Provider Manual - Prestige Health Choice

Transcription

HEALTH CHOICE ®
www.prestigehealthchoice.com
Provider Manual
Effective July 2015
Foreword
This Prestige Health Choice Provider Manual contains proprietary information. Providers agree to use this
Medicaid provider manual exclusively as a reference pertaining to medical services for Prestige Health
Choice members. No content found in this publication or in the Prestige Health Choice’s participating
network provider agreement is intended to be interpreted as encouraging providers to restrict medically
necessary covered services or limit clinical dialogue between providers and their patients. Regardless of
benefit coverage limitations, providers may openly discuss all treatment options that are available.
The provisions of this provider manual are applicable to the Medicaid programs implemented by the
Agency for Health Care Administration (AHCA) in 2014, and may be changed or updated periodically.
Providers are encouraged to review prior provider manuals related to previous Medicaid programs.
Prestige Health Choice will provide notice of the updates, and providers are responsible for checking
regularly for updates. The most current provider manual can be found online at
www.prestigehealthchoice.com.
Privacy and Security Standards
The Health Insurance Portability and Accountability Act - Administrative Simplification of 1996
(HIPAA-AS) was impacted by the Health Information Technology for Economic and Clinical Health Act
(HITECH), which was passed as part of the American Recovery and Reinvestment Act. HITECH imposes
new health information obligations on HIPAA-AS covered entities (Prestige, physicians and other
providers and healthcare clearinghouses) and our business associates. As covered entities, we are required
to understand how the HIPAA-AS and HITECH privacy and security standards directly apply to our
specific type of business. Please be aware of these requirements to ensure that member’s protected health
information (PHI) is safeguarded in accordance with the HIPAA-AS and HITECH requirements.
Prestige Health Choice
Provider Manual
Table of Contents
I. Overview................................................................................................................................................... 7
Purpose of this Provider Manual............................................................................................................... 7
Medicaid Program Overview .................................................................................................................... 7
Prestige Health Choice .............................................................................................................................. 7
Medicaid Eligibility .................................................................................................................................. 8
Prestige Enrollment ................................................................................................................................... 8
Members with Medicare Coverage (Dual Eligible) .............................................................................. 9
Newborn Enrollment ............................................................................................................................. 9
Member Identification and Eligibility Verification .................................................................................. 9
Member Rights and Responsibilities ...................................................................................................... 10
Member Rights.................................................................................................................................... 10
Member Responsibilities..................................................................................................................... 11
II. Provider and Network Information ................................................................................................... 14
Prestige Medicaid Provider Eligibility.................................................................................................... 14
Initial Credentialing and Re-Credentialing Criteria and Standards ........................................................ 14
Provider Rights ....................................................................................................................................... 15
Site Visit Evaluation ............................................................................................................................... 16
Facility/Provider Site Evaluation ............................................................................................................ 16
New Provider Orientation ....................................................................................................................... 17
Provider Relations................................................................................................................................... 18
Orientation Training................................................................................................................................ 18
Provider Education and Ongoing Training ............................................................................................. 19
Secure Provider Portal ............................................................................................................................ 19
Fraud, Waste and Abuse (FWA) ............................................................................................................. 19
False Claims Act ..................................................................................................................................... 20
Provider Responsibilities Related to Fraud, Waste and Abuse ........................................................... 21
Reporting and Preventing Fraud, Waste and Abuse ........................................................................... 22
Provider Responsibilities Related to Reporting Abuse, Neglect and Exploitation of Members ......... 22
Provider Roles and Responsibilities ....................................................................................................... 23
Primary Care Physician (PCP) Roles and Responsibilities..................................................................... 25
Specialist and Other Provider Roles and Responsibilities ...................................................................... 26
Direct Access to Women’s Health .......................................................................................................... 26
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Provider Prohibited Activities................................................................................................................. 26
Access to Care......................................................................................................................................... 26
Office Accessibility ............................................................................................................................ 27
Appointment Scheduling..................................................................................................................... 27
Missed Appointment Tracking............................................................................................................ 27
Access to After-Hours Care ................................................................................................................ 27
Monitoring Appointment Access and After-Hours Access................................................................. 27
Cultural and Linguistic Requirements .................................................................................................... 28
Medical Record Requirements ................................................................................................................ 29
Provider Communications Compliance .................................................................................................. 30
Provider Contract Terminations .............................................................................................................. 31
Provider-Initiated Termination ........................................................................................................... 31
Prestige Initiated “For Cause” Termination ........................................................................................ 31
Prestige Initiated “Without Cause” Termination ................................................................................ 32
Mutually-Agreed Upon Terminations ................................................................................................. 32
Continuity of Care............................................................................................................................... 32
Closing of a Physician Panel................................................................................................................... 33
Provider-Initiated Request to Terminate a Member................................................................................ 33
Potential Quality of Care Concerns .................................................................................................... 34
Provider Services 1-800-617-5727 ......................................................................................................... 37
Provider Dispute Process ........................................................................................................................ 37
Provider Communications ...................................................................................................................... 41
Risk Management ................................................................................................................................... 42
Provider Responsibilities .................................................................................................................... 42
Provider Procedures for Critical/Adverse Incident Reporting ............................................................ 43
III. Member Benefits ................................................................................................................................ 46
Prestige Expanded Benefits .................................................................................................................... 46
Non-Covered Services ............................................................................................................................ 47
Emergency Services ................................................................................................................................ 47
IV. Utilization Management ..................................................................................................................... 50
Anticipated Care Program (Prior Authorization) .................................................................................... 50
Concurrent Review and Discharge Planning .......................................................................................... 50
Prior Authorization Specific to Pregnancy-Related Services ................................................................. 50
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Pregnancy Notification/Global OB Authorization .............................................................................. 50
Services Requiring Prior Authorization .................................................................................................. 51
Services Requiring Notification .............................................................................................................. 51
Exceptions to Prior Authorization........................................................................................................... 51
Standard Authorization Decisions .......................................................................................................... 52
Expedited Authorization Decisions ........................................................................................................ 52
Medical Necessity Standards .................................................................................................................. 52
V. Case Management ................................................................................................................................ 55
Integrated Care Management (ICM) ....................................................................................................... 55
Pregnancy-Related Services/Bright Start® .............................................................................................. 55
Prior Authorization ............................................................................................................................. 56
Prenatal Care ....................................................................................................................................... 56
Obstetrical Delivery ............................................................................................................................ 58
Newborn Care ..................................................................................................................................... 58
Postpartum Care .................................................................................................................................. 58
STAR PATH Transition of Care Program .............................................................................................. 58
VI. Rapid Response................................................................................................................................... 62
VII. Member Complaints, Grievances and Appeals .............................................................................. 64
Member Complaints................................................................................................................................ 64
Grievance Process ............................................................................................................................... 64
Appeals Process .................................................................................................................................. 65
Standard Appeal .................................................................................................................................. 65
Expedited Appeal ................................................................................................................................ 66
Appealing a Decision to the Subscriber Assistance Program (SAP) .................................................. 66
Medicaid Fair Hearing ........................................................................................................................ 66
Continuation of Benefits ..................................................................................................................... 67
VIII. Healthy Behaviors Program ........................................................................................................... 69
IX. Quality Enhancements ....................................................................................................................... 73
X. Quality Improvement Program (QIP) ............................................................................................... 75
Quality Improvement Committee (QIC) ................................................................................................. 75
Practitioner Involvement ......................................................................................................................... 76
Quality Improvement Program Activities ............................................................................................... 76
Performance Improvement Projects ........................................................................................................ 76
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Ensuring Appropriate Utilization of Resources ...................................................................................... 76
Measuring Member and Provider Satisfaction........................................................................................ 77
Member Safety Programs ....................................................................................................................... 77
Preventive Health and Clinical Guidelines ............................................................................................. 77
Preventive Care/Immunizations .............................................................................................................. 77
Immunization Schedules (Childhood, Adolescent and Adult) ............................................................ 77
Vaccines for Children Program (VFC) ............................................................................................... 78
Child Health Check-Up Program (CHCUP) ........................................................................................... 78
CHCUP Schedule for Exams .............................................................................................................. 79
Reporting & Evaluation .......................................................................................................................... 79
Medical Record Audits ........................................................................................................................... 80
Documentation of Care/Medical Record Keeping .................................................................................. 80
XI. Cultural Competency Plan ................................................................................................................ 83
National Culturally and Linguistic Services (CLAS) ............................................................................. 83
XII. Claims Submission ............................................................................................................................ 86
Visit Reporting ........................................................................................................................................ 86
Completion of Encounter Data ............................................................................................................... 86
Procedures for Claim Submission ........................................................................................................... 87
Claim Mailing Instructions ..................................................................................................................... 88
Claim Filing Deadlines ........................................................................................................................... 88
Common Causes of Claim Processing Delays, Rejections or Denials.................................................... 89
Electronic Data Interchange (EDI) for Medical and Hospital Claims .................................................... 90
Electronic Claims Submission (EDI) .................................................................................................. 90
Hardware/Software Requirements ...................................................................................................... 91
Contracting with Emdeon and Other Electronic Vendors................................................................... 91
Contracting the EDI Technical Support Group................................................................................... 91
Specific Data Record Requirements ................................................................................................... 91
Electronic Claim Flow Description..................................................................................................... 91
Invalid Electronic Claim Record Rejections/Denials ......................................................................... 92
Exclusions ........................................................................................................................................... 93
Common Rejections ............................................................................................................................ 93
Resubmitted Corrected Claims ........................................................................................................... 93
XIII. Pharmacy ......................................................................................................................................... 96
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AHCA Preferred Drug List (PDL) .......................................................................................................... 96
Coverage Limitations .............................................................................................................................. 96
Generic Substitution................................................................................................................................ 97
Informed Consent for Psychotropic Medications ................................................................................... 97
Injectable ................................................................................................................................................. 97
Over-the-Counter (OTC) Medications .................................................................................................... 97
Specialty Medications ............................................................................................................................. 97
Working with our Specialty Pharmacy Provider .................................................................................... 98
Prior Authorization ................................................................................................................................. 98
XIV. Behavioral Health .......................................................................................................................... 100
XV. Appendix .......................................................................................................................................... 102
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SECTION I
OVERVIEW
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I. Overview
Purpose of this Provider Manual
This provider manual is intended for Prestige Health Choice’s contracted (participating) Medicaid
providers delivering health care service(s) to Prestige members. This manual serves as a guide to the
policies and procedures governing the administration of Prestige Health Choice and is an extension of and
supplements the Provider Participation Agreement (the Agreement) between Prestige Health Choice and
providers, who include, without limitation: primary care physicians, specialty physicians, facilities, and
ancillary providers (collectively, providers).
This manual is available at www.prestigehealthchoice.com. A paper copy may be obtained, at no cost,
upon request by contacting Provider Services at 1-800-617-5727 or your Provider Account Executive.
Medicaid Program Overview
Medicaid provides medical coverage to eligible, low-income children, seniors, disabled adults and
pregnant women. The state and federal government share the costs of the Medicaid program. Medicaid
services in Florida are administered by the Agency for Health Care Administration (AHCA).
Per federal regulations, certain services must be offered by all states, but each state can place some limits
on the services. There are also optional services that a state may choose to offer, variations in eligibility
groups, different limits on income and assets to decide eligibility, and differences in reimbursement to
their Medicaid providers. These key policy decisions are all made by the Florida Legislature. For more
information about Medicaid covered services, view the Agency website at
http://www.fdhc.state.fl.us/medicaid/.
Each state operates its own Medicaid program under a state plan that must be approved by the federal
Centers for Medicare & Medicaid Services (CMS). The Agency periodically updates and files the
Medicaid state plan with CMS to ensure the state program receives matching federal funds.
Prestige Health Choice participates in the Statewide Medicaid Managed Care Program by offering
coverage to all Medicaid recipients eligible to be enrolled in the managed care programs.
Prestige Health Choice’s goal is to ensure the greatest level of Medicaid member satisfaction and health
care outcomes by providing access to high-quality services. Prestige Health Choice’s focus is on its
members and providers.
Prestige Health Choice herein referred to interchangeably as Prestige and “the Plan” will provide a broad
choice of primary care physicians (PCPs) and managed care capabilities to ensure members receive
appropriate care – when and where they need it.
Prestige is dedicated to providing health care services exclusively to low-income families and people with
disabilities. Our mission is to operate a provider-centric managed care company with an emphasis on
efficient, cost-effective, quality care in our communities.
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Prestige is a step ahead of the rest with the “medical home” model. We strive to improve preventive
primary care services and early prenatal care by closing the gaps in a fragmented service system building
a personalized care management program for unmanaged health problems.
In addition:
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Encouraging stable, long-term relationships between providers and members;
Discouraging medically inappropriate use of specialists and emergency rooms;
Committing to community-based safety nets and community outreach;
Enhancing quality improvement mechanisms;
Involving providers in an integrated healthcare delivery system; and
Encouraging the provider network to become involved with positive health outcome measures
and regular measurement of member satisfaction.
We are dedicated to the vision of improving access to care for our members and partnering with our
providers to build a better healthcare model. Prestige brings extensive experience in Medicaid managed
care operations and is committed to supporting our providers in providing high-quality care to our
members.
Medicaid Eligibility
Medicaid eligibility in Florida is determined by the Department of Children and Families (DCF) or the
Social Security Administration (for Supplemental Security Income [SSI] recipients). AHCA (herein,
referred to interchangeably as the “Agency”) or its agent monitors the Florida Medicaid Management
Information System (FLMMIS) on a regular basis and notifies all potential members of their eligibility.
Potential members have thirty (30) calendar days to choose a Florida Medicaid Plan. If the potential
member fails to select a Florida Medicaid Plan, the Agency or its agent auto-assigns the individual to a
Florida Medicaid Plan.
Medicaid recipients who meet the eligibility requirements for enrollment must also live in counties where
Prestige is an authorized Plan to be able to enroll and receive services.
Prestige Enrollment
Prestige will accept Medicaid recipients without restriction and in the order in which they enroll. Prestige
will not discriminate on the basis of religion, gender, sexual orientation, race, color, age, national origin,
health status, pre-existing condition, or need for health care services and will not use any policy or
practice that has the effect of such discrimination.
Prestige members will be required to select a PCP. If a PCP is not selected, Prestige will assign a PCP
based on a variety of factors, including but not limited to:
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The member’s last PCP (if known).
Closest PCP to the member’s ZIP code location.
Children/adolescents are assigned to the same PCP as other family members.
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Members with Medicare Coverage (Dual Eligible)
• Prestige will not require the member to choose a new PCP through the Plan.
• Prestige will not prevent the member from receiving primary care services from the Member’s
existing Medicare PCP.
• Prestige will not assign a PCP to a member who has an existing Medicare PCP (No PCP indicated
on Prestige member ID card).
• Prestige will assist the member in choosing a PCP, if the member does not have a Medicare
assigned PCP.
Eventually, quality indicators will also be used in the auto-assignment process. Once the selection or
assignment has been made, a Prestige member identification card (ID) with the PCP’s name (or group
name) is mailed to the member. Members are advised to keep the ID card with them at all times. The
member’s ID card includes:
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The member’s name and Medicaid ID number;
The Plan’s name, address, member services number; and
A telephone number that a provider may call for information.
Newborn Enrollment
Providers must adhere to the Florida Medicaid newborn delivery notification requirements. Hospitals
must notify Prestige when a pregnant member presents to the hospital for delivery (via notification of
delivery). Prestige shall determine if the newborn has a record on the Florida Medicaid Management
Information System (FLMMIS) that is waiting activation (Unborn Activation Process). Upon notification
of a member’s delivery, Prestige shall notify the Department of Children and Families (DCF) of the
delivery.
If a pregnant member presents for delivery without having an unborn eligibility record that is awaiting
activation, the Plan shall submit the spreadsheet to DCF immediately upon birth of the child. The
newborn will automatically become a Plan member retroactive to birth.
If the mother has not previously identified a PCP for her newborn, a PCP will be assigned by Prestige no
later than the beginning of the last trimester of gestation.
Member Identification and Eligibility Verification
Prestige member eligibility varies by month. Therefore, each participating provider is responsible for
verifying member eligibility with Prestige before providing services. Eligibility may be verified by
visiting the provider portal (Availity) of Prestige’s website at www.prestigehealthchoice.com or by
calling Provider Services at 1-800-617-5727.
Please note that the presentation of a Prestige ID card is not sole proof that a person is currently enrolled
in Prestige. For example, when a member becomes ineligible for Medicaid, the member does not return
the Prestige membership card. Providers should request a picture ID to verify that the person presenting is
the person named on the ID card. Services may be delayed being rendered, if the provider suspects the
presenting person is not the card owner and no other ID can be provided, except for emergent situations.
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If providers suspect a non-eligible person is using a member’s ID card, please report the occurrence to
Prestige’s Fraud and Abuse Hotline at 1-866-833-9718.
Prestige will contact each new member at least twice, if necessary, within ninety (90) calendar days of the
member’s enrollment to offer to schedule the initial appointment with the PCP. This appointment is to
obtain an initial health assessment including a Child Health Check-Up (CHCUP) screening, if applicable.
PRESTIGE HEALTH CHOICE ID CARD
Member Rights and Responsibilities
Florida law requires that health care providers and facilities recognize member rights. Providers must post
a copy of the summary of Florida’s Patient’s Bill of Rights and Responsibilities. Members have the right
to request and receive from their health care provider, a complete copy of the Florida Patient’s Bill of
Rights and Responsibilities.
Member Rights
• To be treated with dignity, respect, and have his/her privacy protected.
• To receive care that is at least equal to service offered by similar health plans.
• To be provided with detailed information about emergency and after-hours options.
• Some details include:
o Emergency services do not require prior approval
o Any hospital can be used for emergency care
o Lists of emergency conditions
o What to do after receiving emergency care
• To participate in decisions about his/her health care. To ask about other available treatments,
including the right to refuse treatment.
• To be free from any form of limitations used to discipline, for convenience, or retaliation.
• To talk to his/her PCP about family planning. These services are available without prior approval.
The services are available from any Medicaid provider.
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To be informed about free translation services. To be provided with support for any language he/
she speaks. To be informed about free services for members with vision and hearing loss.
Members will receive the communication services needed to help make choices about their care.
Please call Member Services at 1-855-355-9800 or TTY/TDD 1-855-358-5856.
To access the Notice of Privacy Practices. This tells when, why, and with whom we must
sometimes share a member’s Personal Health Information (PHI).
To see his/her Personal Health Information (PHI).
To have his/her privacy protected in accordance with the Health Insurance Portability and
Accountability Act (HIPAA) requirement.
To see a list of the people who have asked to see his/her Personal Health Information (PHI).
To obtain a copy of his/her Personal Health Information (PHI) in the provider’s records.
To request a copy of his/her medical records and have the Personal Health Information (PHI)
updated or corrected if there is an issue.
Information about the grievance, appeal and Medicaid Fair Hearing process. To be provided with
support for any language he/she speaks. To receive support from the State so that he/she has
freedom to exercise their rights. This should not affect the way Prestige, and its providers or the
State treats the member.
To have health care services provided in accordance with both state and federal regulations.
To receive yearly updates about the disenrollment process.
To receive updates on major changes in his/ her benefits. The member will be notified at least
thirty (30) days in advance.
To voice a complaint or concern, call Member Services at 1-855-355-9800 or TTY/TDD
1-855-358-5856.
Member Responsibilities
• Read the member handbook. Call Member Services with any questions.
• Choose a new PCP upon receiving the member welcome kit.
• Help his/her new PCP care for themselves and their family. Fill out all information sheets
carefully. Help his/her PCP obtain records from their previous doctor.
• Help his/her doctors manage their care. Follow the care plan they make. If the care plan does not
work, inform his/her PCP. They want their patients to feel better. They will adjust his/her care
plan to make it work.
• Keep his/her appointments for all regular care. Examples are Child Health Check-Ups (CHCUPs),
family planning, and health screenings.
• Obtain a referral from his/her PCP before seeing a specialist, non-participating provider or going
to the hospital. Only go to the hospital or specialist if it is recommended by his/her PCP, unless
it’s an emergency. If visiting a non-participating provider, he/she will need to call Prior
Authorization at 1-855-371-8074.
• If his/her Prestige ID card is ever lost or stolen, call Member Services.
• Present his/her ID card any time medical services are received from a doctor, hospital, clinic or
pharmacy.
• Call his/her PCP when feeling sick. Do not wait. Go to the nearest emergency room (ER) if
he/she feels their life is in danger.
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Call Member Services if any information about his/her family changes. Call Member Services if
his/her mailing or home address changes. This helps avoid most problems. The member must also
contact the Department of Children and Families (DCF) and tell them about the change. Visit
http://www.dcf.state.fl.us/programs/access/map.shtml and select your county to find the nearest
office. If the member’s address has changed, please login to his/her My ACCESS Account and
update the address. Log on to his/her “My ACCESS System” at
https://myaccessaccount.dcf.state.fl.us/Login.aspx. The member can also contact the ACCESS
Customer Call Center toll-free at 1-866-762-2237. The member must also contact the Social
Security Administration (SSA) toll-free at 1-800-772-1213 or visit the SSA website at
http://www.ssa.gov.
Is kind to all persons involved in his/her care. Be on time for his/her appointments. Call the
doctor’s office if the appointment cannot be kept.
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SECTION II
PROVIDER AND NETWORK INFORMATION
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II. Provider and Network Information
Prestige’s Provider Network is composed of quality primary health care providers, specialists, ancillary
and facility providers to administer health care to its Medicaid members.
This section provides information for establishing and maintaining network privileges and sets forth
expectations and guidelines for participating PCPs, specialists, ancillary and facility providers.
Prestige Medicaid Provider Eligibility
Health care providers are selected to participate in the Prestige network based on an assessment and
determination of the network's needs, and the application of Plan and Agency guidelines. All providers
must be registered with the Medicaid program and have a valid provider Medicaid ID number prior to
being enrolled with Prestige, and as a condition to being paid for services rendered.
The criteria, verification methodology and processes used by Prestige are designed to credential and
re-credential providers in a non-discriminatory manner, with no attention to race, ethnic/national identity,
gender, age, sexual orientation, specialty or procedures performed. Prestige does not discriminate against
particular providers that serve high-risk populations or who specialize in conditions that require costly
treatments.
Initial Credentialing and Re-Credentialing Criteria and Standards
Prestige conducts background screening and verifies initial credentialing and re-credentialing criteria for
all professional providers that, at a minimum, meet the Agency's Medicaid participation standards. The
criteria includes, but is not limited to:
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Current medical licensure pursuant to s. 641.495, F.S.
No revocation or suspension of the provider's state license by the Division of Medical Quality
Assurance, Department of Health, and the Agency.
Disclosure related to ownership and management (42 CFR 455.104), business transactions (42
CFR 455.105) and conviction of crimes (42 CFR 455.106).
Proof of the provider's board certification or evidence of medical school graduation, residency
and other post-graduate training.
Evidence of specialty board certification, if applicable.
Evidence of the provider's professional liability claims history.
Evidence of the provider’s professional liability insurance coverage or a Financial Responsibility
Form.
Satisfactory review of any sanctions imposed on the provider by Medicaid or Medicare.
The provider‘s Medicaid ID number, Medicaid provider registration number or documentation of
submission of the Medicaid provider registration form.
