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

Transcription

National Vision Administrators, L.L.C.
(NVA)
&
Vision
Provider Manual
1200 Route 46 West
Clifton, NJ 07013
1-888 830-5630
www.e-nva.com
This document contains proprietary and confidential information and
may not be disclosed to others without written permission.
Copyright 2015. All rights reserved.
NVA Provider Manual New York
2
NVA IPA, LLC.
About Partners Health Plan and People with Disabilities
Welcome
NVA IPA, LLC. (NVA) has entered into an agreement to provide services to Partners Health
Plan (PHP). Partners is the first fully integrated duals advantage(FIDA) plan approved by the
Center for Medicare and Medicaid Services (CMS) and the New York State Department of
Health (SDOH) to serve eligible adults with intellectual and other developmental disabilities
(IDD) in all five boroughs of New York City as well as Nassau, Rockland, Suffolk, and
Westchester Counties. PHP’s FIDA-DD program provides all Medicare- and Medicaid-covered
services to dually eligible people with IDD that are at least 21 years of age and need medical,
behavioral, dental, and long-term services and supports (LTSS)―including Office of People
with Developmental Disabilities (OPWDD) waiver services―to remain in their homes and
communities as long as possible. Vision care is one of the basic services provided to members
under this arrangement.
The ability to serve participants effectively is dependent on the quality of the provider network.
By joining the network, you are helping us serve eligible individuals by providing high-quality
and accessible services and supports. You and your office staff represent one of the most critical
components of our service delivery approach.
This manual is intended to serve as an extension of our provider agreement. It includes valuable
information to help you understand our program and provides helpful tips on how to work with
PHP members. It should be a valuable resource for you and your office staff.
About Partners Health Plan
Partners Health Plan, Inc. (“PHP”) is a federal 401(c)(4) tax exempt New York not-for-profit
corporation aligned with the Downstate New York chapters of the NYSARC, Inc. PHP’s sole
corporate member is Partnerships for Healthcare Solutions, Inc. ("Partnerships"), which is also a
New York not-for-profit corporation. Partnerships has one corporate member, PHSI, Inc., which
is also a New York not-for-profit corporation.
PHP is led by invested stakeholders, family members, and advocates with decades of experience
in health care, health insurance, and in managing services and supports for people with IDD.
These industry leaders have collaborated in a pioneering effort to implement a high-quality
managed care program for persons with intellectual and other developmental disabilities and
those who support them.
Since 1994, regardless of budget cuts and changes in New York’s political and economic
climate, the Downstate AHRCs/ARCs have worked tirelessly to ensure that compassionate
community-based programs for people with IDD continue now and into the future. With more
than six decades of experience serving persons with IDD, PHP has the expertise to develop and
implement a personalized Life Plan that ensures that each participant receives the essential
medical, dental, behavioral, habilitation, vision and social services needed to support his or her
3
health, safety, personal preferences, and valued outcomes in a manner that promotes courtesy,
respect, and compassion.
Mission and Values
PHP is a person-centered managed care plan that supports participants to live the life they
choose. PHP’s values and goals include:
•
Promoting wellness
•
Supporting choice
•
Integrating services
•
Respecting diversity
•
Promoting quality of life
PHP’s objective is to provide a seamless array of supports and services with the individual at the
center. They are dedicated to keeping each of our participants healthy, happy, and as independent
as possible while they pursue their dreams and valued outcomes in the diverse communities they
call home. Working in close collaboration with families and other members of the community,
PHP will continue the proud AHRC/ARC tradition of supporting the unique needs and wishes of
the individuals in their care, fully integrating their supports and services, advocating on their
behalf, and assisting participants throughout their lives. Their goals are lofty, but so too are the
expectations of the people they are committed to supporting.
About Intellectual and Other Developmental Disabilities
According to the New York State Mental Hygiene Law, an intellectual or other developmental
disability (IDD) is attributable to mental retardation, cerebral palsy, epilepsy, neurological
impairment, or autism that originates before a person attains age twenty two and is expected to
continue indefinitely. Persons with IDD have widely varying degrees of abilities and deficits that
often require direct-support professionals to know their unique forms of verbal and non-verbal
communication to provide necessary supports. In addition, many people with IDD display
challenging behaviors often associated with an inability to communicate effectively. For
example, a person experiencing pain or medical illness may rely on self injurious behavior as a
means of expressing physical discomfort.
