PROVIDER MANUAL 2015 Arizona California Nevada

Transcription

PROVIDER MANUAL
2015
Arizona
California
Nevada
Table of Contents
CareMore Health Plan
Table of Contents
CHAPTER 1: INTRODUCTION .............................................................. 10
Welcome to the Provider Manual .......................................................................................10
CareMore Service Area .......................................................................................................10
Using This Manual ..............................................................................................................11
How to Access Information and Forms on the Provider Portal Website ................................11
Legal and Administrative Requirements ..............................................................................11
Disclaimer................................................................................................................................. 11
Third Party Websites ................................................................................................................ 12
Privacy and Security Statements ............................................................................................. 12
Confidentiality and Disclosure of Medical Information ........................................................12
Collection of Personal and Clinical Information ...................................................................... 12
Maintenance of Confidential Information ............................................................................... 13
Member Consent ..................................................................................................................... 14
Member Access to Medical Records ........................................................................................ 14
Disease Management Organizations ....................................................................................... 14
Release of Confidential Information ....................................................................................15
Archived Files/Medical Records ............................................................................................... 18
Misrouted Protected Health Information ................................................................................ 18
CHAPTER 2: IMPORTANT CONTACT INFORMATION ........................... 19
CareMore Care Centers Contact Information, Services and Programs ..................................19
Other CareMore Contact Information .................................................................................20
CHAPTER 3: MEMBER BENEFITS......................................................... 23
CareMore Health Plan Overview .........................................................................................23
Health Plan Products Description ........................................................................................25
Outpatient Ancillary Services ..............................................................................................26
Pharmacy Services ..............................................................................................................26
Overview .................................................................................................................................. 26
Formulary ................................................................................................................................. 27
Requests for Formulary Changes ............................................................................................. 27
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Notification of FDA Recalls ....................................................................................................... 28
Preferred Diabetic Supplies ..................................................................................................... 28
Vision Services ....................................................................................................................29
CHAPTER 4: MEMBER SERVICES ......................................................... 30
Member Services ................................................................................................................30
Health Risk Assessments .....................................................................................................30
Appointment Scheduling ....................................................................................................31
Routine Podiatry Services Appointment Line .......................................................................... 31
Transportation Scheduling ....................................................................................................... 31
Translation, Interpreter and Sign Language Services ............................................................32
CHAPTER 5: MEMBER ENROLLMENT AND ELIGIBILITY ........................ 33
Member Enrollment ...........................................................................................................33
Member Eligibility ..............................................................................................................33
Eligibility Verification Process .................................................................................................. 33
Eligibility/Discrepancy .............................................................................................................. 33
Member Identification Cards ..............................................................................................34
Overview .................................................................................................................................. 34
Health Plan Identification Card ................................................................................................ 34
CHAPTER 6: CLAIMS PROCESSING ...................................................... 36
Claims Submission Guidelines .............................................................................................36
Overview .................................................................................................................................. 36
Electronic Claims ................................................................................................................36
Paper Claims.......................................................................................................................37
Paper Claims Processing .......................................................................................................... 38
CMS-1500 Form ..................................................................................................................38
Claims Processing Timelines ................................................................................................39
National Provider Identifier ................................................................................................39
Clinical Submissions Categories ...........................................................................................40
Claim Forms and Filing Limits ..............................................................................................41
Filing and Reimbursement Limits for Medi-Cal Claims .........................................................41
Other Filing Limits...............................................................................................................42
Claims Returned for Additional Information ........................................................................43
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Common Reasons for Rejected and Returned Claims ...........................................................44
Claims and Encounter Data Inquiries ...................................................................................45
Encounter Data ........................................................................................................................ 45
Claims Status Inquires .............................................................................................................. 46
Clean Claims Payment ........................................................................................................46
Payment of Claims ................................................................................................................... 46
Electronic Remittance Advice .................................................................................................. 47
Electronic Funds Transfer ........................................................................................................ 47
Procedure for Processing Overpayments .............................................................................47
Provider Payment Disputes .................................................................................................47
Required Information for an Appeal ........................................................................................ 48
Submission of Provider Appeals ..........................................................................................48
Hold Harmless ....................................................................................................................49
Coordination of Benefits .....................................................................................................49
Claims Filed With Wrong Plan .............................................................................................50
Claims Follow-Up/Resubmissions........................................................................................50
CHAPTER 7: BILLING PROFESSIONAL AND ANCILLARY CLAIMS ............ 51
Overview ............................................................................................................................51
Anesthesia ................................................................................................................................ 52
Emergency Services ................................................................................................................. 52
E/M Coding – Consultations and Follow up Visits ................................................................52
Durable Medical Equipment ...............................................................................................53
DME Rentals ............................................................................................................................. 53
DME Purchase .......................................................................................................................... 54
DME Wheelchairs/Scooters ..................................................................................................... 54
DME Modifiers ......................................................................................................................... 54
Laboratory, Radiology and Diagnostic Services ....................................................................55
CMS-1500 Claim Form.........................................................................................................55
CMS-1500 Claim Form Fields ...............................................................................................55
CHAPTER 8: BILLING INSTITUTIONAL CLAIMS ..................................... 58
Overview ............................................................................................................................58
Institutional Inpatient Coding .............................................................................................58
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Institutional Outpatient Coding ..........................................................................................58
Emergency Room Visits.......................................................................................................59
Recommended Fields for CMS-1450 ....................................................................................59
CHAPTER 9: UTILIZATION MANAGEMENT .......................................... 63
Utilization Management Program .......................................................................................63
Medical Review Criteria ......................................................................................................63
The Referral Process ...........................................................................................................64
Self-Referral Services ..........................................................................................................65
Service Requests .................................................................................................................65
Service Request and Service Request Form ............................................................................. 65
Services Requiring Pre-service Review .................................................................................... 65
Services That Do Not Require Pre-service Review................................................................... 66
Service Request Function ......................................................................................................... 66
Determination Definitions ....................................................................................................... 66
Medical Necessity .................................................................................................................... 68
Authorization Expiration Time Frame ...................................................................................... 68
Unauthorized Care ................................................................................................................... 68
Retrospective Review............................................................................................................... 69
Utilization Management Contact Information ........................................................................ 69
Information for Specialists Only ..........................................................................................69
Additional Services ................................................................................................................... 69
Current Procedure Terminology (CPT) Codes .......................................................................... 69
New Medical Problem.............................................................................................................. 70
Written Report to PCP ............................................................................................................. 70
Utilization Management Contact Information ........................................................................ 70
Durable Medical Equipment ...............................................................................................70
Medically Necessary Services ..............................................................................................73
Emergency Room Utilization ...............................................................................................74
Second Opinions .................................................................................................................75
UM Committee ...................................................................................................................75
CHAPTER 10: CASE MANAGEMENT .................................................... 78
Case Management ..............................................................................................................78
Overview .................................................................................................................................. 78