The initial credentialing and re-credentialing process also includes, but is not limited to, background
screening and verification of the following additional requirements for physicians in order to ensure
compliance with 42 CFR 438.214:
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Attestation to the correctness/completeness of the provider's application.
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Good standing of privileges at a participating hospital designated as the primary admitting facility
by the physician, or if the physician does not have admitting privileges, good standing of
privileges at a participating hospital by another provider with whom the provider has entered into
an arrangement for hospital coverage.
Valid Drug Enforcement Administration (DEA) certificates, where applicable.
Attestation that the total active patient load (all populations with Medicaid Fee-For-Service
[FFS], Children‘s Medical Services Network, Health Maintenance Organization [HMO], Provider
Service Network [PSN], Medicare and commercial coverage) is no more than three thousand
(3,000) patients per PCP. An active patient is one that is seen by the provider a minimum of three
(3) times per year.
Complete a site visit evaluation for each office location submitted by the PCP or
Obstetrician/Gynecologist (OB/GYN). Prestige’s Site Visit Inspection Evaluation Tool may be
accessed in the Appendix of this manual. See more information below in the Site Visit
Evaluation sections.
Statement regarding any history of loss or limitation of privileges or disciplinary activity as
described in s. 456.039, F.S.
A statement from each provider applicant regarding the following:
o Any physical or mental health problems that may affect the provider's ability to provide
health care
o Any history of chemical dependency/substance abuse
o Any history of loss of license and/or felony convictions
o The provider is eligible to become a Medicaid provider
o Current curriculum vitae, which includes at least five (5) years of work history
All applications and attestation/release forms must be signed and dated one hundred eighty (180) days
prior to the credentialing committee decision date. Additionally, all supporting documents must be current
at the time of the decision date.
Provider Rights
During the credentialing process, every applicant has the right to:
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Review information contained in their credentialing file. This does not include information
collected from references, recommendations, peer review and other protected information.
Providers have the right to be notified and to correct erroneous information if the credentialing
information received varies substantially from the information that was submitted on the
application. However, variances in information obtained from references, recommendations, peer
review and other protected information are not subject to this notification.
Be informed of the status of their application upon request.
Receive notification of these rights.
Questions regarding the status of a credentialing application may be directed to the Prestige Credentialing
Department at 1-305-718-1100 ext. 21937.
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Prestige’s Quality Improvement Program (QIP) provides oversight of credentialing. For more
information, refer to the Quality Improvement Program section of this manual.
Site Visit Evaluation
Prestige’s credentialing and re-credentialing process requires PCPs and OB/GYNs to have a site visit
evaluation for each credentialing location in accordance with Prestige and Agency standards outlined
below:
The site evaluation will verify the following provider requirements, including but not limited to:
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Upholding Prestige organizational standards
Accessibility to persons with disabilities
Adequate space for waiting area and examination rooms
Adequate operating supplies
Proper sanitation and clean, smoke-free facilities
Proper fire and safety procedures are in place
Medical record keeping practices conform to Prestige’s organizational standards and state and
federal regulations
Posting of the following documents in the provider’s office:
o The Agency’s statewide consumer call center number, including hours of operation
o A copy of the summary of Florida’s Patient’s Bill of Rights and Responsibilities, in
accordance with s. 381.026 F.S.
• Note: The provider must have a completed copy of the Florida Patient’s Bill of
Rights and Responsibilities, available upon request by a member, at each
provider’s office
o Prestige’s Grievance Department number
Evidence that the provider is maintaining adequate access standards
Facility/Provider Site Evaluation
Prestige performs a site visit evaluation on each ancillary or facility/provider location submitted for
credentialing who are not accredited or do not have an Agency or CMS site survey. For providers who are
either accredited or have had an Agency or CMS site survey, a copy of the accreditation or site survey
must be submitted with the initial credentialing documentation. Additional site visits for accredited
facility providers may be performed at the discretion of Prestige.
Site Visits Resulting from Receipt of a Complaint, On-Going Monitoring, Member Dissatisfaction,
or Regarding Office Environment or Facility
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Prestige may identify the need for additional site visits upon receipt of member dissatisfaction or
other complaint regarding the provider’s office environment or facility.
Prestige’s Provider Account Executive (or other representative) may conduct a full or focused site
visit to address the specific issue(s) raised. Follow-up site visits are conducted on an as needed
basis.
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Focused site visits, where the full site evaluation is not performed, do not count toward the every
three (3) year site visit requirement.
Final disposition is at the Plan’s discretion.
Communication of Results
1. The Provider Account Executive reviews the results of the site visit evaluation with the office
contact person.
2. If the site meets or exceeds Prestige’s requirements, the site visit evaluation is signed and dated
by both Prestige and the office contact person.
If the site does not meet Prestige’s requirements, Prestige follows the follow-up procedure for Initial
Deficiencies outlined below.
Follow-Up Procedure for Initial Deficiencies
1. The Provider Account Executive requests a corrective action plan from the office contact person
(to be received within one week of the visit).
2. Each follow-up contact and visit is documented in the provider’s file.
3. The Provider Account Executive schedules a re-evaluation visit with the provider’s office within
sixty (60) days of the initial site visit to review the site and verify that the deficiencies were
corrected.
4. The Provider Account Executive reviews the corrective action plan and the results of the followup site visit (including a re-review of any deficiencies) with the office contact person.
5. If the site meets or exceeds Prestige’s requirements, the site visit evaluation form is signed and
dated by both Prestige and the office contact person.
6. If the site does not meet Prestige’s requirements, the Provider Account Executive follows the
follow-up procedure for Secondary Deficiencies outlined below.
Follow-Up Procedure for Secondary Deficiencies
1. The Provider Account Executive will re-evaluate the site monthly, up to three (3) times (from the
date of the first site visit).
2. If after four (4) months there is evidence that the deficiency is not being corrected or completed,
then the site does not meet Prestige’s evaluation requirements, unless there are extenuating
circumstances.
3. Further decisions on whether to pursue the credentialing process or terminate provider
participation who does not meet Prestige’s site visit requirements, will be handled on a case-bycase basis by the Prestige Medical Director and the credentialing committee.
New Provider Orientation
Upon completion of Prestige’s contracting and credentialing processes, the Plan sends each new provider
a welcome letter, which includes the effective date and information on how to access online resources,
including provider orientation training information and the provider manual. The provider manual serves
as a source of information regarding Prestige’s covered services, policies and procedures, relevant statutes
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and regulations, telephone access and special requirements to ensure all Agency contract requirements are
met. The welcome letter explains how a hard copy of the provider manual may be obtained by contacting
Provider Services at 1-800-617-5727.
Provider Relations
Prestige’s Provider Account Executives function as a provider relations team to advise and educate
Prestige providers. Provider Account Executives assist providers in adopting new business policies,
processes and initiatives. Providers will, from time to time, be contacted by Prestige representatives to
conduct meetings that address topics such as, but not limited to:
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Credentialing or re-credentialing site visits
Orientation, education and training
Provider complaints
Training self-service tools
Contract negotiations
Program updates and changes
Health management programs
Quality enhancements
Orientation Training
Prestige conducts initial training shortly after placing a newly contracted PCP provider or PCP provider
group on active status, or may conduct a training upon request from a provider. Orientation training will
include, but is not limited to:
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Re-credentialing
Provider responsibilities
Cultural competency
Policies and procedures
Utilization Management, Quality Improvement and Integrated Care Management Programs
Medicaid compliance
Covered services, benefit limitations and value-added services
Provider inquiry and complaint process
Billing and claims filing, and encounter data reporting
Electronic funds transfers/remittance advice
Quality enhancement programs/community resource capability
Children’s programs including immunizations, nutrition and Child Health Check-Up (CHCUP)
Substance abuse screening
Adverse incident reporting
If you are a PCP or PCP group and your Provider Account Executive has not scheduled your orientation
training within thirty (30) days of becoming active with Prestige, call Provider Services at 1-800-6175727.
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Provider Education and Ongoing Training
Training and development are fundamental components of continuous quality and superior service.
Prestige offers on-going educational opportunities for providers and their staff. Prestige has a
commitment to provide all appropriate training and education to help ensure providers maintain
compliance with Prestige standards, Agency standards and other state requirements as well as applicable
federal requirements. This training may occur in the form of an on-site visit or in an electronic format,
such as online training sessions or interactive training sessions. Detailed training information is available
at www.prestigehealthchoice.com. Prestige providers may obtain information from Provider Account
Executives or Provider Services at 1-800-617-5727.
Secure Provider Portal
Prestige will utilize Availity as our portal for providers to review claims and submit and review
authorizations, as well as other important information.
Detailed services provided via the provider portal are as follows:
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Claims Status Inquiry - Claim Status Inquiry service is a fast, easy way to check the status of
claims, including denial reasons.
Authorizations - With the Authorization functionality, providers can easily submit requests for
procedural inpatient or specialist visits as required and check the status of existing authorizations
in real time.
Eligibility and Benefits Inquiry - Providers can submit an electronic request for verification of a
patient's eligibility and benefits information and get instant results, including covered services,
co-pays and deductibles, if applicable.
Clinical Information Exchange - Clinical information is available via the portal, such as: PCP
Panel Reports, Care Reminders, Clinical Patient Summaries, and Care Gap Alerts (which will be
presented when the provider checks a member’s eligibility) and other reports.
If not already using the provider portal, please visit www.availity.com and click on “Get Started.” If you
need assistance with registration, please contact Availity at 1-800-AVAILITY.
For more information, please visit the Prestige website at www.prestigehealthchoice.com.
Fraud, Waste and Abuse (FWA)
Prestige has a designated Medicaid Compliance Officer who carries out the provisions of the Plan’s
Compliance and Anti-Fraud Plan, which includes oversight of Prestige’s Fraud and Abuse Program.
Designed in accordance with state and federal rules and regulations, Prestige’s Compliance and AntiFraud Plan is aimed at preventing and detecting activities that constitute fraud, waste and abuse. The plan
includes FWA policies and procedures designed to help prevent, reduce, detect, investigate, correct, and
report known or suspected fraud, waste, and abuse activities, and implement corrective action. Prestige
has fraud, waste and abuse information available on our website at www.prestigehealthchoice.com.
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Fraud
“Fraud” is an intentional deception or misrepresentation made by a person with the knowledge that the
deception results in unauthorized benefit to that person or another person (FS 409.913 “Fraud Definition”
Section 2 paragraph “C”). The term includes any act that constitutes fraud under applicable federal or
state law. As applied to the federal health care programs (including the Medicaid program), health care
fraud generally involves a person or entity’s intentional use of false statements or fraudulent schemes
(such as kickbacks) to obtain payment for, or to cause another to obtain payment for, items or services
payable under a federal health care program. Some examples of fraud include:
•
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Billing for services not furnished
Soliciting, offering or receiving a kickback, bribe or rebate
Violations of the physician self-referral prohibition
Waste
“Waste,” though not specifically defined by Florida Statute, is the overutilization of services or other
practices that result in unnecessary costs. Generally not considered caused by criminally negligent
actions, but rather the misuse of resources.
Abuse
“Abuse” is defined as provider practices that are inconsistent with generally accepted business or medical
practice that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or
services that are not medically necessary or that fail to meet professionally recognized standards for health
care; or recipient practices that result in unnecessary cost to the Medicaid program (FS 409.913 “Abuse
Definition” Section 1 paragraph A, subparagraph 1). In general, program abuse, which may be intentional
or unintentional, directly or indirectly results in unnecessary or increased costs to the Medicaid program.
Some examples of abuse include:
•
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•
Charging in excess for services or supplies unintentionally
Providing medically unnecessary services
Providing services that do not meet professionally recognized standards
False Claims Act
The Federal False Claims Act (FCA) is a federal law that applies to fraud involving any contract or
program that is federally funded, including Medicare and Medicaid. Health care entities that violate the
Federal FCA can be subject to civil monetary penalties ranging from $5,500 to $11,000 for each false
claim submitted to the United States government or its contactors, including state Medicaid agencies.
The Federal FCA contains a “qui tam” or whistleblower provision to encourage individuals to report
misconduct involving false claims. The qui tam provision allows any person with actual knowledge of
allegedly false claims submitted to the government to file a lawsuit on behalf of the U.S. Government.
The FCA protects individuals who report under the qui tam provisions from retaliation that results from
filing an action under the Act, investigating a false claim, or providing testimony for or assistance in a
federal FCA action.
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Effective in 2007, the Deficit Reduction Act of 2005 (DRA) increased the states’ requirements to fight
fraud, waste, and abuse activities within their state Medicaid plans and introduced incentives for the states
to enact their own False Claims Acts. Florida has a False Claims Act, codified at F.S.68.081 et seq.
The purpose of the Florida FCA is to deter persons from knowingly causing or assisting in causing state
government to pay claims that are false or fraudulent, and to provide remedies for obtaining treble
damages and civil penalties for state government when money is obtained from state government by
reason of a false or fraudulent claim. No proof of intent to defraud is required for liability to attach, but an
innocent mistake may be a defense to an action under the Florida FCA. Florida’s FCA includes provisions
similar to the federal FCA, allowing for qui tam actions by relators; the Florida Department of Legal
Affairs may also bring an action under the Florida FCA. A portion of the amount recovered from
prosecuting Medicaid false claims in Florida is deposited to the Medicaid Operating Trust Fund in order
to fund rewards for persons who report and provide information relating to Medicaid fraud.
Provider Responsibilities Related to Fraud, Waste and Abuse
Providers agree to include in their compliance program provisions regarding these statutes and provisions
protecting whistleblowers in these matters. The object of the False Claims Act is to prevent and detect
fraud, waste and abuse.
Prestige, providers and all group physicians shall comply with the False Claims Act to the extent
applicable and assist in the detection and prevention of fraud, waste, and abuse in connection with the
provision of services under the Agreement and the State Contract.
All suspected or confirmed instances of internal and external fraud and abuse relating to the provision of,
and payment for, Medicaid services including, but not limited to, Prestige employees/management,
providers, subcontractors, vendors, delegated entities, or enrollees under state and/or federal law must be
reported to MPI within fifteen (15) calendar days of detection.
Upon request, and as required by state and/or federal law, providers shall adhere to the following:
Records maintenance, providers/facilities are required to maintain an adequate record system for
recording services, charges, dates and all other commonly accepted information elements for services
rendered to Medicaid members under the Agreement. Providers/Facilities shall maintain and shall provide
access to such records as required by state and federal law until the expiration of six (6) years from the
close of the Contract or, if longer, until the resolution of any ongoing review or audit with respect thereto
is complete. Providers/ Facilities shall request and obtain prior approval from Prestige for the disposition
of records if the Agreement is continuous. Providers/Facilities shall make available to the Secretary of the
Department of Health and Human Services (DHHS) and AHCA and their designee(s) upon request, the
Agreement, this Addendum and all books, documents and records necessary to inspect and certify the
quality, appropriateness and timeliness of services performed the cost of those services, payment thereof
and for any other lawful purpose. Further, Providers/Facilities shall make available to DHHS and AHCA,
including Medicaid Program Integrity (MPI) and Medicaid Fraud Control Unit (MFCU), for inspection,
evaluation and audit all (i) pertinent books; (ii) financial records; (iii) medical records and (iv) documents,
papers and records of any transactions, financial or otherwise, related to the Contract. Providers/Facilities
shall fully cooperate in any investigation by AHCA, MPI or MFCU or any subsequent legal action that
may result from such investigation. Failure to fully cooperate in investigations, reviews, or audits
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Provider Manual
conducted by Prestige, the Agency, MFCU or any other authorized entity, including but not limited to,
allowing access to the premises, allowing access to Medicaid–related records, or furnishing copies of
documentation upon request may constitute a material breach of this contract and render it immediately
terminated. Providers/Facilities shall (i) safeguard information about members in accordance with 42
C.F.R. 438.224; and (ii) comply with applicable HIPAA privacy and security provisions.
Reporting and Preventing Fraud, Waste and Abuse
Compliance with state and federal laws and regulations is a priority of Prestige. If providers or any other
entity you contract with to provide health care services on behalf of Prestige beneficiaries identifies
potential FWA, please contact the Prestige Fraud, Waste and Abuse Hotline at 1-866-833-9718.
Additionally, you may report suspected fraud or abuse by contacting the Florida Attorney General’s
office at 1-866-966-7226 or the Agency Consumer Complaint Call Center at 1-888-419-3456.
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline tollfree at 1-888-419-3456. If you report suspected fraud and your report results in a fine, penalty, or
forfeiture of property from a doctor or other health care provider, you may be eligible for a reward
through the Attorney General's Fraud Rewards Program at 1-850-414-3990. The reward may be up to
twenty-five (25) percent of the amount recovered, or a maximum of $500,000 per case (Florida statutes
Chapter 409.9203). You can talk to the Attorney General's Office about keeping your identity confidential
and protected.
Below are examples of information that will assist Prestige with an investigation:
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Contact information (i.e., name of individual making the allegation, address, telephone number)
Type of item or service involved in the allegation(s)
Place of service
Nature of the allegation(s)
Timeframe of the allegation(s). As situations warrant, Prestige may make referrals to appropriate
law enforcement and/or the Medical Education Development in Communities (MEDIC)
Provider Responsibilities Related to Reporting Abuse, Neglect and Exploitation of Members
Prestige requires participating and direct service providers to report adverse incidents to Provider Services
at 1-800-617-5727 within twenty-four (24) hours of the incident. Reporting will include information such
as the member’s identity, description of the incident and outcomes including current status of the
member.
“Abuse” means any willful act or threatened act by a caregiver that causes or is likely to cause significant
impairment to a member’s physical, mental, or emotional health. Abuse includes acts and omissions.
“Neglect” of an adult means the failure or omission on the part of the caregiver to provide the care,
supervision, and services necessary to maintain the physical and behavioral health of the vulnerable adult,
including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, that a
prudent person would consider essential for the well-being of the vulnerable adult. The term “neglect”
also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult from abuse,
neglect, or exploitation by others. “Neglect” is repeated conduct or a single incident of carelessness that
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Provider Manual
produces, or could reasonably be expected to result in serious physical or psychological injury or a
substantial risk of death.
“Neglect” of a child occurs when a child is deprived of, or is allowed to be deprived of, necessary food,
clothing, shelter or medical treatment. Additionally, when a child is permitted to live in an environment
where such deprivation or environment causes the child’s physical, behavioral, or emotional health to be
significantly impaired or to be in danger of being significantly impaired.
“Exploitation” of a vulnerable adult means a person who:
•
•
Stands in a position of trust and confidence with a vulnerable adult and knowingly, by deception
or intimidation, obtains or uses, or endeavors to obtain or use, a vulnerable adult’s funds, assets,
or property for the benefit of someone other than the vulnerable adult.
Knows or should know that the vulnerable adult lacks the capacity to consent, and obtains or
uses, or endeavors to obtain or use, the vulnerable adult’s funds, assets, or property with the intent
to temporarily or permanently deprive the vulnerable adult of the use, benefit, or possession of
the funds, assets, or property for the benefit of someone other than the vulnerable adult.
Provider Roles and Responsibilities
Prestige is regulated by Florida State law under the Agency. Please refer to your Prestige Network
Participation Agreement or contact your Provider Account Executive for clarification of any of the
following. Providers who participate in Prestige have responsibilities, including but not limited to:
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Coordinate with applicable state agencies for any members receiving service or under
conservatorship from DCF.
Provide covered services to members with Plan coverage.
Provide timely covered services to members at all times.
Abide by and cooperate with the policies, rules, procedures, programs, activities and guidelines
contained in your Provider Agreement (which includes the most current Prestige Provider
Manual).
Accept Prestige payment, plus any applicable member copayment, as payment-in-full for covered
services.
Adhere to guidelines for usage of all electronic self-service tools.
Comply fully with Prestige’s Quality Improvement, Utilization Management, Integrated Care
Management and Audit Programs.
Comply with all applicable training requirements, including training for Fraud, Waste and Abuse,
as required by CMS.
Promptly notify Prestige of claims processing payment or encounter data reporting errors.
Maintain all records required by law regarding services rendered for the applicable period of
time, making such records and other information available to Prestige or any appropriate
government entity.
Treat and handle all individually identifiable health information as confidential in accordance
with all laws and regulations, including HIPAA-AS and HITECH requirements.
Immediately notifying Prestige of adverse actions against license or accreditation status.
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Comply with all applicable federal, state, and local laws and regulations.
Maintain liability insurance in the amount required by the terms of the Provider Agreement.
Notify Prestige of the intent to terminate the Provider Agreement as a participating provider
within the timeframe specified in the Provider Agreement.
If the Provider Agreement is terminated:
o Continue to provide services to members who are receiving inpatient services until they
are appropriately discharged and/or the specific episode of care is completed.
o Accept payment at rates in effect under the Agreement immediately prior to termination.
Verify eligibility immediately prior to rendering service.
Obtain signed consents prior to rendering service.
Obtain prior authorization for applicable services.
Maintain hospital privileges when required for the delivery of the covered service.
Maintain all medical and Medicaid-related member records and communications for a period of
ten (10) years according to legal, regulatory and contractual rules of confidentiality and privacy.
Provide prompt access to records for review, survey or study if needed.
Cooperate fully in any investigation or review by Prestige, Agency, Medicaid Program Integrity
(MPI), Medicaid Fraud Control Unit, Office of the Attorney General (MFCU), or other state or
federal entity and in any subsequent legal action that may result from such an audit, investigation
or review.
When presenting a claim for payment to Prestige, the network provider is indicating an
understanding that the provider has an affirmative duty to supervise the provision of, and be
responsible for, the covered services claimed to have been provided, to supervise and be
responsible for preparation and submission of the claim, and to present a claim that is true and
accurate and that is for Prestige covered services that:
o Have actually been furnished to the recipient by the provider prior to submitting the
claim.
o Are medically necessary.
Report known or suspected child, elder or domestic abuse to local law authorities and have
established procedures for these cases.
Provide encounter data accepted by the Florida Medicaid Management Information System
(FLMMIS), as either actively enrolled Medicaid providers or as Prestige registered providers
and/or the State’s encounter data warehouse.
Inform members of the availability of Prestige’s interpreter services and encourage their use.
Notify Prestige of any changes in business ownership, business location, legal or government
action, or any other situation affecting or impairing the ability to carry out duties and obligations
under the Prestige Network Provider Agreement.
Maintain oversight of non-physician practitioners as mandated by state and federal law.
Post or display a copy of the summary of Florida’s Patient’s Bill of Rights and Responsibilities
(in accordance with s. 381-026, F.S.) and have a complete copy available upon member request at
each of the provider’s offices.
Obtain consent from the parent or guardian for children under thirteen (13) years old who are
prescribed psychotropic medicines, and maintain documentation in the child’s medical record.
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Provide a copy of the signed consent with the hard copy of the prescription to be taken to the
pharmacy. Consent forms are located at www.prestigehealthchoice.com.
Notify Prestige promptly of patient member pregnancies.
Do not discriminate in any manner between Prestige members and non-Prestige members.