The average life expectancy of people with IDD was just 22 years in 1931, compared to 59 years
in 1976, 66 years in 1993, and 76 years at present. Currently, the cause of death for all
individuals with IDD mirrors that of the general population (i.e., coronary heart disease, type 2
diabetes, respiratory illnesses, and cancer), except for those with Down syndrome, who typically
die earlier due to dementia-related causes (over half of those with Down syndrome are expected
to live into their 50s and roughly 13 percent will reach age 65). There are approximately six
million individuals in the US with an IDD diagnosis and nearly 315,000 are over the age of 65 –
a number that is expected to increase to more than 500,000 by 2020. 1
1
Laura Walker, Christine Rinck, Ph.D., Vim Horn, M.P.A., and Tom McVeigh, “Aging with Developmental
Disabilities: Trends and Best Practices,” University of Missouri Kansas City Institute for Human Development and
The Missouri Division of MR/DD (2007); Toby Long and Sarkis Kavarian, “Aging with Developmental
Disabilities: An Overview,” Topics in Geriatric Rehabilitation 24 (2008).
4
Despite their handicaps, the issues confronting aging persons with IDD are not dissimilar from
those of their non-disabled counterparts, including locating safe and affordable housing, living
independently, accessing assistance when it is needed, leading productive and meaningful lives,
and staying healthy. However, the situation is especially challenging for older adults with IDD
owing to an array of issues unique to this population, including aging caregivers, work-related
issues, and medical and behavioral health problems.
Physical Health Issues
There are many physical health factors associated with intellectual and other developmental
disabilities, and these often manifest in chronic health conditions as persons with IDD age. For
example, recent studies have documented higher incidents of disease and death for aging adults
with IDD due to a number of health conditions, such as difficulty eating or swallowing, dental
disease, gastroesophageal reflux, esophagitis, respiratory disease and infections (leading cause of
death), and constipation. A number of chronic conditions also seem to be more widespread
among persons with IDD than in the general population, including non-atherosclerotic heart
disease, hypertension, hyperlipidemia, diabetes, obesity, reduced mobility, bone
demineralization, and osteoporosis. In addition, thyroid disease, the effects of taking multiple
psychotropic drugs, and deaths due to pneumonia, bowel obstruction, and intestinal perforation
have a higher prevalence among aging adults with IDD. 2
Some specific syndromes and diagnoses are inherent (e.g., epilepsy, sensory problems like poor
vision and hearing, poor heart function in people with Down syndrome), while others are
avoidable but overrepresented among the developmentally disabled (e.g., obesity, diabetes, poor
dental health). Also, symptoms of aging like diminished hearing, the development of cataracts,
respiratory difficulties, the onset of menopause, and obesity-related diseases like high cholesterol
and diabetes can all occur earlier in those with Down syndrome than in the general population.
Behavioral Health Issues
In general, older adults are more prone to depression and other behavioral health issues than
younger persons and this tendency is even more pronounced among individuals with IDD,
although it is frequently under-assessed, under-diagnosed, and left untreated. It is often
challenging to identify behavioral health problems among aging individuals with IDD because
they are generally less capable of describing and conveying their feelings, and symptoms of
conditions like depression may be expressed as physical complaints instead (e.g., headaches).
Anti-depressant medication is generally effective in addressing these conditions, but
considerable care has to be taken to prevent potentially harmful interactions with other
prescribed medications. 3
Persons with a dual diagnosis of IDD and a co-occurring behavioral health condition can be
found at all ages and levels of intellectual and adaptive functioning. Estimates of the frequency
of dual diagnoses vary widely; however, current professional consensus is that 30-40 percent of
all persons with IDD have a psychiatric disorder, although this percentage could be as high as 60
percent if aggressive and disruptive behavior is included. The full range of psychopathology that
exists in the general population also can co-exist in persons who have IDD.
2
Beth Marks and Jasmina Sisirak, “Age-Related Health Changes for Adults with Developmental Disabilities,”
University of Minnesota (2009). http://ici.umn.edu/products/impact/231/20.html
3
; Alan R. Factor, Ph.D., “Growing Older with a Developmental Disability: Physical and Cognitive Changes and
Their Implications,” Institute on Disability and Human Development, University of Illinois at Chicago (1997).
http://depts.washington.edu/aedd/growing_older_dd_Factor.html
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Professional Competencies for Providers
This section highlights the core competencies, skills, and attitudes necessary to provide high
quality care and services to adults with IDD.
Knowledge
•
Clinical Knowledge Specific to IDD: Clinical knowledge includes causes, symptomology,
characteristics, and the natural history of developmental disorders, as well as the specific
medical conditions that are known to co-occur with developmental disabilities. Additional
topics include diagnostic testing, psychotropic medications, behavioral interventions, use of
adaptive equipment, and management of chronic disease.