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Case Management Components.............................................................................................. 78
Role of Case Managers........................................................................................................79
Case Management Interventions............................................................................................. 80
Hospitalist Program ............................................................................................................80
Communicable Disease Services..........................................................................................80
CHAPTER 11: HEALTH PROGRAMS AND EDUCATION .......................... 81
CareMore Programs & Services ...........................................................................................81
Anti-Coagulation Center .......................................................................................................... 81
Chronic Kidney Disease Care Program ..................................................................................... 81
Chronic Obstructive Pulmonary Disease Program ................................................................... 81
CareMore Care Center ............................................................................................................. 81
Congestive Heart Failure Care Program................................................................................... 81
Diabetes Management Program .............................................................................................. 82
Exercise and Strength-Training Program ................................................................................. 82
Fall Prevention Center ............................................................................................................. 82
Foot Center .............................................................................................................................. 82
Healthy Start Program ............................................................................................................. 82
Hospitalist Program.................................................................................................................. 82
Hypertension Program ............................................................................................................. 83
Physician House Call Program .................................................................................................. 83
Pre-Op Center .......................................................................................................................... 83
Touch Management Program .................................................................................................. 83
Wound Care Center ................................................................................................................. 83
Health Education ................................................................................................................84
Health Education Services ...................................................................................................84
Health Education Materials .................................................................................................85
Newsletters .............................................................................................................................. 85
CHAPTER 12: PROVIDER ROLES AND RESPONSIBILITIES ...................... 86
The Primary Care Provider (PCP) .........................................................................................86
Primary Care Provider Role .................................................................................................86
Provider Specialties ............................................................................................................87
Responsibilities of the Primary Care Provider ......................................................................87
Provider Access and Availability ..........................................................................................89
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Member Missed Appointments...........................................................................................90
Noncompliant Members .....................................................................................................91
Primary Care Provider Transfers..........................................................................................91
Provider Disenrollment Process ..........................................................................................91
Covering Physicians ............................................................................................................91
Continuity of Care ...............................................................................................................92
Delivery of Primary Care .......................................................................................................... 93
Coordination of Services .......................................................................................................... 93
Specialty Care Providers .....................................................................................................96
Reporting Changes in Address and/or Practice Status ..........................................................96
Provider Termination Notification.......................................................................................97
Americans with Disabilities Act Requirements ....................................................................97
Disclosure of Ownership and Exclusion from Federal Health Care Programs ........................97
Health Insurance Portability and Accountability Act (HIPAA) ...............................................98
Medical Records .................................................................................................................99
Confidentiality of Information ................................................................................................. 99
Misrouted Protected Health Information ................................................................................ 99
Security................................................................................................................................... 100
Storage and Maintenance ...................................................................................................... 100
Availability of Medical Records .............................................................................................. 100
Medical Record Documentation Standards ....................................................................... 101
Clinical Practice Guidelines ............................................................................................... 102
Advance Directives ........................................................................................................... 102
Prohibited Activities ......................................................................................................... 103
Coding .............................................................................................................................. 103
Medicare Risk Adjustment ................................................................................................ 103
Concurrent Review ........................................................................................................... 103
Patient Annual Health Assessment Form (PAHAF) ............................................................ 104
Chart Reviews................................................................................................................... 104
Education and Training ..................................................................................................... 104
Healthcare Effectiveness Data Information Set (HEDIS) Requirements ............................... 104
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CHAPTER 13: PROVIDER GRIEVANCES AND APPEALS ....................... 106
Overview .......................................................................................................................... 106
Provider Grievances Relating to the Operation of the Plan ................................................ 106
When to Expect Resolution for a Grievance or Appeal ....................................................... 107
Provider Dispute ............................................................................................................... 107
Provider Appeals: Arbitration ........................................................................................... 108
CHAPTER 14: CREDENTIALING AND RE-CREDENTIALING ................... 109
Overview .......................................................................................................................... 109
Credentialing .................................................................................................................... 109
Council for Affordable Quality Healthcare (CAQH) ............................................................. 110
Initial Credentialing .......................................................................................................... 111
Recredentialing ................................................................................................................ 112
Provider Responsibilities & Rights during Credentialing/Recredentialing ........................... 113
Provider Rights to Review Credentialing Information ........................................................ 113
Groups Delegated for Credentialing .................................................................................. 115
CHAPTER 15: MEMBER RIGHTS AND RESPONSIBILITIES .................... 116
Member Rights and Responsibilities ................................................................................. 116
CHAPTER 16: MEMBER GRIEVANCE AND APPEALS ........................... 118
Member Complaints ......................................................................................................... 118
Member Grievances: Filing a Grievance............................................................................. 118
Member Grievances: Resolution ....................................................................................... 119
Member Appeals .............................................................................................................. 119
Member Appeals: Expedited Appeals ................................................................................ 120
Member Appeals: Response to Appeals ............................................................................ 120
CHAPTER 17: MEMBER TRANSFERS AND DISENROLLMENT .............. 121
Provider-Initiated Member Disenrollment ........................................................................ 121
CHAPTER 18: FRAUD, ABUSE AND WASTE ........................................ 122
First Line of Defense against Fraud, Abuse and Waste ....................................................... 122
Examples of Provider Fraud, Abuse and Waste ..................................................................... 122
Examples of Member Fraud, Abuse and Waste .................................................................... 122
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Reporting Provider or Recipient Fraud, Abuse or Waste .................................................... 123
Anonymous Reporting of Suspected Fraud, Abuse and Waste ............................................. 124
Investigation Process ........................................................................................................ 124
Acting on Investigative Findings ............................................................................................ 124
False Claims Act ................................................................................................................ 125
Code of Conduct ............................................................................................................... 126
CHAPTER 19: QUALITY MANAGEMENT ............................................ 127
Quality Management Program .......................................................................................... 127
Quality Management Committee ...................................................................................... 128
CHAPTER 20: CULTURAL AND LINGUISTIC SERVICES ......................... 130
Overview .......................................................................................................................... 130
24-Hour Access to Interpreter Services .............................................................................. 130
Facility Signage ....................................................................................................................... 131
Materials in Other Languages and Alternative Formats ........................................................ 131
Disability Access ............................................................................................................... 132
Cultural Competency Trainings and Resources .................................................................. 132
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CHAPTER 1: INTRODUCTION
Welcome to the Provider Manual
Welcome to the CareMore Health Plan (CareMore) family of dedicated physicians. 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.
Improvement in health care delivery has been achieved by the thoughtful implementation
of added CareMore services such as our Diabetes Management Program and Anti-Coagulation
Center, to name a few. These patient benefits serve as tools that enable you, to provide
unparalleled patient care. Take the time to review them and you will see how the integration of
these services has the effect of both reducing the stress of your professional life and improving
your patients’ outcomes.
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:
Arizona:
Maricopa County (partial county)
Pima County (full county)
California:
Los Angeles County (partial county)
Orange County (partial county)
San Bernardino County (partial county)
Santa Clara County (partial county)
Stanislaus County (full county)
Nevada:
Clark County (partial county)
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Chapter 1: Introduction
Using This Manual
Designed for CareMore physicians, hospitals and ancillary Providers who are participating with
CareMore. 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 cost-effective ways to deliver quality health care to our
Members.
This manual is available to view or download on our website at 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.
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).
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. Throughout this manual, we will refer you to items located on the Provider
Portal page. To access this page, please visit providers.caremore.com.
If you have questions about Provider Portal access or training, please contact your Regional
Performance Manager or 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
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.
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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 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 and security statements related to the Health Insurance Portability
and Accountability Act of 1996 (HIPAA) 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.
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 State and Federal laws, including HIPAA, court orders or subpoenas. Release of
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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 State and Federal law.