Primary Care Physician (PCP) Roles and Responsibilities
Additionally, Prestige’s participating PCPs are responsible for providing or coordinating medical services
including, but not limited to:
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Inpatient admissions
Case management for non-surgical admissions
Nursing home visits
Physician hospital care
Office visits
Education on preventive health
Injections and immunizations
Laboratory and X-ray services per the Prestige contractual arrangement
Minor office surgeries/procedures
Periodic health assessments
Smoking cessation program screenings
Substance abuse and domestic violence screenings
Screening EKGs ordinarily performed in a physician’s office
Well-child care, including CHCUP services
Outpatient services
Emergency services
Home health care
Therapy
Other medical care normally rendered by the physician
Prestige PCPs must provide, or arrange for coverage of services, consultation or approval for referrals
twenty-four hours a day, seven days a week (24/7) by Medicaid-enrolled providers who will accept
Medicaid reimbursement. This coverage will consist of an answering service, call forwarding, provider
call coverage or other customary means approved by the Agency. The chosen method of 24/7 coverage
must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical
decision. The after-hours coverage must be accessible using the medical office’s daytime telephone
number.
The PCP is responsible for arranging coverage of primary care services during absences due to vacation,
illness or other situations that render the PCP unable to provide services. A Medicaid-eligible PCP must
provide coverage.
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Note: Members with chronic or disabling illnesses or children with special health care needs may request
a specialist to act as their PCP. Pregnant members are also allowed to choose an obstetrician as their PCP
to the extent that the obstetrician is willing to participate as a PCP.
Please refer to your Prestige Network Participation Agreement or contact your Provider Account
Executive for further clarification.
Specialist and Other Provider Roles and Responsibilities
The member’s PCP may refer the member to a specialist to diagnose and treat medical conditions that are
outside of the PCP’s range of practice. Specialty and Ancillary care is limited to the Plan’s covered
benefits and may require prior authorization. Prestige’s benefit coverage and prior authorization list can
be found at www.prestigehealthchoice.com. Specialists who are designated as a PCP are required to
adhere to the PCP responsibilities.
Direct Access to Women’s Health
Female members can directly access a women's health specialist within the network for covered services
necessary to provide women's routine and preventive health care services. This is in addition to a
member’s designated PCP, if that provider is not a women's health specialist. Prestige ensures access to
certified or licensed nurse midwife services for low-risk members, licensed in accordance with Chapter
467, F.S.
Provider Prohibited Activities
Prestige providers are prohibited from the following activities:
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Discriminating against any member on the basis of race, color, religion, sex, national origin, age,
health status, participation in any governmental program, source of payment, marital status, sexual
orientation or physical or mental handicap.
Segregating members from other patients (applies to services, supplies, equipment).
Billing members for covered services including disputed amounts.
Refusing to furnish a member with a covered Medicaid service solely because the member’s
eligibility has not yet transmitted to Florida Medicaid Management Information System (FLMMIS)
when the member possesses one form of acceptable proof of eligibility.
Access to Care
Prestige providers must meet standard guidelines to help ensure Prestige members have timely access to
care. Prestige endorses and promotes comprehensive and consistent access standards for members to
assure member accessibility to health care services. Prestige establishes mechanisms for measuring
compliance with existing standards and identifies opportunities for the implementation of interventions
for improving accessibility to health care services for members.
The following areas are monitored by Prestige to ensure physician access standards are continually met:
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Office accessibility
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Provider Manual
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Appointment scheduling timeframes
After-hours care
Office Accessibility
PCP office hours must be clearly posted and reviewed with members during the initial office visit. The
PCP is required to arrange for coverage of primary care services during absences due to vacation, illness
or other situations that render the PCP unable to provide services. A Medicaid-eligible PCP must provide
the coverage to Prestige members.
Appointment Scheduling
Prestige monitors the following access standards on an annual basis per Medicaid Managed Care
guidelines.
General Appointment Scheduling for PCPs and Specialists
Urgent Examination
Within 1 day
Routine Sick Patient Care
Within 1 week
Well-care Visit
Within 1 month
Postpartum Exam
Within 6 weeks of delivery
Note: Emergency services must be provided immediately upon presentation, twenty-four hours a day/ seven
days a week (24/7).
Missed Appointment Tracking
If a member misses an appointment with a provider, the provider must document the missed appointment
in the member’s medical record. Providers must make at least three (3) documented attempts to contact
the member and determine the reason. The medical record should reflect any reasons for delays in
performing the examination and should also include any refusals by the member.
Access to After-Hours Care
Prestige members will have access to quality, comprehensive health care services twenty-four hours a
day, seven days a week (24/7). PCPs must have either an answering machine or an answering service for
members during after-hours for non-emergent issues. The answering service must forward calls to the
PCP or on-call provider, or instruct the member that the provider will contact the member within thirty
(30) minutes. When an answering machine is used after hours, the answering machine must provide the
member with a process for reaching a provider after hours. The after-hours coverage must be accessible
using the medical office’s daytime telephone number.
For emergent issues, both the answering service and answering machine must direct the member to call
911 or go to the nearest emergency room. Prestige will monitor access to after-hours care by conducting a
survey of PCP offices after normal business hours.
Monitoring Appointment Access and After-Hours Access
Prestige monitors appointment waiting times using various mechanisms, including:
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Reviewing provider records during the initial and triennial facility site review.
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Monitoring administrative complaints and grievances.
Conducting an annual Access to Care Survey to assess member access to daytime appointments
and after-hours care.
Non-compliant providers will be subject to corrective action and/or termination from the network.
A non-compliance letter will be sent to the provider.
The noncompliant provider will be re-surveyed within three (3) to six (6) months after the
infraction.
Cultural and Linguistic Requirements
Communication, whether in written, verbal, or "other sensory" modalities is the first step in the
establishment of the patient/ health care provider relationship. The key to ensuring equal access to
benefits and services for Limited English Proficiency (LEP), Low Literacy Proficiency (LLP) and sensory
impaired members is to ensure that our providers can effectively communicate with these members.
To ensure accurate, objective and confidential communication, Prestige never requires or suggests family,
friends or other unqualified individuals be utilized as interpreters. Prestige contracts with competent
interpreters and translators that utilize internal quality control measures to ensure the accuracy of the
language services provided.
This service provides a fast and easy way to communicate with our members with interpreters in more
than two hundred (200) languages that are available twenty-four hours a day, seven days a week (24/7).
Please call Member Services at 1-855-355-9800 to access this free service.
To ensure that all Prestige members are served in a way that is responsive to their cultural and linguistic
needs providers are required to:
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Provide Prestige members verbal and/or written notice (in their preferred language or format)
about their right to receive free language assistance services from Prestige.
o Note: The assistance of friends, family and bilingual staff is not considered competent,
quality interpretation services. These persons should not be used for interpretation
services except where a member has been made aware of his/her right to receive free
interpretation and continues to insist on using a friend, family member or bilingual staff
for assistance in his/her preferred language.
Post and offer easy-to-read member signage and materials in the languages of the common
cultural groups in your service area. Vital documents, such as patient information forms and
treatment consent forms, must be made available in other languages and formats.
Additionally, under the National Standards for Culturally and Linguistically Appropriate Service (CLAS),
as set forth by the U.S. Department of Health and Human Services. Prestige providers are strongly
encouraged to:
•
Provide effective, understandable and respectful quality care and services that are responsive to
diverse cultural health beliefs and practices, preferred languages, health literacy and other
communication needs.
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Implement strategies to recruit, retain and promote a diverse office staff and organizational
leadership representative of the demographics in your service area.
Educate and train staff at all levels, across all disciplines, in the delivery of culturally and
linguistically appropriate services (CLAS).
Establish written policies to provide interpretive services for Prestige members upon request.
Routinely document preferred language or format (such as Braille, audio, or large type) in all
member medical records.
Prestige’s Cultural Competency Plan is outlined in Section XI of this manual. Providers may request a
full copy of the cultural competency plan free of charge by contacting Member Services at 1-855-3559800 or by visiting www.prestigehealthchoice.com.
Medical Record Requirements
Providers must follow the medical record standards outlined below, for each member’s medical record, as
appropriate:
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Include the member’s identifying information including name, member ID number, date of birth,
sex and legal guardianship (if any).
Each record will be legible and maintained in detail.
Include a summary of significant surgical procedures, past and current diagnoses or problems,
allergies, untoward reactions to drugs and current medications.
All records shall contain an immunization history.
All entries will be dated and signed by the appropriate party.
All entries will indicate the chief complaint or purpose of the visit, the objective findings,
diagnoses, medical findings or impression of the provider.
All entries will indicate studies ordered (e.g., laboratory, X-ray, EKG) and referral reports.
All entries will indicate therapies administered and prescribed.
All entries will include the name and profession of the provider rendering services (e.g., MD, DO,
OD), including the signature or initials of the provider.
All entries will include the disposition, recommendations, instructions to the member, evidence of
follow-up and outcome of services.
All records will contain an immunization history.
All records will contain information relating to the member’s use of tobacco products, alcohol,
and drugs/substance abuse.
All records will contain summaries of all emergency services and care and hospital discharges
with appropriate medically indicated follow-up.
Include all services provided. Such services must include, but not necessarily be limited to,
family planning services, preventive services and services for the treatment of sexually
transmitted diseases.
All records will reflect the primary language spoken by the member and any translation needs of
the member.
All records will identify members needing communication assistance in the delivery of health
care services.
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•
•
•
•
•
•
•
•
•
All records will contain documentation that the member was provided with written information
concerning the member’s rights regarding advance directives (written instructions for living will
or power of attorney) and whether or not the member has executed an advance directive. Neither
Prestige, nor any of its providers will, as a condition of treatment, require the member to execute
or waive an advance directive.
Copies of any advance directives executed by the member.
Include copies of any consent or attestation form used or the court order for prescribed
psychotherapeutic medication for a child under the age of thirteen (13).
Include documentation regarding missed/canceled appointments.
Include an update of medications at each visit, including any changes in prescription and nonprescription medication with name and dosage.
Diagnostic or therapeutic intervention as part of clinical research is clearly contracted with entries
regarding provision of non-research related care.
When proposed course of treatment involves risks, there is evidence of discussion with member
regarding risks, alternatives incorporated into the clinical record.
Document referral services in the member’s medical/case record.
Include copies of Pre-admission Screening and Resident Review (PASRR) and evaluations
competed in accordance with rule 59G-1.040, F.A.C. for members admitted to or residing in a
nursing facility under any provision of this contract.
Providers must maintain medical records for at least ten (10) years from the close of the Agency Contract
and retained further if the records are under review or audit until the audit or review is complete. Prior
approval for the disposition of records must be requested and approved by Prestige if the provider
contract is continuous.
Providers are required to adhere to the requirements of 42 CFR Part 431, Subpart F, in safeguarding the
confidentiality of member medical records.
Ensure compliance with the privacy and security provisions of the Health Insurance Portability and
Accountability Act (HIPAA).
Ensure the confidentiality of medical/case records in accordance with 42 CFR, Part 431, Subpart F.
A member or authorized representative shall sign and date a release form before any clinical or case
records can be released to another party. Clinical/Case record release shall occur consistent with state and
federal law.
Providers are also required to comply with the privacy and security provisions of HIPAA; and are further
required to maintain the confidentiality of a minor’s consultation, examination and treatment for a
sexually-transmitted disease, in accordance with s. 384.30(2) F.S.
Provider Communications Compliance
Providers must comply with the following requirements:
•
Providers may display health-plan specific materials in their offices.
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•
•
•
•
•
Providers may not orally or in writing compare benefits or provider networks among health plans,
other than to confirm whether they participate in a health plan’s network.
Providers may announce a new affiliation with a health plan and give their patients a list of health
plans with which they contract.
Providers may co-sponsor events, such as health fairs, and advertise with Prestige, such as
television, radio, posters, flyers and print advertisement, only after approval from the Agency.
Providers are not permitted to furnish lists of their Medicaid patients to Prestige or any other
Medicaid health plan with which they contract, or any other entity, nor can providers furnish
other health plan’s membership lists to Prestige, nor can providers assist with Prestige enrollment.
Providers may distribute information about non-health-plan-specific health care services and the
provision of health, welfare and social services by the State of Florida or local communities as
long as any inquiries from prospective members are referred to the member services section of
the Plan or the Agency’s choice counselor/enrollment broker.
Provider Contract Terminations
Prestige Provider Agreements specify provider contract termination requirements in compliance with
Agency requirements. Provider terminations are categorized as follows:
•
•
•
•
Provider Initiated
Plan Initiated “For Cause”
Plan Initiated “Without Cause”
Mutual
Aside from those requirements identified in the Provider Agreement, Prestige will comply with the
following guidelines, based on category of termination.
Provider-Initiated Termination
• The Provider must provide ninety (90) days notification, or unless otherwise agreed to in writing,
to Prestige of intent to terminate from the Prestige network by certified mail, hand delivered or
faxed letter with authorized signature.
• If the provider is a PCP, Prestige will send a written notification to the Bureau of Managed Care
(BMHC) and effected members who have chosen the provider as their PCP no less than fifteen
(15) calendar days after receipt of the termination notice.
• For other provider types, Prestige will send written notification to BMHC.
• If a Prestige member has a prior authorized, on-going course of treatment with a provider who
becomes unavailable to continue to provide services, (such as resulting from contract
termination), Prestige will notify the member in writing within ten (10) calendar days from the
date Prestige becomes aware of the unavailability.
• Unless otherwise agreed to by Prestige, the effective date of the termination will be on the last
day of the month.
Prestige Initiated “For Cause” Termination
Prestige may initiate termination when the provider fails to abide by the material terms and conditions of
the Agreement, or in the sole discretion of the Agency, the provider fails to come into compliance with
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the Agreement within fifteen (15) calendar days after receipt of notice from Prestige specifying such
failure and requesting such provider abide by the terms and conditions thereof. Prestige will:
•
•
•
Send applicable termination letters by certified mail or by other means as noted in the Network
Provider Agreement.
Notify provider, BMHC and Medicaid Program Integrity (MPI) immediately in cases where a
Prestige Plan member’s health is subject to imminent danger or a physician's ability to practice
medicine is effectively impaired by an action by the Board of Medicine or other governmental
agency.
Provide BMHC with reason(s) for termination for cause.
Prestige Initiated “Without Cause” Termination
Prestige may initiate a “without cause” termination for various reasons (e.g., provider relocation, going
out of business). Prestige will:
•
•
•
Send applicable termination letters by certified mail or Express Mail Delivery.
Notify Prestige Network provider, BMHC and members in active care at least sixty (60) calendar
days before the effective date of the termination (when feasible.).
Offer coordination of care to transition members to new providers.
Mutually-Agreed Upon Terminations
Prestige and a provider may mutually agree to terminate their contractual relationship, whereby the
effective date of termination is agreed upon by both parties. The termination date may be other than the
required days’ notice specific to the Prestige Network’s Provider Agreement language.
•
•
•
All mutual termination letters require signatures by both parties.
Regarding mutual terminations of any Prestige Network Provider Agreement, the termination
date should provide a minimum number of required days in order to provide notice to members.
A mutual agreement termination date should not be a retroactive date.
Prestige will notify BMHC and members in active care at least sixty (60) calendar days before the
effective date of the termination.
Continuity of Care
Unless the provider has been terminated for cause, Prestige members who are in active treatment will be
allowed to continue care with a terminated treating provider:
•
•
Through completion of treatment for a condition for which the member was receiving care at the
time of the termination.
Until the member changes to a new provider.
Note: None of the above may exceed six (6) months after the termination of the provider's contract.
Prestige will allow pregnant members who have initiated a course of prenatal care, regardless of the
trimester in which care was initiated, to continue care with a terminated treating provider until completion
of postpartum care.
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Notwithstanding the provisions in this section, a terminated provider may refuse to continue to provide
care to a member who is abusive or noncompliant.
For continued care, Prestige and the terminated provider will continue to abide by the same terms and
conditions as outlined in the Network Provider Agreement and in the Quality section of this publication.
For members new to Prestige, the continuity of care period is defined as a period of sixty (60) days after
the effective date of enrollment, or until the enrollee's PCP or behavioral health provider (as applicable to
medical care or behavioral health care services, respectively) reviews the enrollee's treatment plan,
whichever comes first. During this period, Prestige will cover any ongoing course of treatment (services
that were previously authorized or prescheduled prior to the enrollee’s enrollment in the plan) with the
recipient’s provider, even if that provider is not enrolled in the Prestige network.
In addition, the following services may be covered beyond the initial sixty (60) day continuity of care
period:
•
•
•
Prenatal and postpartum care
Transplant services (through the first year post-transplant)
Radiation and/or chemotherapy services (for the current round of treatment)
Please contact Provider Services concerning the approval process at 1-800-617-5727.
Closing of a Physician Panel
When requesting closure of a panel to new and/or transferring Prestige members, providers must:
•
•
•
Submit the request in writing at least sixty (60) days (or such other period of time provided in the
Agreement) prior to the effective date of closing the panel;
Maintain the panel to all Prestige members who were provided services before the closing of the
panel;
Provide documented evidence that the provider has closed or is requesting to close the panel of all
Medicaid plans the provider is contracted with, for the same period of time.
Provider-Initiated Request to Terminate a Member
A Prestige provider may not seek or request to terminate his/her relationship with a member, or transfer a
member to another provider of care, based upon the member’s medical condition, amount or variety of
care required, or the cost of covered services required by Prestige’s member.
Reasonable efforts should always be made to establish a satisfactory provider and member relationship in
accordance with practice standards. The provider should have three (3) documented attempts in the
member’s medical record to support his/her efforts to develop and maintain a satisfactory provider and
member relationship.
If a satisfactory relationship cannot be established or maintained due to member noncompliance, the
provider shall continue to provide medical care for the Prestige member until such time that written
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notification is received from Prestige stating that the member has been transferred from the provider’s
practice, and such transfer has occurred.
Potential Quality of Care Concerns
• All potential quality of care concerns are fully investigated.
• The Medical Director’s outcome determination of the quality of care concern may render a referral to
the Quality Improvement Committee (QIC) for further review. The QIC may recommend action
including, but not limited to, panel restriction or termination from Prestige’s network.
• If the concern is referred to the QIC, follow-up actions are conducted based on the QIC’s
recommendation(s), which may include sanctioning the practitioner/provider.
• If the QIC decision/recommendation includes any reportable action, the practitioner/provider’s case
information is reported to the National Practitioner Data Bank (NPDB), Healthcare Integrity and
Protection Data Bank (HIPDB), and State regulatory agencies as appropriate.
• The QIC reserves the right to impose any of the following actions based on its discretion:
• Require the practitioner/provider to submit a written description and explanation of the
quality of care event or issue, as well as the controls and/or changes that have been made to
processes to prevent similar quality issues from occurring in the future. In the event that the
practitioner/provider does not provide this explanation, the QIC reserves the right to impose
further actions.
• Conduct a medical record review audit.
• Require written documentation that the practitioner/provider agrees to conform to a
Corrective Action Plan which may include continued monitoring by Prestige to ensure that
adverse events do not continue. A Corrective Action Plan may also include provisions that
the practitioner/provider maintain an acceptable pass/fail score with regard to a particular
performance metric.
• Implement formal sanctions including dismissal from the Prestige network if the offense is
deemed an immediate threat to the well-being of Prestige members. Prestige also reserves the
right to impose formal sanctions if the practitioner/provider does not agree to abide by any of
the corrective actions listed above.
• Based on the recommendation(s) of the QIC, the practitioner/provider is notified by letter of the
concern and the actions recommended by the QIC, including an appropriate time period within which
the practitioner/provider must conform to the recommended action.
o The letter is clearly marked: CONFIDENTIAL: PRODUCT OF PEER REVIEW.
o Repeated non-conforming behavior will subject the practitioner/provider to a second
notification letter and potential suspension of panel/authorizations pending additional
investigation.
o Failure to conform thereafter is considered grounds for the initiation of the formal sanctioning
process described below.
• In the event that health care services rendered to a member by a practitioner/provider represent a
serious deviation from, or repeated non-compliance with, recognized treatment patterns or standard(s)
of care of the organized medical community or Prestige’s quality standards, as determined by the
QIC, Prestige’s Medical Director may immediately initiate the formal sanctioning process described
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•
below. Prestige sends the practitioner/provider a letter via certified mail or another means providing
for evidence of receipt, informing him/her of:
o The decision to initiate the formal sanctioning process which may include suspension of
panel/authorizations pending additional investigation and/or termination.
o The proposed action and reason for such action.
o The practitioner/provider’s appeal rights.
Formal Sanctioning Process
o Notice of Proposed Professional Review Action – Following a determination to initiate the
formal sanctioning process, Prestige sends the practitioner/provider written notification of the
following by certified mail or via another means providing for evidence of receipt:
• That a Professional Review Action has been proposed to be taken against the
practitioner/provider.
• The reason(s) for proposed action.
• That the practitioner/provider has the right to request a hearing on the proposed
action.
• That the practitioner/provider has thirty (30) days following receipt of notification
within which to submit a written request for a hearing; otherwise, the right to a
hearing will be forfeited. The practitioner/provider must submit the hearing request
by certified mail, and must state what section(s) of the proposed action he/she wishes
to contest.
• A summary of practitioner/provider rights in the hearing.
• The practitioner/provider may waive his/her right to a hearing.
o Notice of Hearing – If the practitioner/provider requests a hearing within in a timely manner
in accordance with Section 8.a, the practitioner/provider will be notified of the following in
writing:
• The place, date, and time of the hearing, which date shall not be less than thirty (30)
days after the date of the notice.
• The practitioner/provider has the right to request postponement of the hearing, which
may be granted for good cause as determined by the Prestige Medical Director and/or
upon advice of Prestige’s Legal Affairs Department.
• A list of witnesses (if any) expected to testify at the hearing on behalf of Prestige.
o Conduct of the Hearing and Notice – The hearing shall be held before:
• A panel of individuals appointed by Prestige (the Hearing Panel).
• Individuals on the Hearing Panel will not be in direct economic competition with the
practitioner/provider involved, nor will they have participated in the initial decision
to propose sanctions.
• The Hearing Panel will be composed of physician members of Prestige’s qualityrelated committees, Prestige’s Medical Director and other physicians and
administrative persons affiliated with Prestige as deemed appropriate by Prestige’s
Medical Director, such as legal counsel.
• Prestige’s Medical Director serves as the hearing officer.
• The right to the hearing will be forfeited if the practitioner/provider fails, without
good cause, to appear.
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•
o Practitioner/Provider’s Hearing Rights – The practitioner/provider has the right:
• To representation by an attorney or other person of the practitioner/provider’s choice.
• To have a record made of the proceedings (copies of which may be obtained by the
practitioner/provider upon payment of reasonable charges associated with the
preparation).
• To call, examine, and cross-examine witnesses.
• To present evidence determined to be relevant by the hearing officer, regardless of its
admissibility in a court of law.
• To submit a written statement at the close of the hearing.
• To receive the written recommendation(s) of the Hearing Panel within fifteen (15)
working days of completion of the hearing, including statement of the basis for the
Hearing Panel’s recommendation(s), which will be provided by certified mail or via
another means providing for evidence of receipt.
• To receive Prestige’s written decision within sixty (60) days of completion of the
hearing, including the basis for Prestige’s decision(s), which will be provided by
certified mail or via another means providing for evidence of receipt.
o Appeal of Prestige Decision – The practitioner/provider may request an appeal after the final
decision of Prestige:
• The practitioner/provider must submit a written appeal by certified mail or via
another means providing evidence of receipt, within thirty (30) days of the receipt of
Prestige’s decision, otherwise the right to appeal is forfeited.
