National Vision Administrators, L.L.C. (NVA)

Transcription

National Vision Administrators, L.L.C.
(NVA)
Fidelis Senior Care
Vision
Provider Manual
1200 Route 46 West
Clifton, NJ 07013
1-888 830-5630
www.e-nva.com
This document contains proprietary and confidential information and
may not be disclosed to others without written permission.
Copyright 2015. All rights reserved.
NVA LLC
NVA Provider Manual Michigan
2
About Fidelis Senior Care and the Michigan MIHealth Link
Program
Welcome
National Vision Administrators (NVA) has entered into an agreement to provide services to
Fidelis Senior Care (FSC).
This manual is intended to serve as an extension of our provider agreement. It includes valuable
information to help you understand our program and provides helpful tips on how to work with
FSC members. It should be a valuable resource for you and your office staff.
About Fidelis Senior Care
Fidelis of Michigan, Inc. was founded in 2005, and began as a Medicare Advantage Special
Needs Plan for eligible individuals residing in nursing facilities. Since then they have expanded
their plans to cover Medicare and dual-eligible members who reside in their own homes, as well
as those in Group Homes and Adult Foster Care Homes.
Beginning in 2015, Fidelis will offer a Medicare-Medicaid Plan in accordance with the Michigan
Demonstration Program to Integrate Care for Persons Eligible for Medicare and Medicaid,
known as MI Health Link. Fidelis’ service area for MI Health Link includes Wayne and Macomb
counties. This Provider Manual contains updates to reflect the requirements of the MI Health
Link program.
Fidelis plans are available for individuals who desire a more focused coordination of care than
traditional Medicare can provide. Fidelis’ employed and contracted physicians and their
extenders, nurse practitioners and care managers provide a high quality of care while effectively
managing the medical and psychosocial needs of these frail members.
Fidelis firmly believes that the quality of life of our members can be significantly improved and
their rate of decline measurably reduced through clinically focused and consistently attentive
care. In concert with nursing staff, physician partners and a network of expert healthcare
professionals they strive daily to achieve improved health outcomes for every member served.
Vision
Fidelis is committed to achieving the highest level of care for our population, one that is
compassionate, person-centered, self-directed and focused on the needs of the whole person.
Mission
Fidelis plans to fundamentally improve the way healthcare is delivered to our most vulnerable
populations. It will do so by partnering with physicians to provide care in the most effective and
efficient clinical setting; by creating a person-centered model that coordinates services and
enables communication with all domains of the delivery system; by eliminating barriers to and
encouraging the use of home and community based services; and by providing high quality,
compassionate service focusing on member satisfaction.
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Model of Care
The Fidelis Model of Care uses a Care Center Model by an integrated care team approach which
offers beneficiaries a dedicated care coordinator to facilitate optimal improvement in individual
health outcomes and quality of life. The care coordinator ensures member voice in the care
planning process and orchestrates the interdisciplinary care integration with and on behalf of the
member/family and providers. The Care Coordinator is an anchor for the member ensuring that
all services and benefits are coordinated to maintain quality of life and independence in a
community setting.
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Provider Manual
Table of Contents
Section
Page
Important Address and Telephone Numbers .............................................................................. 6
Member Rights and Responsibilities ........................................................................................... 7
1.00
2.00
Patient Eligibility Verification Procedures................................................................................. 10
1.01
Plan Eligibility.................................................................................................................. 10
1.02
Member Identification Card ............................................................................................ 10
1.03
Eligibility System ............................................................................................................ 11
1.04
Self-Referral Benefit........................................................................................................ 11
Claim Submission Procedures (Claim Filing Options) ............................................................ 11
2.01
Electronic Claim Submission Utilizing NVA’s Internet Website ................................ 11
2.02
Paper Claim Submission ................................................................................................ 12
2.03
Coordination of Benefits (COB)..................................................................................... 13
2.04
Filing Limits ..................................................................................................................... 13
2.05
Receipt and Audit of Claims .......................................................................................... 13
3.00
Health Insurance Portability and Accountability Act (HIPAA)................................................. 13
4.00
Quality Improvement (QI) Program ............................................................................................ 14
5.00
Fraud, Waste, and Abuse (FWA) ................................................................................................ 14
6.00
Credentialing ................................................................................................................................ 15
7.0
Transfer of Medical/Service Records ......................................................................................... 16
8.00
Standards of Care – Routine Care .............................................................................................. 17
9.00
8.01
Examination Standards .................................................................................................. 17
8.02
The Patient Record ......................................................................................................... 18
Cook Children's Health Plan – Texas Utilization Management Section ................................. 19
9.01
10.00
Overview .......................................................................................................................... 19
Utilization Review Process ......................................................................................................... 21
Appendix A
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Attachments
General Definitions ........................................................................................................................A-1
Claim Form ....................................................................................................................................A-3
Claim Form Instruction ..................................................................................................................A-4
Prior Approval for Services – Routine Vision & Materials Form ...................................................A-5
Non-Covered Services Agreement Form Instructions ..................................................................A-6
Non-Covered Services Agreement Form .....................................................................................A-7
Laboratory Order Form ................................................................................................................A-8
Appendix B .............................................................................................................................................. B-1
Covered Benefits (See B-1 – B-3) ............................................................................................... B-1
Prior Approval .............................................................................................................................. B-1
B-1 Medicaid – Medicare Dual Eligible ........................................................................................ B-2
IMPORTANT ADDRESS AND TELEPHONE NUMBERS
Customer Service/Provider Services
National Vision Administrators, L.L.C.
P.O. Box 2187
Clifton, NJ 07015
888-723-6009
E-mail address for Provider Services Department:
(Use for change of address, telephone number or to add associate)
[email protected]
E-mail address for Prior Approvals (PA):
(Use to request PA for Medical Necessity with form attached)
[email protected]
E-mail address for Service Issues:
(Use to report service issues for yourself or on behalf of a patient)
[email protected]
Customer Service/Member Services – NVA
National Vision Administrators
P.O. Box 2187
Clifton, NJ 07015
888-723-6003
Credentialing
National Vision Administrators
P.O. Box 2187
Clifton, NJ 07015
Attn: Credentialing Department
888-723-6009
[email protected]
Paper - vision claims should be sent to:
NVA - Claims
P.O. Box 2187
Clifton, NJ 07015
TDD (Hearing Impaired)
888-820-2990
Fraud Hotline
888-328-0421
6
7
Member Rights and Responsibilities
Providers are responsible for observing all member rights. Fidelis members have the following rights:
•
The right to respect, fairness and dignity. This includes:
o The right to get covered services without concern about race, ethnicity, national origin, religion,
gender, age, to pay, or ability to speak English.
•
•
•
•
The right to request information in other formats (e.g., audio CD-ROM, large print, cassette, Braille).
The right to be free from any form of restraint or seclusion.
The right not to be billed by providers.
The right to get health care information. This includes information on treatment and treatment options.
This information should be on:
o
o
o
o
o
Description of the services we cover.
How to get services.
How much services will cost the enrollee.
Names of health care providers and care managers.
The right to make decisions about care, including refusing treatment. This includes the right:
To choose a Primary Care Provider (PCP) (including a specialist to act as a PCP) and to
change PCP at any time.
To see a woman’s health care provider without a referral.
To get covered services and drugs quickly.
To know about all treatment options, no matter what they cost or whether they are
covered.
To refuse treatment, even if the enrollee’s doctor advises against it
To stop taking medicine.
To ask for a second opinion. The Plan will pay for the cost of a second opinion visit.
The right to timely access to care that does not have any communication or physical
access barriers. This includes the right
In an Emergency
•
Members have the right to see an out of network urgent or emergency care provider, when necessary.
•
The right to confidentiality and privacy. This includes:
o The right to ask for and get a copy of the member’s medical records in a way that the member
can understand and to ask for his or her records to be changed or corrected.
o The right to have personal health information kept private.
o The right to make complaints about covered services or care. This includes the right to:
File a complaint or grievance against Fidelis or any of its providers.
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Ask for a state fair hearing.
Get a detailed reason for why services were denied.
The right not to be balance billed for any covered service. This includes:
The cost of any covered service, including any coinsurance, deductibles, financial
penalties, or any other amount in full or in part.
Fidelis members also have the following responsibilities:
•
•
•
•
•
•
•
•
•
•
•
To ask questions if they don’t understand their rights.
To select a primary care provider (PCP) from Fidelis’ provider directory.
To make any changes in their health plan and PCP in the ways established by the Medicaid/Medicare
programs offered by Fidelis.
To keep their scheduled appointments.
To have their ID cards with them.
To cancel appointments in advance when they can’t keep them.