•
Legal Rights of People with IDD: This knowledge area includes relevant legislation for
people with IDD, as well as the rights of individuals and their families. Examples of rights
for people with IDD include the right to prompt medical care and treatment; freedom from
harm, unnecessary physical restraint or isolation; freedom from excessive medication, abuse
and neglect; and freedom from hazardous procedures.
Skills
•
Communication and Interviewing Skills: This skill includes strategies to gain a history,
screen, and evaluate an individual with IDD, particularly when he or she may be nonverbal.
Communication skills also include the ability to effectively obtain and share information with
families or caregivers.
•
Observation Skills: Observation skills are critical when working with people with IDD,
especially to identify behaviors that may be affecting or may be resulting from the
individual’s health condition. This skill includes the ability to observe subtle changes in a
person’s behavior as these changes may in some cases require medical attention. Observing
subtle changes, as well as gathering the information about such changes and being alert to
caregiver reports about such changes, requires additional time and openness on the part of the
provider.
•
Physical Examination Skills: Physical examination skills specific to working with persons
with IDD include providing assistance with the positioning of the physical exam as well as
patience in working with individuals who may need extra time to be coaxed and talked
through the exam procedure. This also includes the ability to engage in preplanning and
diagnostics in order to assist the participant immediately and effectively.
•
Ability to Identify, Coordinate, and Communicate with Members of the Participant’s
Interdisciplinary Team: This skill encompasses the recognition that a multi-disciplinary
team is required in order to adequately care for a person with IDD. Members of the
participant’s IDT include those who conduct the assessment and develop and implement the
care plan, including care managers and coordinators, service providers, specialists, and
caregivers. In addition to understanding the various roles of the team members, this skill also
includes the ability to effectively coordinate the services for the participant.
Attitudes
•
Compassion and Sensitivity: Sensitivity to the needs and experiences of people with IDD
includes having compassion, good listening skills, and flexibility, as well as an understanding
of the context in which individuals live and how that may influence treatment compliance.
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This also encompasses recognition of the challenges that people with IDD face on a daily
basis and the types of accommodations they may need.
•
Participant- and Family-Centered Attitude: Health care providers should strive to tailor
their care according to what the participant wants. This encompasses extending respect to the
participant by using appropriate terminology, interacting directly with the participant, and
including him or her in the conversation. In addition, this attitude includes being respectful
towards families and providing support when needed. Strong relationships with persons with
IDD and their families are necessary in order for participants to trust and have confidence in
their providers.
•
Cultural Sensitivity: Cultural appropriateness reflects the ability for providers to be
sensitive to differences. In this context, culture encompasses not only race/ethnicity and
language, but also the disability culture. Cultural sensitivity includes using respectful
terminology (e.g., people-first language), providing language assistance when necessary in
order to communicate with participants, and providing care in a manner that takes into
consideration the participant’s background and culture.
•
Recognition of the Additional Time Necessary to Serve Persons with IDD: In order to
adequately serve and meet the needs of people with IDD, providers must be prepared to
spend additional time with them, as they often experience more complex problems compared
to the general population.
About the FIDA Program for People with IDD
PHP's specialized FIDA-DD program integrates Developmentally Disabled waiver services such
as habilitation and residential services with medical, behavioral, dental, vision, and other healthrelated services to provide the full continuum of Medicare- and Medicaid-covered services and
supports to adults with IDD. This program is designed to:
•
Link primary, specialty, and community-based services for some of New York's most
vulnerable residents
•
Break down service delivery silos
•
Reduce or eliminate duplicative and/or unnecessary services and supports
•
Promote timely and effective communications among the various stakeholders involved in a
participant’s care
•
Improve outcomes
•
Enhance participant and family satisfaction
PHP’s goals are lofty, but so too are the expectations of the people served. As a contracted
provider with NVA, we thank you for your willingness to assist us and PHP toward the
achievement of these ambitious goals.
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Emergency Services
Definition
An emergency medical condition manifests itself by acute symptoms of severity (including
severe pain) such that a prudent lay person, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to result in:
•
Placing the health of the individual in serious jeopardy, or in the case of a behavioral
condition, placing the health of the person or others in serious jeopardy
•
Serious impairment of bodily functions
•
Serious dysfunction of any bodily organ or part
•
Serious disfigurement
Emergency services are defined as covered inpatient and outpatient services that are furnished by
a provider/practitioner that is qualified to furnish such services and such services are needed to
stabilize an emergency medical condition.