• Written appeal will be reviewed and a decision rendered by Prestige’s QIC within
forty-five (45) days of receipt of the notice of the appeal.
o Summary Actions Permitted – The following summary actions can be taken, without the
need to conduct a hearing, by the Chief Executive Officer (CEO), President or the Medical
Director:
• Suspension or restriction of Prestige participation status for up to fourteen (14) days,
pending an investigation to determine the need for Professional Review Action.
• Immediate suspension or revocation, in whole or in part, of panel membership or
participating practitioner/provider status, subject to subsequent notice and hearing
when failure to take such action may result in immediate danger to the health and/or
safety of any individual. A hearing will be held within thirty (30) days of this action
to review the basis for continuation or termination of this action.
Adverse Action Reporting –In accordance with Title IV of Public Law 99-660, the Health Care
Quality Improvement Act of 1986, with governing regulations codified at 45 CFR Parts 60 and 61
Prestige reports Adverse Actions against the practitioner/provider in which Prestige is the prevailing
party.
o The manual identifying the NPDB/HIPDB reporting instructions is kept in the Credentialing
Department.
o Prestige’s Credentialing Department reports to the appropriate State Board of Medical or
Dental Examiners, as appropriate, and to HIPDB the following, in accordance with the
procedure set out in Section 9.c.
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•
•
Any adverse action that adversely affects Prestige participation status of a
practitioner/provider for a period longer than thirty (30) days.
• Prestige’s acceptance of the surrender of Prestige participation status or any
restriction of such participation status by a practitioner/provider:
o While the practitioner/provider is under investigation by Prestige relating to
possible incompetence or improper professional conduct; or
o In return for not conducting such an investigation or proceeding.
• Civil judgments against the practitioner/provider in which Prestige is the prevailing
party and other adjudicated actions or decisions, whether or not the
practitioner/provider availed itself of the hearing procedures outlined.
• Other adjudicated actions or decisions, and their bases, as promulgated by the
HIPDB/NPDB.
o Upon advice from Prestige’s Legal Counsel and at the direction of the Prestige Medical
Director, Prestige’s Credentialing Department reports:
• Adverse actions to the State Board of Medical or Dental Examiners, as appropriate,
within fifteen (15) days from the date the adverse action was taken; and
• Other adjudicated actions and decisions to HIPDB within thirty (30) days from the
date of the final action or decision.
All review outcomes, including actionable information, are incorporated in the practitioner/provider
credentialing file and database.
Provider Services 1-800-617-5727
Prestige operates a toll-free telephone line to respond to your questions, comments and inquiries. Provider
services representatives strive to respond to your inquiries thoroughly and in a timely manner. If our
representative is unable to resolve your concern and you do not agree with a decision, please follow the
provider dispute process below.
Provider Dispute Process
At Prestige, we value our relationship with our providers. We understand that you may not always agree
with a decision; therefore, we have provided a process to dispute the decision.
Note: If specific contract wording differs from the guidelines below, the contract takes precedent.
For authorization request denials based on lack of medical necessity (where a Notice of Action
letter is mailed to the provider and member).
If you receive an authorization request denial from Prestige, you have forty-five (45) calendar days from
the date of the Notice of Action (NOA) to request reconsideration as follows:
1.
2.
3.
Contact Prestige Utilization Management at 1-855-371-8074 and request reconsideration.
Fax a request for reconsideration along with additional clinical information to 1-855-236-9285.
Please include the reference number from the NOA letter on your fax cover sheet.
Requests for reconsideration will be reviewed by the original clinical review team.
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4.
5.
6.
7.
8.
During the reconsideration process, the provider may request a peer-to-peer discussion by
contacting Prestige Utilization Management at 1-855-371-8074. Be prepared to provide a
convenient time to receive a call from the Prestige Medical Director.
If our decision is to overturn the original denial, Prestige Utilization Management will notify of
the approval and provide an authorization number. You should expect a response within fourteen
(14) calendar days from the date we receive your reconsideration request.
If our decision is to uphold the original denial, Prestige Utilization Management will notify of the
upheld denial. You should expect a response within fourteen (14) calendar days from the date we
receive your reconsideration request.
If you still disagree with our decision, you have the right to file an appeal on the member’s
behalf. The appeal will require the member’s signature (for hospital claims we will accept the
member’s signature on the hospital admission consent forms). You may file the appeal on the
member’s behalf within thirty (30) days of notification of the upheld denial decision.
A. If you file an appeal on the member’s behalf, this is a considered a member appeal and
will be reviewed by a different clinical review team of the same or similar specialty within
thirty (30) calendar days of receipt of the member appeal and signature.
i.
Please send your appeal request to Prestige Appeals and Grievances Department:
PO Box 7368
London, KY 40742
1-855-371-8078 (phone)
1-855-358-5847 (fax)
B. If our decision is to overturn the original authorization request denial, Prestige Utilization
Management will issue an authorization and you may perform the service (if not already
performed/provided) and submit an appropriate claim.
C. The Agency has contracted with MAXIMUS, an independent dispute resolution
organization, to provide assistance to health care providers and health plans for resolving
claim disputes. If you disagree with our decision to uphold the original claim denial, you
may contact MAXIMUS at 1-866-763-6395.
If you do not file a request for reconsideration, you can file an appeal on the member’s behalf as
outlined in 7.A. above. You have thirty (30) days from the date of the Notice of Action (NOA).
Claims Denial When an Authorization is not Requested or Obtained – Professional Claims
You have the right to file an appeal on the member’s behalf with the member’s signature within thirty
(30) calendar days of the date of the claim decision. For hospital claims, we will accept the member’s
signature on the hospital admission consent forms.
1.
Please send your appeal request to Prestige Appeals and Grievances Department:
Attn: Grievance and Appeals Department
PO Box 7368
London, KY 40742
1-855-371-8078 (phone)
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2.
1-855-358-5847 (fax)
Your request will be reviewed within thirty (30) calendar days from the date we receive the appeal
request.
A. If our decision is to overturn the original claim denial, Prestige Utilization Management
will issue an authorization and the claim will be reprocessed.
B. If our decision is to uphold the original claim denial, you may contact Maximus if you
still disagree.
Claims Denial When an Authorization is not Requested or Obtained – Institutional Claims
1. Within one hundred eighty (180) calendar days of the admission date, Prestige will accept your
request for initial consideration. Please fax notice of admission and all applicable medical records to
Prestige Utilization Management at 1-855-236-9286. If your request meets medical necessity
guidelines, an authorization will be issued and you may proceed with resubmitting your claim. If
medical necessity is not met, an NOA letter will be issued. Follow the steps in Authorization Request
Denials.
2. After one hundred eighty (180) calendar days from the admission date, you may file an appeal on the
member’s behalf by following the steps below:
A. You have the right to file an appeal on the member’s behalf with the member’s signature
within thirty (30) calendar days of the date of the claim decision. For hospital claims, we will
accept the member’s signature on the hospital admission consent forms.
B. Please send your appeal request to Prestige Appeals and Grievances Department:
PO Box 7368
London, KY 40742
1-855-371-8078 (phone)
1-855-358-5847 (fax)
C. Your request will be reviewed within thirty (30) calendar days from the date we receive the
appeal request.
D. If our decision is to overturn the original claim denial, Prestige Utilization Management will
issue an authorization and the claim will be reprocessed.
E. The Agency has contracted with MAXIMUS, an independent dispute resolution organization,
to provide assistance to health care providers and health plans for resolving claim disputes. If
you disagree with our decision to uphold the original claim denial, you may contact
MAXIMUS at 1-866-763-6395.
Claims Denial When an Authorization was Received/Obtained
Send the denied claim to Prestige Provider Complaints within one hundred twenty (120) calendar days of
the claim denial date. Prestige Provider Complaints Department will review and make a determination
within ninety (90) calendar days from the receipt of your request.
1.
Please send these requests to:
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Attn: Provider Complaints Department
PO Box 7366
London, KY 40742
1-800-617-5727 (phone)
1-305-718-1100 ext. 18427
1-855-358-5853 (fax)
2.
3.
If an authorization can be matched to the claim (i.e., date of service span or CPT/HCPCS codes),
Prestige Provider Complaints will forward to our Claims Department for reprocessing and
Prestige will inform you via a resolution letter.
If an authorization cannot be matched to the claim, the request will be forwarded to Prestige
Utilization Management for review.
A. If the authorization can be adjusted, Prestige Utilization Management will reprocess the
claim and Prestige will inform you via a resolution letter.
B. If the authorization cannot be adjusted, the denial will be upheld and Prestige will inform
you via a resolution letter. The Agency has contracted with MAXIMUS, an independent
dispute resolution organization, to provide assistance to health care providers and health
plans for resolving claim disputes. If you disagree with our decision to uphold the original
claim denial, you may contact MAXIMUS at 1-866-763-6395.
Underpaid or Denied Claims for Non-Clinical Reasons (Both Institutional and Professional)
1. If you are submitting your request without the member’s signature, submit within one hundred twenty
(120) calendar days of the date of the claim denial and it will be processed by the Provider
Complaints Department as a provider complaint.
A. Please send these requests to:
PO Box 7366
London, KY 40742
1-800-617-5727 (phone)
1-305-718-1100 ext. 18427
1-855-358-5853 (fax)
B. If determined that the claim was paid incorrectly, the Prestige Provider Complaints
Department will forward to the Prestige Claims Department for adjustment. You will be
notified of this via a resolution letter within ninety (90) calendar days of receipt of the
provider complaint.
C. If determined that the original claim was paid correctly by Prestige, the claim decision is
upheld and you will be notified of this via a resolution letter within ninety (90) calendar days
of receipt of the provider complaint.
D. The Agency has contracted with MAXIMUS, an independent dispute resolution organization,
to provide assistance to health care providers and health plans for resolving claim disputes. If
you disagree with our decision to uphold the original claim denial, you may contact
MAXIMUS at 1-866-763-6395.
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2. If submitting your request with the member’s signature, submit within thirty (30) calendar days of the
date of the claim denial and it will be handled by the Prestige Appeals and Grievances Department as
a member appeal.
A. Please send these requests to:
PO Box 7368
London, KY 40742
1-855-371-8078 (phone)
1-855-358-5847 (fax)
B. If determined that the claim was paid incorrectly, the Prestige Appeals and Grievances
Department will forward to the Prestige Claims Department for adjustment. You will be
notified of this via a resolution letter within thirty (30) calendar days of receipt of the member
appeal.
C. If determined that the original claim was paid correctly by Prestige, the claim decision is
upheld and you will be notified of this via a resolution letter within thirty (30) calendar days
of receipt of the member appeal.
The Agency has contracted with MAXIMUS, an independent dispute resolution organization, to provide
assistance to health care providers and health plans for resolving claim disputes. If you disagree with our
decision to uphold the original claim denial, you may contact MAXIMUS at 1-866-763-6395.
For all other complaints, please submit your request to the Prestige Provider Complaints
Department at the following location:
PO Box 7366
London, KY 40742
1-800-617-5727 (phone)
1-305-718-1100 ext. 18427
1-855-358-5853 (fax)
Please see Section VII for more details on Member Complaints, Grievances and Appeals.
Provider Communications
Providers will receive or have access to regular communications from Prestige including, but not limited
to, policies, procedures and guidelines, operations, roles and responsibilities and education opportunities.
Communications will be available either in hard copy format and/or electronically and include, but are not
limited to the following:
•
•
•
•
•
Provider manual
Provider newsletters
Website postings
Provider bulletins
Surveys
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•
•
•
•
Forms
Faxes
E-mails
Miscellaneous printed materials
Risk Management
Prestige recognizes the importance of minimizing risks to members during the provision of health care
services. In order to achieve this goal, Prestige utilizes a formal risk management program. The purpose is
to promote the delivery of optimal and safe health care for members. The program allows objective
monitoring, evaluation and correction of situations that may occur in the administration and delivery of
health care services.
Provider Responsibilities
Providers must report all adverse or untoward incidents involving members, which occur in a clinical
setting to Prestige’s Risk Manager within twenty-four (24) hours. The following is a list of types of
“incidents” that would require reporting to Prestige’s Risk Manager:
For reporting purposes the State of Florida defines “adverse or untoward incident” as an event over which
healthcare personnel could exercise control and:
•
•
•
•
•
•
•
Is more probably associated in whole or in part with medical intervention rather than the
condition for which such intervention occurred; and
Is not consistent with or expected to be a consequence of such medical intervention; or
Occurs as a result of medical intervention to which the patient has not given his informed
consent; or
Occurs as a result of any other action or lack thereof on the part of the facility or personnel of the
facility; or
Results in a surgical procedure being performed on the wrong patient; or
Results in a surgical procedure unrelated to the patient’s diagnosis or medical needs being
performed on any patient; and
Causes injury to a patient. Injury is defined as any of the following outcomes when caused by an
adverse incident:
o Death; or
o Brain damage; or
o Spinal damage; or
o Permanent disfigurement; or
o Fracture or dislocation of bones or joints; or
o A resulting limitation of neurological, physical or sensory function which continues after
discharge from the facility; or
o Any condition that requires specialized medical attention or surgical intervention resulting
from non-emergency or medical intervention, other than an emergency medical condition, to
which the patient has not given his/ her informed consent; or
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Any condition that requires the transfer of the patient, within or outside the facility, to a unit
providing a more acute level of care due to the adverse incident, rather than the patient’s
condition prior to the adverse incident; or
o Performance of a surgical procedure on the wrong patient; or
o A wrong surgical procedure; or
o A wrong-site surgical procedure; or
o A surgical procedure otherwise unrelated to the patient’s diagnosis or medical condition; or
o Requires the surgical repair of damage resulting to a patient from a planned surgical
procedure, where the damage was not a recognized specific risk, as disclosed to the patient
and documented through the informed-consent process; or
o Procedure to remove unplanned foreign objects remaining from a surgical procedure; or
o Nosocomial infections that require specialized medical attention.
Any adverse or untoward incidents occurring in a physician’s office that results in the following
must be reported to the Risk Management Department within twenty-four (24) hours of the
occurrence:
o The death of a patient; or
o Severe brain or spinal damage to a patient; or
o Surgical procedure being performed on the wrong patient; or
o A surgical procedure unrelated to the patient’s diagnosis or medical needs being performed
on any patient and including nosocomial infections requiring treatment involving a surgical
procedure.
o
•
Provider Procedures for Critical/Adverse Incident Reporting
Providers are responsible, beginning September 1, 2013, to report serious member injuries as noted on the
Confidential Code 15 Report within twenty-four (24) hours after the incident as outlined on the website at
www.prestigehealthchoice.com and the provider manual.
Providers will be trained on reporting requirements and timeframes for critical adverse incidents, abuse,
neglect and exploitation by Provider Network Management upon initial orientation with Prestige and at
monthly visits.
The risk management program has processes to comply with contractual and reporting requirements.
The risk manager will report allegations of abuse, neglect and exploitation of members within twenty-four
(24) hours of learning of the incident to the Department of Children and Families for children and Florida
Adult Protective Services for elders and individuals with disabilities.
The Compliance Department will keep separate, confidential electronic files and/or paper records of
investigations of alleged abuse, neglect and exploitation of elders and individuals with disabilities.
The risk manager will prepare and submit the Critical Incident Summary Report by the 15th calendar day
of the month following the report month.
The risk manager will report critical /adverse incidents beginning January 1, 2014 immediately upon a
critical incident occurrence and no later than twenty-four (24) hours following detection or notification.
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All potential quality of care concerns will be investigated by the quality department.
For complete information on adverse incident reporting, please visit the Plan website at
www.prestigehealthchoice.com.
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SECTION III
MEMBER BENEFITS
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III. Member Benefits
A listing of Prestige covered benefits may be found on the website at www.prestigehealthchoice.com.
Prestige covered benefits will never be less than the benefits outlined in the Florida Medicaid Coverage
and Limitations Handbooks and the Provider Reimbursement Handbooks.
The following listing of covered services is provided as a brief overview:
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Advanced Registered Nurse Practitioner Services
Ambulatory Surgical Center Services
Assistive Care Services
Behavioral Health Services
Birth Center Services and Licensed Midwife Services
Child Health Check-up Services
Chiropractic Services
Clinic Services, inclusive of Rural Health Centers, Community Behavioral Health Centers,
County Health Department Services, and Federally Qualified Health Centers
Dental Services
Renal Dialysis Services
Emergency Services
Emergency Behavioral Health Services
Family Planning Services and Suppliers
Healthy Start® Services
Hearing Services
Home Health Care Services and Nursing Care
Hospice
Hospital Services, including medically necessary transplants and related services
Immunizations
Laboratory and Imaging Services
Durable Medical Equipment (DME), Medical Supplies, Prosthetics and Orthotics
Optometric and Vision Services
Physician, Physician Assistant Services, and Advanced Registered Nurse Practitioner Services
Podiatry Services
Prescribed Drugs Services
Targeted Case Management
Therapy Services
Transplant Services
Transportation Services
Prestige Expanded Benefits
Expanded Benefits are Agency approved services that are additional benefits specified in the AHCA
Contract. These expanded benefits may be subject to medical necessity and prior authorization. For more
information on expanded benefits, please visit www.prestigehealthchoice.com.
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Non-Covered Services
Prestige will provide services which are identified as a covered service, in accordance with the AHCA
Contract, Coverage and Limitations Handbooks and/or Provider General Handbook and the Medicaid Fee
Schedules.
A provider must inform the recipient of their responsibility for the payment of any services received that
are not covered by Medicaid. The provider must discuss this with the member prior to rendering the
service and include documentation of this conversation in the member’s medical record.
Emergency Services
Prestige is available for emergency services and care inquiries twenty-four hours a day, seven days a
week (24/7) for members and caregivers. You may contact our 24-Hour Nurse Call Line at 1-855-3985615.
Prestige does not deny claims for emergency services and care received at a hospital due to lack of
parental consent. In addition, Prestige does not deny payment for treatment obtained when a
representative of Prestige instructs the member to seek emergency services and care in accordance with s.
743.064, F.S. Prestige provides emergency services and care without any specified dollar limitations.
Emergency services and care under Prestige will not:
•
•
•
•
Require prior authorization for a member to receive pre-hospital transport or treatment for
emergency services or care.
Specify or imply that emergency services and care are covered by Prestige only if secured within
a certain period of time.
Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is
covered.
Deny payment based on a failure by the member or the hospital to notify Prestige before, or
within a certain period of time after, emergency services and care were given.
Prestige covers pre-hospital and hospital-based trauma services and emergency services and care to
members. When a member presents at a hospital seeking emergency services and care, the determination
that an emergency medical condition exists is to be made, for the purposes of treatment, by a physician of
the hospital or, to the extent permitted by applicable law, by other appropriate personnel under the
supervision of a hospital physician.
•
•
•
The physician or the appropriate personnel must indicate on the member's chart the results of all
screenings, examinations and evaluations.
Prestige covers all screenings, evaluations and examinations that are reasonably calculated to
assist the provider in arriving at the determination as to whether the member's condition is an
emergency medical condition.
If the provider determines that an emergency medical condition does not exist, Prestige is not
required to cover services rendered subsequent to the provider's determination unless authorized
by the Plan.
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If the provider determines that an emergency medical condition exists, and the member notifies the
hospital, or the hospital emergency personnel otherwise have knowledge that the patient is a member of
the Plan, the hospital must make a reasonable attempt to notify:
•
•
The member's PCP, if known; or
Prestige, if the Plan has previously requested in writing that it be notified directly of the existence
of the emergency medical condition.
If the hospital, or any of its affiliated providers, do not know the member's PCP, or have been unable to
contact the PCP, the hospital must:
•
•
Notify Prestige as soon as possible before discharging the member from the emergency care area;
or
Notify Prestige within twenty-four (24) hours or on the next business day after the member’s
inpatient admission.
Prestige will cover any medically necessary duration of stay in a non-contracted facility which results
from a medical emergency until such time as Prestige can arrange to safely transport the member to a
participating facility. Prestige may transfer the member, in accordance with state and federal law, to a
participating hospital that has the service capability to treat the member's emergency medical condition.
Notwithstanding any other state law, a hospital may request and collect from a member any insurance or
financial information necessary to determine if the patient is a member of Prestige, in accordance with
federal law, so long as emergency services and care are not delayed in the process.
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SECTION IV
UTILIZATION MANAGEMENT
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IV. Utilization Management
Prestige Utilization Management establishes a process for implementing and maintaining an effective and
efficient utilization management system. Utilization Management activities are designed to assist our
providers with the organization and delivery of appropriate health care services to members within the
structure of the member benefit plan.
Under their participating provider agreements with Prestige, providers are required to comply fully with
medical management programs administered by Prestige and its agents, including:
•
•
•
•
•
Obtaining authorizations and/or providing notifications, depending upon the requested service.
Providing clinical information to support medical necessity when requested.
Permitting access to the member's medical information.
Including Prestige’s medical management nurse in discharge planning discussions and meetings.
Providing a plan of treatment, progress notes and other clinical documentation as required.
Anticipated Care Program (Prior Authorization)
Prior authorization is processed through Prestige’s Anticipated Care Program. The most up-to-date listing
of services requiring prior authorization will be maintained in the provider portal at
www.prestigehealthchoice.com.You may also request a listing by contacting Provider Services at 1-800617-5727. Providers may request prior authorization by contacting Utilization Management at 1-855-3718074 or by sending a fax request for authorization to 1-855-236-9285.
Concurrent Review and Discharge Planning
As an admitting physician, please note you need to work carefully to establish medical necessity for the
admission and for the continued inpatient stay based on clinical information provided to Prestige by the
facility. If medical necessity is established, an authorization will be issued to the facility for the days
where medical necessity is met. Please note that a finding of lack of medical necessity for the inpatient
stay or any part thereof will result in claims denials for both the facility and admitting physician.
The admitting physician is further responsible for assistance with discharge planning to the next level of
care for the member.
Prior Authorization Specific to Pregnancy-Related Services
Pregnancy Notification/Global OB Authorization
All OB care requires a Global OB Notification/Authorization in order for proper and expedient payment
to be made to OB providers. Once approved this authorization includes three (3) OB ultrasounds, labor
checks with place of service, all regularly scheduled pre-natal visits and all post-delivery follow up
appointments. In addition, for high risk pregnancies, unlimited ultrasounds are allowed if provided by
network Maternal/Fetal Medicine specialists.
For the member, this authorization initiates Prestige Care Management follow up from a team who works
closely with pregnant members. Incentives have been developed specifically for these members to ensure
they are keeping up with all of their pre-natal and follow up visits.
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The Pregnancy Notification/OB Care Global Authorization Form is located at
www.prestigehealthchoice.com and can be faxed to Prestige Bright Start® Department at 1-855-358-5852
or submitted on-line via the secure provider portal at www.availity.com.
Services Requiring Prior Authorization
Prior Authorization is required for select elective emergency or non-emergency services as designated by
Prestige. Guidelines for prior authorization requirements by service type may be found in the Prior
Authorization Reference Guide at www.prestigehealthchoice.com.
Prior authorization allows for efficient use of coordinated services and ensures that members receive the
most appropriate level of care, within the most appropriate place of service. Prior authorization may be
obtained by the member’s PCP, treating specialist or facility.