If Fidelis is providing transportation to a medical appointment, to provide a car seat for any child if the child
is 4 years of age or younger, or if the child weighs less than 40 pounds.
To contact their PCP or Fidelis first for their non-emergency medical records.
To only go to the emergency room when they think it is an emergency.
Be sure they have approval from their PCP before going to a specialist except for self-referrals.
To share information relating to their health status with their PCP and become fully informed about services
and treatment options. That includes the responsibility to:
o Tell their PCP about their health.
o Talk to their providers about their healthcare needs and ask questions about different ways their
healthcare problems can be treated.
o Help your providers get your medical records.
o Actively participate in decisions relating to safe services and treatment options, make personal
choices, and take action to maintain their health. That includes the responsibility to:
o Work as a team with their provider in deciding what healthcare is best for them.
o Do the best they can to stay healthy.
o Treat providers and staff with respect.
Fidelis provides services to our enrollees because of a contract Fidelis has with the Michigan
Department of Medicaid and with the Center for Medicare & Medicaid Services (CMS).
•
•
•
•
Members can contact Fidelis to get any other information they want, including the structure and
operation of Fidelis and how we pay our providers.
To tell us about things we should change, please have the member call the Member Services Department
at 1-844-239-7387.
Members have the right to make recommendations about Fidelis per its Rights and Responsibilities
policies.
Members have the right to ask Fidelis about our reasons for the decisions we make about their
healthcare.
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At Fidelis, privacy is important. Fidelis will do all they can to protect members’ health records. By law,
they must protect member health records and send a Privacy Notice, which they send to all members in a
new member packet. The Privacy Notice tells members how they use their health records. It describes
when we can share their records with others. It explains their rights about the use of their health records.
It also tells members how to use those rights and who can see their health records. The notice does not
apply to information that does not identify our members. When we talk about health records in the
notice, it includes any information about members’ past, present or future physical or mental health
while they are a member of Fidelis. This includes providing health care while they are our member. If
you would like a copy of this Privacy Notice, please call Member Services.
1.00
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Patient Eligibility Verification Procedures
1.01
Plan Eligibility
Any person who is enrolled in a Plan’s program is eligible for benefits under the Plan.
1.02
Member Identification Card
Fidelis Senior Care (FSC) members receive identification cards from the Plan. Participating Providers
are responsible for verifying that Members are eligible at the time services are rendered and to determine
if recipients have other health insurance.
NVA recommends that each Vision office make a photocopy of the member’s identification card each
time treatment is provided. It is important to note that the health plan identification card is not dated and
it does not need to be returned to the health plan should a member lose eligibility. Therefore, an
identification card in itself does not guarantee that a person is currently enrolled in the health plan.
To be sure that a member is eligible for benefits at the time of service, you may verify eligibility
with NVA, either by utilizing the on-line system, or by telephone (see below).
1.03
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Eligibility System
The most convenient method of accessing eligibility is by utilizing NVA’s Vision interactive
website (www.e-nva.com). After logging in, you will have the opportunity to verify eligibility
for any member. Once verified, you will receive a control number, for any covered service
(routine services only) provided within thirty (30) days of the date of verification. This number
should be maintained as it will be required for future inquiry and to track claims payment.
Participating providers who do not have access to the internet may also access eligibility
information and receive control numbers by calling the Customer Service Department at 888723-6009.
When verifying eligibility, you will be provided with patient specific benefit information which
may include:
•
•
•
•
1.04
Examination Only
Materials Only
Examination and Materials
Copayments if applicable
Self-Referral Benefit
The vision examination benefit is available to covered members without the requirement for a
referral from the member’s Primary Care Provider (PCP), or specialist.
2.00
Claim Submission Procedures (Claim Filing Options)
NVA receives vision claims in two (2) possible formats. These formats include:
•
•
Electronic claims via NVA’s Provider website (www.e-nva.com).
Paper claims [CMS (HCFA) 1500 required].
Clean claims must be submitted and received by NVA within 180 days from the date of service and
must include your NVA Provider number and individual Provider’s NPI number. Claims received after
the 180-day filing limit will be denied. If it can be demonstrated that a claim denied for timely filing
could not have been submitted within 180, the claim may be resubmitted but in no case will a claim be
submitted for payment after 365 days, from the date of service.
2.01
Electronic Claim Submission Utilizing NVA’s Internet Website
Participating Providers may submit claims directly to NVA by utilizing NVA's Provider
Website. Submitting claims via the website is very quick and easy. It is especially easy if you
have already accessed the site to check a Member’s eligibility prior to providing the service and
received a control number (strongly recommended).
If you have not used the provider website before, you must register using your tax ID, zip code,
email address and suffix code (this is a 4-digit number that was provided to you in your welcome
letter). If you do not have the suffix code, you may contact the Provider Services department,
and a replacement will be provided.
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Once you have logged in using your user name and password, you may verify eligibility, obtain
authorizations, view your authorizations, place your lab order, and submit claims.
To submit a claim enter the patient’s ID#, or name and date of birth, or select the corresponding
authorization number. At this point, you will need to select the examining provider from the drop
down box. Enter all the applicable information, choose the appropriate CPT and ICD-9 codes,
and hit submit to submit the claim. You will receive a confirmation statement when the claim is
submitted.
If you have questions on submitting claims or accessing the website, please contact our
Provider Services Department at 888-830-5630 or [email protected].
2.02
Paper Claim Submission
•
NVA requires that a CMS (HCFA) 1500 Claim Form be used for submission of all paper
claims.
•
Member name and identification number must be listed on all claims submitted.
•
Member control number should be noted. Please place this number on line 10D of the form.
•
The patient’s date of birth must also be listed. If the member identification number is
missing or miscoded on the claim form, the patient cannot be identified. This could result in
the claim being returned to the submitting Provider office, causing a delay in payment.
•
The Provider and office location information must be clearly identified on the claim.
Frequently, if only the Provider signature is used for identification, the Provider’s name
cannot be clearly identified. Please include either a typed Provider (practice) name or the
NVA Provider identification number and provider specific NPI number.
•
The date of service must be provided on the claim form for each service line submitted.
•
Approved Vision codes (CPT and HCPCS), as contained in this agreement, must be used to
define all services.
•
Up to 4 ICD-9 codes (will change to ICD-10 as of October 1, 2015) may be submitted, and
all relevant codes should be included. Professional services without at least one ICD code
will be denied.
•
Affix the proper postage when mailing bulk documentation. NVA does not accept postage
due mail. This mail is returned to the sender and will result in delay of payment.
Paper claims for routine services should be mailed to the following address:
NVA - Claims
P.O. Box 2187
Clifton, NJ 07015
2.03
13
Coordination of Benefits (COB)
When NVA is the secondary insurance carrier, a copy of the primary carrier's Explanation of
Benefits (EOB) must be submitted with the claim. The payment made by the primary carrier
must be indicated in the appropriate COB field, on a CMS 1500 Form. When a primary carrier's
payment meets or exceeds a provider's contracted rate or fee schedule, NVA will consider the
claim paid in full and no further payment will be made on the claim. Examples of Coordination
of Benefits may include no fault insurance carriers and worker’s compensation claims. Only
paper (CMS-1500) claim forms may be utilized to report a claim with COB information.
2.04
Filing Limits
Any claim received beyond the timely filing limit of 180 days will be denied for "untimely
filing." If a claim is denied for "untimely filing", the provider cannot bill the member. If NVA
is the secondary carrier, the timely filing limit begins with the date of payment or denial from the
primary carrier. Claims that are initially denied for timely filing may be resubmitted within 60
additional days, if it can be demonstrated that they could not have been submitted within the 180
days.
2.05
Receipt and Audit of Claims
In order to ensure timely, accurate remittances to each participating Provider, NVA performs an
audit of all claims upon receipt. This audit validates Member eligibility, procedure codes and
provider identifying information. When potential problems are identified, your office may be
contacted and asked to assist in resolving the problem. Please contact our Provider Services
Department with any questions you may have regarding claim submission or your remittance.
3.00
Health Insurance Portability and Accountability Act (HIPAA)
As a healthcare provider, your office is required to comply with all aspects of the HIPAA regulations in
effect as indicated in the final publications of the various rules covered by HIPAA.
NVA has implemented various operational policies and procedures to ensure that it is compliant with the
Privacy, Administrative Simplification and Security Standards of HIIPAA. One aspect of our
compliance plan is working cooperatively with our providers to comply with the HIPAA regulations. In
relation to the Privacy Standards, NVA has previously modified its provider contracts to reflect the
appropriate HIPAA compliance language. These contractual updates include the following, in regard to
record handling and HIPAA requirements:
•
Maintenance of adequate vision/medical, financial and administrative records related to covered
services rendered by Provider in accordance with federal and state law.