Emergency and Post-Stabilization Care
The Plan complies with all federal and state requirements as it relates to the provision and
coverage of emergency and post-stabilization care services. This means that the Plan:
•
Does not require prior authorization for emergency services
•
Does not deny payment for treatment if a participant had an emergency medical condition or
if a staff member instructed the participant to seek emergency services
•
Does not limit what is considered to be an emergency medical condition on the basis of a list
of diagnoses or symptoms
•
Does not refuse to cover emergency services based on the provider not notifying the
participant’s PCP or the Plan of the participant’s screening and treatment within 10 calendar
days of presentation for emergency services
•
Does not allow a participant to be held liable for payment of subsequent screening and
treatment needed to diagnose the specific condition or to stabilize the participant
•
Does not require prior authorization for post-stabilization care services, regardless of whether
the participant obtains the services within or outside of the Plan’s provider network if:
− The Plan pre-approved the services.
− The services were not pre-approved by the Plan because either the Plan did not respond
to the provider’s request within one hour or the Plan could not be reached by the provider
to request pre-approval.
− The Plan and the treating physician could not reach an agreement concerning the
participant’s care and the Plan’s Chief Medical Officer, Chief of Care Management, or
Director of UM was not available for consultation. (PHP also assures that the attending
emergency physician or the treating provider is responsible for a binding determination of
participant stabilization for transfer or discharge based upon the general rule for coverage
and payment.)
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Provider Manual
Table of Contents
Section
Page
Emergency Services .................................................................... ERROR! BOOKMARK NOT DEFINED.
Important Address and Telephone Numbers ............................................................................ 11
Medicaid Member Rights and Responsibilities ........................ ERROR! BOOKMARK NOT DEFINED.
New York State Regulatory Requirements ................................ ERROR! BOOKMARK NOT DEFINED.
1.00
2.00
Patient Eligibility Verification Procedures................................................................................. 17
1.01
Plan Eligibility .................................................................................................................... 17
1.02
Member Identification Card ............................................................................................... 17
1.03
Eligibility System ............................................................................................................... 18
1.04
Self-Referral Benefit .......................................................................................................... 18
Claim Submission Procedures (Claim Filing Options) ............................................................ 18
2.01
Electronic Claim Submission Utilizing NVA’s Internet Website ........................................ 18
2.02
Paper Claim Submission ................................................................................................... 19
2.03
Coordination of Benefits (COB) ........................................................................................ 20
2.04
Filing Limits ....................................................................................................................... 20
2.05
Receipt and Audit of Claims .............................................................................................. 20
3.00
Health Insurance Portability and Accountability Act (HIPAA)................................................. 20
4.00
Medicaid Managed Care Complaint/Appeal Process .... ERROR! BOOKMARK NOT DEFINED.
5.00
4.01
Medicaid Provider Complaint/Appeal ................................................................................ 26
4.02
MedicaidMember Complaint/Appeal ................................. ERROR! BOOKMARK NOT DEFINED.
CHIP Provider – Member Complaint and Appeal Process to NVA and New York Department
of Insurance (TDI).............................................................. ERROR! BOOKMARK NOT DEFINED.
5.01
CHIP Provider Complaint and Appeal Process ................ ERROR! BOOKMARK NOT DEFINED.
5.02
CHIP Member Complaint and Appeal Process ................. ERROR! BOOKMARK NOT DEFINED.
6.00
Quality Improvement (QI) Program ............................................................................................ 26
7.00
Fraud, Waste and Abuse .................................................. ERROR! BOOKMARK NOT DEFINED.
8.00
Credentialing ................................................................................................................................ 28
9.00
Standards of Care – Routine Care .............................................................................................. 29
9.01
Examination Standards ..................................................................................................... 29
9.02
The Patient Record ........................................................................................................... 30
9
10.00 Vision and Eye Care Guidelines ...................................... ERROR! BOOKMARK NOT DEFINED.
11.00
Partners Health Plan – New York Utilization Management Section ........................................ 31
11.01
Overview ........................................................................................................................... 31
11.02
Utilization Management and Prior Medical Approval ........ ERROR! BOOKMARK NOT DEFINED.
11.03
Fundus Photography ......................................................... ERROR! BOOKMARK NOT DEFINED.
11.04
External Photography........................................................ ERROR! BOOKMARK NOT DEFINED.
11.05
Punctal Plugs .................................................................... ERROR! BOOKMARK NOT DEFINED.
11.06
Retinal/NFL/Anterior Segment Imaging ............................ ERROR! BOOKMARK NOT DEFINED.
11.07
Refraction .......................................................................... ERROR! BOOKMARK NOT DEFINED.
11.08
Advanced Diagnostics ...................................................... ERROR! BOOKMARK NOT DEFINED.