Reasons for requiring prior authorization may include:
•
•
•
•
Review for medical necessity;
Ensure services are coordinated with appropriate provider;
Appropriateness of place of service; and/or
Case and disease management considerations.
Some prior authorization guidelines to note are:
•
•
The prior authorization request should include the diagnosis to be treated and the CPT
and HCPCS code describing the anticipated procedure. If the procedure performed and billed is
different from that on the request, but within the same family of services, a revised authorization
is not required.
An authorization may be given for a series of visits or services related to an episode of
care. The authorization request should outline the plan of care including the frequency
and total number of visits requested and the expected duration of care.
Emergency room admission and related services do not require prior authorization. If procedural request
is not listed, please refer to the website for additional instructions.
Services Requiring Notification
•
•
•
•
Outpatient care (includes forty-eight (48) hour observations)
Normal newborn deliveries
Hospice
All inpatient admissions
Exceptions to Prior Authorization
For a list of services that do not require prior authorization review, please refer to the Authorization
Reference Guide at www.prestigehealthchoice.com.
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Standard Authorization Decisions
Prestige will notify the provider and give the member written notice of any decision to deny a service
authorization request, or to authorize a service in an amount, duration, or scope that is less than requested.
For standard authorization decisions, Prestige will:
•
•
Provide notice as expeditiously as the member’s health condition requires.
Provide notice within no more than seven (7) calendar days following receipt of the request for
service.
The time frame can be extended up to seven (7) additional calendar days if:
•
•
The provider or the member requests an extension; or
Prestige justifies the need for additional information and how the extension is in the member’s
interest.
Expedited Authorization Decisions
Prestige will expedite authorization when a provider indicates, or Prestige determines, that following the
standard timeline could seriously jeopardize the member’s life, health or ability to attain, maintain, or
regain maximum function.
•
•
An expedited decision must be made no later than forty-eight (48) hours after receipt of the
request for service.
Prestige may extend two (2) business days for expedited requests, if the member requests an
extension or if Prestige justifies the need for additional information and how the extension is in
the member’s interest.
Medical Necessity Standards
Medically Necessary or Medical Necessity is defined as meeting the following conditions:
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•
•
•
•
Be necessary to protect life, to prevent significant illness or significant disability or to alleviate
severe pain.
Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or
injury under treatment and not in excess of the patient's needs.
Be consistent with the generally accepted professional medical standards as determined by the
Medicaid program, and not be experimental or investigational.
Be reflective of the level of service that can be furnished safely and for which no equally
effective and more conservative or less costly treatment is available statewide.
Be furnished in a manner not primarily intended for the convenience of the member, the
member's caretaker or the provider.
For those services furnished in a hospital on an inpatient basis, medical necessity means that appropriate
medical care cannot be effectively furnished more economically on an outpatient basis or in an inpatient
facility of a different type.
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The fact that a provider has prescribed, recommended or approved medical or allied goods or services
does not, in itself, make such care, goods or services medically necessary, a medical necessity or a
covered service/benefit.
Prestige uses the following screening tool for Utilization Management (UM) determinations related to
Medical Necessity:
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InterQual Adult ISD (Intensity of Service, Severity of Illness & Discharge Screens) Criteria
InterQual Pediatric ISD (Intensity of Service, Severity of Illness & Discharge Screens) Criteria
InterQual Outpatient Therapy Criteria
InterQual Home Care Criteria
InterQual Outpatient Procedures Criteria
InterQual Radiologic Procedure Criteria
InterQual DME Criteria
When applying UM Medical Necessity criteria, UM staff also considers the individual member factors
and the characteristics of the local health delivery system, including:
•
•
Member Considerations
o Age, comorbidities, complications, progress of treatment, psychosocial situation and
home environment
Local Delivery System
o Availability of sub-acute care facilities or home care in the Prestige service area for post
discharge support
o Prestige benefits for sub-acute care facilities or home care where needed
o Ability of local hospitals to provide all recommended services within the estimated length
of stay
The Prestige Medical Director will review service authorizations and confirm medical necessity based on
the Agency’s definition of medical necessity. Additional guidelines used in the review include, but are not
limited to, Apollo Managed Care Medical Review Criteria and Guidelines, Medicare LCD and NCD
Guidelines, and other nationally accepted and approved medical guidelines.
The decision to deny, limit the amount, scope and/or duration of a service will be made by the Prestige
Medical Director, or other designated practitioner under the clinical oversight of the Chief Medical
Officer.
At the discretion of the Prestige Medical Director, participating board-certified physicians from an
appropriate specialty, other qualified healthcare professionals or the requesting practitioner/provider may
provide offer input on a decision. The Prestige Medical Director makes the final decision.
Prestige will not arbitrarily deny or reduce the amount, duration, or scope of required services solely
because of the diagnosis, type of illness, or condition of the member.
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SECTION V
CASE MANAGEMENT
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V. Case Management
Integrated Care Management (ICM)
The Prestige ICM program integrates physical health, behavioral health and social/environmental aspects
of the member’s care into one plan of care. Care management employees include nurses and social
workers with backgrounds and expertise in behavioral health, physical health and social services in the
community. Disease management and chronic care programs are offered for asthma, diabetes, heart
disease (including hypertension) and COPD.
The ICM Program is designed to support the patient centered medical home model by improving
member and provider engagement, care transitions from the specialist office and hospital, and their
overall care within the member’s medical home. For more information call Integrated Care
Management at 1-855-371-3959.
Pregnancy-Related Services/Bright Start®
Prestige will provide the most appropriate and highest level of quality care for pregnant members. The
Prestige Bright Start® Maternity Program is designed to assist pregnant mothers to adopt healthy
behaviors, control risk factors, and educate on infant care and health needs. The Bright Start® Program
consists of care managers, nurses and care connectors with expertise in the area of maternal management.
Bright Start® provides nursing review and counseling, nutrition review, prenatal (pre-birth), delivery,
postpartum (after birth) services and nursery care services in the hospital. Bright Start® combines
scheduled written and telephonic outreach with state-of-the art informatics that provides point-of-contact
notification of health needs to members. Bright Start® uses provider and community programs,
partnerships and creative outreach strategies to facilitate member access to required services. For more
information, contact Bright Start® at 1-855-371-8076.
Processes required for administering care include:
•
Participating providers must contact Prestige immediately after it is determined that a member is
pregnant. Complete the Prestige Pregnancy Notification Form and fax it to the Bright Start®
Maternity Management Program. Faxing this form will serve as notification to the Prestige Bright
Start® Maternity Management Program of the pregnancy and authorization for global services.
Notifications may be faxed to 1-855-358-5852.
o Providers must offer Florida's Healthy Start® prenatal risk screening to each pregnant
member as part of her first prenatal visit.
o Providers must use the Department of Health (DOH) prenatal risk form (DH Form 3134)
available from the local County Health Department (CHD).
o Providers must keep a copy of the completed screening instrument in the member’s
medical record and provide a copy to the member.
o Providers must submit the completed DH Form 3134 to the CHD in the county where the
prenatal screen was completed within ten (10) business days of completion.
o Prestige will collaborate with the Healthy Start® Care Coordinator within the member’s
county of residence to assure delivery of risk-appropriate care.
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Prior Authorization
All OB care requires a Global OB notification/authorization in order for proper and expedient payment to
be made to OB providers. For full details, please see prior authorization in the Utilization Management
section of this manual.
Prenatal Care
• Require a pregnancy test and a nursing assessment with referrals to a physician, PA or ARNP for
comprehensive evaluation.
• Require case management through the gestational period according to the needs of the members.
• Require any necessary referrals and follow-up.
• Schedule return prenatal visits at least every four (4) weeks until week thirty-two (32), every two
(2) weeks until week thirty-six (36), and every week thereafter until delivery, unless the
member’s condition requires more frequent visits.
• Contact members who fail to keep their prenatal appointments as soon as possible, and arrange
for their continued prenatal care.
• Assist members in making delivery arrangements, if necessary.
• Providers must screen all pregnant members for tobacco use and ensure availability of smoking
cessation counseling and appropriate treatment as needed.
• Providers supply nutritional assessment and counseling to all pregnant members.
• Ensure the provision of safe and adequate nutrition for infants by promoting breastfeeding and the
use of breast milk substitutes.
• Offer a mid-level nutrition assessment.
• Provide individualized diet counseling and a nutrition care plan by a public health nutritionist, a
nurse or physician following the nutrition assessment.
• Ensure documentation of the nutrition care plan in the medical record by the person providing
counseling.
Florida hospitals, contracting with the Plan must electronically file the Florida Healthy Start® Infant
(Postnatal) Risk Screening Instrument (DH Form 3135) and the Certificate of Live Birth with the CHD in
the county where the infant was born within five (5) business days of the birth. If the provider is a
birthing facility not participating in the DOH electronic birth registration system the provider must file
required birth information with the CHD within five (5) business days of the birth, keep a copy of the
completed DH Form 3135 in the member's medical record and mail a copy to the member.
•
Pregnant members or infants who do not score high enough to be eligible for Healthy Start® care
coordination may be referred for services, regardless of their score on the Healthy Start® risk
screen, in the following ways:
o If the referral is to be made at the same time the Healthy Start® risk screen is
administered, the provider may indicate on the risk screening form that the member or
infant is invited to participate based on factors other than score; or
o If the determination is made subsequent to risk screening, the provider may refer the
member or infant directly to the Healthy Start® care coordinator based on assessment of
actual or potential factors associated with high risk, such as the human immunodeficiency
virus (HIV), hepatitis B, substance abuse or domestic violence.
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•
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•
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•
•
•
Providers must refer all infants, children under the age of five (5), and pregnant, breast-feeding
and postpartum women to the local office of Women, Infants and Children (WIC).
o Provide a completed Florida WIC program medical referral form with the current height
or length and weight (taken within sixty (60) calendar days of the WIC appointment);
o Hemoglobin or hematocrit; and
o Any identified medical/nutritional problems.
Each time the provider completes a WIC referral form, a copy must be kept in the member’s
medical record and given to the member.
For subsequent WIC certifications, providers must coordinate with the local WIC office to
provide the above referral data from the most recent Child Health Check-Up (CHCUP).
Providers must offer all women of childbearing age HIV counseling and testing at the initial
prenatal care visit and again at twenty-eight (28) and thirty-two (32) weeks of pregnancy.
Providers must attempt to obtain a signed objection if a pregnant woman declines an HIV test.
Pregnant women who are infected with HIV are to be counseled about and offered the latest
antiretroviral regimen recommended by the U.S. Department of Health & Human Services.
Providers must screen all pregnant members receiving prenatal care for the hepatitis B surface
antigen (HBsAg) during the first prenatal visit.
o Providers are to perform a second HBsAg test between twenty-eight (28) and thirty-two
(32) weeks of pregnancy for all pregnant members who tested negative at the first
prenatal visit and are considered high-risk for Hepatitis B infection. This test will be
performed at the same time that other routine prenatal screening is ordered.
o All HBsAg-positive women will be reported to the local CHD and to Healthy Start®,
regardless of their Healthy Start® screening score.
Infants born to HBsAg-positive members should receive hepatitis B immune globulin (HBIG)
and the hepatitis B vaccine once they are physiologically stable, preferably within twelve (12)
hours of birth, and will complete the hepatitis B vaccine series according to the vaccine schedule
established by the Recommended Childhood Immunization Schedule for the United States.
o Providers must test infants born to HBsAg-positive members for HBsAg and hepatitis B
surface antibodies (anti-HBs) six (6) months after the completion of the vaccine series to
monitor the success or failure of the therapy.
o Providers must report to the local CHD a positive HBsAg result in any child age twentyfour (24) months or less within twenty-four (24) hours of receipt of the positive test
results.
o Infants born to members who are HBsAg-positive are to be referred to Healthy Start®
regardless of their Healthy Start® screening score.
Providers must report all HBsAg-positive prenatal or postpartum women to the Hepatitis B
Prevention Coordinator at the local CHD. This reporting includes the name, date of birth, race,
ethnicity, address, infants, contacts, laboratory test performed, date the sample was collected, the
due date or estimated date of confinement, whether the member received prenatal care, and the
immunization dates for infants and contacts.
The provider will use the Practitioner Disease Report Form (DH Form 2136) for such reporting.
Providers must maintain documentation of Healthy Start® screenings, assessments, findings and
referrals in the members’ medical records.
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Obstetrical Delivery
The provider will use generalized accepted and approved protocols for both low-risk and high-risk
deliveries reflecting the highest standards of the medical profession, including Healthy Start® and prenatal
screening.
•
•
The provider will document preterm delivery assessments in the member’s medical record by
week twenty-eight (28).
If the provider determines that the member is high-risk the manage care will ensure that the
providers obstetrical care during labor and delivery includes preparation by all attendants for
symptomatic evaluation and that the member progresses through the final stages of labor and
immediate postpartum.
Newborn Care
The provider supplies the highest level of care for the newborn beginning immediately after birth. Such
level of care should include, but not limited to, the following:
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•
•
•
•
•
•
•
Installing of prophylactic eye medication into each eye of the newborn;
When the mother is Rh negative, securing a cord blood sample for type Rh determination and
direct Coombs test;
Weighing and measuring of the newborn;
Inspecting the newborn for abnormalities and/or complications;
Administering one half (.5) milligrams of vitamin k;
American Pediatric Gross Assessment Record (APGAR) scoring;
Any other necessary and immediate need for the referral in consultation from a specialty
physician, such as the Healthy Start® (postnatal) infant screen and;
Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist
pursuant Chapter 468, F.S, or an individual who has completed documented training specifically
for newborns hearing screenings and who is directly or indirectly supervised by a licensed
physician or a licensed audiologist).
Postpartum Care
The provider shall:
•
•
•
Provide a postpartum examination for the member within six (6) weeks after delivery.
Ensure that its providers supply family planning, including a discussion of all methods of
contraception, as appropriate; and
Ensure that continuing care of the newborn is provided through the CHCUP program and
documented in the child’s medical record.
STAR PATH Transition of Care Program
The STAR PATH (Stratify Touch Assess Recommend Positive Actions Toward Health) Transition of
Care Program is designed specifically to coordinate the care of Prestige members who have frequent
emergency room (ER) visits or have been recently discharged from an acute care hospital.
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The goal is to prevent readmissions, subsequent ER visits and to ensure a seamless transition of care back
home or the next level of appropriate care. The program coordinates or otherwise arranges for appropriate
post-acute admission and directly from the ER where appropriate.
The benefits of the program include reducing risk for:
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•
•
•
•
Hospital admissions/complications secondary to treatment side effects, co-morbidities,
non-compliance with discharge instructions.
Hospitalization due to secondary worsening of primary medical conditions managed during
recent hospitalization.
Multiple ER visits with no coordination of care.
Members who are not engaged with their PCP/Medical Home.
Medication safety and poly-pharmacy.
STAR PATH Transition of Care Process
The program includes the following coordinated services:
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•
•
•
•
•
•
•
•
•
Stratification of member’s needs upon discharge to home (low/medium/high/complex).
Assignment to dedicated case management staff based on stratification.
Case management services to include coordination in the following areas:
o Home care/supplies
o Home intravenous infusion
o Physician office visits
o Home care physician visits
o DME delivery
o Medications reconciliation and compliance/adherence
o Poly-pharmacy
o Multiple transitions of care (multiple provider involvement)
On-site visits by health plan nurses (RN/LPN) to members while in the ED available twentyfour hours, seven (24/7) days a week (selected ED sites).
Education of members to appropriately utilize medical resources.
Timely referrals to ICM and Bight Start® programs to meet on-going case management needs.
Face-to-face visits with care manager and member/family for program engagement prior to
discharge to home.
Identify and resolve any gaps in the member’s discharge plan.
Collaboration with case management, concurrent review nurse and discharge planner for a
smooth transition of care back to the community.
Follow-up with members to ensure compliance with medical appointments and discharge
instructions.
The Prestige case management nurses will collaborate with physicians, treatment facilities and family
members regarding treatment plans and ongoing care coordination needs for the member. This includes
ongoing monitoring for exacerbations and new conditions, as well as recommendations to primary care
and home care physicians on medically necessary interventions. Referrals will be made to Integrated Care
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Management and Bright Start® programs (OB Case Management) for those members needing intensive
short-term and long-term care management needs.
This program represents Prestige’s commitment to quality member care, member engagement, provider
collaboration and cost-containment measures. Prestige is dedicated to improving member health with
meaningful, effective and metric-driven outcomes.
For more information on the STAR PATH Transition of Care Program, please call Rapid Response at
1-855-371-8072 or visit www.prestigehealthchoice.com.
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SECTION VI
RAPID RESPONSE
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VI. Rapid Response
Prestige’s Rapid Response Department addresses the immediate and urgent needs of our members. Rapid
Response is a call center with dedicated individuals available to serve members in a personalized way.
Both members and providers can call for assistance.
The Rapid Response Department consists of a team of energetic, multilingual care connectors (nonclinicians) and nurses who coordinate care for members addressing all their immediate needs. The
department is responsible for identifying barriers to care, navigating the healthcare system, educating the
importance of preventive care services, connecting members with useful community resources and
facilitating access to care to meet healthcare needs.
Along with care connectors and nurses, the department also consists of EPSDT Care Connectors (Early
Periodic Screening, Diagnostic and Testing) who are responsible for Child Health Check-Up (CHCUP)
outbound campaigns to parents/guardians to educate on the CHCUP services available for their children.
Upon receiving a member or provider call, Rapid Response will work diligently with all necessary
departments and network providers to address and resolve member needs. Rapid Response services
members and providers as follows:
•
•
•
•
•
•
•
•
•
•
•
•
Assist members with scheduling PCP and specialist appointments
Arrange transportation and interpreter services
Complete Health Risk Assessment with member
Identify and refer high risk and special needs members to Integrated Care Management
Refer pregnant members to Bright Start®
Collaborate with Member Services, Prior Authorization, Provider Operations along with
participating providers to coordinate service for members
Coordinate DME and home health care services
Assist members with obtaining medications at the pharmacy
Identify members in need of mental health care and dental services
Identify care gaps (HEDIS®/missing preventive services)
Refer qualified members to Healthy Behavior Programs
Transition of care follow-up
Contact Rapid Response at 1-855-371-8072, Monday through Friday, 8:00 a.m. to 6:30 p.m.
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SECTION VII
MEMBER COMPLAINTS,
GRIEVANCES AND APPEALS
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VII. Member Complaints, Grievances and Appeals
Member Complaints
Complaints allow Prestige to resolve a problem without it becoming a formal grievance. If a member has
a concern or question regarding care or coverage under Prestige, he/she should contact Member Services
at the toll-free number on the back of their ID card. A member services representative will answer
questions and/or concerns. The representative will try to resolve the problem. If the member services
representative does not resolve the problem to the member’s satisfaction, he/she has the right to file a
grievance. A complaint that is not resolved by close of business the day following its receipt is
automatically moved into the Prestige Grievance System.
Grievance Process
A grievance expresses dissatisfaction about any matter other than an action by Prestige. The member may
file a grievance in writing or by phone. It must be filed orally or in writing within one (1) year from the
date of the occurrence. It may be filed by the provider on behalf of the member and with the member’s
written consent. A grievance may be filed about such things as the quality of the care the member
receives from Prestige or a provider, rude behavior from a Prestige employee or a provider’s employee, a
lack of respect for their rights by Prestige or a provider or anything else with which the member may be
dissatisfied.
To file a grievance, the provider (with the member’s consent) or the member may call Member Services
at 1-855-355-9800 or TTY/TDD at 1-855-358-5856. Hours of operation are twenty-four hours a day,
seven days a week (24/7).
Or write to:
P.O. Box 7368
London, KY 40742
If the member needs assistance in completing forms and following the procedure for filing his/her
grievance or needs the help of an interpreter, the member may call Member Services at 1-855-355-9800
or TTY/TDD at 1-855-358-5856. The interpreter services are free of charge to the member.
Prestige will send the member an acknowledgement letter within five (5) business days of receiving the
grievance. Prestige will send a decision letter within ninety (90) days of receiving the request. In some
cases, Prestige or the member may need more information. If the member needs more time to get
information, he/she may request up to fourteen (14) additional days. If Prestige needs more time, the
member will be informed of the reason for the extension, in writing, within five (5) business days.
If the member does not agree with the decision and wants to file an administrative appeal, he/she can file
the appeal or can ask their provider, a family member or an authorized representative to file the appeal on
his/her behalf. These appeals are not clinical in nature and do not require medical review. If someone
helps the member file an appeal, he/she must be the member’s “authorized representative.” The member
or their authorized representative may ask for an appeal within thirty (30) days after they receive
Prestige’s decision.
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The member or his/her authorized representative, with the member’s written permission, may ask for a
Medicaid Fair Hearing at any time in the grievance process.
Appeals Process
If Prestige decides to deny, reduce, limit, suspend, or terminate a service that the member is receiving, or
if Prestige fails to act in a timely manner, the member will receive a written Notice of Action (NOA). For
the termination, suspension or reduction of a previously authorized covered service, the NOA will be
mailed at least ten (10) calendar days before the action takes place. For denial of payment, the NOA will
be given at the time of any action that affects the claim. For standard service authorization decisions that
deny or limit services, notices will be given within seven (7) days following receipt of a request for a
standard authorization or within forty-eight (48) hours following receipt of a request for an expedited
authorization, unless an extension is given. If the member does not agree with Prestige’s determination as
outlined in the NOA, the member may file a non-administrative appeal. These appeals are clinical in
nature and require medical review. The member can file the appeal or ask their doctor, a family member
or friend to file the appeal for them. If someone helps the member file an appeal, he/she must be the
member’s authorized representative, or they may have their provider file with the member’s written
consent.
The member or his/her authorized representative with the member’s written permission, may ask for a
Medicaid Fair Hearing at any time in the appeals process.
Standard Appeal
A standard appeal asks Prestige to review a decision about the member’s care.
An appeal may be filed orally or in writing within thirty (30) calendar days of the member’s receipt of the
NOA and, except when expedited resolution is required, must be followed with a written notice within ten
(10) calendar days of the oral filing. The date of oral notice shall constitute the date of receipt.
To file an appeal, the member or authorized representative may send a letter to:
P.O. Box 7368
London, KY 40742
Prestige will assist the member in completing documentation and following the appeal procedure. The
review begins the day Prestige receives the oral request. Prestige will send a written acknowledgement to
the member within five (5) business days of receipt of the appeal. Prestige has forty-five (45) calendar
days in which to make a decision regarding the case. Before Prestige makes a decision, the member
and/or the person helping the member with the appeal can give information to Prestige. The new
information may be in writing or in person. If the member needs more time to get information, he/she
may have it. The member or Prestige may request an extension up to fourteen (14) calendar days. If
Prestige asks for more time, a letter will be sent within five (5) business days to inform the member why
Prestige needs extra time.
The member may review his/her file any time while Prestige is reviewing the appeal. The member and
his/her authorized representative may look at the case file. In the event the member expires prior to, or
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during the appeal process, the member's estate representative may review the file after the member's
death. The member’s estate representative may review the file after the member’s death. Prestige will
send the member or their authorized representative a letter with the decision, explaining how Prestige
made its decision.
