CHAPTER 12: HEALTH PROGRAMS AND EDUCATION
CareMore Programs & Services
CareMore is continually implementing programs to enhance its services to our Members. These
programs are designed to provide Members with additional services not usually covered by other
medical groups or health plans. Members may self-refer as authorization is not needed. Member
encounter documentation from the Care Center Clinician will be shared with the primary care
provider. It is recommended to send historical medical information to the Care Center prior to
the members appointment. Primary care provider and/or extensivits are responsible for
initiating or discontinuing treatment. Some of these programs include:
Anti-Coagulation Center
The Anti-Coagulation Center provides on-site testing with immediate reporting and counseling
regarding proper anticoagulant medication dosing. The program promotes self-care by providing
health education about the safe use of anticoagulant therapy. This education includes
information on the signs and symptoms of bleeding or thromboembolism, as well as drugs and
diet that inhibit or augment the effects of anticoagulation therapy, and the importance of
ongoing monitoring.
Chronic Kidney Disease Care Program
CareMore's comprehensive Chronic Kidney Disease Care Program includes an individualized
health evaluation and health risk assessment designed to support the complex specialized needs
of those with chronic kidney disease and end-stage renal disease (ESRD). In this program,
CareMore works collaboratively with the Member’s nephrologist to insure better health
outcomes.
Chronic Obstructive Pulmonary Disease Program
The Chronic Obstructive Pulmonary Disease (COPD) Program provides support for those living
with asthma, chronic bronchitis, emphysema and COPD. The program provides Members with
self-management techniques that can be applied immediately to their daily routine.
CareMore Care Center
The CareMore Care Center manages frail and high-risk Members using a multi-disciplinary team
approach. In addition to continuous follow-up with their PCP, high-risk Members are seen as
often as is necessary to help fine-tune their therapy upon discharge from the hospital or after
referral by their specialist or PCP.
Congestive Heart Failure Care Program
CareMore's Congestive Heart Failure Care Program is designed for Members who have been
diagnosed with congestive heart failure (CHF). CareMore helps these Members manage their CHF
through medications, maintenance of appropriate weight levels, dietary guidance and physical
activity. Members are educated on how to take control of their condition, how to choose the
right types of food to reduce or limit sodium intake, how to monitor high blood pressure levels
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and how to develop and implement a physical activity plan. The care team also works closely
with the Member’s cardiologist. Members who require closed monitoring may be enrolled into a
wireless monitoring program with a scale and celluarl pod to transmit their wights to a webbased program monitored by an advanced practice clinician 7 days per week.
Diabetes Management Program
Effectively manages diabetic patients and promotes well-being, prevents complications of the
disease through education, self-management, clinical management, medication dosing, and
dietary management.
Exercise and Strength-Training Program
The CareMore Health Plan Exercise and Strength Training program provides strength and balance
training for those Members who would benefit from increased muscle strength. Both types of
training aim to improve our Members’ level and duration of independence. This program also
offers specialized exercises for Members’ with certain chronic diseases.
Fall Prevention Center
This program targets Members who are predisposed to fall or who have fallen. It provides
Member assessment, education and multi-systemic examination to determine reason for fall or
predisposition to fall and works to reverse and/or reduce the risk of future falls.
Foot Center
Staffed by in-house podiatrists, the Foot Centers provide medical podiatric care and routine
podiatry (e.g. nail clipping) to CareMore Health Plan Members
Healthy Start
All newly-enrolled CareMore Health Plan Members receive a no-cost and voluntary head-to-toe
medical assessment conducted by the clinical team at the Member’s neighborhood CareMore
Care Center. The goal of the assessment is not only to enable the clinical team to make specific
recommendations that are tailored to the Member’s needs, but also to introduce the Member to
their new health plan and unique programs. After the assessment is complete, the Member will
receive a care plan offering a summary of their health, medical and social needs, along with
preventive and proactive recommendations for follow-up care that will focus on the Member’s
overall well-being. This information will be shared with the Member’s primary care physician.
Hospitalist Program
This program functions on a 24/7 basis; the Hospitalists perform all admitting patient chart
maintenance and discharge summaries. Hospitalists will manage any CareMore member
admitted to any of our contracted hospitals until discharged.
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Hypertension Program
This program manages the uncontrolled hypertensive Member through education and
monitoring of their blood pressure. Members who require close monitoring may be enrolled into
a wireless monitoring program with a blood pressure machine and cellular pod to transmit their
raedilngs to a web-based program monitored by an Advanced Practice Clinician.
House Call Program
This program offers our Members a home visit or visits by a clinician following an inpatient stay
in the hospital. Upon discharge, the attending hospitalist identifies frail Members and the home
visit(s) is arranged. The clinician’s visit includes assessing the Member’s condition at home,
catching early signs of recurrent illness, and making sure the Member is taking medications
properly.
Pre-Op Center
For the clinical assessment of senior Members scheduled for surgery. A medical history is taken
and a physical is performed to, as best as possible, identify potential medical complications. The
goal of the clinicians in the Pre-Op Center is to, as best as possible, assure the Member’s ability
to undergo surgery without complications.
Touch Management Program
The Touch Management Program provides care directly to the bedside of CareMore members
who require the same level of care as someone living in a skilled nursing facility, but lives in a
program-approved community such as a contracted skilled nursing facility, assisted living facility,
board and care home, group home, and adult care home. Members who qualify receive regular
onsite visits from a mid-level provider such as a nurse practitioner or physician’s assistant and
can expect an exceptional level of coordination of care that includes: a comprehensive initial and
annual health assessment, quarterly Primary Care Provider visits, medication management,
routine lab tests and xrays, wound care management and supplies, and the clinical management
of chronic diseases and conditions.
Wound Care Center
Our Wound Care Center effectively manages acute and chronic wounds utilizing wound care
products as well as addressing underlying medical issues that can impact healing. Patients are
educated on self-care management that includes foot checks, management of contributing
medical problems and signs/symptoms of when to call the Care Center by our Advanced Practice
Clinicians at the wound clinic.
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More Information
For information regarding any of CareMore Health Plan’s Care Programs, please
contact Provider Relations. For more information, please refer to CareMore Contact Information
(Chapter 2) for phone and fax numbers.
If CareMore Health Plan members have questions regarding the CareMore’s Care Programs,
please direct them to call Member Services. For more information, please refer to CareMore
Contact Information (Chapter 2) for phone number and hours of operation.
Health Education
Providers are required to provide a variety of health education services as mandated by
California’s Department of Healthcare Services (DHCS). As Providers, you are in the best position
to meet the many educational needs of our Members at the time of their medical visits. You are
the most credible educator for your patients. To support contracted Providers, CareMore makes
available many Health Education Programs, materials and services to assist in meeting the
educational needs of our Members.
Health Education Services
All CareMore Providers can access the health education services provided at CareMore Care
Centers (CCC) by logging on to our provider portal at Providers.caremore.com and completing a
referral request. It is recommended that members attend education classes for their primary
diagnosis. If a member has multiple co-morbidities, individual dietary counseling may be
needed.
Health education services include:

Classes for Members on self-management support for: diabetes, COPD, heart failure,
heart disease, and chronic kidney disease.

Classes on general nutrition

Appointment with a registered dietician for individual nutrition counseling
Providers can also complete a health education referral form via the provider portal to request
assistance in locating a health education class on a topic not offered at one of the CCC facilities.
Process for referring a CareMore Member to Health Education Services:

Obtain agreement for a referral to Health Education from the Member;

Stress compliance as part of the Member’s overall care plan;

Please refer Members for only one condition at a time. This will help keep Members from
feeling overwhelmed by their overall care plan;

Document the referral in the Member’s medical record;

Reinforce key concepts and compliance with Member at follow-up office visits.
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Health Education Materials
CareMore selects and develops patient education materials that are culturally appropriate for
various target populations in key subject areas. All materials are written at the sixth grade
reading level or below to meet the literacy needs of our Members. The most appropriate setting
for a Member to receive written literature is from his or her Provider, and the materials should
be accompanied by a brief discussion of their importance. Health education materials are
available on a variety of topics including:

Alcohol use

Asthma

Cholesterol

Chronic Obstructive Pulmonary Disease (COPD)

Diabetes

Heart health

Hypertension

Injury prevention

Flu and pneumonia vaccinations

Medication safety

Living well with mental health illness

Nutrition

Physical activity and fitness

Weight management

Preventive care
Materials are available at Providers.caremore.com. All materials are also available in other
languages and alternative formats.
If a Provider chooses to use their own materials they must ensure that those materials meet the
literacy levels mandated by DHCS and are culturally appropriate for the patient. Providers must
document in the Member’s chart all distributions of educational materials.
Newsletters
CareMore mails to all Members at least twice each year an educational newsletter containing a
variety of required health education topics. A disclaimer is printed on the newsletter informing
the Member that the contents are for information only and do not take the place of Provider
advice.
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Individual Health Education and Behavioral Assessment (IHEBA)
Primary Care Providers are required to complete an Individual Health Education Behavioral
Assessment (IHEBA) developed by DHCS (also known as the “Staying Healthy Assessment”),
within 120 days of enrollment as part of their initial health assessment for each Cal MediConnect
patient. For existing patients, the assessment must also be completed at their next non-acute
care visit and when entering into a new age category. Patients should be encouraged, when
appropriate, to complete the IHEBA on their own. PCPs are required to review the completed
assessment with their patients and provide need-based counseling and health educations service
referral.
Providers can access the age-appropriate IHEBA tools and educational tips in all threshold
languages through the DHCS website at
http://www.dhcs.ca.gov/formsandpubs/forms/pages/stayinghealthy.aspx.
Health Education Compliance - Facility Site Reviews
Compliance with all Health Education requirements is monitored through facility site reviews
which are required every three years or at the discretion of facility site review nurses. The Facility
reviewers will check on availability of health education services, documentation in the Member’s
medical record of health education services provided and measure compliance with the
implementation of the Individual Health Education Behavioral Assessments (IHEBA).
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CHAPTER 13: PROVIDER ROLES AND RESPONSIBILITIES
The Primary Care Provider (PCP)
The PCP is the foundation of the medical home, responsible for providing, managing and
coordinating all aspects of the Member’s medical care and all care that is within the scope of his
or her practice. The PCP is responsible for coordinating Member care with specialists and
conferring and collaborating with the specialists using a collaborative concept known as a
medical home.
CareMore Health Plan (CareMore) promotes the medical home concept to all our Members. The
PCP is the Member’s initial contact point when accessing health care. The PCP’s relationship with
the Member and family, together with the health care Providers within the medical home and
the extended network of consultants and specialists with whom the medical home works, have
an ongoing and collaborative contractual relationship. The Providers in the medical home are
knowledgeable about the Member’s and his or her family’s special, health-related social and
educational needs and are connected to necessary resources in the community that will assist
the family in meeting those needs. When a Member is referred for a consultation or specialty
and/or hospital services or health and health-related services by the PCP through the medical
home, the medical home Provider maintains the primary relationship with the Member and
family. He or she keeps abreast of the current status of the Member and family through a
planned feedback mechanism with the PCP who receives them into the medical home for
continuing primary medical care and preventive health services.
Primary Care Provider Role
The Primary Care Provider (PCP) is a network Provider who is responsible for the complete care
of his or her patient, who is a CareMore Health Plan (CareMore) Member. The PCP serves as the
entry point into the health care system for the Member. The PCP is responsible for the complete
care of his or her patient, including but not limited to providing primary care, coordinating and
monitoring referrals to specialist care and maintaining the continuity of care.
At a minimum, the PCP’s responsibilities shall include:

Managing the medical and health care needs of Members to assure all medically necessary
services are made available in a timely manner

Monitoring and following up on care provided by other medical service Providers for
diagnosis and treatment, to include services available under Fee-For-Service (FFS) Medicaid

Providing the coordination necessary for the referral of patients to specialists and for the
referral of patients to services that may be available through FFS Medicaid

Providing education and coordination for recommended preventive health care services and
appropriate guidance for healthy behaviors

Maintaining a medical record of all services rendered by the PCP and other referral Providers
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Chapter 13: Provider Roles and Responsibilities
Cal MediConnect
A PCP must be a physician or network Provider or subcontractor who provides or arranges for
the delivery of medical services to ensure all services which are found to be medically necessary
are made available in a timely manner. The PCP may practice in a solo or group setting or may
practice in a clinic, e.g., a Federally Qualified Health Center (FQHC).
We encourage Members to select a PCP who provides preventive and primary medical care, as
well as authorization and coordination of all medically necessary specialty services. Members are
encouraged to make an appointment with their PCP within 90 calendar days of their effective
date of enrollment.
FQHCs may function as a PCP. Providers must arrange for coverage of services to assigned
Members:

24 hours a day, 7 days a week, in person or by an on-call physician

Providers must also answer emergency telephone calls from Members within 30 minutes