11.09
Visual Fields ...................................................................... ERROR! BOOKMARK NOT DEFINED.
11.10
Serial Tonometry ............................................................... ERROR! BOOKMARK NOT DEFINED.
11.11
Gonioscopy ....................................................................... ERROR! BOOKMARK NOT DEFINED.
11.12
Vision Training/Orthoptics/Pleoptics ................................. ERROR! BOOKMARK NOT DEFINED.
11.13
Pachymetry ....................................................................... ERROR! BOOKMARK NOT DEFINED.
11.14
Corneal Topography ......................................................... ERROR! BOOKMARK NOT DEFINED.
11.15
Sensori-Motor Examination ............................................... ERROR! BOOKMARK NOT DEFINED.
11.16
Specular Microscopy ......................................................... ERROR! BOOKMARK NOT DEFINED.
11.17
Extended Ophthalmoscopy ............................................... ERROR! BOOKMARK NOT DEFINED.
12.00
Medicaid () Utilization Review Process...................................................................................... 33
13.00
CHIP Utilization Review Process ..................................... ERROR! BOOKMARK NOT DEFINED.
Appendix A
Attachments
General Definitions ........................................................................................................................A-1
Claim Form ....................................................................................................................................A-3
Claim Form Instruction ..................................................................................................................A-4
Medical Prior Approval (Vision And Materials) Form ....................................................................A-5
Medical Prior Approval (Medical And Ancillary Testing)...………………...………………………...A-6
Non-Covered Services Instructions ..............................................................................................A-7
Non-Covered Services Agreement Form .....................................................................................A-8
Laboratory Order Form ................................................................................................................A-9
Appendix B .............................................................................................................................................. B-1
Covered Benefits (See B-1 – B-3) ............................................................................................... B-1
Prior Approval .............................................................................................................................. B-1
10
Appendix B-1 (Medicaid) ........................................................................................................................ B-2
1.00
Age............................................................................................. B-ERROR! BOOKMARK NOT DEFINED.
1.01
Examination................................................................................................................................ B-2
1.02
Additional Examinations – Children Only............................................................................... B-2
1.03
Medical and Ancillary Services............................................B-Error! Bookmark not defined.
2.00
Dispensing .................................................................................................................................. B-2
3.00
Contact Lens Fitting – Medically Necessary Contact Lenses ............................................... B-3
3.01
Prior Approval ............................................................................................................................ B-3
3.02
Contact Lens Fitting – Cosmetic Contact Lenses ............B-Error! Bookmark not defined.
3.03
Benefit .....................................................................................B-Error! Bookmark not defined.
3.04
Reimbursement .....................................................................B-Error! Bookmark not defined.
4.00
Payments .................................................................................................................................... B-4
5.00
Assistance .................................................................................................................................. B-4
6.00
Materials ...................................................................................................................................... B-4
7.00
Contract Laboratory................................................................................................................... B-4
8.00
Ordering ...................................................................................................................................... B-4
9.00
Frames......................................................................................................................................... B-6
10.00
9.01
Samples ...................................................................................................................................... B-6
9.02
Plan Covered Frames – No Charge to Members ................................................................. B-6
9.03
Plan Covered Frames ............................................................................................................... B-6
9.04
Non-Plan Frames ...................................................................................................................... B-6
9.05
Traceable Means – Shipping .......................................................................................... B-6
Lenses ......................................................................................................................................... B-7
10.01
Lens Options – Plan Paid......................................................................................................... B-7
11.00
Contact Lenses .......................................................................................................................... B-7
12.00
Replacement Eyeglasses And Contact Lenses ...................................................................... B-8
Eyeglasses ............................................................................................................................................... B-8
Contact Lenses – Cosmetic ...............................................................B-Error! Bookmark not defined.
Contact Lenses – Medically Necessary ............................................................................................... B-8
13.00
Emergency Services .................................................................................................................. B-9
14.00
Payment Reconciliation of Copayments ............................... B-ERROR! BOOKMARK NOT DEFINED.
15.00
Covered Codes and Associated Fees ...................................................................................... B-9
IMPORTANT ADDRESS AND TELEPHONE NUMBERS
Customer Service/Provider Services
National Vision Administrators, L.L.C.