•
Safeguarding of all information about Members according to applicable state and federal laws
and regulations. All material and information, in particular information relating to Members or
potential Members, which is provided to or obtained by or through a Provider, whether verbal,
written, tape, or otherwise, shall be reported as confidential information to the extent confidential
treatment is provided under state and federal laws.
4.00
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•
Neither NVA nor Provider shall share confidential information with a Member’s employer
absent the Member’s consent for such disclosure.
•
Provider agrees to comply with the requirements of the Health Insurance Portability and
Accountability Act (“HIPAA”) relating to the exchange of information and shall cooperate with
NVA in its efforts to ensure compliance with the privacy regulations promulgated under HIPAA
and other related privacy laws.
•
Provider and NVA agree to conduct their respective activities in accordance with the applicable
provisions of HIPAA and such implementing regulations.
•
In relation to the Administrative Simplification Standards, you will note that the benefit tables
included in this Provider Manual reflect the most current coding standards (CPT and HCPCS).
Effective the date of this manual, NVA will require providers to submit all claims with the
proper CPT or HCPCS codes listed in this manual. In addition, all paper claims must be
submitted on the current approved claim form. ICD-9 diagnosis codes must be provided (ICD-10
once mandated).
•
Note: Copies of NVA’s HIPAA policies are available upon request by contacting NVA’s
Provider Services Department at 888-723-6009, or via e-mail at [email protected].
Quality Improvement (QI) Program
NVA currently administers a Quality Improvement (QI) Program modeled after National Committee for
Quality Assurance (NCQA) standards. The NCQA standards are adhered to as the standards apply to
ancillary services. The Quality Improvement program includes:
•
•
•
•
•
•
•
•
Provider Credentialing and Re-credentialing.
Member Satisfaction Surveys.
Provider Satisfaction Surveys.
Random Chart Audits.
Member Complaint Monitoring and Trending.
Peer Review Process.
Site Reviews and Vision Record Reviews.
Quarterly Quality Indicator tracking (i.e., complaint rate, appointment waiting time, access to
care, etc.).
A copy of NVA’s QI Program is available, upon request, by contacting NVA’s Provider Services
Department at 888-723-6009 or via e-mail at [email protected].
5.00
Fraud, Waste, and Abuse (FWA)
Health care fraud costs taxpayers tens of billions of dollars every year. State and federal laws are
designed to crack down on these crimes and impose strict penalties. There are several stages to
addressing fraudulent acts, including detection, prevention, investigation, and reporting. In this section,
NVA provides information on how to help prevent participant and provider fraud by identifying the
different types.
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Many types of fraud, waste, and abuse have been identified, including:
•
Provider Fraud, Waste, and Abuse:
o Billing for services not rendered
o Billing for services that were not medically necessary
o Double billing
o Unbundling services
o Up coding services
Providers can prevent fraud, waste, and abuse by ensuring that services rendered are medically necessary,
accurately documented in the medical records, and billed according to NVA guidelines.
•
Participant Fraud, Waste, and Abuse:
o Benefit sharing
o Collusion
o Drug trafficking
o Forgery
o Illicit drug seeking
o Impersonation
o Misinformation/misrepresentation
o Subrogation/third-party liability fraud
o Transportation fraud
One of the most important steps to help prevent participant fraud is as simple as reviewing the participant's ID
card. NVA will not accept responsibility for the costs incurred by providers rendering services to a patient who
is not a current FSC participant, even if that patient presents a FSC participant ID card. Providers should take
measures to ensure the cardholder is the person named on the card and his or her participation in FSC is up-todate, by obtaining an authorization from NVA for the services.
Additionally, providers can assist in encouraging participants and their caregivers to protect their cards as they
would a credit card or cash, carry their participant ID card at all times, and report any lost or stolen cards as
soon as possible.
FSC encourages its participants, participants’ representatives, and providers to immediately report any
suspected instance of fraud, waste, and abuse. No individual who reports violations or suspected fraud, waste,
or abuse will be retaliated against, and FSC will make every effort to maintain anonymity and confidentiality.
You can contact NVA’s Fraud and Abuse Hotline at 888-328-0421.
6.00
Credentialing
NVA, in conjunction with the Plan, has the sole right to determine which Providers (O.D., M.D., D.O.,
or Opticians) it shall accept and continue as Participating Providers. Providers must be enrolled with
Medical Assistance and have a valid Medicaid number, or Medicaid ID, which shall be verified by
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NVA. The purpose of the credentialing plan is to provide a general guide for the acceptance, discipline
and termination of Participating Providers. NVA considers each Provider’s potential contribution to the
objective of providing effective and efficient Vision and Eye Care services to Members of the Plan.
NVA’s credentialing process adheres to National Committee of Quality Assurance (NCQA) guidelines
as the guidelines apply to ancillary services.
Nothing in this Credentialing Plan limits NVA’s sole discretion to accept and discipline Participating
Providers. No portion of this Credentialing Plan limits NVA’s right to permit restricted participation by
a vision office or NVA’s ability to terminate a Provider’s participation in accordance with the
Participating Provider’s written agreement, instead of this Credentialing Plan.
The Plan has the final decision-making power regarding network participation. NVA will notify the
Plan of all disciplinary actions enacted upon Participating Providers.
Appeal of Credentialing Committee Recommendations
If the Credentialing Committee recommends acceptance with restrictions or the denial of an application,
the Committee will offer the applicant an opportunity to appeal the recommendation.
The applicant must request a reconsideration/appeal in writing and the request must be received by NVA
within 30 days of the date the Committee gave notice of its decision to the applicant.
Discipline of Providers
NVA believes in and works hard to maintain positive professional relations with our provider network.
In rare instances, it may become necessary to discipline a provider up to and including termination from
the program. NVA maintains the right to take such action under the terms of the Provider Agreement
that all providers are required to sign prior to beginning participation.
Re-credentialing
Network Providers are re-credentialed at least every 36 months as required by the plan.
Note: The aforementioned policies are available upon request by contacting NVA’s Provider Services
Department at 888-723-6009 or via e-mail at [email protected].
7.0
Transfer of Medical/Service Records
Providers/Practitioners are responsible for making participant records available to health plans to which
participants are transferring and/or to other providers/practitioners, upon request, and in compliance with
FSC’s internal confidentiality requirements as well as HIPAA/HITECH. At a minimum, providers are
requested to transmit medical/service records related to current diagnostic tests and determinations,
current treatment services, immunizations, recent hospitalizations (within the past year) with concurrent
review data and discharge summaries (if data and summaries available), current medications list, recent
specialist referrals, and emergency care.
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FSC will facilitate the transfer of pertinent medical/service records (as needed) and will transfer other
requested records that exceed the requirements of the policy if so directed or required.
Receiving providers/practitioners may request records directly from the relinquishing
provider/practitioner.
8.00
Standards of Care – Routine Care
8.01
Examination Standards
An intermediate or comprehensive eye examination shall include all of the following items and
all findings shall be completely and legibly documented in the patient’s record with
quantitative/numerical findings where appropriate.
Current Status
1.
2.
3.
4.
5.
Patient demographics (age/DOB, gender, race).
Personal and family medical and ocular history.
All current medications and medication allergies.
Patient's assessment of current vision status, use of eyeglasses or contact lenses.
Chief complaint/reason for visit.
Vision Assessment
1. Visual acuities in each eye at distance and near with or without correction.
2. Objective and subjective refraction at distance and near with the best corrected visual
acuity at distance and near.
3. Gross and quantitative evaluation of color vision and the accommodative and binocular
abilities of the patient.
Eye Health Assessment
1. Evaluation of external structures: lids, lashes, conjunctiva, gross visual fields, and pupil
anatomy and responses (direct, indirect, accommodative, and afferent defects).
2 Bio-microscopic examination of the cornea, iris, lens, anterior chamber, anterior chamber
angle estimation, and measurement of the intra-ocular pressure (specifying instrument
and time).
3 Ophthalmoscopic examination of the internal eye structures including the vitreous,
retina, blood vessels, optic nerve head (including C-D ratios), macula and peripheral
retina.
4. Dilated/binocular indirect ophthalmoscopic, retinal examination should be performed
when professionally indicated.
Disposition
1. List all diagnoses, prescriptions and treatment recommendations including, but not limited
to:
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a.
b.
c.
d.
Refractive and eye health diagnoses.
Eyeglass and contact lens prescriptions.
Medications prescribed and/or treatment plans.
Patient education on their ocular status and any increased risk factors for any
personal or family conditions.
e. Recall/re-examination/referral recommendations
2. Doctor’s signature and date
8.02
The Patient Record
A.
Organization
The patient record must have areas for documentation of the following registration and
administrative information:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Patient’s first and last name.