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.
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
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. 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 CareMore’s compliance office, the Member may provide 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
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).
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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 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.
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.
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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.

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
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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).
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.
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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 Option3, 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. Please refer to Chapter 11: Health Programs and Education for
an overview of services and programs CareMore has available. A list of the programs and services
can be found below.
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

End Stage Renal Disease Program

Back Pain Program

Fall Prevention Center

Brain Health

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

Wound Care
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Other CareMore Contact Information
Name and Address
Phone/Fax
Hours of Operation and
Website Info
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: 1-800-499-2793
Fax: 1-562-741-4406
TTY 711
8 a.m. – 8 p.m.
Monday through Friday (except
Holidays)
Member Eligibility
Ph: 1-888-291-1358
(Option 3, Option 1)
Fax: 1-562-741-4412
5 a.m. – 5 p.m.
Coding Department
MS - 6100
12900 Park Plaza Drive, Suite
150
Cerritos, CA 90703
Ph: 1-888-649-5899
8 a.m. - 5 p.m.
Case Management
Ph: 1-888-291-1385
Fax: 1 562-207-3657
24 hours a day, 7 days a week
After hours Case Manager:
Nights and Weekends:
Ph:
Claims/ Encounter Data
Attn. Claims Dept
MS-6110
P.O. Box 366
Artesia, CA 90702
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Ph: 1-800-300-7011
8 a.m. – 5 p.m.
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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
Fraud Hotline
Ph: 1-877-725-2702
Hospitalist
Ph: 1-800-613-9374
(Option 1, Option 1)
Sales Managers
Ph: 1-562-207-3614
Nelly De Risio
8 a.m.-5 p.m.
Ph: 1-562-207-3643
John Ramirez
Pharmacy Department
MS-175
12900 Park Plaza Drive #150
Cerritos, CA 90703
*For compounded nebulized
Ph: 1-800-965-1235
7 a.m. -5 p.m.
Fax: 1-800-589-3149
medications vendor, please reference
the forms under the Portal
Telesales West
Ph: 1-877-211-6614
5 a.m. to 8 p.m. Monday
through Friday
Transportation
Ph: 1-877-211-6687
7 a.m. - 6 p.m.
Fax: 1-562-741-4406
TTY: 711
Vision Services:
Arizona and Nevada: Block
View/Eye Specialists
Ph: Block View/Eye
Specialists
1-888-273-2121
California: UniView Vision
Insight
Ph: UniView Vision
Insight
1-855-592-2895
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
Emdeon
Ph: 1-866-506-2830
8 a.m. - 5 p.m.
www.emdeon.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
Regional Performance Managers (RPMs) are assigned to specific CareMore Neighborhoods.
Your Regional Performance Manager can help you with the following:





Orientation to CareMore and unique CareMore Model
Questions about CareMore Care Center programs and services
Contract questions
Individual Patient Quick View Training
Individual Online Provider Portal Training
Please contact our Provider Relations Department for your Regional Performance Manager
contact information at 1-888-291-1358 (Select Option3, Option 5).
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CHAPTER 3: MEMBER BENEFITS
CareMore Health Plan Overview
CareMore Health Plan provides comprehensive, coordinated medical services to members on a
prepaid basis through an established provider network. HMO members must choose a Personal
Physician (or PCP) and have all care coordinated through this physician provider.
Medicare Advantage plans are regulated by the Centers for Medicare and Medicaid Services
(CMS), the same federal agency that administers Medicare.
CareMore Health Plan HMO Products
Medicare Advantage Prescription Drug Plan (MAPD)
CareMore Value Plus
CareMore StartSmart Plus
Special Needs Plan – Chronic Conditions (C-SNP)
CareMore Reliance (Diabetes)
CareMore Diabetes (Diabetes)
CareMore Breathe (Lung disorders)
CareMore ESRD (End-stage renal disease)
CareMore Heart (Cardiovascular conditions: CHF, CAD, PVD)
Special Needs Plan – Dual-Eligible (D-SNP)
CareMore Connect
Special Needs Plan – Institutional (I-SNP)
CareMore Touch
Health Plan Products by Service Area
Arizona – Maricopa County
CareMore Value Plus
CareMore Diabetes
CareMore Breathe
CareMore Heart
Arizona – Pima County
CareMore Value Plus
CareMore Diabetes
CareMore Breathe
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CareMore Heart
CareMore Touch
California – Los Angeles & Orange County
CareMore Value Plus
CareMore Reliance
CareMore Breathe
CareMore ESRD
CareMore Heart
CareMore Connect – (LA County Only)
CareMore Touch
California - San Bernardino County
CareMore Value Plus
CareMore Reliance
CareMore Breathe
CareMore ESRD
CareMore Heart
California - Santa Clara County
CareMore Value Plus
CareMore Diabetes
CareMore Breathe
CareMore Heart
CareMore Connect
California - Stanislaus County
CareMore Value Plus
CareMore Diabetes
CareMore Breathe
CareMore Heart
CareMore Flex
CareMore Retiree
Nevada – Clark County
CareMore Value Plus
CareMore Diabetes
CareMore Breathe
CareMore Heart
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Health Plan Products Description
CareMore Value Plus
CareMore Value Plus is available to all Medicare-eligible beneficiaries. It's a plan that serves the
health care needs of seniors as they age and helps them through the process by providing
extraordinary care and attention. We deliver a full spectrum of care and an abundance of
attention, along with innovative programs designed around the growing needs of Medicare
beneficiaries.
CareMore StartSmart Plus is designed to make health care simple and save members money at
the same time. This Medicare Advantage Prescription Drug Plan features a monthly Medicare
Part B premium reduction in some markets. StartSmart Plus is very attractive to active seniors
who do not have chronic health conditions.
CareMore Reliance & CareMore Diabetes
CareMore understands that life can be very challenging for patients who live with chronic
illnesses. Our Reliance and Diabetes plans are specifically structured for individuals with
Diabetes. Each plan includes health management programs and benefits to stabilize health such
as, diabetes education, nutritional training, diabetic supplies and wound care, routine and
medical podiatry care.
By providing an exceptional level of care and attention for their specific condition, the CareMore
Reliance / CareMore Diabetes product helps improve members’ lifestyle, outlook, and attitude
while empowering members to take a proactive approach to their overall well being.
CareMore Breathe
CareMore Breathe is a Special Needs Plan designed exclusively for the needs of Medicare
beneficiaries who have chronic Lung Disorders, such as Chronic Obstructive Pulmonary Disease
(COPD), Asthma, Chronic Bronchitis, Emphysema, Pulmonary Fibrosis, and Pulmonary
Hypertension.
CareMore ESRD
CareMore ESRD is a Special Needs Plan designed exclusively for seniors who have been
diagnosed with end-stage renal disease requiring dialysis (any mode of dialysis).
CareMore Heart
CareMore Heart is a Special Needs Plan designed exclusively seniors who have been diagnosed
with cardiovascular conditions, such as Congestive Heart Failure (CHF), Coronary Artery Disease
(CAD), Peripheral Vascular Disease (PVD); Cardiovascular disorders limited to: Cardiac
Arrhythmias, Coronary Artery Disease, Peripheral Vascular Disease, Chronic venous
thromboembolic disorder and Chronic Heart Failure.
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CareMore Connect
CareMore Connect was created for seniors who are eligible for both Medicare and Medicaid. As
the plan name suggests, it "connects" beneficiaries with services covered under State-funded
and Federally-funded programs. Members must be eligible for Medicare and Medicaid to enroll
in the CareMore Connect Plan.
CareMore Touch
CareMore Touch is for Medicare beneficiaries living in a nursing home or assisted living
facility/community offering on site primary and preventive care as well as special medical and
social needs of patients and their families. CareMore Touch is currently being offered in Los
Angeles and Orange Counties in California and Pima County in Arizona.
CareMore Flex
CareMore Flex is a Medicare Advantage plan that is available to all Medicare eligible beneficiaries
residing in Stanislaus County. It includes all of the benefits of Original Medicare and includes
prescription coverage and other ancillary benefits. It’s a plan that includes exclusive access to a
neighborhood CareMore Care Center and innovative clinical programs.
CareMore Retiree
CareMore Retiree is a plan with custom benefits designed for Employer Group Waiver Plans
(EGWP).
Outpatient Ancillary Services
All laboratory, radiology, therapy*, DME and medical soft goods services must be performed at a
contracted facility.
*Therapy services include physical therapy, occupational therapy and speech therapy.
Co-pay Guidance for Outpatient Services
Please refer to the appropriate Evidence of Coverage (EOC) document for information
regarding applicable co-pays for outpatient services. This information is available at
www.caremore.com.
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.
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Formulary
CareMore’s formulary for our members has been reviewed and approved by CMS as well as our
Pharmacy and Therapeutics Committee. The formulary consists of generic and brand Medicare
covered medications that may be prescribed for CareMore 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 formulary. Your office will be notified when these
changes take place.
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 2: 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.
Prior Authorization/ Exception Requests
Prior authorization/Exception Requests are used for formulary drugs that require a 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.
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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 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.
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.
Part B Medication Rx Copay Calculations
CareMore’s authorizations does not include the member’s cost sharing for Medicare Part B
drugs. We will continue to provide the coinsurance so that your office staff may calculate the
copay dollar amount to collect.
If you are accustomed to serving Medicare Fee-For-Service patients, your office staff may be
familiar with determining a patient’s cost sharing responsibility. To assist in the calculation,
please visit the following links:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-BDrugs/McrPartBDrugAvgSalesPrice/2015ASPFiles.html
OR
www.cms.gov and enter keyword search "2015 ASP Drug Pricing Files.
If you need assistance in understanding how to calculate the copayment for Medicare
Part B Medication Rx, please contact Provider Relations at (562) 622-2950 or (888) 291-1358
(Select Option 3, then Option 5), Monday – Friday, 8am – 5pm (PST).
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Vision Services
Vision benefits are offered to all CareMore Members through our contracted vision vendor.
For vision vendor contact information specific in to your state, please reference the CareMore
Contact Information available on CareMore’s online Provider Portal at providers.caremore.com.

Arizona: Block Vision/Eye Specialists

California: UniView Vision Insight

Nevada: Block Vision/Nevada Eye Specialists
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CHAPTER 4: MEMBER SERVICES
Member Services
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

General benefits

Assigned physician

Hospital information

Pharmacy locations

Status of referrals and authorizations

Network Providers

Billing questions

Hospital Coverage and Locations

Prescription Drug Coverage

Grievances and Appeals process

ID card replacements
Please refer to CareMore Contact Information (Chapter 2) for phone number and hours of
operation.
Health Risk Assessments
Within 60 days of enrollment in CareMore, 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:

A complete medical history

A head-to-toe physical examination

An assessment of health behaviors

On-site lab testing with a complete metabolic panel, additional tests may include A1C,
PT/INR, random urine microalbumin, if needed

Depression Screening to identify Members requiring treatment for depression.

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.

A fall risk screen to identify Members at risk of falling.

Pain assessment screening to identify if the Member requires additional treatment.

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
Most plans will include routine podiatry as part of their benefit package. Members within those
plans may self-refer to the CareMore Foot Centers for routine foot care, such as toenail clipping
and callus removal. 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 a list of the
CareMore Care Centers, their contact information and the services offered at each location,
please refer to CareMore’s online Provider Portal at providers.caremore.com
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, pharmacy, dental appointments, Member Services/Sales Events, or to pick up medical
records to take to another doctor’s office.
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 is available for members who are ambulatory or
use standard-sized wheelchairs, and do not have any limiting medical condition that would
restrict them from normal means of public transportation. Each member is allowed one escort.
All escorts must be 17 years or older. 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
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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, p lease refer to CareMore Contact Information
(Chapter 2) for phone number and hours of operation.
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 Braille, large print, 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 LEP Members
Call Member Services at the numbers listed at the beginning of this chapter to access translation
services for more than 150 languages.
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
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.
operation.
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CHAPTER 5: MEMBER ENROLLMENT AND ELIGIBILITY
Member Enrollment
CareMore Health Plan’s benefit plans are open to all Medicare beneficiaries, including those
under age 65 who are entitled to Medicare on the basis of Social Security disability benefits, who
meet all of the applicable eligibility requirements for membership, have voluntarily elected to
enroll, have paid any premiums required for initial enrollment to be valid, and whose enrollment
in CareMore Health Plan has been confirmed by the Centers for Medicare and Medicaid Services
(CMS).
Member Eligibility
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.
Please refer to the CareMore Contact Information (Chapter 2) for phone numbers and hours of
operation.
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 and/or your capitation report are not accurate, please contact the
Eligibility Department or investigation and resolution. Please include:

Member’s Name

ID Number

Date of Birth

Primary Care Provider

Explanation of discrepancies to include the months in question.
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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 Eligibility if one or more of the following discrepancies occur:

The patient is eligible with the health plan but is not listed on the eligibility webpage;

The patient is not eligible with the health plan but is listed on the eligibility webpage;

The PCP assignment is not accurate;

The patient is listed on the eligibility webpage but is not listed on the capitation report;

The identification information on the eligibility webpage is not accurate.
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
1-888-291-1358 (Option 3, Option 1) or you may contact your Regional Performance Manager.
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
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

Effective Date

Primary Care Physician - name and phone number
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
Pharmacy Information, including Pharmacy Benefit Manager (PBM) help desk and phone
number, PCN ID, BIN#, Group#, Pharmacy ID and person code

Member Services - toll-free number

Copayments for PCP office visit, Specialist Office Visit, Emergency Room and Urgent Care
*For some service areas, the card may also include the name and phone number of the assigned Ophthalmology
Provider. For more information, contact Provider Relations. Please refer to CareMore Contact Information (Chapter
2) for phone number and hours of operation.
MEMBER IDENTIFICATION CARD SAMPLE
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CHAPTER 6: 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 refer to CareMore Contact Information (Chapter 2) for phone
number and hours of operation.
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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.

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 Department
P.O. Box 366
Artesia, CA 90702
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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
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

National Uniform Claims Committee:
www.nucc.org
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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
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:






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.
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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
 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.
Please reference CareMore Contact Information (Chapter 2) for phone number and hours of
operation.
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Form
Type of Service to be Billed
Time Limit to File
CMS-1500
Professional services,
including physician services.
For services provided to HMO 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.
clean claim within 365days of the service
date.
CMS-1500
Ancillary services, including:
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, hospice,
laboratories, prosthetics and
orthotics
CMS-1450
(UB-04)
Hospitals and Institutions;
therapy services conducted
clean claim within 365 days of the service
in the skilled nursing facilities 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.
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Action
Description
Time Limit to File
Checking Claim
Status
Claim status may be checked any time
on providers.caremore.com, or by
calling the Claims Department. Please
reference CareMore Contact
Information (Chapter 2) for phone
number and hours of operation.
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
and make a determination based on
guidelines.
Determination is made within 45
business days from the Plan's
receipt of dispute or amended
dispute.
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.
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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
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.
providers.caremore.com.
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 24 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 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 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 DME, prosthetic devices, we require
a manufacturer's invoice.
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.
Provider Manual
Then, look up claim status on the Provider portal at
365 days from date of service for professionals (CMS1500)
365 days from date of service in institutions (CMS-1450)
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Problem
Explanation
Resolution
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
Please mail encounter data at least once a month to:
Attn: Claims Department MS 6110
P.O. Box 366
Artesia, CA 90702
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Providers may also submit encounter data electronically through their Office Ally™ account. For
electronic submission, please refer to CareMore Contact Information (Chapter 2) for phone number and
hours of operation.
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.
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
month and mailed with payment by the 27th of each month. All payments made reflect the
current month and six months retro-activity.
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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, please refer to
CareMore Contact Information (Chapter 2) for phone number and hours of operation.
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. Please refer to CareMore
Contact Information (Chapter 2) for phone number and hours of operation.
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
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:
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.
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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:
Attn: Claims Disputes MS 6110
P.O. Box 366
Artesia, CA 90702
Claims processing errors should be brought to the attention of the Claims Department as soon as
possible so that the claim(s) may be corrected. These types of errors may be submitted in writing
via paper mail or through Access Express.
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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 HMO 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.
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.
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
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. For more information, please refer
to CareMore Contact Information (Chapter 2) for phone number and hours of operation.
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 60days 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 7: 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.
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.
Prior Authorization Number: Indicate the Prior Authorization number in Box 23 of the CMS-1500
form.
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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.
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.
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.
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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.
Durable Medical Equipment
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:

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.

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.
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
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 wheelchair claims undergo claims examination. The claims examiners follow CMS 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

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.
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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.
CMS-1500 Claim Form
All professional Providers and vendors should bill us using the most current version of the CMS1500 claim form.
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.
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Field #
Title
Explanation
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.
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.
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Field #
Title
Explanation
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.
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 8: 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.
Institutional Inpatient Coding
Use the following codes for inpatient billing:

CMS-1450 Revenue Codes

ICD-9 Procedure Codes

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).

CPT Codes: Refer to the current edition of the Physicians' Current Procedural Terminology
manual published by the American Medical Association (AMA).
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.
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CareMore Health
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 no 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
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
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
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CareMore Health
Field
Box Title
Description
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
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
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CareMore Health
Field
Box Title
Description
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
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)
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CareMore Health
Field
Box Title
Description
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 9: 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 ensures 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:

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 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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

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. For more information, please refer to CareMore Contact Information (Chapter 2) for
phone number and hours of operation.
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. For more information, please refer to CareMore Contact
Information (Chapter 2) for phone number and hours of operation.
The Referral Process
CareMore has two methods for referring patients to specialists and ancillary facilities:

Self-Referral

Service Request
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Self-Referral Services
Members do not need prior authorization and may self-refer for the following services provided
by qualified, in-network Providers:

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. For more information, please refer to CareMore
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. This form is located in
the Caremore Provider Portal under the user manual of the main menu.
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)

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
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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.
operation.
Service Requests are not required for:

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 long 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
Service Requests, even when automatic approval is granted, support the following functions:

Provide authorization for claims payment

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.
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
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 services.


Standard: within 14 calendar days from receipt of request
Expedited: within 72 hours from receipt of request
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. For more
information, please refer to CareMore Contact Information (Chapter 2) for phone number and hours of
operation.
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.
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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 and Members may contact Members Services department. For
more information, please refer to CareMore Contact Information (Chapter 2) for phone number and
hours of operation.
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 must call the UM
Department to request an authorization extension. They may also submit a new Service Request
Form via the Provider Portal. For more information, please refer to CareMore Contact Information
(Chapter 2) for phone number and hours of operation.
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
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 the CMS guidelines for medical necessity, appropriateness of setting and length
of stay. This 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.
When that occurs, retrospective review for medical necessity is not performed. The Provider is
responsible for completion of the claims review/appeals process. The Member is not financially
liable for any administrative denial related to Provider contract issues and cannot be balance
billed.
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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 provider portal at
providers.caremore.com to access 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 5 a.m. to 5 p.m. Monday through
Friday to submit telephone requests for verification and to request authorization determinations.
Please refer to the CareMore Contact Information (Chapter 2) for phone numbers and hours of
operation.
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 Specialist must submit a Service Request along with supporting clinical
documentation, (i.e. history and physical, diagnostic studies, lab results, treatment to date, and
plan of care) to the CareMore Health Plan Utilization Management Department via the On-Line
Provider Portal.
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.
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 E & M guidelines to determine appropriate and accurate coding.
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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 (3)
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 from 8 am to 5pm Pacific Time Monday through Friday to
submit telephone requests for verification and to request authorization determinations. Please
refer to CareMore Contact Information (Chapter 2) for phone number and hours of operation.
Durable Medical Equipment
Below is a table with useful information regarding proper durable medical equipment (DME)
request procedures. This table is available online on our website at:
https://providers.caremore.com/sg/User%20Guides/CareMore%20UM%20DME%20Medical%20Suppl
ies%20Reference%20Sheet.pdf
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)
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Oxygen, portable
(Gas)
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)
Mobility Items
Description
HCPCs
Companion Wheelchair
Only for Members unable to
self-propel
E1038-RR

Member’s height and weight

Can the Member self-propel?