P.O. Box 2187
Clifton, NJ 07015
877-865-9981
E-mail address for Provider Services Department:
(Use for change of address, telephone number or to add associate)
[email protected]
E-mail address for Prior Approvals (PA):
(Use to request Prior Approval for Medical Necessity with form attached)
[email protected]
E-mail address for Service Issues:
(Use to report service issues for yourself or on behalf of a patient)
[email protected]
Customer Service/Member Services – NVA
National Vision Administrators
P.O. Box 2187
Clifton, NJ 07015
877-865-7925
Credentialing
National Vision Administrators
P.O. Box 2187
Clifton, NJ 07015
Attn: Credentialing Department
877-865-9981
[email protected]
Paper - vision claims should be sent to:
NVA - Claims
P.O. Box 2187
Clifton, NJ 07015
TDD (Hearing Impaired)
888-820-2990
Fraud Hotline
888-328-0421
11
Participant Rights
Participants are guaranteed the right:
•
To receive medically necessary items and services as needed to meet the participant’s needs,
in a manner that is sensitive to the participant’s language and culture, and that is provided in
an appropriate care setting, including the home and community
•
To receive timely access to care and services
•
To request and receive written and oral information about PHP, its network providers, its
benefits and services, and the participant’s rights and responsibilities in a manner that the
participant and/or the participant’s representative understands
•
To receive materials and/or assistance in a foreign language and in alternative formats, if
necessary
•
To be provided qualified interpreters, free of charge, if a participant and/or a participant’s
representative needs interpreters during appointments with providers and when talking to
PHP
•
To be treated with consideration, respect, and full recognition of his or her dignity, privacy,
and individuality
•
To be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation
•
Not to be neglected, intimidated, physically or verbally abused, mistreated, or exploited
•
Not to be discriminated against on the basis of and to receive care without regard to sex, race,
health status, disability, color, age, national origin, sexual orientation, marital status, or
religion
•
To be told where, when, and how to get the services the participant needs, including how to
get covered benefits from out-of-network providers if they are not available in PHP’s
network
•
To complain to NYSDOH or the Local Department of Social Services, and to use the New
York State Fair Hearing System and/or a New York State External Appeal, if appropriate
•
To be advised in writing of the availability of the NYSDOH toll-free hotline, the telephone
number, the hours of its operation and that the purpose of the hotline is to receive complaints
or answer questions about home care agencies
•
To appoint someone to speak on the participant’s behalf about the care he or she needs
•
To be informed of all rights, and the right to exercise such rights, in writing prior to the new
participant’s Effective Date of Enrollment
•
To participate in his or her Life Planning and participate in any discussions regarding
changes to the Life Plan, if or when they are warranted
•
To recommend changes in policies and services to agency personnel, NYSDOH, or any
outside representative of the participant’s choice
•
To have telephone access to a nursing hotline and on-call network providers 24/7 in order to
obtain any needed emergency or urgent care or assistance
A-12
•
To access care without facing physical barriers. This includes the right to be able to get in
and out of a provider’s office, including barrier-free access for participants with disabilities
or other conditions limiting mobility, in accordance with the Americans with Disabilities Act
•
To receive reasonable accommodations in accessing care, in interacting with PHP and its
providers, and in receiving information about one’s care and coverage
•
To see a specialist and request to have a specialist serve as Primary Care Provider
•
To talk with and receive information from providers on all conditions and all available
treatment options and alternatives, regardless of cost, and to have these presented in a manner
the participant or his or her representative understands. This includes the right to be told
about any risks involved in treatment options and about whether any proposed medical care
or treatment is part of a research experiment.
•
To choose whether to accept or refuse care and treatment, after being fully informed of the
options and the risks involved. This includes the right to say yes or no to the care
recommended by providers, the right to leave a hospital or other medical facility, even if
against medical advice, and to stop taking a prescribed medication.
•
To receive a written explanation if covered items or services were denied, without having to
request a written explanation.