Parent of guardian’s name, if appropriate.
Date of Birth.
Gender.
Race.
Address.
Telephone number/numbers.
Emergency contact person and telephone number.
Primary care physician.
Medicaid ID Number or other identification number.
In addition to the patient registration information, the patient record must contain the
examination data from all prior visits, all ancillary test results, consultation requests and
reports, copies of all Prior Approval Requests and Non-Covered Services Agreements,
and all eyewear and/or contact lens specifications.
Each individual page of the patient record must contain the patient’s name and/or
identification number and the date the care recorded on that sheet was provided.
B.
Content
For every routine examination, the patient examination record should contain all of the
information including the recording of all of the detailed qualitative and quantitative
information as described in the examination standards, 8.01, above.
Emergency and non-routine examination visits should contain all of the relevant clinical
data and history to adequately describe the situation/condition at hand and support the
diagnoses and treatments provided as appropriate for the situation.
C.
Compliance
All entries in the record are legible and located consistently within the record
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Symbols and abbreviations used in the record must be uniform, easily understood and are
commonly accepted within the profession.
The entire patient record should be maintained as a unit for at least the most recent seven
(7) years or the time period required by the State Board of Registration, whichever is
greater. For minors, records must be maintained until they reach majority (age 18), plus
seven (7) years at minimum.
The patient record should be maintained in a format that will allow the doctor to make the
entire record available to NVA for routine Quality Assurance review activities.
Electronic medical records (EMR) utilizing default settings must ensure that the defaults
are appropriate for the specific patient or are modified to present an actual and accurate
clinical picture.
9.00
Fidelis Senior Care – Utilization Management Section
9.01
Overview
The priority in NVA programs is to allow patients easy access to the care that they require. This
is best achieved by providing the doctors simple straightforward guidelines to follow in
rendering and billing for the care that the patients require.
Our full vision benefit will encompass both routine vision care (examination) as well as
dispensing of eyewear. Our program will allow access to both components for the patients while
allowing the providers to bill for the appropriate service provided. We also appreciate the need
for simplicity and consistency for the provider’s office and staff in working with this program.
For this reason, we have constructed a protocol that is applicable to all patients, in all programs,
and to all providers.
We will allow patients freedom of choice in the selection of their eye care provider. Patients may
self-refer to your office for care, without the need for a referral or ‘gate-keeper’. It is our belief,
and practice at NVA, that optometrists should be treated as trustworthy professionals. As such,
we expect our doctors to provide the care that the patients need and bill for their services
appropriately (i.e. not attempt to make a routine examination a medical service to receive higher
reimbursements).
Members requiring additional services for medical reasons shall be directed to Fidelis
SecureCare, MI Health Link to the number found on the back of their ID card, for approval or
referral. In emergency situations the provider shall render care as required or make immediate
referrals to another provider or facility (including Hospital Emergency Room) if necessary.
Professional Staff
Carl Moroff, O.D., Chief Vision Officer
Leonard Pine, O.D, Optometric Consultant
Barnet Shuman, O.D., M.P.H., F.A.A.O., Optometric Consultant
Daniel Townsend, M.D., F.A.A.O., Ophthalmology Consultant
20
Operational Protocols and Policies
All initial patient visits should be considered as a routine vision care visit, and a comprehensive
examination should be provided. A description of our comprehensive examination is included as
Section 8.01 of this manual. Temporary codes, local codes and ‘S’ codes will not be allowed,
and all claims with ‘S’ codes will be denied.
The comprehensive examination should be coded as one of the following: 92002, 92004, 92012,
or 92014.
Referrals
All patient referrals for further evaluation or care must be made to an approved NVA or Fidelis
Senior Care panel provider. Any non-emergency referrals to a provider or facility outside of the
current approved NVA and Fidelis Senior Care provider network will require Prior Approval. A
copy of all referrals should be sent to the member’s primary care physician (PCP).
Program Limitations
As with all health care programs, there are some limitations to coverage for which you should be
aware. Most are listed in the categories below.
1. Services which are the responsibility of another insurer and not the responsibility of NVA
or Fidelis Senior Care should be billed directly to the responsible party. NVA or Fidelis
Senior Care will not pay these claims.
o Automobile accidents
o Job-related/Workers Compensation claims
2. Services which are not covered by this program are the complete financial responsibility
of the patient. NVA and Fidelis Senior Care will not pay these claims. These services,
supplies, and materials include:
o Refractive surgery, its complications, and post-operative care, including but not
limited to:
Lasik
PRK
Intacs
Clear lens extractions.
Implantable contact lenses.
Radial Keratotomy.
21
o Services provided as part of clinical trials.
o Experimental procedures.
o Unspecified services (any CPT XX999).
Additional Services
Low Vision services or devices - While covered, prior to rendering care members requiring Low Vision
Services should be referred to Fidelis SecureCare MI Health Link at 844 239-7387.
Vision Training/Orthoptics/Pleoptics – vision training may be covered, subject to certain limitations.
Prior to rendering care contact Fidelis SecureCare MI Health Link at 844 239- 7387.
10.00 Utilization Review Process
Prior authorization is not a guarantee of payment. All services are subject to the plan provisions,
limitations/exclusions, and member eligibility at the time the services are rendered. Services requiring
prior authorization are not eligible for reimbursement by NVA if authorization is not obtained and
cannot be billed to the member. The decision to render medically necessary services lies with the
member and the treating provider.
Prior Authorization Determinations
NVA processes service requests in accordance with the clinical immediacy of the request. If priority is
not specified on the referral request, the request will default to routine status.
•
•
•
Routine – within three (3) business days of receipt of all the necessary information.
Urgent – within one (1) business day of receipt of all the necessary information.
Emergent – within one (1) hour of receipt of all the necessary information.
Medical Necessity Screening Criteria
In the event that criteria are not published in this provider manual for proposed services, other resource
guidelines (i.e., Medicaid Provider Manual, internally developed criteria, etc.) are used to determine
medical necessity and appropriate level of care. Criteria utilized in the medical necessity review of a
service request will be faxed to you upon request. The final decision as to the approval or denial of any
Medically Necessary Service(s) resides with the Medical Director of Fidelis Senior Care.
Notices of Action
NVA must notify members and providers of any Action. An Action includes the 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; or the denial, in whole or in part, of payment for a
service. Only the Chief Medical Officer or designee of FSC, may render a denial for lack of medical
necessity (adverse determination).
22
Appeals
Time frames for filing appeals related to benefits will be unified. Providers should contact Provider
Relations at 888-723-6009 or email [email protected].
APPENDIX A
Attachments
General Definitions
The following definitions apply to this Office Reference Manual:
A.
Responsible Agency
a. For Members:
Michigan MI Health Link Program
• Michigan’s Demonstration Program which provided services to dual-eligible members who
are enrolled in a Medicare-Medicaid Plan (MMP).
B.
“Contract” means the document specifying the services provided by NVA
•
•
C.
to:
A Medicaid beneficiary, directly or on behalf of a Plan, as agreed upon between the State or
its regulatory agencies or Plan and NVA (a “Medicaid Contract”).
A Medicare beneficiary, directly or on behalf of a Plan, as agreed upon between the Center
for Medicare and Medicaid Services (“CMS”) or Plan and NVA (a “Medicare Contract”).
“Covered Services” is a Vision or Eye Care service or supply that satisfies all of the following
criteria:
•
•
•
Provided or arranged by a Participating Provider to a Member;
Authorized by NVA in accordance with the Plan Requirements; and
Submitted to NVA according to NVA’s filing requirements.
D.
“NVA” shall refer to National Vision Administrators, L.L.C.
E.
"NVA Service Area" shall be defined as the covered counties (Wayne and Macomb) in the State
of Michigan
F.
“Medically Necessary” means a service or benefit is medically necessary if it is compensable
under the MA Program and if it meets any one of the following standards:
•
•
•
•
The Service or benefit will, or is reasonably expected to, prevent the onset of an illness,
condition, or disability.
The service or benefit will, or is reasonably expected to, reduce or ameliorate, the physical,
mental, or developmental effects of an illness, condition, injury, or disability.
The service or benefit will assist the individual to achieve or maintain maximum functional
capacity in performing daily activities, taking into account both the functional capacity of the
individual and those functional capacities that are appropriate for individuals of the same age.
Determination of medical necessity for covered care and services must be documented in
writing.
The determination is based on medical information provided by the Member, the Member’s
family/caretaker and the Primary Care Practitioner, as well as any other Providers, programs,
and agencies that have evaluated the member.
A-1
All such determinations must be made by qualified and trained Health Care Providers. A
Health Care Provider who makes such determinations of Medical Necessity is not considered
to be providing a health care service under this Agreement.