How long will Member require usage of the item?
Heavy-duty Wheelchair
(250+ lbs.)
K0006-RR
Standard Wheelchair
K0001-RR
Elevated Leg Rests (ELR)
K0195-RR
Lightweight Wheelchair
K0003-RR
Mobility Items
Description
HCPCs
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)
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

How long will Member require usage of the item?
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Low air loss mattress (for
pressure ulcers Stage II and
above)
E0277-RR
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
E0562-NU
Cool humidifier
E0561-NU
Medical Supplies
To order medical supplies, please submit a service request via Provider Portal at
providers.caremore.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.
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Information required in notes for Medical Supply requests
Wound care supplies
Ostomy supplies
Catheter 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

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
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
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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:

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
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the morning of the next business day. Utilization Management may be contacted at
1-888-291-1358 [Option 3, Option 3, Option 2].
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. Once approved, the PCP will notify the Member of the date and time of the
appointment and forward copies of all relevant records to the consulting Provider. The PCP will
notify the Member of the outcome of the second opinion.
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
When we request a second opinion, we’ll make the necessary arrangements for the
appointment, payment and reporting. We’ll inform the Member and the PCP of the results of the
second opinion and the consulting Provider’s conclusion and recommendations regarding further
action.
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.
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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.

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.
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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 10: CASE MANAGEMENT
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*.
* 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
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
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. Please refer to CareMore Contact Information (Chapter 2) for phone number and hours of
operation.
For information regarding any of CareMore’s Care Programs, please contact Provider Relations, if
a CareMore Members have questions regarding CareMore’s Care Programs, please direct them
to call Member Services. Please refer to CareMore Contact Information (Chapter 2) for phone number
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 physicians and other Providers

Help Members access needed services

Develop individual care plans

Coordinate and integrate acute and long-term care services; and integrate behavioral health
services when necessary

Evaluate and coordinate community based resources

Facilitate authorizations to Providers for covered services

Promote improvement in the Member’s quality of life

Facilitate access to appropriate health plan resources and benefits for 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 encounters with the Member and/or family at our local CareMore Care Centers

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

Communication within interdisciplinary care team meetings
Hospitalist Program
CareMore has a Hospitalist Program that serves as the admitting and attending physicians for
health plan Members. They 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 11: 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 Comprehensive 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
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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
and how to develop and implement a physical activity plan. The care team also works closely
with the Member’s cardiologist. Members who require close monitoring may be enrolled into a
wireless monitoring program with a scale and cellular pod to transmit their weight to a webbased program which is monitored by an Advanced Practice Clinician 7 days a 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.
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 and callus removal) to CareMore Health Plan Members
Healthy Start Program
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’s benefits and unique health 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 Hospitalists
Program 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 the
monitoring of their blood pressure. Members who receive close monitoring may be enrolled into
a wireless monitoring program with a blood pressure machine and cellular pod to transmit their
readings to a web-based program monitored by an Advanced Practice Clinician.
Physician 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. The Touch Management Program is
currently being offered in Santa Clara County in California, Maricopa County in Arizona, Clark
County in Nevada. 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 x-rays,
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 underlying
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
Health Education
Providers are required to provide a variety of health education services to their patients. 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 educational 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 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;
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 Reinforce key concepts and compliance with Member at follow-up office visits.
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 www.caremore.com/Care-Programs All materials are also available in
other languages.
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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CHAPTER 12: 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.

Providing the coordination necessary for the referral of patients to specialists and for the
referral of patients to services that may be available.

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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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 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), community-based provider and
county services providers

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
patients

Participate and cooperate with us in any reasonable internal and external quality assurance,
utilization review, continuing education and other similar programs CareMore has
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 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 nonresearch-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 90 percent of telephone calls
within 45 seconds and 100 percent within two minutes.
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
lead to a potentially harmful outcome if not
appointment
treated
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
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Medical Appointment Wait Time Standards
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
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
appointment
Behavioral urgent care
Within 48 hours of 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.

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 upon request.
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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 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 may 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. 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 at 1-888-499-2793 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 is 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.
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
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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
Continuity and Coordination of care is ensured through the offering of a health care professional,
(the Primary Care Physician) who is formally designated as having primary responsibility for
coordinating the member’s overall health care.
The Primary Care Physician (PCP) has the responsibility and authority to direct and coordinate
the members’ services.
The primary care medical record is designated to receive and contain documentation of all care
and services rendered to the member by the PCP, specialists, inpatient care and ancillary
services.


This includes any documentation of care/services provided regarding mental health
and/or substance abuse, providing the member has authorized the mental
health/substance abuse provider to disclose that information.
Documentation may be direct or consist of summary, consultation letters, discharge
notes and progress notes submitted by outside providers.
The day-to-day activity of continuity of care is conducted by the health plan.
Each member is ensured an ongoing source of primary care through this mechanism.
When a member chooses a new PCP within the same network, the medical records are
transferred to the new provider in a timely manner.
Member information will be shared with any organization with which the member may
subsequently enroll, upon member request.
New member information is assessed by the Health Care Services (HCS).
Department staff for continuity of care issues, once enrollment has been verified by the
enrollment department.
Enrollment verification sheets are reviewed by HCS staff to determine if there are any continuity
of care issues, which may include but not be limited to:




Ongoing DME in use in the member’s home by the member (i.e., wheelchair, hospital
bed, oxygen, etc.)
Open authorizations to specialty or diagnostic testing services (i.e., MRI, PT, Specialty
consultation/follow-up visits, etc.)
Specialty care being provided to the member on an ongoing basis (i.e., member with HIV
under the care of Infectious Disease practitioner; ESRD member undergoing dialysis,
pregnant member under an OB’s care, etc.
Pharmacy utilization issues (i.e., non-formulary medications, poly-pharmacy issues;
contraindicated medications, etc.) and the Pharmacy Director reviews all potential
pharmacy issues.
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
Other issues (i.e., member out of area 3 months out of the year, member resides in a
custodial care facility, etc.).
Any issues identified are communicated to the appropriate entity:



Primary Care Physician of record is notified via letter of the specific continuity of care
issue and given suggested resolution, when indicated (i.e., prior authorization required by
Medical Group; assess member for poly-pharmacy issues; member on non-formulary drug
(suggest xyz drug), etc.;
Pharmacist is notified of pharmacy utilization issues via a weekly report; and
Other issues are communicated to the appropriate individuals, as appropriate.
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. Primary care services will be available according to CareMore’s established access and
availability standards. (See Primary Care 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.
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:
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
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.
Authorization of Services
Services should be recommended by the PCP or the Specialty Care Provider (SCP) as appropriate.
Members have a right to request any covered services, whether or not the service has been
recommended by the PCP/SCP.
The services may require approval through the health plan utilization management system

Some of the services may be obtained via self-referral as described in the Members
Evidence of Coverage (EOC)
Whenever possible, services will be coordinated through community and social services that are
available through both contracted and non-contracted providers in the designated service area.
Members who are unable or unwilling to participate in their own care will be assessed through
case management and appropriately counseled and given all of their health care options in order
to be channeled into the most appropriate community agencies.
The areas where members need to be able to fully participate in their care include, but are not
limited to the following:






Self Care
Medication Management
Use of medical equipment
Potential complications and when those should be reported to providers
Scheduling of follow-up services
Member education, especially as it relates to discharge planning
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Transition of Care When Benefits End
CareMore Health Plan UM staff will provide assistance to members in the transition of their care.

When coverage of services ends while a member still needs care, the member must be
offered education on the alternatives to continuing care and how to obtain that care.
Terminated Provider - Transition/Continuity of Care
In order to provide for the continuity of care during the transition of members from a terminated
practitioner to a contracted practitioner, with minimum disruption to the member’s healthcare,
coverage to continue care with a non-participating practitioner for a transitional period will be
provided, when appropriate.
CHP allows for continued access when a practitioner’s contract is discontinued, for reasons other
than professional review actions, utilizing at a minimum:


Continuation of treatment through the lesser of the current period of active treatment
for members undergoing active treatment for a chronic or acute medical condition.
Active course of treatment – treatment in which discontinuity could cause a recurrence or
worsening of the condition under treatment and interfere with anticipated outcomes.
CareMore Health Plan assists the member in selecting a new provider.
The terminating practitioner and accepting practitioner will communicate all health care
treatment to ensure continuity of care for the member.
The terminating physician will be requested to transfer all medical records to the receiving
physician by contacting the member and obtaining a “Release of Medical Information.”
Member Requests Continuity of Care with a Terminated Physician:
If the member requests continuity of care with a terminated physician, CareMore Health Plan will
review the following information:


Rational for termination, e.g. physician voluntarily terminated his/her contract,
terminated for business reasons, disciplinary action, etc.
Willingness of the physician to agree to continue present contractual agreement if he/she
will continue to provide treatment to members undergoing continuity of care.
There is no obligation by the Medical Group to continue the provider’s services beyond the
contract date if:



The terminated provider does not agree to comply or does not comply with the same
contractual terms and conditions that were imposed upon the provider prior to
termination.
The terminated provider voluntarily leaves the Health Plan.
The provider’s contract has been terminated for reasons relating to medical disciplinary
causes or reasons.
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The member must meet one of the following criteria for continuity of care associated with
physician termination:
Acute Condition: A medical condition that involves a sudden onset of symptoms due to
an illness, injury or other medical problem that requires prompt medical attention that
has a limited duration.
Serious Chronic Condition: A medical condition due to disease, illness, or other medical
problem or medical disorder that is serious in nature and that does either of the
following:


Persists without full cure or worsens over an extended period of time.
Requires ongoing treatment to maintain remission or prevent deterioration.
High Risk Pregnancy: A condition identified during the prenatal assessment or during
subsequent examinations, which predisposes a women to fetal or maternal compromise.
CareMore Health Plan will document clearly and concisely what services may or may not be
provided to avoid any member or physician confusion on what has been authorized and the
length of the time period the authorization covers.
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.
Reporting Changes in Address and/or Practice Status
Providers can contact CareMore Provider Relations for demographic updates by submitting
changes in writing and faxing them to Provider Relations. For more information, please refer to
CareMore Contact Information (Chapter 2) for phone and fax numbers.
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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 any existing
barrier and/or to accommodate the needs of Members with disabilities. This action plan
includes:

Accessibility into and throught the facility

Access to examination room and restrooms that accommodates a mobility device

Accessible parking clearly marked

Auxiliary aids and services to ensure effective communications
For more information and guidance to meet these requirements 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.
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.
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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
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
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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:


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
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Relations. For more information, please refer to CareMore Contact Information (Chapter 2) for phone
and fax numbers.
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
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
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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

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
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
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. For more information, please refer to CareMore Contact Information (Chapter 2)
for phone and fax numbers
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
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.
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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
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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Patient Annual Health 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.
operation.
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:
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




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.
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 13: 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. For more information, please refer to CareMore Contact Information (Chapter 2) for
phone and fax numbers.
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
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

Date of the incident
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 14: 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. 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 credential and recredentials 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
o 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:
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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.

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 Providers
to the following:

Universal application for all states are completed and maintained online by the Provider

All documents are uploaded online through the secure CAQH website at:
https://upd.caqh.org/das/
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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
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.
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:
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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
Please note: The above hospital privileges does not apply to PCPs as they do not require hospital
privileges. Coverage is provided by CareMore Hospitalists.
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 90 days to provide the information. If the
information is not received within 90 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 section 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.
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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.
Provider Responsibilities & Rights during Credentialing/Recredentialing
During the credentialing/recredentialing process, the practitioner or Provider will be given, but
may not be limited to, the following rights:

Via written request, the practitioner or 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 practitioner or 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 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 practitioner or 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 practitioner or 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 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
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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.
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 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
regards 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.
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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 an Anthem auditor. If a group holds
an existing delegation agreement with Anthem, 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
providers who are participating under our contractual arrangement should be submitted.
Required data elements for quarterly updates are as follows:

Provider 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

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]
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CHAPTER 15: 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 regards to their “Rights
and Responsibilities,” their first point of reference should be their Evidence of Coverage Booklet
A second point of contact for the Member is Member Services Department. Please refer to
CareMore Contact Information (Chapter 2) for phone number and hours of operation.
CareMore requires that the Member Rights and Responsibilities be posted in all Provider offices.
CareMore Members have the right to:

To be treated with respect and recognition of their dignity and need for privacy. To receive
dignified, courteous, and considerate treatment from all staff, doctors, and nurses who work
or are contracted with CareMore Health Plan.

To be provided with information about CareMore Health Plan and its services.

To choose a Primary Care Provider (PCP) from the medical group’s network and to be
guaranteed continuity of health care.

To receive from their attending provider information about illness, the course of treatment,
and prospects for recovery in clear and understandable terms.