Each PCP must provide a minimum of 20 office hours per week per office location of personal
availability as a PCP
Provider Specialties
Physicians with the following specialties can apply for enrollment with us as a PCP:

Family practitioner

General practitioner

General internist

Specialists who perform primary care functions, (e.g., surgeons, clinics, including but not
limited to FQHC, RHC, Health Departments and other similar community clinics)

Other Providers approved by the California Department of Health Care Services (DHCS)
The Provider must be enrolled in the Medicaid program at the service location where he or she
wishes to practice as a PCP before contracting with CareMore. Independent Advanced Practice
Nurses (APN) interested in participating with us cannot enroll as a PCP.
Responsibilities of the Primary Care Provider
The PCP is a network physician responsible for the complete care of his or her Members,
whether providing it himself or herself or by referral to the appropriate Provider of care within
the network. FQHCs may be included as PCPs. Below are highlights of the PCP’s responsibilities.
The PCP shall:

Manage the medical and health care needs of Members, including monitoring and following
up on care provided by other Providers including (FFS)

Provide education and coordination for recommended preventive health care services and
appropriate guidance for healthy behaviors
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Provide coordination necessary for referrals to specialists and FFS Providers (both in- and
out-of-network); maintain a medical record of all services rendered by the PCP and other
Providers

Provide 24-hour-a-day, 7-day-a-week coverage with regular hours of operation clearly
defined and communicated to Members

Provide services ethically, legally and in a culturally competent manner and meet the unique
needs of Members with special health care needs

Participate in any system established by CareMore to facilitate the sharing of records, subject
to applicable confidentiality and HIPAA requirements

Make provisions to communicate in the language or fashion primarily used by his or her
Membership

Participate and cooperate with us in any reasonable internal and external quality assurance,
utilization review, continuing education and other similar programs we’ve established

Participate in and cooperate with our grievance procedures; we will notify the PCP of any
Member grievance

Not balance-bill Members; however, the PCP is entitled to collect applicable copayments for
certain services

Continue care in progress during and after termination of his or her contract for up to 60 days
until a continuity of care plan is in place to transition the Member to another Provider or
through postpartum care for pregnant Members in accordance with applicable state laws and
regulations

Comply with all applicable federal and state laws regarding the confidentiality of patient
records

Develop and have an exposure control plan in compliance with Occupational Safety and
Health Administration standards regarding blood-borne pathogens

Establish an appropriate mechanism to fulfill obligations under the Americans with
Disabilities Act

Support, cooperate and comply with our quality improvement program initiatives and any
related policies and procedures; to provide quality care in a cost-effective and reasonable
manner

Inform us if a Member objects to provision of any counseling, treatments or referral services
for religious reasons

Treat all Members with respect and dignity; provide Members with appropriate privacy and
treat Member disclosures and records confidentially, giving the Members the opportunity to
approve or refuse their release

Provide Members complete information concerning their diagnosis, evaluation, treatment
and prognosis and give Members the opportunity to participate in decisions involving their
health care except when contraindicated for medical reasons
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Advise Members about their health status, medical care or treatment options, regardless of
whether benefits for such care are provided under the program or have limitations; advise
Members on treatments which may be self-administered

Contact Members when clinically indicated, as quickly as possible for follow-up regarding
significant problems and/or abnormal laboratory or radiological findings

Have a policy and procedure to ensure proper identification, handling, transport, treatment
and disposal of hazardous and contaminated materials and wastes to minimize sources and
transmission of infection

Agree to maintain communication with the appropriate agencies such as local police, social
services agencies and poison control centers to provide high-quality patient care

Agree that any notation in a Member’s clinical record indicating diagnostic or therapeutic
intervention as part of the clinical research shall be clearly contrasted with entries regarding
the provision of non research-related care
Note: We do not cover the use of any experimental procedures or experimental medications
except under certain circumstances.
Provider Access and Availability
When medically necessary, enrollees have access to acute, emergent care 24 hours a day, seven
7 days a week.
During office hours, practitioner’s office staff will answer at least eighty percent (80%) of
telephone calls within 30 seconds.
Average hold time must not exceed two (2) minutes. The average hold time is defined as the
time spent on hold by the caller following the interactive voice response (IVR) system, touch tone
response system, or recorded greeting and before reaching a live person.
Disconnect rate of all incoming calls must not exceed five (5) percent.
The maximum waiting time for the following services with the exception of LTSS (including
behavioral health, when applicable) should be:
Medical Appointment Wait Time Standards
Emergency Exam: Serious condition requiring
immediate intervention-no authorization
needed
Immediately
Urgent (PCP or specialist): Condition that could Less than 24 hours of patient request for an
appointment
lead to a potentially harmful outcome if not
treated
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Medical Appointment Wait Time Standards
Non-urgent (PCP)
Within 7 calendar days of patient request for
appointment
Adult Health Assessment: Unless a more
prompt exam is warranted that is termed
“urgent”
Within 30 calendar days of patient request
for appointment
Non- Urgent Consult/Specialist Referral
Within 14 calendar days of patient request
for appointment
Waiting time in practitioner’s office excludes
walk-in/same day appointments
30 minutes or less
After-hours access
Answering service or answering system with
an option to page a practitioner or provides
instructions for further care access, to include
calling 911 or present to the nearest
Emergency Room for serious medical
conditions
Behavioral Health non-life threatening
emergency
Within 6 hours of patient request for an
appointment
Behavioral urgent care
Within 48 hours of a patient request for an
appointment
Behavioral Health routine office visit
Within 10 business days of a patient request
for an appointment
Member Missed Appointments
When Members miss appointments, Providers must do the following:

Document the missed appointment in the Member’s medical record.

Make at least three attempts to contact the Member to determine the reason for the missed
appointment.
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Provide a reason in the Member’s medical record for any delays in performing an
examination, including any refusals by the Member. Documentation of the attempts to
schedule an Initial Health Assessment must be available to CareMore or state reviewers upon
request.
Our Members who frequently cancel or fail to show up for an appointment without rescheduling
the appointment may need additional education in appropriate methods of accessing care. In
these cases, please call Case Management at 1-888-291-1384 to address the situation. Our staff
will contact the Member and provide more extensive education and/or case management as
appropriate. Our goal is for Members to recognize the importance of maintaining preventive
health visits and to adhere to a plan of care recommended by their PCP.
Please Note: Members cannot be billed for missed appointments.
Noncompliant Members
We recognize you might need help in managing Members who fail to adhere to their prescribed
treatment plan. If you have an issue with a Member regarding behavior, treatment cooperation
and/or completion of treatment, and/or making or appearing for appointments, please call Case
Management at 1-888-291-1384. A Member advocate will contact the Member either by
telephone or in person to provide the education and counseling to address the situation and will
report to you the outcome of any counseling efforts.
Primary Care Provider Transfers
Member may change their Primary Care Physician for any reason, at any time. Member should
be directed to contact CareMore Member Services toll-free at 1-888-350-3447 if they would like
to change Primary Care Physician. Member Services will coordinate any existing approvals that
require PCP approval (such as home health services and durable medical equipment) in efforts to
ensure specialists care or other covered services are not disrupted.
Provider Disenrollment Process
Providers may cease participating with us for either mandatory or voluntary reasons.
Mandatory disenrollment occurs when a Provider becomes unavailable due to immediate,
unforeseen reasons. Examples of this include death and loss of license. Members are autoassigned to another PCP to ensure continued access to our covered services, as appropriate. We
will notify Members of any termination of PCPs or other Providers from whom they receive
ongoing care.
CareMore will provide notice to affected Members when a Provider disenrolls for voluntary
reasons such as retirement. Providers must provide written notice to us within the time frames
specified in their Participating Provider Agreement. Members who are linked to a PCP that has
disenrolled for voluntary reasons will be notified of their new PCP assignment or given the option
to self-select a new PCP.
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Covering Physicians
CareMore mandates that Providers provide or arrange for specialist physician services, including
emergency services, to be accessible to Members 24 hours a day, seven days a week. Those
providing these services must meet CareMore’s credentialing standards and must be approved
by CareMore before providing or arranging specialist physician services for Members.
Continuity of Care
CareMore will allow Members to continue seeing their current doctors which are outside of
CareMore's contracted network for a certain amount of time. Members keep their current
providers and service authorizations at the time they enroll for up to six months for Medicare
services and up to 12 months for Medi-Cal services if all of the following criteria are met:

The Provider, Member or his/her representative makes a direct request to CareMore to
continue to seeing his/her current Provider.

CareMore is required to approve this request if the member can show an existing relationship
with a primary or specialty care Provider, with some exceptions.

CareMore will determine a pre-existing relationship by reviewing the Member's health
information available to us. The Provider or Member may also give CareMore information to
show this pre-existing relationship with a Provider.

An existing relationship means that the Member saw an out-of-network primary care
Provider at least once or specialty care Provider at least twice for a non-emergency visit
during the 12 months prior to the date of your initial enrollment in Cal MediConnect.

CareMore will have 30 days to respond to the request. The Member may also ask CareMore
to make a faster decision and CareMore will respond within 15 days for those requests which
are deemed urgent, or within 3 days if it is deemed that there is risk of harm to the member.

When the Member or his/her Provider makes a request to continue care with a current
Provider, the Member or his/her Provider must show documentation of an existing
relationship and agree to certain terms.

This request cannot be made for Providers of durable medical equipment (DME),
transportation, other ancillary services, or services not included under Cal MediConnect.
After the continuity of care period ends, the Member will need to see doctors and other
Providers in the CareMore network unless CareMore makes an agreement with your out-ofnetwork doctor. A network Provider is a Provider who works with the health plan.
CareMore provides continuity of care for Members with qualifying conditions when health care
services are not available within the network or when the Member or Provider is in a state of
transition. When these situations arise, we work to ensure that Members continue to have
access to medically necessary items, services, and medical and Long Term Services and Supports
providers.
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**Qualifying Condition: A medical condition that may qualify a Member for continued access
to care and continuity of care. These conditions include, but are not limited to:

Acute conditions (cancer, for example)

Degenerative and disabling conditions, which includes conditions or diseases caused by a
congenital or acquired injury or illness that require a specialized rehabilitation program or a
high level of service, resources or coordination of care in the community

Surgery that has been prior approved and scheduled to occur within 180 days of the
contract's termination or within 180 days of the effective date of coverage for a newlycovered enrollee

Serious chronic conditions (hemophilia, for example)

Terminal illness
States of transition may be any one of the following:

The Member is newly enrolled

The Member is disenrolling to another health plan

The Provider’s contract terminates
All new enrollees receive Evidence of Coverage (EOC) Membership information in their
enrollment packets. This also provides information regarding Members’ rights to request
continuity of care if the Member transitions to another health plan. A terminated Provider or
Provider group who actively treats Members must continue to treat Members until the
Provider's date of termination. CareMore makes every effort to notify Members at least 30 days
prior to termination.
Providers help ensure continuity and coordination of care through collaboration. This includes
the confidential exchange of information between PCPs and specialists as well as behavioral
health Providers. In addition, CareMore helps coordinate care when the Provider's contract has
been discontinued to help smooth the transition to a new Provider.
Providers must maintain accurate and timely documentation in the Member’s medical record
including, but not limited to:

Consultations

Prior authorizations

Referrals to specialists

Treatment plans
All Providers share responsibility in communicating clinical findings, treatment plans, prognosis
and the Member’s psychosocial condition as part of the coordination process. Utilization
Management nurses review Member and Provider requests for continuity of care. These nurses
facilitate continuation with the current Provider until a short-term regimen of care is completed
or the Member transitions to a new practitioner.
Please Note: Only CareMore can make adverse determination decisions regarding continuity of
care.
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Adverse determination decisions are sent in writing to the Member and Provider within two
business days of the decision. Members and Providers can appeal the decision by following the
procedures in the appropriate Grievances and Appeals chapter in this manual. Reasons for
continuity of care denials include, but are not limited to the following:


Continuity of care is not available with the terminating Provider
Course of treatment is complete