G.
“Member” means any individual who is eligible to receive Covered Services pursuant to a
Contract and the eligible dependents of such individuals. A Member enrolled pursuant to a
Commercial Contract is referred to as a “Commercial Member.” A Member enrolled pursuant to
a Medicaid Contract is referred to as a “Medicaid Member.” A Member enrolled pursuant to a
Medicare Contract is referred to as a “Medicare Member.” A member pursuant to both a
Medicaid and Medicare contract is consider “Dual Eligible” under an authorized FIDA Program.
H.
“Participating Provider” is a Vision or Eye Care professional or facility or other entity, including
a Provider that has entered into a written agreement with NVA, directly or through another entity,
to provide Vision or Eye Care services to selected groups of Members.
I.
“Plan” is an insurer, health maintenance organization, or any other entity that is an organized
system which combines the delivery and financing of health care and which provides basic health
services to enrolled members for a fixed prepaid fee.
J.
“Plan Certificate” means the document that outlines the benefits available to Members.
K.
"Provider" means the undersigned health professional or any other entity that has entered into a
written agreement with NVA to provide certain health services to Members. Each Provider shall
have its own distinct tax identification number.
L.
“Vision Provider” is an Optometrist (O.D.), Doctor of Medicine (M.D. or D.O.), or Optician,
duly licensed, as applicable and qualified under the applicable laws who practices as a
shareholder, partner, or employee of Provider, and who has executed a Provider Vision
Participation Agreement.
M
“Primary Care Practitioner (PCP)” is a specific physician, physician group, or a CRNP operating
under the scope of his/her licensure, and who is responsible for supervising, prescribing, and
providing primary care services; locating, coordinating and monitoring other medical care and
rehabilitative services; and maintaining continuity of care on behalf of a Member.
A-2
NVA
P.O. Box 103, Grafton, WI 53024
Toll Free: 888-696-9551
Fax: 888-696-9552
A-3
A-4
Prior Approval for Services – Routine Vision & Materials
Patient Information
Member Identification Number
Patient Birth Date
/
Age
Auth # (if provided)
/
Patient Name (Last, First, Middle)
Sex (M/F)
Provider Information
Provider Number - NPI
Provider Name
NVA Provider Number
Office Name
Street Address
Telephone Number
(
City/State
)
Zip Code
Requested Services (Please list all applicable CPT or HCPCS codes):
_____________________
_____________________
_____________________
Reason for additional service(s) – (check one):
____
Replacement for Lost or Broken Frames
____
Replacement for Lost or Broken Lenses
Medically Necessary (Check specific reason below)
____
Contact Lenses
Tint_________
UV Coating ___________
Press on Prisms _______
___ Change of Prescription
___
Please explain: ________________________________________________________________
Old Prescription
SPHERICAL
Distance
CYLINDRICAL
AXIS
PRISM
AXIS
PRISM
O.D.
O.S.
Additional Information
O.D.
Add
O.S.
New Prescription
SPHERICAL
Distance
CYLINDRICAL
O.D.
O.S.
O.D.
Additional Information
Add
O.S.
___________________________________________________
Signature of Provider
____________________________
Date
Approval: Authorization # ______________________
Denial: __________________________
Type: Examination Only _____________________
Materials Only
_____________________
Examination and Materials ______________
Reason: _________________________
Approved by:________________________________
Date: ___________________________
Approved by:________________________________
Date: ___________________________
A-5
NON-COVERED SERVICES AGREEMENT FORM – Directions and Use
NVA has included the following non-covered services agreement form for use when members request services that are not
covered under the plan certificate. Members may be billed for non-covered services in the event that they willingly elect
to receive such non-covered services, understand the financial responsibility involved in receiving such services, and
agree to be financially responsible for such services.
As a provider, you have agreed to hold covered members harmless for covered services, and you should make best efforts
to minimize out-of-pocket expenses. In select circumstances, when the aforementioned requirements have been fulfilled,
members may be financially responsible for non-covered services. The disclosure and agreement form has been provided
as an option for securing member consent of financial responsibility. Examples of circumstances where members may be
billed include:
•
Non-Covered Frames
•
Non-Covered Lens Types or Options
•
Non-Covered Professional Services
•
Cosmetic Contact Lenses (Member must acknowledge that cosmetic contact lenses are in lieu of eyeglasses for the
current benefit period.)
A-6
Non-Covered Services Agreement
I, ____________________________________________________________, being a patient of Dr.
_______________________________________ located
at_____________________________________________________________, do hereby
acknowledge that it has been explained to me that a certain portion of my care will not be covered
under the terms of my Health Plan. The portion of care not covered is:
________________________________________________________________
___
.
I understand that acceptance of services or treatments not covered by Medicaid is voluntary and that
I may refuse the service or treatments. I acknowledge that I have been told in advance of treatment
what portion of my care I will have to self-pay for, and I agree to make financial arrangements with the
aforementioned Provider to pay for these services myself.
If Cosmetic Contact Lenses have been selected, I understand that they are in lieu of all other
eyeglass benefits for the current benefit period and that they may not be exchanged or returned.
________________________________________________________________
(Patient Name - Print)
________________________________________________________________
(Patient Name - Signature)
Date
Member I.D. # __________________________________________
Plan Name
Members: If you feel you have not been offered alternatives that are within the benefit limits and/or allowance amount, or
feel uncomfortable signing this agreement, please contact member services at the number listed below before signing.
Customer Service/Member Services
888-723-6003
A-7
Laboratory Order Form
To be Supplied by Classic Optical
A-9
APPENDIX B
Covered Benefits (See B-1 – B-3)
This section provides specific benefit information for Fidelis Senior Care:
888-723-6009
Upon request, by either the member or the participating Provider, NVA will supply a
copy of the review criteria utilized in determining a benefit.
Vision providers are not allowed to charge members for missed appointments. Plan
members are to be allowed the same access to treatment, as any other patients in the
practice.
The NVA claim system can only recognize services described using the current CPT,
HCPCS code list or authorized by NVA. All other service codes not contained in the
following tables will be rejected when submitted for payment.
Furthermore, NVA subscribes to the definition of services performed as described in
this manual.
The benefit description in B-1 is all-inclusive of covered services. Each category of
service is contained in a separate table and lists:
1.
2.
3.
4.
The approved CPT or HCPCS service code to submit when billing.
Brief description of the covered service.
Any age limits imposed on coverage.
A description of documentation that must be submitted when a claim, request
for authorization, or Medical Prior Approval is submitted.
5. An indicator of whether or not the service is subject to Medical Prior
Approval.
6. Lens and frame options, member charges, and additional dispensing fees.
7. Any other applicable benefit limitations.
Prior Approval
Services that require prior approval are noted in the benefit designs.
B-1
Appendix B-1 Medicaid – Medicare Dual Eligible
Covered Benefits: Where benefits differ between products, the coverage for each product
will be clearly labeled with the product description.
1.00
Examination
1.01
Members
Eligible members covered for one (1) routine eye examination, consistent with
CPT codes 92002, 92004, 92012 or 92014 once in each benefit period, which is
based on calendar year.
1.02
Additional Examinations
When an additional examination, within the same benefit period, is required due
to a referral from a physician, or due to a required change of prescription of at
least 0.75 or more in the meridian of greatest change, or a change in the cylinder
axis of at least 10 degrees for a cylinders of 1.00D or more, a prior approval form
(see page A-8) must be completed, signed, and submitted. If approved by NVA’s
professional staff, you will be notified and provided with a PAS number for
submission of your claim.
It is essential that this PAS number be submitted as part of your claim
(electronically or by paper) in order for the claim to process correctly.
2.00
Dispensing
In instances where a patient requires eyeglasses to correct vision with a minimum
prescription of +/- .50 or equivalent, use codes 92340, 92341, or 92342. This will
generate a dispensing fee payment to you in accordance with the fee schedule. You do
not need to include the code 92340, 92341, or 92342 on your claim as this will be
automatically generated by the laboratory system when using the provider portal.
Dispensing payments will be made for approved replacements provided that 60 days from
the original date of dispensing have past.
Dispensing Services Include:
•
•
•
•
•
Prescribing and ordering proper lenses.
Assisting in the selection of a frame.
Verifying accuracy of completed eyeglasses.
Proper fitting and adjustment.
Periodic re-adjustment – minor repairs (screws, nose pads, etc.).
Minor repairs, which will not require a replacement frame ordered from the laboratory,
but will involve your provision of additional materials such as pads, temples, or temple
B-2
covers from your own laboratory supplies, will be reimbursed once every 60 days for
children and once every 24 months for adults (age 21 or greater) with submission of code
92370.