To give approval for any medical care service after receiving all information necessary to
make an informed choice.

To participate actively in decisions pertaining to his/her own medical care. To the extent
permitted by law, this includes the right to refuse care.

To receive full consideration of privacy regarding the medical care program. Case discussion,
consultation, examination and treatments are confidential matters and should be conducted
discreetly.

To receive reasonable and timely responses to requests for services including evaluation and
referrals.

To receive information on all available health services, including a clear explanation of how to
locate and render services.

To be informed of the continuing health care requirements following discharge from a
hospital or office.

To receive information in and communicate in his/her native language at no cost.

To receive information and assistance on how to file a complaint when unhappy with
CareMore Health Plan’s services, any care they receive or any covered service.
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
To receive information and direction on filing a reconsideration of a partial or wholly adverse
Determination.

To receive a second opinion from another CareMore Health Plan contracted or subcontracted
physician.

To have access to his/her medical records.

To formulate Advance Directives for healthcare.

To make recommendations regarding the Healthcare Entity’s member rights and
responsibilities Policies.
CareMore Health Plan Members have the responsibility:

To know, understand, and abide by the terms, conditions and provisions of their assigned
plan.

To actively seek this information in order to make use of the services available through their
plan benefits.

To establish and maintain a positive patient-physician relationship.

To carry their current membership identification card with them at all times.

To pay any applicable co-payment, deductible, co-insurance or charge for non-covered
services when requested by their CareMore physician.

To follow preventative health guidelines, prescribed treatment plans, and guidelines given by
those providing health care services.

To schedule or reschedule appointments and informing their physician when it is necessary
to cancel an appointment.

To provide accurate information needed by professional staff to ensure that the best possible
care is made for them.
The complete list of Member rights and responsibilities is available in the Evidence of Coverage.
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CHAPTER 16: MEMBER GRIEVANCE AND APPEALS
Member Complaints
If a Member has a complaint regarding CareMore Health Plan or any of its contracted providers,
including a complaint about the quality of care they have received, the Member may contact
Member Services. Member complaints are documented, forwarded to the appropriate
department for resolution and kept on file. The formal name for requesting a complaint is called
a grievance.
Please refer to CareMore Contact Information (Chapter 2) for Member Services phone number
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
four ways:

Call Member Services (Please refer to CareMore Contact Information (Chapter 2) for
phone number and hours of operation), or

Write a letter and mail it to the Appeals and Grievances Department at the address listed
below, or

Write a letter and fax it to the Appeals and Grievances Department, or

Submit a complaint to the Appeals and Grievances Department via our website
www.caremore.com
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),
Designation of Representative (DOR), 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 a 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

What happened
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
When it happened

Where it happened

Why the Member was not happy with the health care services

Include any documents that will help us look into the problem
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 may also be considered an appeal.
Member Grievances: Resolution
CareMore will investigate the Member’s grievance to develop a resolution. This investigation
includes the following steps:

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 by either phone, mail or
fax.

Providers are expected to comply with requests for additional information within seven
calendar days for a standard grievances and appeals, and within 24 hours for an expedited
grievance or appeal.
The Member will receive a Grievance Resolution letter within the appropriate timeframe.
Member Appeals
Appeals are divided into two categories: Standard appeals and Expedited appeals.
Standard Appeal (Medicare Part C and Part D) – We’ll give the Member a written decision on a
standard Medicare Part C appeal within 30 calendar days after we receive the appeal. For a
standard Medicare Part D appeal, we will give the Member a written decision within 7 calendar
days after we receive the appeal. Our decision might take longer if the Member asks for an
extension, or if we need more information about the case. We will inform the Member if we’re
taking extra time and will explain why more time is needed. If the appeal is for payment of a
Medicare Part C service the Member has already received, we will give the Member a written
decision within 60 calendar days. If we approve a request to pay the Member back for a drug
they already bought, we are required to send payment to the Member within 30 calendar days
after we receive the appeal request. If the Member asks for a standard appeal by phone, we will
send them a letter confirming what they told us.
Fast (Expedited) Appeal (Medicare Part C and Part D) – We’ll give the Member a decision on a
fast (expedited) Medicare Part C or Part D appeal within 72 hours after we receive the appeal.
The Member can ask for a fast appeal if they or their doctor believe the Member’s health could
be seriously harmed by waiting up to the standard timeframe for a decision.
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Member Appeals: Expedited Appeals
If CareMore denies a request for an expedited appeal, CareMore must:

Transfer the appeal to the time frame (30 calendar days) for standard resolution.
If CareMore approves a request for an expedited appeal, CareMore must:

Complete the expedited reconsideration and give the Member (and the provider involved, as
appropriate) notice of its reconsideration as expeditiously as the enrollee’s health condition
requires, but no later than 72 hours after receiving the request.
Member Appeals: Response to 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 for Standard Appeals and within 24 hours for Expedited Appeals.
If the Member asks for an appeal and we continue to deny the request for a service, we will send
the Member a written decision and will explain if the Member has additional appeal rights.
The Member, Power of Attorney (POA) or designated representative can mail, fax or deliver their
grievance or appeal request to:
Attn: Appeals and Grievances Department
12900 Park Plaza Drive Suite 150, Mail Stop 6150
Cerritos, CA 90703
Fax: 888-426-5087 or 562-741-4414
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CHAPTER 17: 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 Group Initiated Disenrollment 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 18: 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 ID
Not telling the truth about the amount of money or resources the Member has in order to
get benefits
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•
•
•
•
•
•
•
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 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 Anthem
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 17: 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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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.
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CHAPTER 19: 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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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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
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.
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CHAPTER 20: 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 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 hearing
impaired Members.

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 Members.
When a CareMore 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 to request
assistance with interpreter services. The Member and Provider are then connected to our
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telephonic interpreter service vendor. To communicate with Members who have a
speech or hearing disability, the Provider must call the 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 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, 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
members of their 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 Service Department to request these services.
Facility Signage
Providers are required to post signs informing Members of the availability of interpreter services.
If you need assistance in locating, appropriate signage 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
level. Providers may call Member Services Department for assistance with locating materials
that are:
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
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 disabilities. These include:

Accessible parking area and walkways

Accessibility into and throughout the facility

Restrooms and exams 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 communicate 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/
Cultural Competency Trainings and Resources
Providers 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.
Trainings are offered through a variety of venues including but not limited to:

Web-based Provider training programs

Written communications

Provider Office trainings
Training will include but not be limited to the following:

Cultural and linguistic requirements including disability (CLAS and ADA)

Health care disparities
Provider Manual
Version 1.0
Page 132

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 cultural and linguistic 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 cultural and linguistic resources are available through the provider portal. These
include but are not limited to:

Provider tool kits

Provider bulletins
Provider Manual
Version 1.0
Page 133

PROVIDER MANUAL 2015 Arizona California Nevada

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