Expedited Appeal
A member or their authorized representative, with the member’s written consent, can request an expedited
appeal when taking the time for a standard resolution could jeopardize the member’s life, health or ability
to attain, maintain or regain function. Expedited appeals are for health care services, not denied claims.
To ask for an expedited appeal the member or his/her authorized representative may call 1-855-371-8078.
If Prestige denies a request for an expedited resolution of an Appeal, Prestige shall provide oral notice by
close of business on the day of disposition, and written notice within two (2) calendar days after the
disposition. The appeal will immediately be moved into the standard appeal timeframe, if it does not meet
the criteria for an expedited appeal.
Prestige shall resolve each expedited appeal and provide notice to the member as quickly as the member’s
health condition requires, within state established time frames not to exceed three (3) business days after
the request for expedited appeal is received. Prestige also shall provide oral notice by close of business on
the day of disposition, and written notice within two (2) calendar days of the disposition.
Appealing a Decision to the Subscriber Assistance Program (SAP)
The member or his/her authorized representative has the right to appeal an adverse decision to the
Subscriber Assistance Program (SAP). The member must complete the Prestige appeal process first. The
member has one (1) year after the date of the final decision letter from Prestige to submit their appeal.
The SAP will not consider an appeal that has been to a Medicaid Fair Hearing.
The member can call or write with his/her request for review:
Agency for Health Care Administration
Subscriber Assistance Program
2727 Mahan Drive, Building 3, Mail Stop 45
Tallahassee, Florida 32308
Phone: 1-850-412-4502
Toll-Free: 1-888-419-3456
Fax: 1-850-413-0900
Email: [email protected]
Medicaid Fair Hearing
The member or his/her authorized representative may seek a Medicaid Fair Hearing at any time. If the
member does not pursue the Prestige grievance and appeal process, the Medicaid Fair Hearing must be
requested within ninety (90) days of receipt of the NOA.
If the member or his/her authorized representative chooses to complete the grievance and appeal process
before they file for a Medicaid Fair Hearing, they have ninety (90) calendar days from the receipt of the
notice of resolution from Prestige. Parties to the Medicaid Fair Hearing are Prestige, the member or
his/her authorized representative.
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The address to send the request for a Medicaid Fair Hearing is:
Department of Children and Families
Office of Appeal Hearings
Building 5, Room 255
1317 Winewood Boulevard
Tallahassee, Florida 32399-0700
Phone: 1-850-488-1429
Fax: 1-850-487-0662
Email: [email protected]
For more information on Appeal Hearings, please visit http://www.myflfamilies.com/about-us/officeinspector-general/investigation-reports/appeal-hearings.
Continuation of Benefits
A member may continue to receive services while waiting for Prestige’s decision if all of the following
apply:
•
•
•
•
•
•
The appeal is filed within ten (10) days after the notice of the adverse action is mailed.
The appeal is filed within ten (10) days after the intended effective date of the action.
The appeal is related to reduction, suspension or termination of previously authorized services.
The services were ordered by an authorized provider.
The authorization has not ended.
The member requested the services to continue.
The member’s services may continue until one (1) of the following happens:
•
•
•
•
The member decides not to continue the appeal.
Ten (10) days have passed, from the date of the notice of resolution unless the member has
requested a Medicaid Fair Hearing with continuation of services.
The time covered by the authorization is ended or the limitations on the services are met.
The Medicaid Fair Hearing office issues a hearing decision adverse to the member.
The member may have to pay for the continued services if the final decision from the Medicaid Fair
Hearing is against them.
If the Medicaid Fair Hearing Officer agrees with the member, Prestige will pay for the services received
while waiting for the decision.
If the Medicaid Fair Hearing or the SAP decision agrees with the member and he/she did not continue to
get the services while waiting for the decision, Prestige will issue an authorization for the services to
restart as soon as possible and Prestige will pay for the services.
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SECTION VIII
HEALTHY BEHAVIORS PROGRAM
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VIII. Healthy Behaviors Program
Prestige encourages and rewards member behaviors designed to improve the member’s overall health.
The Healthy Behaviors Program has been developed to encourage members to lose weight, stop smoking,
and to stop abusing alcohol or other substances. For more information regarding the Healthy Behaviors
Program, visit www.prestigehealthchoice.com.
Weight Loss Program
The program provides incentives for care management and education designed to reduce the risks
associated with morbid obesity. An adult is considered morbidly obese if he/she is one hundred (100)
pounds over his/her ideal body weight, has a Body Mass Index (BMI) of forty (40) or more, or thirty-five
(35) or more and experiencing obesity-related health conditions, such as high blood pressure or diabetes.
The program provides members with weight loss resources and support incentives and/or rewards for
dietary counseling, nutritional counseling, behavior therapy, joining a community-based exercise
program, and for reducing overall Body Mass Index (BMI). Rewards shall not be used to direct
individuals to select a particular provider. Rewards shall not be used for gambling, alcohol, tobacco or
drugs (except for over-the-counter drugs), and the designated gift card will have an imprinted disclaimer
that reads, “No Alcohol, Tobacco, or Lottery Purchases.” Engagement letters are sent out to all members
describing the program and a contact phone number for member services is provided for additional
information. The weight loss program must be medically supervised and is for adult members who have a
PCP documented BMI of thirty-five (35) or greater and have been evaluated by the PCP. Child and
adolescent members should have a PCP documented BMI equal to or greater than the 95th percentile for
engagement into the program. The member will be supervised by the PCP and case management will
follow the progress. As a result of the program features, the member will lose weight while decreasing the
chance of developing comorbidities, maintain healthy habits and move toward a healthy lifestyle.
Smoking Cessation Program
The program provides incentives for care management and education designed to reduce the health risks
associated with smoking and/or tobacco use. The program provides members with resources for smoking
cessation and support from well-trained quit coaches as well as rewards for smoking cessation counseling
and group sessions, seminars, and participation in community programs. Rewards shall not be used to
direct individuals to select a particular provider. Rewards shall not be used for gambling, alcohol, tobacco
or drugs (except for over-the-counter drugs), and the designated gift card will have an imprinted
disclaimer that reads, “No Alcohol, Tobacco, or Lottery Purchases.” Engagement letters are sent out to all
members describing the program and a contact phone number for member services is provided for
additional information. The smoking cessation program must be medically approved and is for members
who have completed an initial risk assessment with a nurse case manager and have been evaluated by the
PCP. Public programs that are offered and supported by Area Health Education Center (AHEC) and state
funding are available in sixty-seven (67) counties in the state of Florida. The AHEC Tools to Quit
Program will also provide up to four (4) weeks of free NRT (Nicotine Replacement Therapy), which
includes patches, lozenges, and gum. Case management will monitor the member’s progress in the
program(s) and follow up with members who have participated. As a result of the program features, the
member will have major health benefits, decrease cardiovascular risks, decrease risks for various cancers
and Chronic Obstructive Pulmonary Disease (COPD), as well as decreased health care utilization.
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Alcohol and Substance Abuse Program
Prestige partners with the Beacon Health Options Encompass Medical Integration Program for substance
abuse. The substance abuse program has multiple components to address the needs of members, from
identification of an existing substance abuse clinical issue or diagnosis, through the treatment phase of the
interventions, to the abstinence and recovery period. The program provides members with resources for
alcohol and substance abuse, as well as rewards for alcohol and substance abuse for remaining sober for
periods of thirty (30), ninety (90), and one hundred eighty (180) days. Rewards shall not be used to direct
individuals to select a particular provider. Rewards shall not be used for gambling, alcohol, tobacco or
drugs (except for over-the-counter drugs), and the designated gift card will have an imprinted disclaimer
that reads, “No Alcohol, Tobacco, or Lottery Purchases.” Engagement letters are sent out to all members
describing the program and a contact phone number for member services is provided for additional
information. The alcohol and substance abuse program must be medically approved for members who
have completed an initial risk assessment with a nurse case manager and have been evaluated by the PCP.
Beacon Health Options will provide an annual training for both behavioral health specialists and PCPs on
screening and identification of members with alcohol or substance related disorders. Beacon Health
Options can provide this in-person and WebEx training to accommodate participants. Prestige will make
the following screening tools available to PCPs and specialists:
•
•
Drug Abuse Screening Test – 10 (DAST-10): Used for members who have possible involvement
with drugs, not including alcohol.
Alcohol Use Disorders Identification Test (AUDIT): Is used for early detection of individuals
with risky or high risk drinking.
The Plan will have all PCPs screen members for signs of alcohol or substance abuse as part of prevention
evaluation at the following times: initial contact, routine physical exams, initial prenatal contact, overutilization of medical, surgical, trauma or emergency services, and when documentation of emergency
room visits suggests the need. The Plan will monitor all over-utilization of medical, surgical, trauma or
emergency services to determine if there is a need for further evaluation by the PCP for collaboration with
behavioral health services. The Plan will utilize the Beacon Health Options Encompass Medical
Integration Program to ensure integration of medical/substance abuse/mental health care. The
coordination of services and integrating substance abuse/mental health/medical treatment plays a vital
role in the member’s ability to attain and sustain recovery. The Healthy Behaviors Program encourages
the integration of treatment and coordination of care with the Encompass Medical Integration Program.
Upon eligibility verification the member will receive an enrollment packet including, but not limited to:
•
•
•
•
•
Local and community resources that provide education and information regarding addictions,
recovery communities, locations and meeting times for Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) within the member’s access area.
Consent for the release of information to facilitate effective coordination of care while
safeguarding the member’s right to privacy.
Copy of the member’s rights and responsibility as they relate to health care and treatment.
Member attestation that they are willingly participating in the program.
Designated Beacon Health Options Care Coordinator Case Manager that will be assigned to the
member’s care. This designated staff member will be responsible to complete the case
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management assessment to identify the member’s readiness and level of functionality in order to
facilitate the development of the care plan. The member will have direct access to this staff
member to assist with appointments, coordination efforts, communication with treating
practitioners, etc.
Depending on the severity of the case, initial engagement efforts can occur as follows:
•
•
•
•
•
Psychiatric consults for members who are admitted on a medical unit or in an emergency room
(ER) and have a co-occurring substance abuse issue that has had an impact on the current medical
treatment or presentation.
Effective discharge planning to include post-discharge aftercare that includes specific treatment
addressing substance abuse components.
In collaboration with the health plan and treating medical practitioners, provide effective
coordination of care for members identified as having a substance abuse disorder which is
untreated or requires current intervention.
Following an initial outreach call to the identified member, an enrollment packet will be sent to
members who have expressed a willingness to participate in the Encompass Medical Integration
Program.
The designated care coordinator or case manager will be responsible for monitoring the member’s
level of participation, progress in treatment, needs, and contribute to the care plan developed in
collaboration with treating practitioners.
Members enrolled in the program will be engaged in treatment with community practitioners and
providers, AA, NA, on-line and face-to-face support groups, and other resources that will assist the
member in attaining sobriety and recovery. Because of the vital role that anonymity plays in AA and NA,
programs will not confirm a member’s participation in meetings. However, Beacon Health Options has
partnered with community providers, and a targeted case manager will be assigned to verify a member
has maintained a “sobriety chip” in order to qualify for a reward. Membership is open to anyone who
wants to do something about his/her drinking or drug abuse problem. To participate in the Healthy
Behaviors Substance Abuse Program, the member will need to engage in AA or NA groups. The program
will monitor a member’s active engagement and compliance with the Healthy Behaviors Substance Abuse
Program, which will be reported from Beacon Health Options to Prestige.
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SECTION IX
QUALITY ENHANCEMENTS
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IX. Quality Enhancements
Prestige coordinates access for members to certain health-related, community-based services for
children’s programs, domestic violence, pregnancy prevention, prenatal/postpartum pregnancy programs
and behavioral health programs. A complete list and additional detail on these quality enhancements are
available by visiting www.prestigehealthchoice.com.
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SECTION X
QUALITY IMPROVEMENT PROGRAM
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X. Quality Improvement Program (QIP)
Prestige’s Quality Improvement Program (QIP) provides a framework for the evaluation of the delivery of
health care and services provided to members. The QIP description sets out the quality improvement
structure, function, scope and goals defined for Prestige. The Prestige Board of Managers provides
strategic direction for the QIP and retains ultimate responsibility for ensuring that the QIP is incorporated
into Prestige’s operations. Operational responsibility for the development, implementation, monitoring,
and evaluation of the QIP is delegated by the Prestige Board of Managers through the CEO to Prestige
and the Quality Improvement Committee (QIC).
The purpose of the QIP is to provide a formal process to systematically monitor and objectively evaluate
the quality, appropriateness, efficiency, effectiveness and safety of the care and service provided to
Prestige members by providers.
The QIP also provides oversight and guidance for the following:
•
•
•
•
•
•
Determining practice guidelines and standards on which the program’s success will be measured.
Complying with all applicable laws and regulatory requirements, including but not limited to,
AHCA, other applicable state and federal regulations, AAAHC and NCQA accreditation
standards.
Providing oversight of all delegated services.
Ensuring through the credentialing/re-credentialing process that a qualified network of providers
and practitioners is available to provide care and service to members.
Conducting member and practitioner satisfaction surveys to identify opportunities for
improvement.
Reducing health care disparities by measuring, analyzing and redesigning services and programs
to meet the health care needs of our diverse membership.
Prestige develops goals and strategies considering applicable state and federal laws and regulations and
other regulatory requirements, AAAHC and NCQA accreditation standards, evidence-based guidelines
established by medical specialty boards and societies, public health goals, and national medical criteria.
The goals, objectives and related measures used to monitor and evaluate performance are incorporated
into the QIP work plan. The work plan identifies annual objectives and program scope, quality
improvements and monitoring activities for the coming year, planned monitoring of previously identified
issues and a scheduled annual evaluation. The work plan also identifies the responsible party and a time
frame for completion of all activities. The work plan is revised as necessary to add new initiatives.
Quality Improvement Committee (QIC)
The QIC oversees Prestige’s efforts to measure, manage and improve quality of care and services
delivered to Prestige members, and evaluate the effectiveness of the QIP. The scope of committee
activities includes utilization management, clinical practice guideline review, member service metrics,
provider service metrics, provider satisfaction, cultural competency program plan, monitoring of member
complaints, and satisfaction. Additional committees and councils support the QIP and report to the QIC:
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•
•
•
Provider Advisory Council - solicits input from provider and community stakeholders regarding
the structure and implementation of new and existing clinical policies, initiatives and strategies.
Pharmacy and Therapeutics Committee - monitors drug utilization patterns, preferred drug list
(PDL) composition, pharmacy benefits management procedures and quality concerns.
Credentialing Committee - reviews practitioner and provider applications, credentials and
profiling data (as available) to determine appropriateness for participation in the Prestige
network.
Practitioner Involvement
We encourage provider participation in our QIP. Providers who are interested in participating in one of
our quality committees should contact their Provider Account Executive directly.
Quality Improvement Program Activities
The QIP is designed to monitor and
evaluate the quality of care and service
provided to members. QIP activities are
conducted using the Plan-Do-Check-Act
(PDCA) methodology:
•
•
•
•
Plan
Plan: Establish objectives and
Do
Act
processes necessary to meet
performance or outcome goals.
Do: Implement Prestige processes;
collect data for further analysis.
Check
Check: Evaluate and compare the
results to the performance/outcome
goal; identify differences between
the actual/expected/target outcomes.
Figure 1: PDCA Quality Process
Act: Develop and implement
corrective action to address significant differences between the actual and planned results;
conduct root cause analysis; as necessary, return to Plan step.
Performance Improvement Projects
Prestige develops and implements Performance Improvement Projects (PIPs) focusing on areas of
concern or low performance, both clinical and service-related, identified through internal analysis and
external recommendations.
Ensuring Appropriate Utilization of Resources
Prestige monitors utilization of key indicators, including inpatient admission rates and length of stay,
emergency room utilization rates, and clinical guideline adherence for preventive health and chronic
illness management services to identify those areas that fall outside the expected range to assess over or
under utilization.
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Measuring Member and Provider Satisfaction
Prestige uses the standardized Consumer Assessment of Healthcare Providers and Systems (CAHPS)
survey to assess member satisfaction. Prestige also conducts provider satisfaction studies annually.
Survey results, along with analysis and trends on dissatisfactions and member opt-outs are reported to the
QIC for review and identification/prioritization of opportunities for improvement.
Member Safety Programs
The QIP is responsible for coordinating activities to promote member safety. Initiatives focus on
promoting member knowledge about medications, home safety and hospital safety. Members are screened
for potential safety issues during the initial assessment.
Preventive Health and Clinical Guidelines
Prestige adopts guidelines established by nationally recognized professional organizations for use by
Prestige providers. Guidelines are distributed via the provider portal, with hard copy available upon
request. The Preventive Clinical Guidelines are reviewed annually by the Prestige QIC.
Preventive Care/Immunizations
Preventive care includes a broad range of services (including screening tests, counseling, and
immunizations/vaccines).
•
•
•
•
Providers are required to administer immunizations in accordance with the Recommended
Childhood Immunization Schedule for persons age birth through eighteen (18) years for the
United States for 2015, or when medically necessary for the member’s health.
All vaccines for which a member is eligible at the time of each visit should be administered
simultaneously.
Providers are required to participate in the Vaccines for Children Program (VFC).
PCPs are encouraged to provide immunization information about members requesting Temporary
Cash Assistance program (TCA) from DCF, upon request by DCF and receipt of the member’s
written permission. This information is necessary in order to document that the member has met
the immunization requirements for members receiving temporary cash assistance.
Prestige has adopted the recommended immunization schedules for age birth through eighteen (18) years
for immunization for children and adults that is published by the Advisory Committee on Immunization
Practices (ACIP) from the Centers for Disease Control and Prevention (CDC) and the American Academy
of Pediatrics (AAP).
Immunization Schedules (Childhood, Adolescent and Adult)
For the recommended vaccines and immunization schedules, please visit
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html for children and adolescents and
http://www.cdc.gov/vaccines/schedules/hcp/adult.html for adults.
Visit http://www.uspreventiveservicestaskforce.org/uspstopics.htm for the Guide to Clinical Preventive
Services for recommendations made by the U.S. Preventive Services Task Force (USPSTF) for clinical
preventive services.
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Vaccines for Children Program (VFC)
The Vaccines for Children Program (VFC) is a federally funded program that provides vaccines at no cost
to children who might not otherwise be vaccinated because of an inability to pay. The CDC buys vaccines
at a discount and distributes them to grantees, e.g., state health departments and certain local and
territorial public health agencies, that then distribute them at no charge to those private physicians' offices
and public health clinics registered as VFC providers. Children who are eligible for VFC vaccines are
entitled to receive pediatric vaccines that are recommended by the Advisory Committee on Immunization
Practices. For more information visit http://www.cdc.gov/vaccines/programs/vfc/index.html.
•
•
•
•
Providers for Medicaid members must use his/her Vaccines for Children Program (VFC) supply
and bill Prestige for the administrative fee only. The VFC program covers children from birth
through eighteen (18) years of age. Florida Medicaid requires vaccines for Medicaid children
from birth through twenty (20) years of age. Members nineteen (19) through twenty (20) years of
age should receive their vaccinations from their PCP.
Prestige will provide reimbursement to the participating provider for immunizations covered by
Medicaid, but not provided through VFC.
Providers are expected to plan for a sufficient supply of vaccines.
Prestige will pay the immunization administration fee at no less than the Medicaid rate when a
member receives immunizations from a non-participating provider so long as:
o The non-participating provider contacts Prestige at the time of service delivery;
o Prestige is unable to document to the non-participating provider that the member has
already received the immunization; and
o The non-participating provider submits a claim for the administration of immunization
services and provides medical records documenting the immunization to Prestige.
Child Health Check-Up Program (CHCUP)
The State of Florida’s CHCUP is a program for Medicaid members under the age of twenty-one (21).
Prestige coverage includes CHCUP and participating providers are required to adhere to the following
CHCUP service standards:
•
Conduct a comprehensive health screening evaluation that includes a past medical history,
developmental history and behavioral assessment. The screening evaluation should also include:
o A nutritional assessment
o Comprehensive unclothed physical exams
o Growth measurements
o Appropriate immunizations based on the Recommended Childhood Immunization
Schedule for the United States
o Laboratory testing (including blood lead testing as outlined below)
o Health education (including anticipatory guidance)
o Dental screening (including a direct referral to a dentist for members beginning at age
three (3) or earlier as indicated)
o Vision screening (including objective testing as required)
o Hearing screening (including objective testing as required)
o Diagnosis and treatment
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Referral and follow-up as appropriate
Blood lead testing:
• All providers are required to screen all enrolled children for lead poisoning at the
age of twelve (12) months and twenty-four (24) months.
• Children between the ages of twelve (12) months and seventy-two (72) months
must receive a screening blood lead test if there is no record of a previous test.
• Prestige will provide additional diagnostic and treatment services determined to
be medically necessary to a child/adolescent diagnosed with an elevated blood
lead level.
• Prestige recommends, but does not require, the use of paper filter tests as a
method to meet the lead screening requirement.
• If children or adolescents are identified as having abnormal levels of lead through
blood lead screenings, Prestige will provide case management follow-up
services.
Providers are required to inform members when tests or screenings are due based on the
periodicity schedule in the CHCUP Handbook.
Prestige does not require authorization for a member to be seen by a participating specialist when
determined that it is needed by the PCP.
PCP is to refer to the appropriate provider within four (4) weeks of these examinations for further
assessment and treatment of conditions found during the initial examination.
Providers are expected to cooperate with Prestige to accommodate new member appointments
within 30 days of the member’s enrollment with Prestige.
Provide assistance with scheduling for members to ensure they keep medical appointments.
Provide or coordinate other important health care diagnostic services and treatment including
necessary referrals as they relate to physical and mental illnesses and/or conditions discovered
through screening services in accordance with EPSDT contractual requirements.
o
o
•
•
•
•
•
•
CHCUP Schedule for Exams
• Birth or neonatal examination;
• 2-4 days for newborns discharged in less than 48 hours after delivery;
• By 1 month, and at 2, 4, 6, 9, 12, 15 and 18 months; and
• Once per year for 2-year-olds through 20-year-olds.
Federal guidelines prescribe minimal requirements included in each Well Child Care (WCC) exam for
each of the following age groups; (0-18) months, (2-6) years, and (7-20) years. Per these federal
guidelines, providers are advised to deliver services during the CHCUP visit. Prestige does not currently
cover the use of telemedicine for CHCUP services. Full CHCUP schedule is available at
http://ahca.myflorida.com/medicaid/childhealthservices/chc-up/index.shtml.
Reporting & Evaluation
The QIP is evaluated as needed and at least annually to measure its effectiveness. The evaluation assesses
all aspects of the QIP including clinical and service PIPs, quality studies and activities, and the rationale,
methodology, results and subsequent improvement associated with each study. The evaluation includes
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recommendations for improvement in the QIP, proposes goals and objectives for the following year and
identifies the resources needed to accomplish the proposed goals and objectives.
Medical Record Audits
Prestige conducts medical record audits to assess the provision and documentation of high quality
primary care according to established standards. PCP sites with ten (10) or more linked members undergo
a Medical Record Review (MRR) a minimum of once (1) every three (3) years. A PCP practice may
include both an individual office and a large group facility site. Ad-hoc reviews of OB-GYN’s and
specialists may also be conducted, as needed, using the same process.