Member is ineligible for coverage

Not a qualifying condition

Request is for change of PCP only and not for continued access to care

Requested services are not a covered benefit

Services rendered are covered under a global fee

Treating Provider is currently contracted with our network
Delivery of Primary Care
After selecting their PCP, it is important that the Member establish an ongoing relationship with
this source of their primary care.
The Member will be encouraged to make an appointment with their PCP immediately after
selection. Newly-enrolled Members will complete an assessment process within 90 days of
enrolling in Cal MediConnect. Primary care services will be available according to CareMore’s
established access and availability standards. (See Provider Access and Availability.)
When urgent services are not available from the Member’s PCP and the Member requires care
while in the local area, the PCP will arrange/refer the Member to the appropriate source for care
within the network.
If the Member is outside the service area, the PCP may recommend the appropriate level of care,
but the final decision as to where to obtain services for the urgent care needs will reside with the
Member or a responsible adult.
Emergency services are available without prior authorization through the Emergency Medical
Services system (911) or through an emergency room either within or outside the service area.
Coordination of Services
A health care professional, usually the PCP or designee, has the primary responsibility for
evaluating the Member’s needs before recommending and arranging the services required by the
Member. This PCP/designee is also responsible for facilitating communication and information
exchange among the different Providers/practitioners treating the Member.
The PCP/designee will ensure that all referrals contain sufficient clinical information for the
specialist/diagnostician to make a decision regarding the treatment of the Member.
The PCP/designee will ensure that all specialty consultation reports are received and filed
promptly in the Member’s medical record.
Providers will request information from other treating Providers as necessary to provide care.
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Each practitioner participating in the Member’s care will give information on available treatment
options (including the option of no treatment) or alternative courses of care and other
information regarding treatment options in a language that the Member understands. This
information should include:

The Member’s condition

Any proposed treatments or procedures and alternatives

The benefits, drawbacks and likelihood of success of each option

The possible consequences of refusal of care or non-compliance with a recommended course
of care.
Members are included in the planning and implementation of their care, with special emphasis
on those Members with mental health or substance abuse problems, chronic illnesses or those
Members at the “end of life”.
Members who are unable to fully participate in their treatment decisions may be represented by
parents, guardians, other family Members or other conservators, as appropriate, and per the
Member’s wishes. Minors can be represented by their parents. Advance directives may dictate
who can represent the Member, and family members with power of attorney can represent a
Member unable to represent themselves.
The determination as to who represents those Members who are unable to fully participate in
their treatment decisions will be made based on the law and the circumstances.
Specialty Care Providers
Specialists, licensed with additional training and expertise in a specific field of medicine,
supplement the care given by Primary Care Providers (PCPs) and are charged with the same
responsibilities. That includes the responsibility for ensuring that necessary prior authorizations
have been obtained before providing services.
Access to specialty care begins in the PCP’s office. The PCP will refer a Member to a specialist for
conditions beyond the PCP’s scope of practice that are medically necessary. Specialty care
providers diagnose and treat conditions specific to their area of expertise.
The following guidelines are in place for our specialists:


For urgent care, the specialist should see the Member within 24 hours of receiving the
request.
For routine care, the specialist should see the Member within 2 weeks of receiving the
request.
Behavioral Health Providers
Roles and Responsibilities
Beacon Health Strategies is responsible for providing access to medically necessary behavioral
health services for CareMore members, and for coordinating access to additional behavioral
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health services available through the County Specialty Mental Health Plan. Beacon is available
24/7/365 to facilitate access to emergent or urgent behavioral health services, and from 8am to
8pm for routine service requests. Beacon can be reached at 1-855-371-8092.
Transition after Acute Psychiatric Care
To access outpatient behavioral health services after an acute psychiatric episode, contact
Beacon at 1-855-371-8092.
Reporting Changes in Address and/or Practice Status
Providers can contact CareMore Provider Relations for demographic updates by calling and/or
submitting changes in writing and faxing them to Provider Relations. Please refer to “How to
Reach Us” contact sheet for contact information.
Provider Termination Notification
To ensure compliance with CMS timeframes for Member notifications and to minimize disruption
to care as much as possible, Providers are contractually obligated to provide CareMore with
ninety (90) calendar days prior written notice of any participating physician provider
terminations. In the event a participating physician provider is terminated with less than ninety
(90) calendar days notice, then the Provider is to provide CareMore with written notice within
five (5) business days of becoming aware of the termination.
Americans with Disabilities Act Requirements
Our policies and procedures are designed to promote compliance with the Americans with
Disabilities Act of 1990. Providers are required to take reasonable actions to remove an existing
barrier and/or to accommodate the needs of Members with disabilities. This action plan
includes:

Accessible entrance to the facility

Elevator or accessible ramp into facilities

Access to examination room and restrooms that accommodates a mobility device

Accessible parking for people with disabilities clearly marked

Auxiliary aids and services
For more information visit http://www.ada.gov/.
Disclosure of Ownership and Exclusion from Federal Health Care Programs
As a CareMore Provider, you must fully comply with federal requirements for disclosure of
ownership and control, business transactions, and information for persons convicted of crimes
against federal related health care programs, including Medicare and Medicaid programs, as
described in 42 CFR § 455 Subpart B.
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Please familiarize yourself with federal requirements regarding Providers and entities excluded
from participation in federal health care programs (including Medicare and Medicaid programs).
Screen new employees and contractors to verify they have not been excluded from participation
from these programs, and verify monthly that existing employees or contractors have not been
excluded. The Federal Health and Human Services – Office of Inspector General (HHS-OIG) and
the GSA Excluded Parties List System (EPLS) prior to the hiring of any employee supporting
CareMore Medicare Part C or D functions, and monthly thereafter to ensure individuals are not
excluded from participation in federal programs. Excluded individuals require immediate
removal from CareMore Medicare Programs Work.
CareMore utilizes the Anthem (and all its affiliates) Compliance HelpLine. If you discover any
exclusion information, please immediately report to us by calling the Anthem Helpline at
877-725-2702.
For questions related to Disclosure of Ownership or Exclusions from Federal Health Care
Programs, please contact our Plan Compliance Officer hotline at 1-562-741-4552. Callers may
leave a message on voicemail and remain anonymous, if so desired.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in August
1996. The legislation improves the portability and continuity of health benefits, ensures greater
accountability in the area of health care fraud and simplifies the administration of health
insurance. In 2009, HIPAA was enhanced by the American Recovery and Reinvestment Act’s
section on Health Information Technology for Economic and Clinical Health act (HITECH).
Provisions of HITECH improve Member privacy and security by:

Requiring patient notification of breaches of unsecure Protected Health Information (PHI)
while creating a safe harbor for encrypted electronic PHI and shredded paper PHI.

Applying certain provisions of the privacy and security rules to business associates.

Modifying the marketing and fundraising rules
Information regarding the breach notification rule can be found on the federal Department of
Health and Human Services (DHHS) website at:
www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/index.html.
Proposed changes to HIPAA are also located on the DHHS website at:
www.hhs.gov/news/press/2011pres/05/20110531c.html.
CareMore strives to ensure that both we and contracted participating Providers conduct business
in a manner that safeguards patient and Member information in accordance with the privacy
regulations enacted pursuant to HIPAA. Effective April 14, 2003, contracted Providers shall have
the following procedures in place to demonstrate compliance with the HIPAA privacy regulations.
We recognize our responsibility under the HIPAA privacy regulations to request from Providers
the minimum Member information necessary to accomplish the intended purpose. Conversely,
network Providers should request only the minimum necessary Member information required to
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accomplish the intended purpose when contacting us. However, please note that the privacy
regulations allow the transfer or sharing of Member information, such as a Member’s medical
record. We may request this information in order to:

Conduct business and make decisions about care

Make an authorization determination

Resolve a payment appeal
Such requests are considered part of the HIPAA definition of treatment, payment or health care
operations.
Fax machines used to transmit and receive medically-sensitive information should be maintained
in an environment where access is restricted to individuals who need Member information to
perform their jobs. When faxing information to us, verify that the receiving fax number is correct,
notify the appropriate staff at CareMore and verify that the fax was appropriately received.
Internet email (unless encrypted) should not be used to transfer files containing Member
information to us (e.g., Excel spreadsheets with claim information). Such information should be
mailed or faxed.
Please use professional judgment when mailing medically sensitive information such as medical
records. The information should be in a sealed envelope marked confidential and addressed to a
specific individual, post office box or CareMore department.
Our voice mail system is secure and password-protected. When leaving messages for our
associates, please leave the minimum amount of Member information that is necessary to
accomplish your intended purpose of the call.
When contacting us, please be prepared to verify your name, address and Tax Identification
Number (TIN) or National Provider Identifier (NPI) numbers.
Medical Records
CareMore Health Plan requires Providers to maintain medical records in a manner that is current,
organized and permits effective and confidential Member care and quality review. We perform
medical record reviews of all PCPs upon signing of a contract and, at a minimum, every three
years thereafter to ensure that network Providers are in compliance with these standards.
Confidentiality of Information
Providers shall agree to maintain the confidentiality of Member information and information
contained in a Member's medical records according to the Health Information Privacy and
Accountability Act (HIPAA) standards. The Act prohibits a Provider of health care from disclosing
any individually identifiable information regarding a patient's medical history, mental and
physical condition, or treatment without the patient's or legal representative's consent or
specific legal authority and will only release such information as permitted by applicable federal,
state and local laws and that is:
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Necessary to other Providers and the health plan related to treatment, payment or health
care operations; or
Upon the Member’s signed and written consent
Misrouted Protected Health Information
Providers and facilities are required to review all Member information received from CareMore
to ensure no misrouted Protected Health Information (PHI) is included. Misrouted PHI includes
information about Members that a Provider or facility is not treating. PHI can be misrouted to
Providers and facilities by mail, fax, email, or electronic remittance advice. Providers and facilities
are required to destroy immediately any misrouted PHI or safeguard the PHI for as long as it is
retained. In no event are Providers or facilities permitted to misuse or re-disclose misrouted PHI.
If Providers or facilities cannot destroy or safeguard misrouted PHI, please contact Provider
Relations at 1-888-291-1358 (select option 3 > option 5).
Security
Medical records must be secure and inaccessible to unauthorized access in order to prevent loss,
tampering, disclosure of information, alteration or destruction of the record. Information must
be accessible only to authorized personnel within the Provider’s office, CareMore Health Plan,
DHCS, or to persons authorized through a legal instrument.
Office personnel will ensure that individual patient conditions or information is not discussed in
front of other patients or visitors, displayed, or left unattended in reception and/or patient flow
areas.
Storage and Maintenance
Active medical records shall be secured and must be inaccessible to unauthorized persons.
Medical records are to be maintained in a manner that is current, detailed and organized, and
that permits effective patient care and quality review while maintaining confidentiality. Inactive
records are to remain accessible for a period of time that meets state and federal guidelines.
Electronic record keeping system procedures shall be in place to ensure patient confidentiality,
prevent unauthorized access, authenticate electronic signatures and maintain upkeep of
computer systems. Security systems shall be in place to provide back-up storage and file
recovery, to provide a mechanism to copy documents, and to ensure that recorded input is
unalterable.
Availability of Medical Records
The medical records system must allow for prompt retrieval of each record when the Member
comes in for a visit. Providers must maintain Members' medical records in a detailed and
comprehensive manner that accomplishes the following:



Conforms to good professional medical practice
Facilitates an accurate system for follow-up treatment
Permits effective professional medical review and medical audit processes
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Medical records must be legible, signed and dated.
Providers must offer a copy of a Member’s medical record upon reasonable request by the
Member at no charge, and the Provider must facilitate the transfer of the Member’s medical
record to another Provider at the Member’s request. Confidentiality of and access to medical
records must be provided in accordance with the standards mandated in HIPAA and all other
state and federal requirements.
Providers must permit CareMore and representatives of DHCS to review Members’ medical
records for the purposes of:

monitoring the Provider’s compliance with medical record standards

capturing information for clinical studies or HEDIS

monitoring quality

any other reason
Medical Record Documentation Standards
Every medical record is, at a minimum, to include:

The patient’s name or ID number on each page in the record

Personal biographical data including home address, employer, emergency contact name
and telephone number, home and work telephone numbers, and marital status

All entries dated with month, day, and year

All entries contain the author’s identification (for example, handwritten signature, unique
electronic identifier or initials) and title

Identification of all Providers participating in the Member’s care, and information on
services furnished by these Providers

A problem list, including significant illnesses and medical and psychological conditions

Presenting complaints, diagnoses, and treatment plans, including the services to be
delivered

Physical findings relevant to the visit including vital signs, normal and abnormal findings,
and appropriate subjective and objective information

Information on allergies and adverse reactions (or a notation that the patient has no
known allergies or history of adverse reactions)

Information on Advance Directives

Past medical history, including serious accidents, operations, illnesses, and substance
abuse

Physical examinations, treatment necessary and possible risk factors for the Member
relevant to the particular treatment

Prescribed medications, including dosages and dates of initial or refill prescriptions
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Information on the individuals to be instructed in assisting the patient

Medical records must be legible, dated, and signed by the physician, physician assistant
or nurse practitioner providing patient care

Appropriate immunization history

Documentation attempts to provide immunizations. If the Member refuses immunization,
proof of voluntary refusal of the immunization in the form of a signed statement by the
Member or guardian shall be documented in the Member’s medical record

Evidence of preventive screening and services in accordance with CareMore Health Plan
preventive health practice guidelines

Documentation of referrals, consultations, diagnostic test results, and inpatient records.
Evidence of the Provider’s review may include the Provider’s initials or signature and
notation in the patient’s medical record of the Provider’s review and patient contact,
follow-up treatment, instructions, return office visits, referrals, and other patient
information