3.00
Contact Lens Fitting – Medically Necessary Contact Lenses
Patients requiring contact lenses for the correction of certain qualifying medical
conditions (including Keratoconus, Antimetropia, Anisometropia (2.0 diopters
minimum), Aphakia, or other ocular conditions may receive contact lenses.
3.01
Prior Approval
You must obtain Prior Approval for the fitting of Contact Lenses. Follow the
same procedure as for additional examinations above and be sure to complete the
form found in A-6. Also be sure to include the PAS number on your claim form
or electronically. Prior Approval for fitting will also provide approval for
materials (see materials section).
Reimbursement for fitting will be in accordance with the Medicaid Fee Schedule
then in effect.
4.00
Payments
NVA believes that good provider relations demand rapid payment and has, therefore,
determined a bi-weekly payment process.
We process all claims on the 15th and last day of each month and checks are mailed
within 5-7 business days following.
5.00
Assistance
If further information or assistance is required, please contact the Provider Services
Department at 888-723-6009 or [email protected].
6.00
Materials
Contact lenses necessary for the correction of any of the above noted medically necessary
conditions may be provided once Prior Approval has been requested and authorized. Be
sure to include the PAS number in your claim (paper or electronic). Contact lenses are to
be supplied from your normal sources and will be reimbursed up to the Medicaid Fee
Schedule, then in effect for Medically Necessary Contact Lenses, or up to the schedule
found in paragraph 15.00 for Cosmetic Contact Lenses.
7.00
Contract Laboratory
The provision of materials (frames and lenses) is an essential part of this program. NVA
maintains a primary emphasis on providing quality services within budgetary constraints
and, for this reason, will utilize the services of a contract laboratory to provide plan
covered frames and spectacle lenses, as well as a range of lens options. The laboratory
B-3
has been selected on the basis of its professional reputation, volume production
capabilities, and economics.
8.00
Ordering
Accessing the laboratory to place your eyeglass order is easy. The most efficient way is
through the internet at www.e-nva.com. Once you log on with your Provider name and
password (first time Providers will need their TIN, zip code and location suffix which is
provided by provider relations, and an e-mail address to obtain a Provider name and
password) you will have a range of services available, including:
•
•
•
•
•
•
•
•
•
Verify member eligibility and receive authorizations.
Submit claims for payment.
Place eyeglass orders.
Track claims.
Track eyeglass orders.
Benefit Description – Covered Services.
Electronic copy of Provider Manual.
Forms.
Codes and Fees.
You may also fax eyeglass orders to the laboratory directly at 888-522-2022. To call the
laboratory directly, please use 888-522-2020 and select option #5. This number is
reserved for customer service contact as telephone orders are not accepted, except in
emergencies as defined in Section 12.00.
9.00
Frames
9.01
Samples
Your office was selected to participate in this program in that you currently
participate in the Michigan Medicaid Program and have an existing relationship
with Classic Optical, our Contract Laboratory. As a result you have an existing
selection of approved frames which shall be used for servicing the FSC members.
NVA may determine to provide additional samples to your office at any time in
the future for this program. If provided these samples will remain the property of
NVA and Classic Optical and your office will be responsible for the cost of any
missing frames.
9.02
Plan Covered Frames – No Charge to Members
The initial selection that was made available contains appropriate styles for
patients of all ages, in a variety of materials, colors, styles, and sizes, and it is
your responsibility to ensure that all applicable styles are shown to beneficiaries.
The frames will result in the standard dispensing fee paid to your office and
should be billed with the code V2020. You do not need to include the code
V2020 on your claim as this will be automatically generated by the laboratory
system, when using the provider portal.
B-4
9.03
Plan Covered Frames
All Plan covered frames are to be ordered from the contract laboratory.
When utilizing the Provider Portal, frame and lens codes are generated
automatically.
9.04
Member’s Frames
It is also possible that a patient will want to use their own frame. Although the
contract laboratory will accept member’s frames, please check them carefully as
the laboratory maintains the right to refuse a frame that is non-ophthalmic, old,
cracked, and shows signs of excessive wear or when it believes it is likely to
break during lens insertion. Please be sure that patients understand that the
contract laboratory is not responsible for breakage. A signed waiver is a good
practice to follow.
When placing the laboratory order for lenses, please indicate that a member’s
frame was selected. This will place the lens order and hold it for arrival of the
frame. It will also generate payment of the lens only dispensing fee to your office
although no frame allowance is paid. You do not need to include the code M2025
on your claim as this will be automatically generated by the laboratory system,
when using the provider portal.
9.05
Traceable Means – Shipping
When shipping to the laboratory (non-plan covered frames and member frames),
it is strongly advised that you use a traceable means. The contract laboratory is
not responsible for replacing frames lost in transit. The maximum amount for
which the laboratory will be responsible for lost or damaged frames is $50.00.
10.00
Lenses
As stated above all plan lenses will be provided by the contract laboratory and should be
ordered in the same manner as frames.
Standard single vision, bifocal, and trifocal (Flat top, round segments, or executive style)
lenses are covered.
One of the advantages of utilizing a contract laboratory is the elimination of the need for
the provider offices to code claims with HCPCS for materials supplied by the laboratory.
As a result, you do not need to include the lens codes or option codes with this program,
as they will be automatically generated by the laboratory system if utilizing the provider
portal.
Standard single vision, bifocal, and trifocal (Flat top, round seg or executive style) lenses
are covered.
B-5
10.01
Lens options – Plan Paid
Certain lens options may be covered with Prior Approval, when medically or
professionally indicated not for cosmetic reasons. They include:
•
•
•
•
Tints
UV Coating
Press on prisms
Polycarbonate Lenses
For members age 21 and over, polycarbonate lenses are a Medicaid benefit when
diopter criteria is met and the lenses are inserted into a safety frame marked “Z
87” or “Z 87-2”.
Please submit for Prior Approval in instances when one of these services are
required. Following review by NVA’s professional staff, you will be provided
with a PAS number if approved. Please be sure to include this PAS number with
your claim information. Please remember that you do not need to include the
HCPCS code for options (see above) when utilizing the provider portal.
11.00
Contact Lenses
Members requiring contact lenses for medical necessity may receive a fitting, training,
and follow up care in conjunction with contact lens materials, consistent with the services
provided to your private patients.
Medical Necessity will be determined through the Prior Approval process described in
the Professional Services section of this manual. In general, the conditions requiring
medically necessary contact lenses are:
•
•
•
•
•
•
Aniridia
Antimetropia or Anisometropia (> 2.00 diopters)
Aphakia
Irregular cornea
Keratoconus (if vision cannot be improved to 20/40 or better with eyeglasses)
Other ocular conditions which have no alternative treatments
Please use the appropriate HCPCS code for the materials provided (See Table Below)
along with the PAS number on your claim. You will need to include the HCPCS code(s)
for contact lenses as they are not ordered from the contract laboratory.
Payment will be made to you for the fitting as well as the materials, and you should order
the lenses from your usual sources.
Replacements for lost or damaged contact lenses, or with a significant change in RX (=/.75 diopters), may be made with Prior Approval.
B-6
12.00
Replacement Eyeglasses and Contact Lenses
Eyeglasses
Members who require replacement or repair of broken eyeglasses may receive such
replacement with prior approval.
Replacement will also be made when there is a change of prescription of at least 0.75 or
more in the meridian of greatest change, or a change in the cylinder axis of at least 10
degrees for a cylinder of 1.00D or more, and prior Approval is also required.
Please complete the Prior Approval form and be sure to include the PAS number with
your claim. Payment for dispensing replacements will be made in full provided sixty (60)
days have passed between dispensing dates.
As referenced in Section 2.00 of this Appendix (B-1), dispensing payments will be made
for approved replacements provided that 60 days from the original date of dispensing
have past.
Contact Lenses – Medically Necessary
Members age 21 and above who require replacement of lost or damaged medically
necessary contact lenses are eligible for replacement with Prior Approval.
Members under 21 years of age who require replacement of lost or damaged medically
necessary contact lenses may receive such replacement with prior approval.
Replacement of medically necessary contact lenses for members will be as follows:
•
Replacement for lost or damaged lenses with Prior Approval.
•
Replacement will also be made when there is a change of prescription of at least
0.75 or more in the meridian of greatest change, or a change in the cylinder axis
of at least 10 degrees for a cylinder of 1.00D or more. Prior Approval is also
required.
Please complete the Prior Approval form and be sure to include the PAS number with
your claim.
13.00
Emergency Services
The contract laboratory has agreed to meet rigorous standards for quality and turnaround
time. In some cases, however, due to loss or breakage, a member may require more
immediate correction, and the laboratory has agreed to a process in these cases to
expedite handling.