A minimum of five (5) records are reviewed for each site. Records are selected using a random number
methodology among members assigned to the PCP for a minimum of six (6) months. The Plan has the
right to issue a retrospective review. These reviews may be conducted on a quarterly, semiannually,
annually, or otherwise permitted contractually.
Documentation of Care/Medical Record Keeping
The Documentation of Care (DOC) review component of the Prestige Quality Program provides a
mechanism to monitor and evaluate the quality and appropriateness of professional providers’
documentation of office medical records. Prestige providers must maintain a medical records system that
is consistent with professional standards. Prestige complies with all legal requirements and all federal,
state and other laws, regulations and contractual obligations (e.g., Agency, Balance Budget Act of 1997,
CMS, HIPAA, Medicare Modernization Act of 2003, OIG, OIR and major account service
specifications).
All medical records, Medicaid-related member cards and communications are to be maintained for a
period of ten (10) years according to legal, regulatory and contractual rules of confidentiality and privacy.
Providers are to deliver prompt access to records for review, survey or study if needed.
Medical record standards are available via the online provider manual.
•
•
•
•
Prestige providers are required to develop and implement confidentiality procedures to protect
member PHI in accordance with HIPAA privacy standards.
Providers must store medical records in a secure manner that permits easy retrieval. Only
authorized personnel may have access to patient medical records.
Florida licensed nurses perform the documentation-of-care medical record review using
guidelines that are updated annually and include at a minimum, the following:
o Two medical conditions.
o Two behavioral health conditions (preventive or non-preventive).
o Preventive guidelines for health evaluations, education and immunizations.
Documentation of whether a member has executed an advance directive must be contained in the
member’s medical record. If the member provides his/her PCP with a copy of an advance
directive, it will be made a part of the member’s medical record. This information may be
obtained by contacting Member Services at 1-855-355-9800.
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Medical records should reflect all services and referrals supplied directly by all providers. This includes
all ancillary services and diagnostic tests ordered by the provider, and the diagnostic and therapeutic
services for which the provider referred the member. Members’ medical records must be treated as
confidential information and be accessible only to authorized persons.
Prestige Medical Record Standards are distributed to providers during Prestige’s orientation and are also
available through the following sources:
•
•
•
Provider manual
Prestige website
Upon request through Provider Network Management
Providers may access Prestige Medical Record Standards and Medical Record Review Criteria in the
appendix section of this manual.
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SECTION XI
CULTURAL COMPETENCY PLAN
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XI. Cultural Competency Plan
At Prestige, we recognize the increasing population growth of racial and ethnic groups in our
communities, each with their own cultural traits, linguistic needs and health profiles. Prestige
acknowledges the responsibility to engage the provider network, to effectively connect with our diverse
patient population. Therefore, all network providers are responsible for their active participation with
Prestige’s Cultural Competency Plan.
Embedded in all of our efforts is a culturally and linguistically approach to the delivery of health care
services. We foster cultural awareness both in our staff and in our provider community by leveraging
ethnicity and language data to ensure that all cultures in our membership are reflected to the greatest
extent possible. The role and overall objective of the Cultural Competency Plan is to assure that all
members are served in a way that is responsive to their cultural and linguistic needs, monitor for
disparities among plan members, and carry out corrective actions.
National Culturally and Linguistic Services (CLAS)
The plan utilizes the fifteen (15) National Culturally and Linguistically Appropriate Services (CLAS)
Standards, developed by the United States Department of Health and Human Services’ Office of Minority
Health, as its guide and baseline.
The fifteen (15) National CLAS Standards are:
• Provide effective, equitable, understandable, and respectful quality care and services that are
responsive to diverse cultural health beliefs and practices, preferred languages, health literacy
and other communication needs.
• Advance and sustain organizational governance and leadership that promotes CLAS and health
equity through policy, practices and allocated resources.
• Recruit, promote, and support a culturally and linguistically diverse governance, leadership
and workforce that are responsive to the population in the service area.
• Educate and train governance, leadership and workforce in culturally and linguistically
appropriate policies and practices on an ongoing basis.
• Offer language assistance to individuals who have limited English proficiency and/or other
communication needs, at no cost to them, to facilitate timely access to all health care and
services.
• Inform all individuals of the availability of language assistance services clearly and in their
preferred language, verbally and in writing.
• Ensure the competence of individuals providing language assistance, recognizing that the use
of untrained individuals and/or minors as interpreters should be avoided.
• Provide easy-to-understand print and multimedia materials and signage in the languages
commonly used by the populations in the service area.
• Establish culturally and linguistically appropriate goals, policies and management
accountability, and infuse them throughout the organization's planning and operations.
• Conduct ongoing assessments of the organization's CLAS-related activities and integrate
CLAS-related measures into measurement and continuous quality improvement activities.
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•
•
•
•
•
•
Collect and maintain accurate and reliable demographic data to monitor and evaluate the
impact of CLAS on health equity and outcomes and to inform service delivery.
Conduct regular assessments of community health assets and needs and use the results to plan
and implement services that respond to the cultural and linguistic diversity of populations in
the service area.
Partner with the community to design, implement and evaluate policies, practices and services
to ensure cultural and linguistic appropriateness.
Create conflict and grievance resolution processes that are culturally and linguistically
appropriate to identify, prevent and resolve conflicts or complaints.
Communicate the organization's progress in implementing and sustaining CLAS to all
stakeholders, constituents and the general public.
Providers must adhere to the Cultural Competency Plan as set forth above.
All member materials may be translated in any language or format requested by a member. The member
handbook and welcome kit are readily available for members in Spanish, Creole, large print format,
braille and audio, as these are prevalent in Prestige’s areas of operation.
Providers may request a full copy of Prestige’s Cultural Competency Plan free of charge by contacting
Member Services at 1-855-355-9800 or by visiting www.prestigehealthchoice.com.
For Language assistance services, please contact Member Services at 1-855-355-9800.
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SECTION XII
CLAIMS SUBMISSION
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XII. Claims Submission
Visit Reporting
CMS defines an encounter as "an interaction between an individual and the healthcare system."
Encounters occur whenever a Prestige member is seen in a provider’s office or facility, whether the visit
is for preventive health care services or for treatment due to illness or injury. An encounter is any health
care service provided to a Prestige member. Encounters must result in the creation and submission of an
encounter record (CMS-1500 or UB-04 form or electronic submission) to Prestige. The information
provided on these records represents the encounter data provided by Prestige to the Florida Medicaid
Program.
Completion of Encounter Data
PCPs must complete and submit a CMS-1500 form or file an electronic claim every time a Prestige
member receives services. Completion of the CMS-1500 form or electronic claim is important for the
following reasons:
•
It provides a mechanism for reimbursement of medical services, including payment of inpatient
newborn care and attendance at high risk deliveries.
It allows Prestige to gather statistical information regarding the medical services provided to
Prestige members, which better support our statutory reporting requirements.
It allows Prestige to identify the severity of illnesses of our members to better case manage them.
•
•
Prestige can accept claim submissions via paper or electronically (EDI). For more information on
electronic claim submission and how to become an electronic biller, please refer to the "EDI Technical
Support Hotline" topic in the manual. In order to support timely statutory reporting requirements, we
encourage PCPs to submit claims within thirty (30) days of the visit. However, all claims must be
submitted within the allowed time frame posted in your contract, or as otherwise permitted by law, from
the date services were rendered or compensable items were provided. The following mandatory
information is required on the CMS-1500 form for a primary care visit:
•
•
•
•
•
•
•
•
•
•
Prestige Health Choice member's ID number
Member's name
Member's date of birth
Other insurance information: company
name, address, policy and/or group
number, and amounts paid by other insurance, copy
of EOBs
Information advising if patient's condition
is related to employment, auto accident,
or liability suit
Name of referring physician, if appropriate
Dates of service, admission, discharge
Primary, secondary, tertiary and fourth
ICD-9/10 diagnosis codes, coded to the highest
degree of specificity
Authorization or referral number
CMS place of service code
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•
•
•
•
•
•
•
•
•
HCPCS procedures, service or supplies
codes; CPT procedure codes with
appropriate modifiers, if applicable
Charges
Days or units
Physician/supplier federal tax
identification number or Social Security
Number
National Practitioner ID (NPI) and
Taxonomy Code
Individual Prestige assigned practitioner
number
Name and address of facility where services were
rendered
Physician/supplier billing name, address, zip code,
and telephone number
Invoice date
Provider Manual
Prestige monitors encounter data submissions for accuracy, timeliness and completeness through claims
processing edits and through network provider profiling activities. Encounters can be rejected or denied
for inaccurate, untimely and incomplete information. Network providers will be notified of the rejection
via a remittance advice and are expected to resubmit corrected information to Prestige in the allowed
timeframe listed in the provider’s contract. Network providers may also be subject to sanctioning by
Prestige for failure to submit accurate encounter data in a timely manner.
Contact Provider Services at 1-800-617-5727 to address questions concerning claims submission.
Rejected claims are defined as claims with invalid or required missing data elements, such as the provider
tax identification number or member ID number, that are returned to the provider or EDI* source without
registration in the claim processing system. Rejected claims are not registered in the claim processing
system and can be resubmitted as a new claim.
Denied claims are registered in the claim processing system but do not meet requirements for payment
under Prestige guidelines. They should be resubmitted as a corrected claim. Denied claims must be
resubmitted in the allowed timeframe in the provider agreement, or as otherwise permitted by law, for
participating providers and as outlined in federal/state statues (whichever is more stringent) for nonparticipating providers.
Note: These requirements apply to claims submitted on paper or electronically.
*For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical
and Hospital Claims in this manual.
Procedures for Claim Submission
Prestige is required by state and federal regulations to capture specific data regarding services rendered to
its members. All billing requirements must be adhered to by the provider in order to ensure timely
processing of claims.
When required data elements are missing or are invalid, claims will be rejected by Prestige for correction
and re-submission.
Claims for billable services provided to Prestige members must be submitted by the provider who
performed the services.
Claims filed with Prestige are subject to the following procedures:
1. Verification that all required fields are completed on the CMS 1500 or UB-04 forms.
2. Verification that all diagnosis and procedure codes are valid for the date of service.
3. Verification of member eligibility for services under Prestige during the time period in which
services were provided.
4. Verification that the services were provided by a participating provider or that the nonparticipating provider has received authorization to provide services to the eligible member.
5. Verification that the service being performed is a covered service and that member has not
exhausted their benefits.
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6. Verification that the provider is eligible to participate with the Medicaid Program at the time of
service.
7. Verification that an authorization has been given for services that require prior authorization by
Prestige.
8. Verification of whether there is Medicare coverage or any other third-party resources and, if so,
verification that Prestige is the “payer of last resort” on all claims submitted to Prestige.
Claim Mailing Instructions
Submit claims to Prestige at the following address:
P.O. Box 7367
London, KY 40742
Prestige encourages all providers to submit claims electronically. For those interested in electronic claim
filing, contact your EDI software vendor or Emdeon’s Provider Support Line at 1-877-363-3666 to
arrange transmission.
Claim Filing Deadlines
Original invoices must be submitted to Prestige as set forth in your provider contract, or as otherwise
permitted by law, from the date services were rendered or compensable items were provided. Resubmission of previously denied claims with corrections and requests for adjustments must be submitted
within the allowed time frame listed in the participating provider’s contract, or as otherwise permitted by
law, or as outlined in federal/state statues (whichever is more stringent).
Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within ninety (90)
days of the date of the primary insurer’s EOB.
Requests for adjustments may be submitted electronically, on paper or by telephone.
By telephone:
Provider Services
1-800-617-5727
On paper:
If you prefer to write, please be sure to stamp each claim submitted “corrected” or “re-submission” and
address the letter to:
P.O. Box 7367
London, KY 40742
Refer to the Provider Manual or look online at the provider portal of the Prestige website at
www.prestigehealthchoice.com for complete instructions on submitting appeals.
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Important: Claims originally rejected for missing or invalid data elements must be corrected and resubmitted in the allowed timeframe in the provider agreement, or as otherwise permitted by law, for
participating providers and as outlines in federal/state statues (whichever is more stringent) for nonparticipating providers. Rejected claims are not registered as received in the claim processing system.
Note: Prestige Health Choice EDI Payer ID# 77003
Common Causes of Claim Processing Delays, Rejections or Denials
Authorization or Referral Number Invalid or Missing - A valid authorization number must be
included on the claim form for all services requiring prior authorization.
Attending Physician ID Missing or Invalid – Inpatient claims must include the name of the physician
who has primary responsibility for the patient's medical care or treatment, and the medical license number
on the appropriate lines in field number 82 (Attending Physician ID) of the UB-04 (CMS 1450) claim
form. A valid medical license number is formatted as two (2) alpha, six (6) numeric, and one (1) alpha
character (AANNNNNNA) OR two (2) alpha and six (6) numeric characters (AANNNNNN).
Billed Charges Missing or Incomplete – A billed charge amount must be included for each
service/procedure/supply on the claim form.
Diagnosis Code Missing 4th or 5th Digit – Precise coding sequences must be used in order to accurately
complete processing. Review the ICD-9-CM manual for the 4th and 5th digit extensions. Look for the 4th
or 5th symbols in the manuals to determine when additional digits are required. ICD-10 manual standard
should also be followed (when applicable) to ensure the highest degree of specificity is always coded.
Diagnosis, Procedure or Modifier Codes Invalid or Missing - Coding from the most current coding
manuals (ICD-9/10, CPT or HCPCS) is required in order to accurately complete processing. All
applicable diagnosis, procedure and modifier fields must be completed.
EOBs (Explanation of Benefits) from Primary Insurers Missing or Incomplete – A copy of the EOB
from all third party insurers must be submitted with the original claim form. Include pages with run dates,
coding explanations and messages.
External Cause of Injury Codes – External Cause of Injury “E” diagnosis codes should not be billed as
primary and/or admitting diagnosis.
Future Claim Dates – Claims submitted for medical supplies or services with future claim dates will be
denied, for example, a claim submitted on October 1st for bandages that are delivered for October 1st
through October 31st will deny for all days except October 1st.
Handwritten Claims – Completely handwritten claims will be rejected. Legible handwritten claims are
acceptable on resubmitted claims. (See Illegible Claim Information)
Illegible Claim Information – Information on the claim form must be legible in order to avoid delays or
inaccuracies in processing. Review billing processes to ensure that forms are typed or printed in black ink,
data is lined up correctly in appropriate fields, that no fields are highlighted (this causes information to
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Provider Manual
darken when scanned or filmed), and that spacing and alignment are appropriate. Handwritten
information often causes delays or inaccuracies due to reduced clarity.
Member Plan Identification Number Missing or Invalid – Prestige’s assigned identification number
must be included on the claim form or electronic claim submitted for payment.
Member Date of Birth Does Not Match Member ID Submitted – a newborn claim submitted with the
mother’s ID number will be pended for manual processing causing delay in prompt payment.
Newborn Claim Information Missing or Invalid – Always include the first and last name of the mother
and baby on the claim form. If the baby has not been named, insert “Baby Girl” or “Baby Boy” in front of
the mother’s last name as the baby’s first name. Verify that the appropriate last name is recorded for the
mother and baby.
Payer or Other Insurer Information Missing or Incomplete – Include the name, address and policy
number for all insurers covering the Prestige member.
Electronic Data Interchange (EDI) for Medical and Hospital Claims
Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submission for
providers. EDI, performed in accordance with nationally recognized standards, supports the health care
industry’s efforts to reduce administrative costs.
The benefits of billing electronically include:
•
•
•
•
•
Reduction of overhead and administrative costs. EDI eliminates the need for paper claim
submission. It has also been proven to reduce claim re-work (adjustments).
Receipt of clearinghouse reports makes it easier to track the status of claims.
Faster transaction time for claims submitted electronically. An EDI claim averages about twentyfour (24) to forty-eight (48) hours from the time it is sent to the time it is received. This enables
providers to easily track their claims.
Validation of data elements on the claim form. By the time a claim is successfully received
electronically, information needed for processing is present. This reduces the chance of data entry
errors that occur when completing paper claim forms.
Quicker claim completion. Claims that do not need additional investigation are generally
processed quicker. Reports have shown that a large percentage of EDI claims are processed
within ten (10) to fifteen (15) days of their receipt.
Note: All the same requirements for paper claim filing apply to electronic claim filing.
Electronic Claims Submission (EDI)
The following sections describe the procedures for electronic submission for hospital and medical claims.
Included are a high-level description of claims and report process flows, information on unique electronic
billing requirements, and various electronic submission exclusions.
Note: Prestige Health Choice EDI Payer ID# 77003
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Hardware/Software Requirements
There are many different products that can be used to bill electronically. As long as you have the
capability to send EDI claims to Emdeon, whether through direct submission or through another
clearinghouse/vendor, you can submit claims electronically.
Contracting with Emdeon and Other Electronic Vendors
If you are a provider interested in submitting claims electronically to Prestige but do not currently have
Emdeon EDI capabilities, you can contact Provider Services at 1-800-617-5727. You may also choose to
contract with another EDI clearinghouse or vendor who already has Emdeon capabilities.
Contracting the EDI Technical Support Group
Providers interested in electronic claims submission may contact the EDI Technical Support Group via
Specific Data Record Requirements
Claims transmitted electronically must contain all the same data elements identified within the EDI Claim
Filing sections of this booklet. EDI guidance for Professional Medical Services claims can be found at the
beginning of this claims section. EDI guidance for Facility Claims can be found at the beginning of this
claims section. Emdeon or any other EDI clearing-house or vendor may require additional data record
requirements.
Electronic Claim Flow Description
In order to send claims electronically to Prestige, all EDI claims must first be forwarded to Emdeon. This
can be completed via a direct submission or through another EDI clearinghouse or vendor.
Once Emdeon receives the transmitted claims, the claim is validated for HIPAA compliance and
Prestige’s Payer Edits as described in Exhibit 99 at Emdeon. Claims not meeting the requirements are
immediately rejected and sent back to the sender via an Emdeon error report. The name of this report can
vary based upon the provider’s contract with their intermediate EDI vendor or Emdeon.
Accepted claims are passed to Prestige, and Emdeon returns an acceptance report to the sender
immediately.
Claims forwarded to Prestige by Emdeon are immediately validated against provider and member
eligibility records. Claims that do not meet this requirement are rejected and sent back to Emdeon, which
also forwards this rejection to its trading partner – the intermediate EDI vendor or provider. Claims
passing eligibility requirements are then forwarded to the claim processing queues. Claims are not
considered as received under timely filing guidelines if rejected for missing or invalid provider or
member data.
Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or
rejected claims received from Emdeon, or other contracted EDI software vendors, must be reviewed and
validated against transmittal records daily.
Since Emdeon returns acceptance reports directly to the sender, submitted claims not accepted by
Emdeon are not transmitted to Prestige.
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For assistance in resolving submission issues reflected on either the Acceptance or R059 Plan Claim
Status reports, contact the Emdeon Provider Support Line at 1-877-363-3666.
For assistance in resolving submission issues identified on the R059 Plan Claim Status report, contact
•
For assistance in resolving submission issues identified on the R059 Plan Claim Status report,
contact Provider Services at 1-800-617-5727.
Invalid Electronic Claim Record Rejections/Denials
All claim records sent to Prestige must first pass Emdeon HIPAA edits and Plan specific edits prior to
acceptance. Claim records that do not pass these edits are invalid and will be rejected without being
recognized as received at Prestige. In these cases, the claim must be corrected and re-submitted within the
required filing deadlines. It is important that you review the Acceptance or R059 Plan Claim Status
reports received from Emdeon or your EDI software vendor in order to identify and resubmit these claims
accurately and timely.
Requests for adjustments may be submitted electronically, on paper or by telephone.
By telephone:
Provider Services
1-800-617-5727
On paper:
If you prefer to write, please be sure to stamp each claim submitted “corrected” or “re-submission” and
address the letter to:
Attn: Claims Department
P.O. Box 7367
London, KY 40742
Administrative or medical appeals must be submitted in writing to:
P.O. Box 7368
London, KY 40742
Please refer to the Provider Dispute Process on page 37 for more information on administrative or
medical appeals.
Plan Specific Electronic Edit Requirements
Prestige currently has specific edits for professional and institutional claims sent electronically.
837P – 005010X098A1 – Provider ID Payer Edit states the ID must be less than thirteen (13)
alphanumeric digits.
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837I – 005010X096A1 – Provider ID Payer Edit states the ID must be less than thirteen (13)
alphanumeric digits.
Member Number must be less than seventeen (17) AN. Date submitted must not be earlier than date of
service. Plan Provider ID is strongly encouraged.
Exclusions
Certain claims are excluded from electronic billing. These exclusions fall into two groups:
These exclusions apply to inpatient and outpatient claim types.
Excluded Claim Categories
At this time, these claim records must be submitted on paper.
Claim records requiring supportive documentation; for example, sterilization claims requiring a
consent form.
Claim records for medical, administrative or claim appeals.
Excluded Provider Categories
Claims issued on behalf of the following providers must be submitted on paper.
Providers not transmitting through Emdeon or providers sending to vendors that are not transmitting
(through Emdeon) NCPDP Claims.
Pharmacy (through Emdeon)
Common Rejections
Invalid Electronic Claim Records – Common Rejections from Emdeon
Claims with missing or invalid batch level records
Claim records with missing or invalid required fields
Claim records with invalid (unlisted, discontinued, etc.) codes (CPT-4, HCPCS, ICD-9/10, etc.)
Claims without member numbers
Invalid Electronic Claim Records – Common Rejections from Prestige (EDI edits within the
claim system)
Claims received with invalid provider numbers
Claims received with invalid member numbers
Claims received with invalid member date of birth
Resubmitted Corrected Claims
Providers using electronic data interchange (EDI) can submit “institutional” and “professional” corrected
claims electronically rather than paper claims to Prestige.
A corrected claim is defined as a re-submission of a claim with a specific change that you have made,
such as changes to CPT codes, diagnosis codes or billed amounts. It is not a request to review the
processing of a claim.
Your EDI clearinghouse or vendor needs to:
•
Use “6” for adjustment of prior claims or “7” for replacement of a prior claim utilizing bill type
or frequency type in loop 2300,CLM05-03 (837P or 837I).
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•
•
•
•
•
Include the original claim number in segment REF01=F8 and REF02=the original claim number;
no dashes or spaces.
Do include Prestige’s claim number in order to submit your claim with the 6 or 7.
Do use this indicator for claims that were previously processed (approved or denied).
Do not use this indicator for claims that contained errors and were not processed (rejected
upfront).
Do not submit corrected claims electronically and via paper at the same time.
NPI Processing – Prestige’s Provider Number is determined from the NPI number using the following
criteria:
•
•
•
•
•
•
Plan ID, Tax ID and NPI number.
If no single match is found, the Service Location’s ZIP code is used.
If no service location is include, the billing address ZIP code will be used.
If no single match is found, the Taxonomy is used.
If no single match is found, the claim is sent to the Invalid Provider queue (IPQ) for processing.
If a plan provider ID is sent using the G2 qualifier, it is used as the provider on the claim.
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SECTION XIII
Pharmacy
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XIII. Pharmacy
Pharmaceutical management is a critical component of Prestige’s success. Prescription services are one of
the largest service and expenditure areas under the Florida Medicaid program. The Plan’s goal is to
manage pharmacy costs while effectively maintaining optimal health outcomes for our members.