Notations of patient appointment cancellations or “No Shows” and the attempts to
contact the patient to reschedule

No evidence that the patient is placed at inappropriate risk by a diagnostic test or
therapeutic procedure

Documentation on whether an interpreter was used, and, if so, that the interpreter was
also used in follow-up
Clinical Practice Guidelines
CareMore adopts Clinical Practice Guidelines for the purpose of improving health care and
reducing unnecessary variations in care. The guidelines are evidence‐based, sourced from
recognized organizations, approved by the CareMore Quality Management Committee, and
disseminated to CareMore healthcare providers. The Clinical Practice Guidelines in these
documents are considered essential for health care for the member population served by
CareMore. We review the guidelines at least every two years or when changes are made to
national guidelines for content accuracy, current primary sources, new technological advances
and recent medical research.
The guidelines are available online on the provider portal.
The CareMore portal offers the most up-to-date clinical resources and guidelines. If you do not
have Internet access, you can request a hard copy of the Clinical Practice Guidelines by calling
Provider Relations at 1-888-291-1358 (select option 3, option 5).
Please Note: Our recommendation of these guidelines is not an authorization, certification,
explanation of benefits, or a contract. Actual Member benefits and eligibility for services are
determined in accordance with the requirements set forth by the State of California. With
respect to the issue of coverage, each Member should review his/her Certificate of Coverage and
Schedule of Benefits for details concerning benefits, procedures and exclusions prior to receiving
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treatment. The Certificate of Coverage and/or Schedule of Benefits supersede the preventive
health guideline recommendations.
Advance Directives
CareMore Health Plan recognizes a person's right to dignity and privacy. Our Members have the
right to execute an Advance Directive, also known as a "living will," to identify their wishes
concerning health care services in the event that they become incapacitated. Providers may be
asked to assist Members in procuring and completing the necessary forms.
Advance Directive documents should be on hand in the event a Member requests this
information. Member requests for Advance Directive documents should be noted in the Medical
Record when applicable.
Prohibited Activities
All Providers are prohibited from:

Billing eligible Members for covered services

Segregating Members in any way from other persons receiving similar services, supplies
or equipment

Discriminating against CareMore Members or Medicare/Medicaid participants
Healthcare Effectiveness Data Information Set (HEDIS) Requirements
As a CMS contracted health plan, CareMore Health Plan participates each year in the Healthcare
Effectiveness Data & Information Set (HEDIS®), the most widely used set of performance
measures in the Managed Care Industry. According to the narrative supplied by NCQA in Volume
I of the HEDIS® manual, quality improvement activities, health management systems and
provider profiling efforts have all used HEDIS® as a core measurement set. It is also a set of
measures that are mandated by the Centers for Medicaid and Medicare Services (CMS) and as
such, is an integral part of CareMore Health Plan’s Utilization and Quality Management
Program(s).
Since HEDIS® is a national project; there are certain specifications that must be met. Each
contracted provider needs to ensure that their processes support CareMore Health Plan’s HEDIS®
data specifications and data transmission timelines to include the following:



Industry standard codes (ICD-9, CPT) are used consistently and all characters are
collected, captured and transmitted to CareMore Health Plan.
Principal codes are identified and secondary codes are captured, when appropriate.
Data receipt and entry processes are effective and efficient and ensure timely, accurate
and complete transmission to CareMore Health Plan.
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Electronic submissions conform to industry standards and have necessary checking
procedures to ensure data accuracy (i.e., logs, counts, receipts, etc.).
Encounter/claims data is submitted to CareMore Health Plan in a format specified by
CareMore Health Plan (consistent with HEDIS® requirements) and on a timely basis so as
to support any quality improvement activities undertaken by CareMore Health Plan, but
no less than quarterly.
In addition to the above, the provider must:




Ensure accuracy and completeness of encounter-level data;
Measure their performance against data quality standards;
Measure their performance against quality timeliness standards; and
Monitor data transfers between CareMore Health Plan and provider(s) to ensure no data
necessary for HEDIS® reporting are lost or inappropriately modified.
In order to ensure compliance with the above, CareMore Health Plan may perform oversight
activities (i.e., review of reports, delegation oversight audits, etc.) on any delegated activities,
including but not limited to utilization management, claims payment and credentialing.
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CHAPTER 14: PROVIDER GRIEVANCES AND APPEALS
Overview
CareMore Health Plan (CareMore) encourages Providers to seek resolution of issues through our
grievance and appeals process. The issues may involve dissatisfaction or concern about another
Provider, the Plan, or a Member.
We want to assure Providers that they have the right to file an appeal with us for denial, deferral
or modification of a claims disposition or post-service request. They also have the right to appeal
on behalf of a Member for denial, deferral or modification of a Service Request. These appeals
are treated as Member appeals and follow the Member appeal process as discussed in Chapter
16: Member Grievances and Appeals.
Grievances are tracked and trended, resolved within established time frames and referred to
peer review when necessary. CareMore’s grievance and appeals process meets all requirements
of state law and accreditation agencies.
The building blocks of this process are the grievance and the appeal.
**Grievance: Any expression of dissatisfaction about any matter other than an "action"
to CareMore by a Member or Provider.
**Appeal: A formal request for CareMore to change a decision upheld by CareMore
through the grievance and appeal process.
Please Note: CareMore does not discriminate against Providers for filing a grievance or an
appeal. Providers are prohibited from penalizing a Member in any way for filing a grievance.
Provider grievances and appeals are classified into the following three categories:



Grievances relating to the operation of the Plan, including:
o Benefit Interpretation
o Claim Processing
o Reimbursement
Provider appeals related to adverse determinations
Provider appeals of nonmedical necessity claims determinations
If a Provider has a grievance, CareMore would like to hear from them, either by phone or in
writing. Grievances may be filed by calling Regional Performance Management or Provider
Relations at 1-888-291-1358 (Option 3, Option 5).
Provider Grievances Relating to the Operation of the Plan
A Provider may be dissatisfied or concerned about another Provider, a Member, or an
operational issue, including claims processing and reimbursement. Provider grievances may be
submitted orally or in writing and must include the following:


Provider’s name
Date of the incident
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Description of the incident
Timelines for the Provider grievance and appeal process:
Provider Grievance May be filed up to 180 calendar days from the date the Provider became
aware of the issue.
Provider Appeal
May be filed up to 365 calendar days from the date of the Notice of Action
letter advising of an Adverse Determination.
CareMore will send a written acknowledgement to the Provider within five calendar days of
receiving a grievance or within five business days of receiving an appeal. We may request
medical records or an explanation of the issues raised in the grievance in the following ways:



By telephone
By fax, with a signed and dated letter
By mail, with a signed and dated letter
The timeline for responding to the request for more information is as follows:

Standard Grievances or Appeals: Providers must comply with the request for additional
information within 10 calendar days of the date that appears on the request.
Providers are notified in writing of the resolution, including their right of appeal, if any. According
to state law, we may not be able to disclose the final disposition of certain grievances due to
peer review confidentiality laws.
When to Expect Resolution for a Grievance or Appeal

Provider Grievances: CareMore sends a written resolution letter to the Provider within 30
calendar days of the receipt of the grievance.

Provider Appeals: CareMore sends a written resolution letter to the Provider within 45
working days of the receipt of the appeal.
Provider Dispute
When a Provider expresses dissatisfaction about an Adverse Determination involving a clinical
issue, the case is automatically handled as a Provider dispute rather than a grievance.
**Adverse Determination: A denial, modification or reduction of services based on eligibility,
benefit coverage or medical necessity.
A clinical reviewer of the same or similar specialty reviews the Provider appeal. This clinical
reviewer will be someone who was not involved in any previous level of review in the decisionmaking process. In addition, the clinical reviewer may not be subordinate to any person involved
in the initial determination. The clinical reviewer will review the case, contact the Provider as
necessary to discuss possible appropriate alternatives, and render a decision.
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Claims denials are also considered an Adverse Determination. Providers who want to challenge a
claims decision may do so by calling 1-888-291-1358 (Select Option 3, then Option2) or may
submit a written notice to the designated CareMore Provider Appeal address provided in
Chapter 2: Important Contact Information.
**Provider Dispute Resolution Appeal: The process by which a Provider may challenge
the disposition of a claim that has already been decided.
Requests for Provider disputes must be submitted using the following guidelines:

The request must be made in writing to CareMore within 365 calendar days of a claim
disposition and include all pertinent information.
Provider Dispute Resolution Appeals are resolved within 45 working days of receipt of the
written request.
Provider Appeals: Arbitration
If the Provider is not satisfied with the outcome of a review conducted through the Provider
Appeal Process, there are additional steps that can be taken through arbitration in accordance
with the CareMore Provider Agreement.
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CHAPTER 15: CREDENTIALING AND RE-CREDENTIALING
Overview
Credentialing is an industry-standard, systemic approach to collecting and verifying an applicant’s
professional qualifications. This approach includes a review of relevant training, licensure,
certification and/or registration to practice in a health care field, and academic background.
Our credentialing process evaluates the information gathered and verified and determines
whether the applicant meets certain criteria related to professional competence and conduct as
well as licensure and certification. We use current National Committee for Quality Assurance
(NCQA) and guidelines for the accreditation of managed care organizations, as well as statespecific requirements, to credential and recredential Providers with whom we contract. This
process is completed before a Provider is accepted for participation in our network.
Groups delegated for credentialing are required to follow the National Committee for Quality
Assurance (NCQA) guidelines and Accreditation Association for Ambulatory Health Care
Standards. Anthem will conduct credentialing delegation audits and oversight on behalf of
CareMore. If your organization is an existing Anthem contracted IPA / Medical Group, your
designated auditor will also serve as your representative for CareMore. Credentialing delegation
audits will be conducted yearly to ensure they are meeting NCQA guidelines.
Credentialing
CareMore credentials and recredentials all licensed practitioners who desire to become a
participating practitioner in the network.
CareMore credentials and recredential all licensed practitioners who desire to become a
participating practitioner or Provider in the network.
The following practitioner types must successfully complete the credentialing process in order to
join the CareMore network:

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

Podiatrist (DPM)

Chiropractor (DC)

Dentist (DDS/DMD only)

Medical therapists, e.g., physical therapists, speech therapists, and occupational therapists,
when an independent relationship exists between the Company and the provider, and
individual provider is listed individually in the Company’s network directory

Behavioral Health practitioners to include
o Doctoral or master’s-level psychologists who are state certified or state licensed
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Master’s-level clinical nurse specialists or psychiatric nurse practitioners who are nationally or
state certified or state licensed
The following practitioner types are not required to be credentialed:
Practitioners who do not need to be credentialed by CareMore or their delegated entity include
the following:

Practitioners who do not have an independent relationship with CareMore

Practice exclusively within the inpatient or facility setting and who provide care to plan
Members only as a result of Members being directed to the inpatient setting, such as:
o Pathologists
o Radiologists
o Anesthesiologist
o Neonatologists
o Emergency department physicians
o Hospitalists
o Other Intensive Care Specialists
o Telemedicine consultants

Practice exclusively within freestanding facilities and who provide care to plan Members only
as a result of Members being directed to the facility such as the following but not limited to:
o Mammography centers
o Urgent-care centers
o Surgicenters
o Ambulatory behavioral health care facilities
o Psychiatric and addiction disorder clinics
o Urgent Care Centers with exception of Arizona. Arizona we credential

Covering practitioners (i.e.: locum tenens)

Practitioners who have a hospital or facility as the primary place of service will be considered
out of scope.