•
To have privacy in care, conversations with providers, and medical records such that:
− Medical and other records and discussions with providers will be kept private and
confidential
− Participant or his or her representative gets to approve or refuse to allow the release of
identifiable medical or personal information, except when the release is required by law
− Participant may request that any communication that contains Protected Health
Information from PHP be sent by alternative means or to an alternative address
− Participant is provided a copy of PHP’s Privacy Practices, without having to request the
same
− Participant may request and receive a copy of his or her medical records and request that
they be amended or corrected, as specified in 45 CFR 164.524 and 164.526, if the privacy
rule, as set forth in 45 CFR 160 and 164, A and E, applies
− Participant may request information on how his or her health and other personal
information has been released by PHP
•
To seek and receive information and assistance from the independent, conflict free
Participant Ombudsman
•
To make decisions about providers and coverage, which includes the right to choose and
change providers within PHP’s network and to choose and change coverage (including how
one receives his or her Medicare and/or Medicaid coverage – whether by changing to another
type of managed care plan, returning to Original Medicare, or making other changes in
coverage)
•
To be informed at the time of enrollment and during Life Plan updates or revision meetings
of what an Advance Directive is and the right to make an Advance Directive – giving
instructions about what is to be done if the participant is not able to make his or her own
medical decisions, and to have PHP and its network providers honor it
A-13
•
To access information about PHP, its provider network, and covered items and services
including:
− Information about PHP’s financial condition, its performance rating, how it compares to
other plans, and the number of appeals made by participants
− Information about the qualifications of network providers and how they are paid
− Information about the rules and restrictions on covered items and services
•
The right to have all plan options, rules, and benefits fully explained, including through the
use of a qualified interpreter if needed
•
The right to have access to an adequate network of primary and specialty providers who are
capable of meeting the participant’s needs with respect to physical access, and
communication and scheduling needs
•
The right to have a voice in the governance and operation of PHP’s system, provider, or
health plan, as detailed in this Contract
•
The right to participate in all aspects of care and to exercise all rights of appeal. Participants
have a responsibility to be fully involved in maintaining their health and making decisions
about their health care, including the right to refuse treatment if desired, and must be
appropriately informed and supported to this end. Specifically, participants must:
− Receive an in-person Comprehensive Assessment upon enrollment in PHP and
participate in the development and implementation of a Life Plan. Participants, or their
designated representative, also have the right to request a Comprehensive Reassessment
by PHP, and to be fully involved in any such Comprehensive Reassessment.
− Receive complete and accurate information on his or her health and functional status by
the Interdisciplinary Team (IDT)
− Be provided information on all program services and health care options, including
available treatment options and alternatives, presented in a culturally appropriate manner,
taking into consideration the participant’s condition and ability to understand. A
participant who is unable to participate fully in treatment decisions has the right to
designate a representative. This includes the right to have translation services available to
make information appropriately accessible. Information must be available:
◊ Before enrollment
◊ At enrollment
◊ At the time an eligible individual’s or participant’s needs necessitate the disclosure
and delivery of such information in order to allow the eligible individual or
participant and/or his or representative to make an informed choice
◊ Be encouraged to involve caregivers or family members in treatment discussions and
decisions
◊ Be afforded the opportunity to file an Appeal if items or services are denied that he or
she thinks are medically indicated, and to be able to ultimately take that Appeal to an
independent external system of review
•
The right to freely exercise his or her rights with the assurance that the exercise of those
rights will not adversely affect the way PHP and its providers or the state agency or CMS
provide, or arrange for the provision of, supports and services to the participant.
•
The right to receive timely information about PHP changes. This includes the right to request
and obtain the information listed in the Marketing, Outreach, and Participant
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Communications materials at least once per year, and the right to receive notice of any
significant change in the information provided in the Orientation materials at least 30 days
prior to the intended effective date of the change.
•
The right to be protected from liability for payment of any fees that are the obligation of
PHP, including the right not to be balanced billed by a provider for the cost of any covered
service, which includes any coinsurance, deductibles, financial penalties, or any other
amount in full or in part.
•
The right not to be charged any cost sharing for Medicare Parts A and B services and/or
Medicaid supports and services
In the event PHP is made aware of a participant being denied any of the rights identified above,
PHP will initiate an investigation into the matter and report the findings to the Chief Compliance
Officer and the Quality Oversight Committee. Any PHP staff member or network provider who
violates this policy will be appropriately disciplined, up to and including termination of
employment/contract.
PHP participants and their authorized representatives will not be penalized or suffer any negative
consequences for exercising their rights.
Participant/Caregiver Responsibilities
PHP participants and/or their authorized representatives have the responsibility:
1) To try to understand Covered Items and Services and the rules around getting Covered
Items and Services
2) To tell providers that they are enrolled in PHP and show their PHP ID card
3) To treat providers and PHP staff with respect
4) To communicate problems immediately to PHP
5) To keep appointments or notify the participant’s care management team/IDT if an
appointment cannot be kept
6) To supply accurate and complete information to PHP’s staff
7) To actively participate in Life Plan development and implementation
8) To notify the state and the FIDA Plan of any changes in income and assets. Assets
include bank accounts, cash in hand, certificates of deposit, stocks, life insurance
policies, and any other assets
9) To ask questions and request further information regarding anything not understood
10) To use PHP’s network providers for services included in PHP’s benefit package
11) To notify PHP of any change in address or lengthy absence from the area
12) To comply with all PHP policies as noted in the Participant Handbook
13) If sick or injured, to call their doctors or care coordinators for direction right away
14) In case of emergency, to call 911
15) If emergency services are required out of the service area, to notify PHP as soon as
possible
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In the event PHP is made aware of a participant not complying with the responsibilities outlined
above, PHP will make a good faith effort to address the issue with the participant and his or her
authorized representative, educate the participant and his or her authorized representative about
their responsibilities, and document the interaction in PHP's MediSked care management system.