The pharmacy benefit is administered by the Pharmacy Benefit Manager (PBM). Certain medications
require prior authorization (i.e., medications not listed on the AHCA Preferred Drug List). For the latest
version of the prior authorization forms, AHCA Preferred Drug List (PDL), or other pharmacy
information, please visit www.prestigehealthchoice.com. You may also call the PBM at 1-855-371-3963.
The information below is provided as a reference for Prestige providers to assist with requests and/or
issues related to the Plan’s pharmacy program.
AHCA Preferred Drug List (PDL)
Prestige has adopted the AHCA PDL and provides all prescription drugs and dosage forms in congruence
with the Agency’s direction. The PDL is a clinical reference of medications that are selected by the
Pharmacy and Therapeutics Committee (P&T Committee). We encourage our providers to prescribe
generic medications when possible and to adhere to the PDL. A complete list of covered drug products
can be found at http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/fmpdl.shtml.
Coverage Limitations
Prestige covers the medication categories that are listed on the PDL. Excluded items are as follows:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Anti-hemophilia products
o Factor products are distributed through the Comprehensive Hemophilia Disease
Management Program
Cough and cold medications for members age twenty-one (21) and over
Drug Efficacy Study Implementation (DESI) ineffective drugs as designated by AHCA
Drugs used to treat infertility
Experimental/Investigational pharmaceuticals or products
Erectile dysfunction products prescribed to treat impotence
Hair growth restorers and other drugs used for cosmetic purposes
Injectable/Oral drugs administered by the provider in the office, outpatient clinic,
infusion center, or a mental health center
Prostheses, appliances and devices (except products for diabetics and products used
for contraception)
Injectable drugs or infusion therapy and supplies (except those listed in the PDL)
Nutritional supplements
Oral vitamins and minerals (except those listed in the PDL)
Over-the-counter (OTC) drugs (except those listed in the PDL)
Drugs covered under Medicare Part B and/or Medicare Part D
Weight loss/gain medications
Page 96
Provider Manual
Additionally, Prestige does not reimburse for early prescription refills, duplicate therapy, or medication
dosages that exceed the Food and Drug Administration (FDA) maximum dose.
Generic Substitution
Prestige requires that brand medications be substituted for generic medications when an equivalent
generic is available. A prior authorization will be required for providers prescribing a brand drug when a
generic equivalent exists.
Informed Consent for Psychotropic Medications
Prestige requires that prescriptions for psychotropic medication prescribed for a member under the age of
thirteen (13) be accompanied by the express written and informed consent of the member’s parent or legal
guardian. Psychotropic (psychotherapeutic) medications include antipsychotics, antidepressants,
antianxiety medications, and mood stabilizers. Anticonvulsants and attention-deficit/hyperactivity
disorder (ADHD) medications (stimulants and non-stimulants) are not included at this time.
The prescriber must document the consent in the child’s medical record and provide the pharmacy with a
signed attestation of the consent with the prescription. The prescriber must ensure completion of an
appropriate attestation form.
The completed form must be filed with the prescription (hardcopy or scanned) in the pharmacy and held
for audit purposes for a minimum of six (6) years. Pharmacies may not add refills to old prescriptions to
circumvent the need for an updated informed consent form. Every new prescription will require a new
consent form. The consent forms do not replace prior authorization requirements for non-PDL
medications or prior authorized antipsychotics for children and adolescents from birth through age
seventeen (17).
For consent forms and resources visit
http://ahca.myflorida.com/Medicaid/Prescribed_Drug/med_resource.shtml
Injectable
Prestige covers limited self-administered, injectable medications (e.g., Imitrex, EpiPen). For a complete
list, please reference the PDL. All other injectable medications will require prior authorization.
Over-the-Counter (OTC) Medications
Prestige covers several OTC products. Our members receive an OTC benefit of $25/month up to
$50/year. A list covering OTC products can be found at
http://www.fdhc.state.fl.us/medicaid/medicaid_reform/enhab_ben/enhanced_benefits.shtml
Specialty Medications
Several specialty/injectable medications are listed on the PDL. Additionally, Prestige also adheres to the
AHCA medication criteria for non-PDL specialty/injectable medications that are posted on our website.
The majority of the specialty/injectable medications listed on PDL and those non-PDL
specialty/injectable agents will require a prior authorization. Please call the Prestige Pharmacy Benefit
Manager at 1-855-371-3963 to obtain more detailed information about these medications.
Page 97
Provider Manual
Working with our Specialty Pharmacy Provider
US Specialty Care (USSC) is the exclusive specialty pharmacy vendor for Prestige’s specialty/injectable
medications. Most of these medications will require a prior authorization. Once approved, providers can
request that our specialty vendor deliver the medication to the office or the member. If you want the
medication delivered to your office or member:
1. Call USSC at 1-800-641-8475 or fax the enrollment form to 1-888-473-7875.
2. If approved, our specialty vendor will contact the provider or member for delivery confirmation.
Prior Authorization
Please refer to the links below for the most up-to-date PDL. The links define the AHCA excluded
medications and those requiring prior authorization.
For the PDL visit http://ahca.myflorida.com/Medicaid/Prescribed_Drug/pharm_thera/fmpdl.shtml
For the non-PDL visit http://ahca.myflorida.com/Medicaid/Prescribed_Drug/drug_criteria.shtml
Prior Authorization Fax: 1-888-473-7875
Prior Authorization Phone: 1-866-240-2204
Clinical Hours: 8:00 a.m.-7:00 p.m. EST
Mailing Address:
WellDyneRx
P.O. Box 90369
Lakeland, FL 33804
Page 98
Provider Manual
SECTION XIV
BEHAVIORAL HEALTH
Page 99
Provider Manual
XIV. Behavioral Health
Behavioral health services are delegated. Providers may access the behavioral health manual at
www.prestigehealthchoice.com. For additional information on behavioral health services, please contact
Page 100
Provider Manual
SECTION XV
APPENDIX
Page 101
Provider Manual
XV. Appendix
Appendix 1: Site Visit Inspection Evaluation Tool
Appendix 2: Medical Records Standards and Medical Records Review Criteria
Page 102
SITE INSPECTION EVALUATION
New Provider
Re-Credentialed
Center/Professional Name:
Address:
Phone:
County
Medical Director Name:
Date of Site Review:
Date Last Monitored:
#of Exam Rooms:
# of Procedure Rooms:
CR 06.03 - Attachment I - Prestige Site Inspection Evaluation
Fax:
Page 1 of 13
Section1 is to be completed for Independent Diagnostic Testing Facilities
Check this box if this does not apply and continue to Section 2, Question 1
Section 1
Standards
Criteria Met (Y/N)
1. The facility Medical Director is licensed to provide radiology services.
Yes
No
2. All radiology procedures are performed only after a written physician order.
Yes
No
3. The facility has policies and procedures for employee safety and hazardous
materials handling.
Yes
No
4. The radiology department is free of hazards for patients and employees.
Yes
No
5. Inspections of x-ray equipment are made at least annually (according to Chapter
10D-91, F.A.C.).
6. Personnel radiation monitoring is maintained for each individual working in areas
of radiation (according to Ch 10D-91, FAC).
7. The use of all diagnostic imaging apparatus is limited to personnel who are
licensed and/or certified by the State of Florida (according to Part IV, Chapter
468, and Chapter 64E-3, F.A.C.).
8. The facility has a system to maintain and update the credentials of each person
providing diagnostic and therapeutic radiation, imaging and nuclear medicine
services, including on-the-job experience and certification or licensure where
applicable.
9. The facility maintains records of radiation detection instrumentation calibration
and repair (as specified in Chapter 10D-91, F.A.C.).
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
10.
Yes
No
Yes
No
Warning signs are in place regarding hazardous energy fields.
11. If the facility includes MRI equipment, the facility maintains a current
accreditation from American College of Radiologists (ACR), Accreditation
Association for Ambulatory Health Care (AAAHC) or Joint Commission for the
Accreditation of Healthcare Organizations (JCAHO) or Agency for Health Care
Administration (AHCA).
Corrective Action
Comments
Page 2 of 13
Section 2 is to be completed for PCP’s, OB/Gyn Providers & Rehabilitation Therapy Centers
Check this box if this does not apply and continue to Section 3, Page 9
Section 2 – List current Doctor’s, PA’s, ARNP’s the Center Manager and Staff:
Professional Provider Name
Standards
12. Distance to bus stop
(within ½ mile).
13. Adequate parking.
Title
Section 2a: Accessibility/Environment
Criteria
Without technical details or formulas, the representative is to
determine if there are reasonably accessible parking spaces for
the practice.
Criteria Met (Y/N)
Yes
No
Yes
No
CPR Certified
(Y/ N/ NA)
Hours
Scheduled
Per Week
Corrective Action
Credentialed
(Y / N / NA)
Comments
Page 3 of 13
14. Building address clearly
visible.
Yes
No
15. Disabled access –
parking.
Check parking area and external area of building for general
access by the disabled. There needs to be at least one
designated handicapped space.
Yes
No
16. Disabled access – office.
This includes items such as: handicapped ramps available
externally, doorways, handrails, at least one accessible
restroom, etc. Wheelchair accessible restroom can be
anywhere in the same building as the physician’s office; it does
not have to be in the same suite. If no, what is their alternative
plan?
Yes
No
17. Disabled access –
interpreter services
available upon request.
There is a protocol in place for accommodating the hearing
impaired. Calling the plan for assistance is appropriate.
Yes
No
18. Telephone access.
Patients have access to a nearby public phone for purposes
related to the office visit (i.e., arranging transportation).
Yes
No
19. Adequacy & cleanliness
of space – waiting room,
exam room and
restroom. Smoke free
environment.
The area appears reasonable for patients’ use during their wait.
Hazards removed, such as cords that could lead to a fall, etc.
This includes waiting room size and cleanliness, exam room size,
sanitary conditions, and exam room privacy, restroom size and
cleanliness.
Yes
No
20. Supplies are properly
stored in exam rooms.
Provider keeps sufficient
supplies on hand.
Hazards removed, such as poisons, etc. out of patient reach.
Yes
No
21. Reading material
available.
Determine whether patients have access to a variety of patient
health education materials, e.g., brochures, pamphlets, etc. A
thorough review of the materials is not needed.
Yes
No
22. Patient Bill of Rights
posted. (Florida only)
Patient Bill of Rights is posted and can be easily viewed by
patients.
Yes
No
23. Telephone number of
Grievance Department
24. Consumer Assistance
notice posted. (Florida
only)
Grievance Department number is posted and can be easily
viewed by patients.
Yes
No
Consumer Assistance Notice is posted and can be easily viewed
by patients.
Yes
No
Page 4 of 13
25. NO Professional Liability
Insurance notice posted,
as applicable.
26. Advance directives
available to patients
and/or guardians of
legal consent age.
Confirm that the Provider carries professional liability insurance
(malpractice).
Standards
Criteria
27. Prominently displayed
illuminated signs with
emergency power
capability at all exits.
Section 2b: Safety
Illuminated is defined as “visible when office is dark”. The sign
can be battery powered or lit by other emergency lighting.
28. Have emergency
lighting as appropriate
to the facility to provide
adequate evacuation of
patients and staff in case
of emergency.
Yes
No
NA
Yes
No
NA
Criteria Met (Y/N)
Yes
No
Yes
No
29. Office fire plan with
employee in-services.
Office should have evacuation floor plans posted in office.
Yes
No
30. Four emergency drills
are performed in a 12 –
month period.
These drills can be a fire drill, a drill for evacuation, a drill for
when a patient has an arrest, etc.
Yes
No
31. Documented
orientation of staff on
usage of equipment
required in diagnosis
and treatment of
patient.
Quality assurance procedures, including, but not limited to,
calibrating equipment periodically and validating test results
through use of standardized control specimens or laboratories.
Yes
No
Yes
No
32. OSHA manual present in
office and all staff given
required, documented
orientation; compliance
with OSHA guidelines.
Corrective Action
Comments
Page 5 of 13
33. Fire extinguishers
available.
Standards
Verify that fire extinguishers are available and note the last
inspection date.
Criteria
38. Frozen vaccines are
kept at 5° F or below.
(PCPs only)
Criteria Met (Y/N)
Corrective Action
Yes
No
Pre-signed and/or postdated prescription pads are prohibited.
Yes
No
Dispensed medications, to include samples, must be noted in
the medical record and include the medication name, dosage,
amount given, and the lot number(s).
Yes
No
This should be in accordance with CDC requirements.
Yes
No
NA
This should be in accordance with CDC requirements.
Yes
No
NA
b. Expired items are
disposed of in a manner
that prevents
unauthorized patient
access.
36. Records and security
are maintained to
ensure the control and
safe dispensing of drugs
in compliance with
federal and state laws.
37. Refrigerated vaccines
are kept at a
temperature not lower
than 35° F and not
higher than 46 °F
degrees. (PCPs only)
Inspection Date:
No
Section 2c: Medication Storage
34 a. All medications,
including vaccines and
samples, are checked for
expiration dates on a
regular basis.
35. Measures have been
implemented to ensure
prescription pads are
controlled and secured
from unauthorized patient
access.
Yes
Comments
Page 6 of 13
Section 2d: Laboratory
Standards
Criteria
Criteria Met (Y/N)
39. Adequate specimen
pick-up frequency?
Yes
No
40. Lab reports have
patient’s name and date
of test.
Yes
No
41. Does the office have an
on-site laboratory? If
NO, go to Section 2e.
Yes
No
NA
42. Equipment manual is
present.
Complete descriptions are available of each test, including
sources of reagents, standards and calibration procedures, and
information concerning the basis for the listed “normal” ranges.
Yes
No
NA
43. Office adheres to
laboratory policies
and/or procedures.
Obtaining, identifying and storing specimens.
Yes
No
NA
44. CLIA certification.
Yes
No
NA
45. Calibration log
maintained.
Yes
No
NA
Section 2e: Infection Control/Bloodborne Pathogens
Standards
46. Adequate hazardous
waste disposal policy.
Criteria
Please print name of waste disposal company in the comments
section.
Criteria Met (Y/N)
Yes
No
47. Is needle disposal
system used?
Yes
No
48. Do blood handlers wear
gloves? Includes any
exposure to blood.
Yes
No
Yes
No
49. Are Universal
Precautions are in place.
Distribute EXPOSURE TO BLOOD
What Health-Care Workers Need to Know.
Comments
Corrective Action
Corrective Action
Cert #:
Comments
Page 7 of 13
Section 2f: X-Ray
Standards
Criteria
Criteria Met (Y/N)
Corrective Action
50. Are X-rays performed
on-site? If NO, continue
to Section 2g.
Yes
No
51. Pregnancy notice
posted.
Yes
No
NA
Yes
No
NA
53. Current technician
licensure on file.
Yes
No
NA
54. Office adheres to X-ray
policies and/or
procedures.
Yes
No
NA
55. Badges worn and
monitored.
Yes
No
NA
52. Date and results of last
state inspection.
Please specify date in comments section.
Section 2g: Office Protocol
Standards
56. Documentation of
physician and office
license/certification.
57. Provider aware of
contract requirements
for
availability/accessibility,
appointments are
scheduled in accordance
with guidelines as
defined in the Provider
Manual.
Criteria
The provider’s license is available upon request for physicians,
ARNPs, and Pas listed on the application.
Criteria Met (Y/N)
Yes
No
Yes
No
Yes
No
Corrective Action
Comments
Comments
Appointment scheduling – Provider has sufficient time slots
available to comply with contract requirements.
Wait times are monitored.
58. Appointment
scheduling – Provider
does patient follow-up
Page 8 of 13
for missed
appointments.
59. Appointment
scheduling – Provider is
aware of requirements
for
availability/accessibility
as defined in Provider
Manual.
Yes
No
Remainder of page intentionally left blank.
Document continued on next page.
Page 9 of 13
Inquire about protocols in place to address confidentiality, to
include compliance with HIPPA Regulations.
The provider should be aware that the release of any
information to a third party should be preceded by the patient
signing a “release of medical information” form. Verify that
precautions are taken to prevent unauthorized access to the
patient records.
Ensure the required HIPPAA Compliance Program Protocols are
in place to include the following:
60. Protocols addressing
security, confidentiality,
including storage of
medical records.
a) Review or inspect their “release of medical information”
form.
b) Verify they have a privacy officer (specify the name in
comments section).
c) “Request to see their HIPPA Privacy Policies and Procedures
and have them show you the policy addressing security,
confidentiality and storage of medical records.
d) Request to see the staff privacy-training program and verify
that all associates are required to receive the training.
e) Verify that they have a Notice of Privacy Practices (“NPP”)
and that it is provided to all new Privacy Practices (“NPP”)
and that it is provided to all new patients (a notation should
be patients (a notation should be in each medical record file
indicating that they signed and received it or attempted to
obtain a signature and the patient waived their right to
show receipt of the NPP).
f) Inquire if they file electronic claims (if yes as them if they
are compliant with final HIPPA Transactions Codes Sets as of
October 16, 2003).
g) Inquire if they file electronic claims (if yes ask them if they
are compliant with final HIPPA Transactions Codes Sets as of
Oct. 16, 2003).
h) Request to see a copy of their Business Associate
Agreement and verify the protocol to show they obtain one
on every business associate whom has access to Protected
Health Information (PHI).
i) Inquire that they have security protocols in place for the
office (to include storage of medical records) and that they
are on target for compliance with the HIPAA Security
regulations by the required compliance deadline of April 21,
2005.
Yes
No
Page 10 of 13
61. Does center have a followup policy for patient
referrals?
Yes
No
62. Students in the office.
Yes
No
63. If yes, is there a policy
for supervision and
scope of responsibilities
for the student.
Yes
No
Section 2h: Medical Records
Standards
64. Adequate filing system
for medical records.
Sufficient space for
Medical records.
Criteria
Contents of the record are secured.
Criteria Met (Y/N)
Yes
No
65. One medical record per
person.
Yes
No
66. Information in
chronological order.
Yes
No
67. Patient’s name on each
page of record.
Yes
No
68. Member’s health ID
number in is the record.
Yes
No
69. Physician name on
medical record.
Yes
No
Corrective Action
Comments
Page 11 of 13
70. A procedure is in place
to obtain reports from
consultations,
diagnostics, emergency
care and hospital
discharge summaries.
(Specialists) A procedure
is in place to
disseminate
consultation reports to
the referring physician.
All reports are dated and signed as appropriate.
Yes
No
71. Written policy for
patient notification of
test results. (In lieu of a
written policy, a
procedure is in place
and can be
demonstrated.)
Lab, X-ray, etc.
Yes
No
Section 2i: After Hours Triage
Standards
Criteria
Criteria Met (Y/N)
Corrective Action
Comments
The following are acceptable for after-hours:
72. Physician available for
after-hours triage.
73. Licensed person
answers triage calls
requiring professional
judgment.
1. Answering service
2. Answering service with option to page the physician
3. An advice nurse with access to the PCP or on-call
physician.
74. Clinical triage
documented and
entered into permanent
medical record by next
working day.
Yes
No
Yes
No
Yes
No
Page 12 of 13
Section 3: Affirmation of Accuracy and Completeness
Compliance Met?
Yes
No
If NO, date Corrective Action Notice sent.
Date followed up with Corrective Action:
Compliance Met?
Yes
No
I affirm that the information provided in or attached to this Site Inspection Evaluation is accurate and complete.
Surveyed by:
Provider Operations Representative Name
Provider Relations Representative Signature
Date:
Center Manager Signature
Date:
Reviewed by:
Center Manager Name:
Page 13 of 13
PRESTIGE HEALTH CHOICE MEDICAL RECORD AUDIT
Physician:
Record 1
Member ID:
Record 2
Member ID:
Record 3
Member ID:
Record 4
Member ID:
Record 5
Member ID::
Site
Total
Standard
Date:
Reviewer:
DOB:
YES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
NO
N/A
YES
DOB:
NO
N/A
YES
DOB:
NO
N/A
YES
DOB:
NO
N/A
YES
NO
N/A
Medications list is current and easily accessible.
Allergies and adverse reactions to medications are
prominently displayed. If patient has no known allergies or history of
adverse reactions, these are noted in record.
Problem list is completed with significant illness or medical
conditions.
Preventive health services (i.e., immunization record form,
well-child form or risk screening) are offered in accordance with the
practice/preventive-care guidelines/childhood checkups & adults.
Immunization records are included for children and adolescents,
either as part of medical history or as a separate standard.
Personal/biographical data are present in record (i.e.,
address, employer, home and work phone number, marital status).
History and physical exam identifies appropriate subjective &
objective information pertinent to presenting complaint(s) / health
maintenance concerns. (History includes serious accidents,
operations and illnesses. For children and adolescents, past medical
history relates to prenatal care, birth operations and childhood
illnesses.)
Record format is conducive to recording subjective and objective
information, documenting clinical findings and evaluation and plan of
treatment pertaining to presenting complaints during each visit.
Consent forms are present for informed consent for psychotropic
medication (under age 13) and for antidepressant medication (under
age 5) and applicable.
Patient name or ID# is on each page of record.
Entries are signed and dated by authorized personnel.
Records are legible to someone other than reviewer.
Information regarding the use of tobacco, alcohol and substance
abuse for patients 10 years and older is present.
Labs and other studies are ordered as appropriate.
Working diagnosis is consistent with findings.
Treatment plans/plans of action are consistent with diagnosis (e.g.,
labs, medications, etc.).
Encounter form or notes have a notation regarding follow-up care,
calls or visits, when indicated. The specific time is noted in days,
weeks, months, or as needed.
Unresolved problems from previous visits are addressed in
subsequent visits. Reflects services provided directly by primary
medical provider, ancillary services and diagnostic tests ordered by
primary medical provider and diagnostic and therapeutic-service
referrals.
Use of consultants is appropriate (e.g., under or over utilized).
Record contains consultant note whenever consultation is requested.
YES
21.
DOB:
Consultation, lab and/or imaging reports in chart indicate review by
evidence of practitioner acknowledgement. Abnormal results have n
notation in record of follow-up plan.
Medical Record Audit Tool 11/18/13
NO
N/A
YES
NO
N/A
YES
NO
N/A
YES
NO
NA
YES
NO
N/A
%
Compliant
22. Documentation in record includes:
Specialty Referrals
Inpatient (discharge summaries)
Emergency care
Outpatient services (diagnostic and ancillary)
23.
Patient does not appear to be placed at inappropriate risk by a
diagnostic or therapeutic procedure.
24.
Advanced directives have been discussed and documented
for every patient 21 years and older. If an advance directive
has been executed, a copy should be present in the medical
record. Written instructions for a living will or durable power of
attorney for health care and are present when the patient i
incapacitated and has such a document.
25.
Missed appointments and any follow-up activities are
documented in the medical record.
TOTALS:
SCORE:
COMMENTS:
Medical Record Audit Tool 11/18/13
Numera
tor:
Denom
inator:
Numerator:
%
%
Denomin
ator:
Numerator:
%
Denomina
tor:
Numerato
r:
%
Denominat
or:
Numerator:
%
Denomin
ator:
HEALTH CHOICE ®
PRES-1422-01
P2000_1507

Provider Manual - Prestige Health Choice

Transcription

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