Pharmacists – who work for pharmacy benefits management
Council for Affordable Quality Healthcare (CAQH)
CAQH is building the first national provider credentialing database system, which is designed to
eliminate the duplicate collection and updating of provider information for health plans,
hospitals and practitioners.
CareMore’s method for obtaining credentialing information is via Provider registration and
participation with the Council for Affordable Quality Healthcare (CAQH). CAQH allows
practitioners to do this via the following process:
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
Universal application for all states can are completed and maintained online by the
practitioner

All documents are uploaded online through the secure CAQH website at:
https://upd.caqh.org/das/
CAQH is mandated in all states with the exception of California and Nevada. Providers in
California can contact their local Regional Performance Manager (RPM) to obtain the most
current California Participating Application.
Health Delivery Organizations (HDOs)
New HDO applicants will submit a standardized application for review.
In Scope Health Delivery Organizational Providers
CareMore credentials and recredentials all accredited Health Delivery Organizational
providers who desire to become a participating provider.
The following provider types must successfully complete the credentialing process in
order to join the CareMore network:
The following Health Delivery Organizational provider types must successfully complete
the credentialing process in order to join the CareMore network:














Hospital
Home Health Care Agencies
Skilled Nursing Facilities
Free Standing Surgical Centers/Ambulatory Surgical Centers
Laboratories
Comprehensive Outpatient Rehabilitation Facilities
Outpatient Physical Therapy and Speech Pathology Providers
Dialysis Centers & End Stage Renal Dialysis (Free Standing)
Behavioral Health/Substance Abuse Facilities (Inpatient, Residential & Ambulatory)
Portable X-ray Suppliers
Hospice
Outpatient Diabetics self-management training providers
Rural Health Clinics
Federally qualified health centers
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Initial Credentialing
Credentialing will verify those elements related to an applicants’ legal authority to practice,
relevant training, experience and competency from the primary source, where applicable, during
the credentialing process.
The Credentialing Department will obtain and review verification of the following from the
application and the corresponding attestation within the 180 day period prior to presentation to
the Credentialing Committee:
During the credentialing process, verifications of the credentialing data as described in the
following tables unless otherwise required by regulatory or accrediting bodies will be review.
These tables represent minimum requirements.
Provider Verification Elements
Health Care Organizations Verification Elements
License to practice in the state(s) in which the practitioner
will be treating Covered Individuals.
Accreditation, if applicable
Hospital admitting privileges at a TJC, NIAHO or AOA
accredited hospital, or a Network hospital previously
approved by the committee
License to practice, if applicable
Malpractice insurance
Malpractice insurance (General and Professional
Insurance)
Malpractice claims history
Medicare certification, if applicable
Board certification or highest level of medical training or
education
Department of Health Survey Results or recognized
accrediting organization certification
Work history
License sanctions or limitations, if applicable
State or Federal license sanctions or limitations
Medicare, Medicaid or FEHBP sanctions
Medicare, Medicaid or FEHBP sanctions
National Practitioner Data Bank report
A Facility Site Review and Medical Records Review where
applicable will be completed.
Please note: The above does not apply to PCPS as they do not require hospital privileges.
Coverage is provided by CareMore Hospitalists.
Behavioral Health Provider Credentialing
CareMore contracted behavioral health vendor is Beacon Health Services. For any credentialing
questions or guidelines, please contact Beacon at 1-855-371-8092.
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Long-Term Care Provider Credentialing
CareMore obtains, verifies and assesses the qualifications of LTSS and HCBS providers that
provide healthcare services to Members and are recognized as health care providers by the state
licensing agency or similar state agency. Credentialing and reassessment of Providers is
conducted in accordance with local, state and federal regulations, CMS and accreditation
requirements.
The credentialing process is intended to facilitate Credentialing Committee review decisions for
medical, behavioral, and other ancillary support providers. Non-traditional, non-medical based
Providers do not require Credentialing Committee oversight, unless otherwise required by
contract.
The following provider types are categorized as LTSS and HCBS providers. These provider types
must be reviewed by the health plan and require initial credentialing and reassessment within
three years of the previous decision, unless otherwise required by the state.
1. Adult Day Care
2. Adult Day Health
3. Adult Family Care Homes
4. Assisted Living Facilities Services (ALF)
5. Case Management Agency
6. Pediatric Day Health
7. Personal Emergency Response Services (PERS)
8. Home Delivered Meals
9. Home Modification/Repair (Environmental Modification)
10. Homemaker Services for Adults
11. Nursing Facility (NF)
12. Nursing Registry
13. Personal Care Services
14. Pest Control
15. Transitional Living Services (TLS)
Note: Provider types listed above must maintain current licensure, certification or registration
and adhere to local state and federal regulations, CMS and accreditation requirements within
California.
The following steps are included in our organizational provider credentialing process:

Confirmation that the provider is in good standing with local, state and federal regulatory
bodies, as applicable;
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Confirmation that the provider has been reviewed and approved by an accrediting body,
or,

As applicable, an onsite quality assessment will be conducted if the organization is nonaccredited, unless the organization meets one of the following conditions:
o Organizational provider may submit a CMS or state review in lieu of the required site
visit.
o Non-accredited organizational providers who reside in a rural area as defined by the
U.S. Census Bureau and have not received a CMS or state agency survey do not
require a health plan onsite assessment.
o Confirmation of the rural designation as outlined by the U.S. Department of Health
and Human Services (HRSA) is reviewed and documented within the Provider’s file to
demonstrate compliance.
Organizational providers meeting CareMore requirements are reviewed in accordance with state,
federal and accreditation guidelines. Incomplete file submissions are placed in an administrative
suspended status when information is missing, incorrect and/or unreadable or expired. Unclean
files are presented to the Credentialing Committee for review and decision.
CareMore’s selection and retention criteria are designated to avoid discrimination against a
provider solely on the basis of license or certification, due to the fact that the provider services
high-risk populations and/or specializes in costly conditions.
Reassessment of LTSS providers shall occur at least every three years following initial
credentialing to confirm they are maintaining their credentials and health plan standards.
Organizational Providers shall maintain compliance with all health plan credentialing and
reassessment standards as a condition of participation--initial and ongoing. Failure to do so may
be grounds for termination.
Requirements for an LTSS provider submission for initial credentialing and reassessment to be
considered complete include:
1. Provider is in good standing with state and federal regulatory bodies and is reviewed and
approved by an accrediting body, as applicable; copy of current, unrestricted state
license, certification or registration, or confirmation with the licensing entity is required.
2. Evidence or attestation of professional liability and commercial general liability insurance
in adequate amounts as specified by the health plan. Organizational providers must
provide evidence (certificate) for Federal Tort coverage letter indicating the required
amounts and listing the business name on the certificate;
3. Evidence of current accreditation status, when applicable;
4. Medicare and/or Medicaid certified, when applicable;
5. Any documentation necessary to establish that credentialing/reassessment standards are
met;
6. Any documentation necessary to waive accreditation criteria are met;
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7. Additional credentialing requirements as outlined in Amendments to this policy;
8. Absence of federal Medicare and Medicaid sanctions, exclusions or debarment from
participating in federal health care programs. Absence of State Medicaid sanctions,
exclusions or debarment from participating in State health care programs.
9. Disclosure of Ownership - Applicants must submit Disclosure of Ownership and Control
Interest Statement in accordance with Federal Regulations 42 C.F.R. §455. A full and
accurate disclosure of ownership and financial interest is required. Direct or indirect
ownership interest must be reported if it equates to an ownership interest of five percent
or more in the disclosing entity.
The Credentialing Committee may approve, deny, or request further information. At the time the
Committee makes its final decision on an application, all primary source verifications and the
signed Attestation must comply with required time frames.
In the event that a Provider’s application and/or attachments are incomplete or inaccurate the
applicant remains responsible for the completion of the application or correcting inaccuracies.
The Credentialing Committee will give the applicant 30 days to provide the information. If the
information is not received within 30 days, the application will be deemed withdrawn.
All credentialing decisions are conducted in a non-discriminatory manner.
Recredentialing
Recredentialing will be performed at a maximum of every 36 months.
During the recredentialing process, Credentialing will review verifications of the credentialing
data as described in the tables under the Initial Credentialing unless otherwise required by
regulatory or accrediting bodies. These tables represent minimum requirement.
At the time of recredentialing CareMore or its designee shall consider findings from quality
improvement monitoring, Member complaints and grievances, and Member satisfaction results.
Failure to Return Recredentialing Application
The Credentialing Department will send a certified notice to the applicant, notifying them of a
“final notice” to return the required documents. If the required documents are not received
within the next 30 days, the practitioner will be withdrawn or terminated.
Providers Responsibilities & Rights during Credentialing/Recredentialing
During the credentialing/recredentialing process, the provider will be given, but may not be
limited to, the following rights:

Via written request, the provider may review the information they have submitted, or that
the Credentialing Department has obtained through their direct source verification, in
support of their application.

The provider has the right to be notified by the Credentialing Department if any information
obtained during the credentialing process varies substantially from the information originally
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submitted. The provider shall have 10 business days to respond to the Department’s
notification. This is to ensure the timely continuation of the application process. All
correspondence will be kept in the provider’s application file.

The provider shall be notified by mail of any erroneous information submitted by another
party, and has the right to correct that information. The provider has 10 business days to
correct any erroneous information and submit corrections to the Department manager in
writing. All corrections received from the provider will be kept in the provider folder and
tracked in the credentialing system.

The provider has the right, upon request, to be informed of the status of their applications.
Requests can be made either in writing, email or verbally by contacting the Credentialing
Department. The Credentialing Department will return the information to the provider in the
same manner (in writing or verbally). They will share the following information:
o Missing or incomplete application information
o Primary source verifications that have been obtained
o Date the provider can expect they will go to committee

The Credentialing Department is not required to share information concerning references or
recommendations, or other information that is peer-review protected.
Practitioners and Providers will be notified of these rights at the time of completing the
credentialing or recredentialing application
Provider Rights to Review Credentialing Information
In the event that credentialing information obtained from other sources varies substantially from
that attested to by the Provider and the discrepancy effects or is likely to adversely affect the
credentialing or reassessment decision, CareMore will notify the Provider of the discrepancy. The
Provider has the right to review information provided in support of their application and to
correct erroneous information.
Applicants are notified by telephone or in writing of specific occurrences of discrepant
information when such discrepancies are determined by the CareMore Medical Director, his/her
designee or CareMore Credentialing Committee to adversely affect the Credentialing decision;
Examples of other sources of information for organizational providers include:
•
Professional or general liability history;
•
History of license reprimands;
•
Suspension of Medicare or Medicaid certification;
•
Accreditation status.
In such cases, the Provider has thirty calendar days to comment and correct erroneous
information. No final credentialing determination will be made until the applicant has responded
or the time has elapsed.
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All provider files and records are considered confidential and are stored in a secure environment.
Provider information is updated by CareMore’s Terms & Conditions Department (T&C) team who
loads and/or updates Provider’s billing and demographic information;
Appropriate credentialing tracking systems are updated to reflect the decision and indicate the
Provider’s participation status.
Please note: As a Provider, you must maintain professional and general liability insurance in
specified amounts in accordance with your CareMore contract.
Reporting Requirement
When Caremore takes a professional review action with respect to a practitioner’s or HDO’s
participation in one or more Network, CareMore may have an obligation to report such to the
NPDB and/or Healthcare Integrity and Protection Data Bank (“HIPDB”). Once credentialing
receives a verification of the NPDB report, the verification report will be sent to the state
licensing board. The credentialing staff will comply with all state and federal regulations in regard
to the reporting of adverse determinations relating to professional conduct and competence.
These reports will be made to the appropriate, legally designated agencies. In the event that the
procedures set forth for reporting reportable adverse actions conflict with the process set forth
in the current NPDB Guidebook and the HIPDB Guidebook, the process set forth in the NPDB
Guidebook and the HIPDB Guidebook will govern.
Groups Delegated for Credentialing
Delegated Groups are required to follow the National Committee for Quality Assurance (NCQA)
guidelines. Oversight as well as annual Credentialing delegation audits will be conducted by
Anthem on behalf of CareMore. Each delegated groups will be assigned a Anthem auditor. If a
group holds an existing delegation agreement with CareMore, the designated auditor will also
serve as you representative for CareMore and will be your point of contact for any questions
regarding the delegation process.
Delegated groups are required to submit quarterly updates to CareMore. Only updates for those
practitioners who are participating under our contractual arrangement should be submitted.
Required data elements for quarterly updates are as follows:

Practitioner Roster to include:
o Name
o Professional degree / Title
o Specialty
o Primary Care Provider or Specialists designation
o State license number
o Board certification status and specialty
o Credentialing/recredentialing approval date
o Date and reason for suspension/termination/resignation
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Total number of initial credentialing for Primary Care Physicians (PCPs) and Specialists
(SCPs)

Total number of recredentialing for Primary Care Physicians (PCPs) and Specialists (SCPs)

Total number of suspensions for Primary Care Physicians (PCPs) and Specialists (SCPs)

Total number of terminations/resignations for Primary Care Physicians (PCPs) and
Specialists (SCPs)
Quarterly Submission and completed Submission Form should be submitted via email to:
Email: [email protected] and [email protected]
Facility Site Reviews
All Primary Care Physicians participating in Cal MediConnect are required to successfully
complete a Facility Site Review (FSR) audit and the Medical Record Review (MRR) survey in
accordance with California Medi-Cal Managed Care Division (MMCD) survey criteria and scoring
as outlined under Policy Letter 02-02 to ensure practitioners have the capacity to:

Provide appropriate primary health care services

Are accessible to provide care to seniors and persons with disabilities

Carry out processes that support continuity and coordination of care

Maintain patient safety standards and practices

Operate in compliance with all applicable federal, state and local laws and regulations
Any deficiencies identified as part of the FSR and MMR process, along with actions needed to
address the deficiencies will be documented in a corrective action plan. Providers will be
required to close any outstanding correction action plans to ensure participation status in Cal
MediConnect.
After completing the initial FSR and MMR, practitioners are subject to subsequent site
inspections every three years unless issues are encountered which require them to occur with
more frequency.
Because an FSR is site/location specific, in the event a practitioner moves from an approved site
to a new site which has not been reviewed, a new FSR and MRR must be completed for the new
location.
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CHAPTER 16: MEMBER RIGHTS AND RESPONSIBILITIES
Member Rights and Responsibilities
CareMore Health Plan (CareMore) communicates to Members what their rights and
responsibilities are when attempting to access care or are in the act of obtaining health care
services. These rights and responsibilities are for all Members, regardless of race, sex, culture,
economic, educational or religious backgrounds.
When a Member exercises his or her right to receive more information in regard to their “Rights
and Responsibilities,” their first point of reference should be their CareMore Cal MediConnect
Member Handbook. A second point of contact for the Member is Member Services Department
at 1-562-677-3554 (Toll free: 1-888-350-3447). CareMore requires that the Member Rights and
Responsibilities be posted in all Provider offices.
Our Members should be clearly informed about their rights and responsibilities so that they may
make the best health care decisions. That includes the right to ask questions about the way we
conduct business, as well as the responsibility to learn about their health care plan.
The following are our Members' rights and responsibilities as stated in the Member Handbook.
Our Members have the right to:

Get the information they need in order to get the most from their health plan and share their
feedback. This includes information on:
o Our company and services
o Our network of doctors and other health care Providers

Know their rights and responsibilities.