Contact the laboratory by telephone at 888-522-2020 and select option #3. Identify your
office and the patient and request emergency processing.
B-7
Depending on the time of day, the laboratory will make every effort to ship the
eyeglasses the same day by overnight service.
This should be reserved for emergencies and only for significant prescriptions, which will
impact the child’s ability to perform critical tasks (i.e., school work). If more immediate
service is necessary, contact the NVA Provider Services Department at 888-723-6009.
14.00
Covered Codes and Associated Fees
Procedure Code
Description
Fee
Eye Examination
92002
Exam New Patient (Intermediate)
92004
Exam New Patient
92012
Exam Existing Patient (Intermediate)
92014
Exam Existing Patient
Spectacle Frames and Lenses
V2020
Vision Services Frames Standard
V2025
Vision Services Frames Specialty
V2100
Lens Sphere Single Plano 4.0
V2101
Single Vision Sphere 4.12-7.00
V2102
Single Vision Sphere 7.12-20.00
V2103
Spherocylinder 4.00D/12-2.00D
Procedure Code
Description
V2104
Spherocylinder 4.00D/2.12-4D
V2105
V2106
Spherocylinder 4.00D/>6.00D
V2107
Spherocylinder 4.25D/12-2D
V2108
V2109
V2110
Spherocylinder 4.25D/Over 6D
V2111
Spherocylinder 7.25D/.25-2.25
V2112
V2113
V2114
Spherocylinder Over 12.00D
V2115
Lens Lenticular Bifocal
V2118
Lens Anisekonic Single
V2121
Lenticular Lens, Single
V2200
Lens Sphere Bifocal Plano 4.00D
V2201
Lens Sphere Bifocal 4.12-7.0
V2202
Lens Sphere Bifocal 7.12-20.
V2203
Lens Sphcyl Bifocal 4.00D/.1
V2204
Lens Sphcyl Bifocal 4.00D/2.1
V2205
Lens Sphcyl Bifocal 4.00D/4.2
V2206
Lens Sphcyl Bifocal 4.00D/Over
V2207
Lens Sphcyl Bifocal 4.25/7D/.
V2208
Lens Sphcyl Bifocal 4.25-7/2.
V2209
Lens Sphcyl Bifocal 4.25-7/4.
V2210
Lens Sphcyl Bifocal 4.25-7/OV
V2211
Lens Sphcyl Bifocal 7.25-12/.25V2212
Lens Sphcyl Bifocal 7.25-12/2.2
B-8
$38.00
$38.00
$38.00
$38.00
Included
Included
Included
Included
Included
Included
Fee
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
V2213
V2214
V2215
V2218
V2219
V2220
V2221
V2300
V2301
V2302
V2303
V2304
V2305
V2306
V2307
V2308
V2309
V2310
V2311
V2312
V2313
V2314
Procedure Code
V2315
V2318
V2319
V2320
V2321
Dispensing Services
92340
92341
92342
92370
Options
V2745
V2718
V2755
V2784
Medically Necessary
Contact Lenses
Services
CPT
Lens Sphcyl Bifocal 7.25-12/4.2
Lens Sphcyl Bifocal Over 12.
Lens Lenticular Bifocal
Lens Anisekonic Bifocal
Lens Bifocal Seg Width Over
Lens Bifocal Add Over 3.25D
Lenticular Lens, Bifocal
Lens Sphere Trifocal 4.00D
Lens Sphere Trifocal 4.12-7.
Lens Sphere Trifocal 7.12-20
Lens Sphcyl Trifocal 4.0/.12Lens Sphcyl Trifocal 4.0/2.25
Lens Sphcyl Trifocal 4.0/4.25
Lens Sphcyl Trifocal 4.00/>6
Lens Sphcyl Trifocal 4.25-7/.
Lens Sphcyl Trifocal 4.25-7/2.
Lens Sphcyl Trifocal 4.25-7/4.
Lens Sphcyl Trifocal 4.25-7/>6
Lens Sphcyl Trifocal 7.25-12/.25Lens Sphcyl Trifocal 7.25-12/2.25
Lens Sphcyl Trifocal 7.25-12/4.25
Lens Sphcyl Trifocal Over 12
Description
Lens Lenticular Trifocal
Lens Anisekonic Trifocal
Lens Trifocal Seg Width >28
Lens Trifocal Add Over 3.25D
Lenticular Lens, Trifocal
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Fee
Included
Included
Included
Included
Included
Fitting of Spectacles
$20.00
$20.00
$20.00
Repair of existing Spectacles including
$6.54
materials/supplies
Each of these options may be provided when Medically Necessary with Prior
Approval of Services (PAS)
Solid Tint
Included
Press On Prism
Included
UV Coating
Included
Polycarbonate Lenses
Included
When contact lenses are provided, they are in lieu of eyeglasses. Medically
Necessary contact lenses require Prior Approval (PAS). Contact Lens fees are
global fees, including fitting, follow up, I and R Training, and Materials.
Service
92311
92312
92313
92071
92072
Medically necessary fit Aphakia Unilateral
Medically necessary fit Aphakia Bilateral
Medically necessary fit Aphakia cornea scleral
Medically necessary fit Ocular Surface Disease
Medically necessary fit - Keratoconus
Material
V2500
PMMA Spherical
HCPCS
Medicaid Fee Schedule
B-9
V2501
PMMA Toric
V2510
Gas Perm Spherical
V2511
Gas Perm Toric
V2520
Soft Spherical
V2521
Soft Toric
B-10
15.00
Provider Roles and Responsibilities
Contracted providers and practitioners with Fidelis Senior Care (FSC) are obligated to
comply with the following rules, regulations, and guidelines:
Providers shall provide services that conform to accepted medical and surgical practice
standards in the community as well as applicable standards. These standards include, as
appropriate, the rules of ethics and conduct as established by medical societies and other
such bodies, formal or informal, governmental or otherwise, from which providers and
practitioners seek advice or guidance or to which they are subject for licensing and
oversight.
Providers must immediately notify NVA's Chief Vision Officer, in writing, of any of the
following circumstances:
− If their ability to carry out their professional responsibilities is restricted or
impaired in any way
− If their license to practice their respective profession is revoked, suspended,
restricted, requires a practice monitor, or is limited in any way
− If any adverse action is taken
− If an investigation is initiated by any authorized local, state, or federal agency
− If there are any new or pending malpractice actions
− If there is any reduction, restriction, or denial of clinical privileges at any
affiliated hospital
Providers shall comply with all FSC administrative, participant referral, quality
assurance, utilization management, reporting, and reimbursement protocols and
procedures.
Providers shall not differentiate or discriminate in the treatment of participants on the
basis of race, sex, color, age, religion, marital status, veteran status, sexual orientation,
national origin, disability, health status, source of payment, or and any other category
protected by law.
Providers shall observe, protect, and promote the rights of participants.
Providers shall cooperate and participate in all FSC peer review functions, including
quality assurance, utilization review, administrative, and grievance procedures as
established by FSC.
Providers shall comply with all final determinations rendered by NVA peer review
programs or external arbitrators for grievance procedures consistent with the terms and
conditions of the provider's agreement with NVA.
Providers shall notify NVA in writing of any change in office address, telephone number,
or office hours. A minimum of thirty (30) calendar days advance notice is requested.
Providers shall notify NVA at least ninety (90) calendar days in advance, in writing, of
any decision to terminate their relationship with NVA or as required by the provider's
agreement with NVA.
B-11
Providers shall not under any circumstances, including non-payment by or insolvency of
the Plan or NVA, bill, seek, or accept payment from Plan participants for covered
services or benefits.
Providers agree to maintain standards for the confidentiality of and documentation of
participant medical/service records.
Providers agree to retain medical/service records for 10 years after the last date of service
or the length of time required by applicable law.
Providers shall maintain appointment availability in accordance with federal and state
requirements.
Primary Care Providers shall maintain 24-hour access in accordance with federal and
state standards. PCPs shall notify FSC of any extended coverage arrangements for sick
leave, vacation, etc.
Providers agree to continue care in progress during and after termination of a
participant’s enrollment in FSC for up to 60 days (so long as they maintain coverage
under Medicare and/or Medicaid), or such longer period of time required by state laws
and regulations, until a continuity of service plan is in place to transition the participant to
another network provider.
Providers must establish an appropriate mechanism to fulfill obligations under the
Americans with Disabilities Act (ADA).
15.01 Informed Consent
The provider must adhere to all federal and state requirements, including
applicable requirements, for obtaining informed consent for treatment. Properly
executed consents must be included in the medical record for all procedures that
require informed consent. Providers must additionally provide
participants/representatives with complete information concerning their diagnosis,
evaluation, treatment, and prognosis and grant them the opportunity to take part in
decisions involving their health care.