Receive notification of their rights and protections in a manner appropriate to their
condition, individual communication style, and ability to understand.

Have access to their medical records as state and federal laws allow.

Speak freely and privately with their doctors and other health Providers about all health care
options and treatment needed for their condition, regardless of cost or whether the
treatment is covered under their plan.

Get written information in alternative formats (including audio, large print or Braille) at no
cost upon request and in a timely way that is correct for the requested format.

Get Member materials in a language other than English at no cost to the Member.

To be treated with respect, and with regard for their dignity and privacy.

Expect us to keep private their personal health information. This is as long as it follows state
and federal laws and our privacy policies.

Be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation.
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
Be in charge of their health care.

Choose their Primary Care Physician (PCP).

Refuse care from their PCP or other caregivers.

Work with their doctors in making choices about their health care.

Do what they think is best for their health without hindrance. Members may make health
decisions without fear of coercion or retaliation from their doctor or health plan.

Receive a second opinion from another CareMore Health Plan contracted or subcontracted
physician.

Receive reasonable and timely responses to requests for services including evaluation and
referrals.

Be informed of the continuing health care requirements following discharge from a hospital
or office.

Never pay more than his/her cost-sharing or copayment amount, if the member is
responsible for cost-sharing or copayments.

Make an Advance Directive, also known as a "living will."

Get a range of covered services.

Get family planning services.

Be treated for Sexually Transmitted Infections (STIs).

Get emergency care outside of the CareMore network, as federal law allows.

Get health care from a Federally Qualified Health Center.

Get health care at an Indian Health Center.

Get free interpreter services, including sign language.

Tell us how they would like to change this health plan.

Make a complaint or file an appeal about:
o Their health plan
o Any care they receive
o Any covered service or benefit ruling that their health plan makes

Ask the Department of Social Services (DSS) for a State Fair Hearing.

Ask the California Department of Managed Health Care (DMHC) for an Independent Medical
Review.

Choose to leave this health plan.
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Members have the responsibility to:

Give their doctors and other health care Providers the information needed so that the
Member may get the best possible care as well as all the benefits to which they are entitled.

Understand their health problems as well as they can and work with their doctors or other
health care Providers to make a treatment plan that all parties can agree upon.

Follow the care plan that they have agreed on with their doctors and other health care
Providers.

Use the right sources of care.

Bring their health plan ID card when they visit their doctor.

Tell us if they move

Treat doctors and other caregivers with respect.

Understand this health plan.

Know and follow the rules of this health plan.

Know that laws govern this health plan and the types of service they get.

Pay any applicable co-insurance, co-payment, deductible, co-insurance, or charge for noncovered services.

Carry their current membership identification card with them at all times.

Schedule or reschedule appointments and inform their physician when it’s necessary to
cancel an appointment.

Know that we cannot discriminate against them because of their age, sex, race, national
origin, culture, language needs, sexual orientation or health.
The complete list of Member rights and responsibilities is available in the Member Handbook.
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CHAPTER 17: MEMBER GRIEVANCE AND APPEALS
Member Grievances
The Member Services Department is designed to assist Members in obtaining health services
according to their needs. If a Member has a complaint regarding CareMore Health Plan
(CareMore) or any of its contracted Providers, the Member may contact Member Services at
1-562-677-3554 (Toll free: 1-888-350-3447). Member complaints are documented, forwarded to
the appropriate department for resolution and kept on file.
CareMore Health Plan Members may file a formal grievance directly with Member Services at the
number listed above.
Members may contact the Department of Managed Health Care (DMHC) to request a grievance
or appeal at any time. The DMHC has a toll-tree telephone number (1-888-HMO-2219) and a
TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web
site is http://www.hmohelp.ca.gov.
Member Grievances: Filing a Grievance
To help ensure that our Members' rights are protected, all CareMore Members are entitled to a
grievance and appeals process. If a Member wants to file a grievance, they can do so in one of
three ways:

Call Member Services at 1-562-677-3554 (Toll free: 1-888-350-3447), or

Write a letter and send it to the Appeals and Grievances Department via fax or mail to the
address listed below, or

Send the complaint form to the Appeals and Grievances Department.
The Member does not need to be the one to file a grievance or appeal. Other representatives
include the following:

Relative

Guardian

Conservator

Attorney

Member's Provider
The Member’s designated representative must provide an Appointment of Representative (AOR)
or Power of Attorney (POA), signed by the Member or the Member must provide their verbal
consent before their designated representative may proceed with the grievance. AOR or POA is
not required for Member’s provider when filing an appeal on behalf of the member.
The grievance submission must include the following information:

Who is part of the grievance
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What happened

When it happened

Where it happened

Why the Member was not happy with the health care services

Attached documents that will help us look into the problem
The grievance documents should be mailed, faxed, or delivered to:
ATTN: Appeals and Grievances Department
12900 Park Plaza Drive Ste. 150
Mail Stop 6150
Cerritos, CA 90703
Fax: 888-426-5087 or 562-741-4114
If the Member cannot mail the documents, we will assist the Member by documenting a verbal
request.
Please note: If the Member’s grievance is related to a decision already made by CareMore, such
as the denial or limited authorization of a requested service, including the type or level of
service, the grievance is considered an appeal.
Actions may include the following:

Denial or limited authorization of a requested service, including the type or level of
service

The reduction, suspension or termination of a previously authorized service

The denial, in whole or in part, of payment for service

Failure to provide services in a timely manner, as defined by the State

Failure of CareMore to act within required timeframes
Timelines for the Member Grievance and Appeal Process:
Cal MediConnect enrollees, their authorized representatives, and Providers may file appeals and
grievances under the Medicare rules or under the Medi-Cal rules. Grievances and appeals will be
processed under either of these pathways based on whether the grievance relates to a Medicare
or Medi-Cal covered service or provider. However, an individual with an overlapping health issue
(including Home Health, Durable Medical Equipment and skilled therapies, but excluding Part D)
will retain his/her right to a State Fair Hearing regardless of the designated Medicare or Medi-Cal
pathway. Please Note: CareMore will resolve grievances and/or appeals at no cost to the
Member.
The chart below provides the timeframes for a member, member’s provider, or authorized
representative to request an appeal or grievance.
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Type of
Action
Medicare
Part C
Cal MediConnect
Medicare
Part D
Medi-Cal
Member
Grievance
180 calendar days after
the date of the incident
that gave rise to the
grievance
the date of the incident
that gave rise to the
grievance
180 calendar days after the
date of the incident that
gave rise to the grievance
Member
Appeal
date of the Notice of
Action letter notifying the
Member of a denial,
deferral or modification
of a request for services
the date of the denial,
deferral or
modification of a
request for services
date of the Notice of Action
letter notifying the Member
of a denial, deferral or
modification of a request for
services
Member Grievances and Appeals: Acknowledgement
The following applies to Part C Medicare and Medi-Cal grievances and appeals:
We will send an acknowledgement letter within five calendar days from the date we receive the
grievance or appeal. If we receive a request for an expedited grievance or appeal, the medical
director will review the request to determine if the request involves an imminent and/or serious
threat to the health of the Member. This may include, but is not limited to, severe pain, and
potential loss of life, limb or major bodily function. This determination is made within 24 hours of
the receipt of the expedited request.
The following applies to Medicare and Medi-Cal expedited appeals and certain expedited
grievances.
If the Medical Director determines a request involves medical care or treatment, for which the
application of the standard time period is appropriate, the Appeals and Grievance (A&G)
Coordinator immediately notifies the Member by telephone, if possible, of the determination. In
addition, the A&G Coordinator immediately sends notification to the Member which indicates
the receipt of the expedited request, the date of the receipt, and notification that the request
was reviewed for urgency but will be handled as a standard grievance or appeal.
If the Medical Director determines the request is for medical care or treatment in which the
application of the time period for making a standard determination would be detrimental to the
Member, the A&G Coordinator immediately notifies the Member by telephone, if possible, that
the request was received.
Member Grievances: Resolution
CareMore will investigate the Member’s grievance to develop a resolution. This investigation
includes the following steps:
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
The grievance will be reviewed by appropriate staff and, if necessary, the Medical Director.

CareMore may request medical records or an explanation from the Provider(s) involved in
the case.

CareMore will notify Providers of the need for additional information either by phone, mail or
fax.

Providers are expected to comply with requests for additional information within seven
calendar days for standard grievances and appeals, and within 24 hours for an expedited
grievance or appeal.
The Member will receive a Grievance Resolution letter within 30 calendar days of the date we
receive the grievance.
Member Appeals
Appeals are divided into two categories: standard appeals and expedited appeals.
**Standard appeals: Standard appeals are the appropriate process when a Member or
his/her representative requests that CareMore reconsider the denial of a service or payment
for services, in whole or in part.
**Expedited appeals: Expedited appeals are the appropriate process when the amount of
time necessary to participate in a standard appeal process could jeopardize the Member’s
life, health or the ability to maintain or regain maximum function.
Member Appeals: Standard Appeals
Members may send their appeal in writing or call Member Services at 1-562-677-3554 (Toll free:
1-888-350-3447) for assistance with filing an appeal.
Member Appeals: Response to Standard Appeals
CareMore may request medical records or a Provider explanation of the issues raised in a
standard appeal by the following means:

By Phone

By Fax

By Mail
Providers are expected to comply with the request for additional information within seven
calendar days.
Member Appeals: Resolution of Standard Appeals
Standard pre-service Medicare Part C and Medi-Cal pre and post-service appeals are resolved
within 30 calendar days from the date of receipt of the initial written or oral request. Standard
payment Medicare Part C are resolved within 60 calendar days. Standard Medicare Part D pre
and post service appeals are resolved within 7 calendar days from the date of receipt of the
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written or oral request. Members are notified in writing of the appeal resolution, including their
right to further appeal, if any. An additional 14 calendar days may be granted when certain
circumstances are met for Medicare services (see 42 CFR 438.40 (c)).
Member Appeals: Expedited
Members may request an expedited appeal by calling Member Services at the numbers listed
above under Member Appeals: Standard Appeals.
If CareMore denies a request for an expedited appeal, CareMore must:

Transfer the appeal to the time frame for standard resolution.

Make a reasonable effort to give the Member prompt oral notice of the denial, and follow up
within three calendar days with a written notice.
If CareMore approves a request for an expedited appeal, CareMore must:

Complete the expedited appeal and give the Member (and the provider involved, as
appropriate) notice of its appeal as expeditiously as the enrollee’s health condition requires,
but no later than 72 hours after receiving the request.
Member Appeals: Response to Expedited Appeals
CareMore may request medical records or a Provider explanation of the issues raised in an
expedited appeal by the following means:

By Phone

By Fax

By Mail
Providers are expected to comply with the request for additional information within the
requested timeframe.
Member Appeals: Resolution of Expedited Appeals
CareMore resolves expedited appeals as quickly as possible and within 72 hours. The Member is
notified by telephone of the resolution, if possible, and with a written resolution letter within 72
hours from the receipt of the appeal request.
Member Appeals: Other Options for Filing Grievances
If a Member exhausts CareMore’s grievance or appeal process and is still dissatisfied with a
decision, the Member may have the right to request one or more of the following reviews.
Office of the Ombudsman
Medi-Cal Managed Care Office of the Ombudsman at the California Department of Health Care
Services: Applies to grievances and appeals related to a Medi-Cal covered service or provider.
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Phone: 1-888-452-8609
Email: [email protected]
Medi-Cal Member Appeals & Grievances: State Fair Hearing
Members with Medi-Cal-related grievances and appeals may request a State Fair Hearing at any
time during the grievance process. Additionally, Members who have overlapping health issues,
such as Home Health, DME, and skilled therapies (but excluding Medicare Part D) may also
request a State Fair Hearing regardless of the designated Medicare or Medi-Cal pathway of the
original grievance or appeal.
Members may request a State Fair Hearing with the California Department of Social
Services (CDSS) at any point prior to, during, or after exhausting CareMore’s grievance or appeal
processes. For grievances not related to a Notice of Action, Members must file a request for a
State Fair Hearing within 90 days from the date the incident or action occurred which caused the
Member to be dissatisfied. However, an Independent Medical Review (IMR) with the Department
of Managed Health Care (DMHC) may not be requested if a State Fair Hearing has already
occurred for a Notice of Action. The request may be submitted by writing to the State of
California at:
Department of Social Services
State Hearing Division
P.O. Box 944243, MS9-17-37
Sacramento, CA 94244-2430
Or by calling the Department of Social Services toll free at 1-800-952-5253.
Once the state receives the Member’s request, the process is as follows:

The state sends a notice of the hearing request to CareMore.