15.02 Confidentiality
All Protected Health Information (PHI), as this term is defined by the Health
Insurance Portability and Accountability Act (HIPAA) of 1996 (45 CFR §
164.501), related to services provided to participants shall be confidential
pursuant to federal and state laws, rules, and regulations. PHI shall be used or
disclosed by the provider only for a purpose allowed by or required by federal or
state laws, rules, and regulations.
Medical/Service records of all FSC participants shall be confidential and only be
disclosed to and by the provider’s staff in accordance with applicable laws and
regulations.
B-12
You Can Help Protect Patient Confidentiality
Protecting privacy is an essential part of building a physician/patient relationship.
You and your staff can help protect patient confidentiality by following these
simple measures:
Avoid discussing cases within earshot of other patients or visitors.
If voices can be heard easily through exam room walls, consider adding
soundproof panels or piping in soft music.
Make sure computer screens that contain patient information are protected from
general view.
Be sure all patient care is provided out of sight from other patients (e.g., taking
body weight, lab draws)
Have an Office Confidentiality Policy for staff to read and keep in your office
personnel files.
Ask your patients and/or their authorized representatives to sign an Authorization
to Release Information prior to releasing medical records to anyone.
Have a protocol for sending confidential information via fax.
15.03 Participant Complaints and Grievance Procedures
All providers and practitioners must respect Participant Rights as outlined in this
Provider Manual. In addition, providers should participate in, and are obligated to
cooperate with, the resolution of any participant complaint or grievance that may
arise relating to the services they provided to a Plan participant. Any concerns
identified by participants and/or their caregivers with NVA, a provider, or any of
a provider’s staff with respect to the provision of services will be handled in
accordance with NVA’s complaint and grievance procedures as described in this
Manual.
15.04 Office Wait Times
FSC’s participants with a previously scheduled appointment must not be made to
wait longer than one (1) hour on a routine basis.
15.05 Missed Appointments
Participants and/or their caregivers may sometimes cancel or not appear for
necessary appointments and fail to reschedule the appointment. FSC encourages
practitioners/providers to attempt to contact participants/representatives who have
not shown up for or canceled an appointment without rescheduling. If you or your
staff experience difficulty in contacting the participant/representative or if a
participant has a pattern of missed or canceled appointments, please contact
Participant Services or the participant's care manager/coordinator for follow-up.
B-13
15.06 Second Medical or Surgical Opinion
Participants and/or their representatives may request a second opinion if they:
Dispute the reasonableness of a decision
Dispute the necessity of a procedure decision
Do not respond to medical treatment after a reasonable amount of time
Participants must obtain a second opinion from a network provider unless a
network provider with the necessary qualifications and experience is unavailable
within a reasonable timeframe. Participants may not visit out-of-network
providers without prior authorization.
15.07 Laws Relating to Federal Funds
The payments that providers receive for furnishing services to FSC participants
are derived in whole or in part from federal funds. Therefore, providers and any
approved subcontractors must comply with certain laws applicable to individuals
and entities receiving federal funds including, but not limited to:
Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR Part 84
The Age Discrimination Act of 1975 as implemented by 45 CFR Part 91
The Rehabilitation Act of 1973
The Americans with Disabilities Act
15.08 Cultural Competency
Cultural Competency is a process of developing and exercising proficiency in
effectively communicating in a cross cultural context. The word “culture” is used
because it implies the integrated pattern of human behavior that includes thoughts,
communications, actions, customs, beliefs, values and institutions of a racial,
ethnic, religious or social group. The word “competence” is used because it
implies having the capacity to function effectively. Cultural competence in health
care describes the ability of systems to provide care to patients with diverse
values, beliefs, and behaviors including tailoring delivery to meet patients’ social,
cultural, and linguistic needs.
The term ‘‘culturally competent', as defined by the Developmental Disabilities
Bill of Rights and Assistance Act of 2000 (DD Act), "means services, supports, or
other assistance that is conducted or provided in a manner that is responsive to the
beliefs, interpersonal styles, attitudes, language, and behaviors of individuals who
are receiving the services, supports, or other assistance, and in a manner that has
the greatest likelihood of ensuring their maximum participation in the program
involved."
B-14
Cultural competency assists providers and participants to:
Acknowledge the importance of culture and language
Assess cross-cultural relations
Embrace cultural strengths with people and communities
Strive to expand cultural knowledge
Understand cultural and linguistic differences
The quality of the patient-provider interaction has a profound impact on the
ability of a patient to communicate symptoms to his or her provider and to adhere
to recommended treatment. Some of the reasons that justify a provider’s need for
cultural competency include, but are not limited to:
The perception that illness and disease and their causes vary by culture.
The understanding that belief systems relating to health, healing, and wellness are
very diverse.
The recognition that an individual’s cultural background influences help-seeking
behaviors and attitudes toward health care providers.
An acknowledgement that individual preferences affect traditional and nontraditional approaches to health care.
FSC strongly encourages providers to recognize cultural factors that shape
personal and professional behavior and to accept that their own world views and
those of the participant and/or his or her caregiver may differ while avoiding
stereotyping and misapplication of scientific knowledge.
FSC staff will gladly assist providers who may have questions or require help in
accessing needed resources such as language translation services or other
available community-based resources for adults with IDD. In addition, FSC
provides detailed information about the provision of culturally competent care for
adults with IDD on our website at www.FSCcares.org.
15.09 Americans with Disabilities Act Requirements
The Americans with Disabilities Act of 1990 (ADA) is a federal civil rights law
that prohibits discrimination against individuals with disabilities in everyday
activities, including medical services. Section 504 of the Rehabilitation Act of
1973 is a civil rights law that prohibits discrimination against individuals with
disabilities in programs or activities that receive federal financial assistance,
including Medicare and Medicaid. This legislation requires that medical providers
offer individuals with disabilities:
Full and equal access to their health care services and facilities
Reasonable accommodations to policies, practices, and procedures when
necessary to make health care services fully available to individuals with
B-15
disabilities, unless the modifications would fundamentally alter the essential
nature of the services
FSC's policies and procedures are designed to promote compliance with the ADA.
Providers are strongly encouraged to take actions to remove an existing barrier
and/or to accommodate the needs of FSC participants, many of whom have some
degree of physical disability. This action plan includes the following:
Providing reasonable accommodations to individuals with hearing, vision,
cognitive, and psychiatric disabilities
Utilizing waiting room and exam room furniture that meets the needs of all
participants, including those with physical and non-physical disabilities
Utilizing clear signage and way-finding throughout facilities
Clearly marking handicap parking unless there is street-side parking
Providing street-level access to provider offices
Providing elevators or accessible ramps into facilities
Providing wheelchair accessible entrances and restrooms
Providing access to an examination room that accommodates a wheelchair
Offering first and last appointment availability to accommodate special needs
visits
All providers are strongly encouraged to complete the NYSDOH ADA
Attestation form that is included as Attachment A to this Provider Manual. If you
should have further questions about ADA provisions and provider responsibilities,
please contact our Provider Relations staff at 1-855-747-5483.
15.10 Policy of Non-Interference with Provider Advice to Participants
FSC will not prohibit or otherwise restrict providers from advising or advocating
on behalf of participants about the following topics:
The participant's health status, medical care, or treatment options (including any
alternative treatments that may be self-administered), including the provision of
sufficient information to provide an opportunity for the participant and his or her
authorized representative to decide among all relevant treatment options
The risks, benefits, and consequences of treatment or non-treatment
The opportunity for the participant and his or her authorized representative to
refuse treatment and to express preferences about future treatment decisions
15.11 Provider Site Visits
NVA's protocols require QM and/or Provider Relations staff to conduct regularly
scheduled and ad hoc site visits to provider/practitioner offices to ensure that
network providers maintain NVA's standards for accessibility, appearance, and
B-16
adequacy of equipment as well as for medical/service record documentation and
privacy in accordance with all state and federal rules and regulations, professional
ethics, and accreditation standards.
NVA uses a standardized tool to evaluate provider/practitioner offices. If staff
identifies a deficiency during an on-site visit, we will require the implementation
of a corrective action plan (CAP) and re-visit the provider in six (6) months to
ensure that the CAP is progressing properly. QM staff will be responsible for
documenting all such corrective actions and related activities, including their
resolution, and entering them into providers’ confidential QM files. QM staff will
further report this information to the Chief Vision Officer and the Quality
Oversight Committee and it may also be used in provider/practitioner recredentialing/certification evaluations. The Chief Vision Officer is also
responsible for overseeing the preparation and submission of summary reports to
the Quality Management Oversight Committee of the Board.
B-17

National Vision Administrators, L.L.C. (NVA)

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