Upon receipt of the request, all documents related to the request are forwarded to the state.

The state notifies all parties of the date, time and place of the hearing. Representatives from
our administrative, medical and legal departments may attend the hearing to present
testimony and arguments. Our representatives may cross-examine the witnesses and offer
rebutting evidence.

An Administrative Law Judge renders a decision in the hearing within 90 business days of the
date the hearing request was made.

If the judge overturns CareMore’s position, we must adhere to the judge’s decision and
ensure that it is carried out.
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Medi-Cal Member Appeals: Independent Medical Review
Independent Medical Review
Members may request an Independent Medical Review (IMR) from the California Department of
Managed Health Care (if eligible) or an expedited review of an urgent grievance or appeal. If the
Member has already had a State Fair Hearing he or she cannot also request an IMR. This option
applies to Medi-Cal related appeals only.
Department of Managed Health Care California Help Center
980 9th Street, Suite 500,
Sacramento, CA 95814-2725,
Phone: 1-888-466-2219 (TDD: 1-877-688-9891)
Fax: 1-916-255-5241
Medicare Member Appeals: Independent Review Entity
Members with Part D Medicare appeals may request a review by the Independent Review Entity.
Non-Part D Medicare appeals are automatically forwarded to the Independent Review Entity if
the health plan has maintained an adverse decision, in whole or in part. An Independent Review
Entity will do a careful review of the health plan’s decision, and decide whether it should be
changed.
 The Independent Review Entity is hired by Medicare and is not connected with
this plan.
 The member may ask for a copy of their file. We are allowed to charge the Member
a fee for copying and sending this information to the Member.
The Independent Review Entity must provide an answer to the member for Standard
Medicare Part C pre-service appeals within 30 calendar days of when it receives the
appeal. For Standard Medicare Part C post service appeals, the IRE must provide an
answer within 60 calendar days. The IRE must provide an answer to the member for
Standard Medicare Part D pre and post-service appeals within 7 calendar days. The IRE
must provide and answer for all expedited appeals within 72 hours. These rules apply if
the member sent the appeal before getting medical services or items.
Member Appeals: Confidentiality
All Grievances and Appeals are handled in a confidential manner and we do not discriminate
against a Member for filing a grievance, appeal, or requesting an Independent Review Entity (IRE)
review, Independent Medical Review (IMR), or a State Fair Hearing. We also notify Members of
the opportunity to receive information about our Grievances & Appeals process and that they
can request a translated version in a language other than English.
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Member Appeals: Discrimination
Members who contact us with an allegation of discrimination are immediately informed of the
right to file a Grievance. This also occurs when one of our representatives working with a
Member identifies a potential act of discrimination. The Member is advised to submit an oral or
written account of the incident and is assisted in doing so if he or she requests assistance.
We document, and track and trend all alleged acts of discrimination. The CareMore Appeals and
Grievance analyst may provide cultural and linguistic grievance data to a cultural and linguistic
specialist.
Member Appeals: Continuation of Benefits during an Appeal
Members may continue benefits while their appeal or State Fair Hearing is pending in accordance
with federal regulations.
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CHAPTER 18: MEMBER TRANSFERS AND DISENROLLMENT
Provider-Initiated Member Disenrollment
The CareMore Health Plan (CareMore) Member Services Department has developed a Policy and
Procedure for documenting the process of disenrolling Members from a physician practice.
Providers may not end a relationship with a Member because of the Member’s medical condition
or the cost and type of care that is required for treatment. Procedures for involuntary transfer or
disenrollment of Members are based on the Centers for Medicare & Medicaid Services (CMS)
requirements. While a Member may be disenrolled from a physician practice by CareMore in
accordance with established policy and procedures, a Member may not be disenrolled from
CareMore without the consent of CMS.
A PCP may submit a request to CareMore for a Member to be disenrolled under any of the
following circumstances:

Repeated (documented) abusive behavior by the Member

Physical assault to the Provider, office staff or another Member

Serious threats by the Member or by their family Member(s)

Disruption to medical group operations

Inappropriate use of out-of-network services

Inappropriate use of medical services

Inappropriate use of Medicare or Medi-Cal services

Non-compliance with prescribed treatment plan

The Member moves out of the CareMore service area.

The Member is temporarily absent from the CareMore service area for more than six
consecutive months
In situations where the Member is disruptive, abusive, unruly or uncooperative, CMS must
review any request for disenrollment from CareMore Health Plan. The CMS review (for most
situations) looks for evidence that the individual continued to behave inappropriately after being
counseled/warned about his or her behavior and that an opportunity was given to correct the
behavior. Counseling done by plan Providers is considered informal counseling and an initial
warning related to the Member’s behavior must be sent by CareMore to the member. CareMore
Health Plan requires documentation/records from the physician group prior to sending the
Member an official warning from the plan. If the inappropriate behavior was due to a medical
condition, CareMore Health Plan must demonstrate that the underlying medical condition was
controlled and was not the cause of the inappropriate behavior.
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CHAPTER 19: FRAUD, ABUSE AND WASTE
First Line of Defense against Fraud, Abuse and Waste
We are committed to protecting the integrity of our health care program and the efficiency of
our operations by preventing, detecting and investigating fraud, abuse and waste.
Combating fraud, abuse and waste begins with knowledge and awareness. CareMore defines
each as follows:

Fraud: Any type of intentional deception or misrepresentation made with the knowledge
that the deception could result in some unauthorized benefit to the person committing it -or any other person. The attempt itself is fraud, regardless of whether or not it is successful.

Abuse: Any practice inconsistent with sound fiscal, business or medical practices that results
in an unnecessary cost to the Medicare and/or Medicaid programs, including administrative
costs from acts that adversely affect Providers or Members.

Waste: Generally defined as activities involving careless, poor or inefficient billing or
treatment methods causing unnecessary expenses and/or mismanagement of resources.
Examples of Provider Fraud, Abuse and Waste
The following are examples of Provider fraud, abuse and waste:
•
•
•
•
•
•
•
•
•
•
Altering medical records
Billing for services not provided
Billing for medically unnecessary tests
Billing professional services performed by untrained personnel
Misrepresentation of diagnosis or services
Over-utilization
Soliciting, offering or receiving kickbacks or bribes
Unbundling
Under-utilization
Upcoding
Examples of Member Fraud, Abuse and Waste
The following are examples of Member fraud, abuse and waste:
•
•
•
•
•
Disruptive or threatening behavior
Frequent emergency room visits for non-emergent conditions
Forging, altering or selling prescriptions
Letting someone else use the Member’s Medi-Cal ID
Not telling the truth about the amount of money or resources the Member has in order to
get benefits
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•
•
•
•
•
•
•
Cal MediConnect
Not telling the truth about a medical condition to get medical treatment
Obtaining controlled substances from multiple Providers
Relocating to out-of-service area
Using more than one Provider to obtain similar treatments and/or medications
Using a Provider not approved by their PCP
Using someone else’s Medi-Cal ID
Violation of the Pain Management Contract**
**Pain Management Contract: A written agreement between a Provider and Member that
the Member will not misrepresent his or her need for medication. If the contract is violated,
the Provider has the right to drop the Member from his or her practice.
Reporting Provider or Recipient Fraud, Abuse or Waste
If you suspect either a Provider (doctor, dentist, counselor, medical supply company, etc.) or a
Member (a person who receives benefits) has committed fraud, abuse or waste, you have the
right and responsibility to report it.
CareMore Health Plan utilizes the Anthem Ethics & Compliance HelpLine. Therefore, all instances
of perceived fraud, waste or abuse affiliated with CareMore should be reported to the HelpLine
at the number listed below.
Providers can report allegations of fraud, abuse or waste by calling the Fraud Hotline at:
1-877-725-2702.
When reporting on a Provider (a doctor, dentist, counselor, medical supply company, etc.)
include:
•
•
•
•
•
•
•
Name, address, and phone number of Provider
Name and address of the facility (hospital, nursing home, home health agency, etc.)
Medicaid number of the Provider and facility, if you have it
Type of Provider (doctor, dentist, therapist, pharmacist, etc.)
Names and phone numbers of other witnesses who can help in the investigation
Dates of events
Summary of what happened
When reporting about a Member who receives benefits, include:
•
•
•
•
The person’s name
The person’s date of birth, Social Security number, or case number if you have it
The city where the person lives
Specific details about the fraud, abuse or waste
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Anonymous Reporting of Suspected Fraud, Abuse and Waste
Any incident of fraud, abuse or waste may be reported to us anonymously; however, we
encourage you to provide as much detailed information as possible, including:
•
•
The name of person reporting and their relationship to the person suspected
A call-back phone number for the person reporting the incident
Please Note: The name of the person reporting the incident and his or her callback number will
be kept in strict confidence by investigators to maintain that person's anonymity.
Investigation Process
We do not tolerate acts that adversely affect Providers or Members. We investigate all reports of
fraud, abuse and waste. Allegations and the investigative findings are reported to the California
Department of Health Care Services (DHCS), the Centers for Medicare and Medicaid Services
(CMS) and other regulatory and law enforcement agencies. In addition to reporting, we take
corrective action, such as:




Written warning and/or education: We send certified letters to the Provider or Member
documenting the issues and the need for improvement. Letters may include education or
request for recoveries, or may advise of further action.
Medical record audit: We may review medical records to substantiate allegations or validate
claims submissions.
Special claims review: A special claims review places payment or system edits on file to
prevent automatic claim payment; this requires a medical reviewer evaluation.
Recoveries: We recover overpayments directly from the Provider. Failure of the Provider to
return the overpayment may be reflected in reduced payment of future claims or further
legal action.
Acting on Investigative Findings
We refer all criminal activity conducted by a Member or Provider to the appropriate regulatory
and law enforcement agencies.
If a Provider has been convicted of committing, abuse or waste, or has been suspended from the
Medicaid program, the following steps may be taken:


The Provider may be referred to the Quality Management Department
The Provider may be presented to the credentialing committee and/or peer review
committee for disciplinary action, including Provider termination
Failure to comply with program policy, procedures or any violation of the contract will result in
termination from our plan.
If a Member has committed fraud, exhibited abusive or threatening behavior, or has failed to
correct issues, he or she may be involuntarily disenrolled from our health care plan with state
and CMS approval. (Refer to Chapter 18: Member Transfers & Disenrollment for more
information on disenrollment.)
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False Claims Act
We are committed to complying with all applicable federal and state laws, including the federal
False Claims Act (FCA).
The FCA is a federal law that allows the government to recover money stolen through fraud by
government contractors. Under the FCA, anyone who knowingly submits or causes another
person or entity to submit false claims for payment of government funds is liable for three times
the damages, or loss, to the government, plus civil penalties of $5,500 to $11,000 per false claim.
The FCA also contains Qui Tam or “whistleblower” provisions. A “whistleblower” is an individual
who reports in good faith an act of fraud or waste to the government, or files a lawsuit on behalf
of the government. Whistleblowers are protected from retaliation from their employer under
Qui Tam provisions in the FCA and may be entitled to a percentage of the funds recovered by the
government.
Health care fraud wastes hundreds of millions of dollars, threatens the health care system and
victimizes consumers. Your cooperation in reporting suspicious incidents to CareMore is greatly
appreciated. It is important that everyone be aware of possible fraud and abuse, and report any
incident as quickly as possible.
Whether it is an organized effort by a Provider, Member or any other individual to deliberately
cheat, or a health care Provider who occasionally bends the rules to serve the perceived needs of
a patient, health care fraud is a serious and growing problem. It exploits Members and robs them
of services and resources critical to their well-being.
By definition, fraud means that someone is trying to obtain something of value by intentionally
deceiving, misrepresenting, or concealing. Proof of fraud involves three elements:

Misrepresentation or concealment

Reliance by the carrier

Intent
You can help us stop this serious problem by educating yourself and reporting suspicious
incidents in writing to:
Office of Compliance
12900 Park Plaza Drive, Suite 150
Cerritos, CA 90703
You may also contact the CareMore Compliance Officer directly by telephone at 1-562-741-4552
or call the Fraud Hotline at 1-877-725-2702.
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Los Angeles County
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Cal MediConnect
Code of Conduct
CareMore has adopted the Anthem Code of Conduct which is made available upon request.
Providers should distribute or make the standards available to employees supporting CareMore
Medicare Part C or D functions.
Providers must review the DHHS OIG List of Excluded Individuals and Entities (LEIE list) and the
GSA Excluded Parties List System (EPLS) prior to the hiring of any employee supporting CareMore
Medicare Part C or D functions, and monthly thereafter to ensure individuals are not excluded
from participation in federal programs. Excluded individuals require immediate removal from
CareMore Medicare Programs Work. For the purposes specified in this section, providers must
agree to make available its premises, physical facilities and equipment, records relating to the
MA Organization’s members, including access to provider’s computer and electronic system and
any additional relevant information that CMS may require.
Providers acknowledge that failure to allow the Department of Health and Human Services, the
Comptroller General or their designees the right to timely access as addressed in this section may
result in a $15,000 non-compliance penalty.
Provider Manual
Los Angeles County
Version 1.0
CHAPTER 20: QUALITY MANAGEMENT
Quality Management Program
CareMore Health Plan (CareMore) has a Quality Management (QM) Program that defines
structures and processes and assigns responsibility to appropriate individuals. The mission of this
program is to:

Ensure continuous quality improvement; and

Provide for quality health care and optimal Member outcomes.
The purpose of this program is to provide an ongoing, integrated program committed to the
delivery of optimal care consistent with current medical science capability. The program is
designed to ensure that the responsibility to Members is fulfilled throughout the health care
delivery continuum.
The focus of the program is to demonstrate a consistent endeavor to deliver safe, effective and
optimal patient care and services in an environment of minimal risk. This focus includes
delivering activities that have both a direct and an indirect influence on the care and service
delivered to Members.
The QM Program’s activities are developed and approved, through the Quality Management
(QM) Committee, by the CareMore Board of Directors. The program is reviewed on an annual
basis and revised, when appropriate. All revisions are approved by the QM Committee and the
CareMore Board of Directors.
Goals and objectives include, but are not limited to:

The establishment, support, maintenance and documentation of improvement in quality of
care and service

The establishment of priorities for the improvement or resolution of known or potential
issues that impact directly or indirectly on care or services.

The maintenance of a consistently high level of quality of service, which meets and/or
exceeds the needs and expectations of the Member.

The measurement, assessment and improvement in processes and outcomes of care;

The coordinate of QM activities with other performance-monitoring and management
activities.

The coordination of the collection of objective, measurable data based on current knowledge
and clinical experience, to monitor and evaluate functions and dimensions of care.

The provision of data for practitioner/Provider performance appraisal through the
identification of trends and patterns of quality of care and service.

The compliance with requirements of federal, state and local regulatory and accreditation
entities.
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Los Angeles County
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Chapter 20: Quality Management
Cal MediConnect
Quality Management Committee
The CareMore Board of Directors has granted the QM Committee the authority to:

Develop and monitor the QM Program.

Oversee the activities to develop clinical criteria.

Serve as an expedited and standard appeals panel, if necessary.

Communicate with participating physicians, as necessary.
The QM Committee reports to the CareMore Board of Directors and presents a quarterly report
of all activities for approval. The Medical Director serves as the chairperson of the QM
Committee and presides over the meetings. In order to conduct a meeting, there must be at least
three physicians present. Minutes are maintained for the meeting and all discussions are
considered confidential.
The QM Committee is composed of:

Physician Members who serve a two-year term on the committee and are either primary care
physicians or specialists. There is also a panel of advisors, consisting of board certified
physicians in many specialty areas, (i.e., behavioral health) that is available to the Medical
Director for consultation, if needed.

Non-physician Members from Health Care Services, Pharmacy, Member Services, Provider
Relations and Risk Management/Compliance.
The QM Committee meets on a regularly scheduled basis, but no less than quarterly to:

Improve and assure the provision of quality patient care and services.

Develop and maintain the QM Program description, policies and procedures, work plan and
evaluation.

Develop and approve practice guidelines that are based on scientific evidence with quality
indicators to monitor Provider performance.

Analyze data to detect trends, patterns of performance or potential problems and implement
corrective action plans.

Review and resolve grievances related to quality of care and/or service.

Prioritize activities to ensure the greatest potential impact on care and service.

Recommend to the CareMore Board of Directors any actions for follow-up on identified
opportunities to improve.

Report findings of quality improvement activities for inclusion in practitioner/Provider
profiles.

Oversee and conduct Risk Management functions.

Oversee UM, Credentialing, and Delegation Oversight functions of Medical Groups
(MG)/Independent Physician Associations (IPAs)
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Chapter 20: Quality Management

Cal MediConnect
Review the scope, objectives organization and effectiveness of the QM Program at least
annually and revise as necessary.
The Health Care Services Department develops and the QM Committee approves a work plan for
the year, which outlines the program activities and corresponding time frames for progress and
completion dates. This work-plan, along with quarterly reports that focus on measuring progress
toward the goals, is then presented, along with the QM Program, to the CareMore Board of
Directors for review and approval.
On an annual basis, the QM Committee performs a retrospective evaluation of its activities to
measure the performance achievements and activities for the year. If goals and objectives are
not met, changes are recommended to the subsequent QM Program and work plan. This annual
evaluation is also presented to the CareMore Board of Directors for review and approval.
Provider Manual
Los Angeles County
Version 1.0
CHAPTER 21: CULTURAL AND LINGUISTIC SERVICES
Overview
CareMore Health Plan (CareMore) is dedicated to serving the needs of our Members and has
made arrangements to ensure that all Members have information about their health care
provided to them in a manner they can understand. CareMore provides a number of important
cultural and linguistic services at no cost to assist Members and Providers.
All CareMore contracted Providers (including LTSS, behavioral health staff, and pharmacists) are
required to comply with the National Culturally and Linguistically Appropriate Services Standards
(CLAS), Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA), and
Section 504 of the Rehabilitation Act of 1973, in the provision of covered services to Members.
Compliance with this provision includes:

Providing interpreters services for limited English proficiency (LEP) and/or Members with
a hearing or speech disability.

Actively discouraging the use of family members and children for interpretation.

Promoting the availability of interpreter service by posting signage in languages of
Members served and alternative formats.

Providing educational materials in the Member’s preferred written language or
alternative formats (Braille, large print and/or audio).

Providing adequate access to Members with disabilities.

Referring Members to multi-ethnic community-based services.
Written procedures are to be maintained by each provider office or facility regarding their
process for obtaining such services. Provision of such services must be documented in the
Member’s chart.
24-Hour Access to Interpreter Services
Contracted Providers are required to provide interpreter services at no cost to the Member.
When a CareMore Cal MediConnect Member needs interpreter services for health care services,
the provider should:

Verify the Member’s eligibility and medical benefits.

Inform the Member that interpreter services are available, including American Sign
Language (ASL) and tactile interpreting.

Document the language and service provided in the Member’s chart.
Interpreter services can be provided through different venues. These include:

Telephonic Interpretation Services - Providers may call Member Services at 1-562-6773554 (Toll free: 1-888-350-3447) to request assistance with interpreter services. The
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Chapter 21: Cultural and Linguistic Services
Cal MediConnect
Member and Provider are connected to our telephonic interpreter service vendor. To
communicate with Members who have a speech or hearing disability, the Provider
(TTY/TTD) California Relay Services at 711.

Face-to-face interpreters - If a Member requires face-to-face interpretation, including
ASL, the Provider may call Member Services at 1-562-677-3554 (Toll free: 1-888-3503447) to request assistance with locating interpreter services. These services should be
provided for scheduled medical visits, if needed, due to the complexity of information
exchange or if requested by the Member. When scheduling an appointment with a LEP
Member or a Member who has a hearing disability, please allow time, if possible, to
coordinate for a face-to-face interpreter. A 3-5 day request notice is recommended.

It is recommended that Providers use a face-to-face interpreter for certain complex
medical situations. These can range from the need to give complex instructions--such as
discharge instructions, how to inject insulin or use a glucometer--to discussing a terminal
prognosis, a critical healthcare issue or one requiring major lifestyle changes. Interpreter
services should be provided if a Member believes that his or her rights to equal access to
medical care, under Title VI or the ADA, will not be met without the services of a face-toface interpreter.

Competent bilingual staff – Providers may use qualified bilingual office staff to
communicate with LEP Members. Providers should keep documentation on how bilingual
office staff are assessed for language competency. A copy of a Language Proficiency
Assessment is posted in our provider portal.
Providers should never ask a family member, friend or minor to interpret. Use of a family
member or minor may pose issues for the family and it creates liability risk for the Provider when
information is not exchanged with LEP patient through a qualified interpreter. State and Federal
laws mandate that it is never permissible to turn a Member away or limit the services provided
to them because of language barriers. It is also never permitted to subject a Member to
unreasonable delays due to language barriers or provide services that are lower in quality than
those offered in English.
When language or ASL services are required by the Member at their assigned PCP or specialist
office, the office must contact the Member Services Department to request these services.
Facility Signage
Providers are required to post signs informing Members of the availability of interpreter services.
To request office signage, please go to Providers.caremore.com or you can contact your Regional
Performance Manager (RPM).
Materials in Other Languages and Alternative Formats
Providers are required to provide LEP and Members with visual impairments with materials in
the Member’s preferred written language or alternative formats (Braille, large print or audio).
Additionally, all Member materials must be written at the appropriate reading and/or grade
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Cal MediConnect
level. Providers may call the Member Services Department at 1-562-677-3554 (Toll free: 1-888350-3447) for assistance with locating materials that are:

Translated into other languages

In alternative formats, including large print, Braille or audio
Disability Access
All health care facilities – primary care, specialty care, behavioral health and diagnostic centers
(such as mammography facilities) must be accessible for persons with a physical disabilities.
Facilities are reviewed for accessibility and safety, including:

Accessible parking area and walkways

Accessibility into and throughout the facility

Restrooms and exam rooms are accessible to people with disabilities Waiting area has
adequate seating, lighting and space.
Providers are required to provide communications in alternative formats such as Braille, large
print, and/or audio for Members with visual impairments.
To facilitate communication with members with hearing impairments providers should access
the CA Relay Services for phone communications and sign language interpreters for in-person
encounters. Providers must ensure effective communication with persons with disabilities.
For more information and guidance to meet these requirements visit
http://www.ada.gov/.
Referrals to Multi-Ethnic Community-Based Services
Providers should keep a list of community resources for referrals to such agencies. To obtain a
list of additional community resources, please call Case Management at 1-888-291-1385.
Providers should document all referrals to community-based services in the Member’s medical
record.
Cultural Competency Trainings and Resources
Providers (including medical, LTSS, behavioral health staff, and pharmacists) are required to
participate in and cooperate with CareMore’s Provider education and training efforts. Providers
are also to comply with all, cultural and linguistic requirements, and disability standards as noted
above.
CareMore recognizes the challenges that may arise when Providers need to cross a cultural
divide to treat Members who may have a disability or who may have different behaviors,
attitudes and beliefs concerning health care. To assist Providers in meeting the needs of a diverse
patient population, inclusive of person with disabilities, CareMore makes available a variety of
cultural and linguistic (C&L) and disability resources and trainings for all contract Providers
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(including LTSS, behavioral health staff, and pharmacists). Trainings are offered through a variety
of venues including but not limited to:

Web-based Provider training programs

Provider Office trainings

Written communications
Training will include but not be limited to the following:

C&L requirements including disability (CLAS and ADA)

Health care disparities

Cultural influences in the Provider encounter (health literacy, past experiences with
health care, language, religious and family beliefs and customs, etc.)

Exploring the Provider-patient exchange

The availability of C&L resources, interpreter services, , translated materials and alternate
formats through the health plan

How to effectively and optimally engage persons with disabilities including:
o
o
o
o
o
Person-center planning and self-determination
Social Model of disability
Independent living philosophy
Recovery models
Self-determination

Special considerations for persons with mental health or behavioral health conditions

Use of evidence-based practices and specific levels of quality outcomes

Working with Members with mental health diagnosis, including crisis prevention and
treatment

Working with Members with substance use conditions, including diagnosis and treatment
Additional C&L resources are available through the provider portal. These include but are not
limited to:

Provider tool kits

Provider bulletins
Provider Manual
Los Angeles County
Version 1.0

cal mediconnect plan provider manual

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