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1.00
Patient Eligibility Verification Procedures
1.01
Plan Eligibility
Any person who is enrolled in a Plan’s program is eligible for benefits under the Plan.
1.02
Member Identification Card
Partners Health Plan (PHP) members receive identification cards from the Plan.
Participating Providers are responsible for verifying that Members are eligible at the time
services are rendered and to determine if recipients have other health insurance.
NVA recommends that each Vision office make a photocopy of the member’s
identification card each time treatment is provided. It is important to note that the health
plan identification card is not dated and it does not need to be returned to the health plan
should a member lose eligibility. Therefore, an identification card in itself does not
guarantee that a person is currently enrolled in the health plan.
To be sure that a member is eligible for benefits at the time of service, you may
verify eligibility with NVA, either by utilizing the on-line system, or by telephone
(see below).
1.03
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Eligibility System
The most convenient method of accessing eligibility is by utilizing NVA’s Vision
interactive website (www.e-nva.com). After logging in, you will have the opportunity to
verify eligibility for any member. Once verified, you will receive a control number, for
any covered service (routine services only) provided within thirty (30) days of the date
of verification. This number should be maintained as it will be required for future inquiry
and to track claims payment.
Participating providers who do not have access to the internet may also access eligibility
information and receive control numbers by calling the Customer Service Department at
877-865-9981.
When verifying eligibility, you will be provided with patient specific benefit information
which may include:
•
•
•
•
1.04
Examination Only
Materials Only
Examination and Materials
Copayments if applicable
Self-Referral Benefit
The vision examination benefit is available to covered members without the requirement
for a referral from the member’s Primary Care Provider (PCP), or specialist.
2.00
Claim Submission Procedures (Claim Filing Options)
NVA receives vision claims in two (2) possible formats. These formats include:
•
•
Electronic claims via NVA’s Provider website (www.e-nva.com).
Paper claims [CMS (HCFA) 1500 required].
Clean claims must be submitted and received by NVA within 90 days from the date of service
and must include your NVA Provider number and individual Provider’s NPI number. Claims
received after the 90-day filing limit will be denied. If it can be demonstrated that a claim denied
for timely filing could not have been submitted within 90, the claim may be resubmitted but in no
case will a claim be submitted for payment after 365 days, from the date of service.
2.01
Electronic Claim Submission Utilizing NVA’s Internet Website
Participating Providers may submit claims directly to NVA by utilizing NVA's Provider
Website. Submitting claims via the website is very quick and easy. It is especially easy
if you have already accessed the site to check a Member’s eligibility prior to providing
the service and received a control number (strongly recommended).
If you have not used the provider website before, you must register using your tax ID, zip
code, email address and suffix code (this is a 4-digit number that was provided to you in
your welcome letter). If you do not have the suffix code, you may contact the Provider
Services department, and a replacement will be provided.
Once you have logged in using your user name and password, you may verify eligibility,
obtain authorizations, view your authorizations, place your lab order, and submit claims.
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To submit a claim enter the patient’s ID#, or name and date of birth, or select the
corresponding authorization number. At this point, you will need to select the examining
provider from the drop down box. Enter all the applicable information, choose the
appropriate CPT and ICD-9 codes, and hit submit to submit the claim. You will receive a
confirmation statement when the claim is submitted.
If you have questions on submitting claims or accessing the website, please contact our
Provider Services Department at 888-830-5630 or [email protected].
2.02
Paper Claim Submission
•
NVA requires that a CMS (HCFA) 1500 Claim Form be used for submission of all
paper claims.
•
Member name and identification number must be listed on all claims submitted.
•
Member control number should be noted. Please place this number on line 10D of
the form.
•
The patient’s date of birth must also be listed. If the member identification number is
missing or miscoded on the claim form, the patient cannot be identified. This could
result in the claim being returned to the submitting Provider office, causing a delay in
payment.
•
The Provider and office location information must be clearly identified on the claim.
Frequently, if only the Provider signature is used for identification, the Provider’s
name cannot be clearly identified. Please include either a typed Provider (practice)
name or the NVA Provider identification number and provider specific NPI number.
•
The date of service must be provided on the claim form for each service line
submitted.
•
Approved Vision codes (CPT and HCPCS), as contained in this agreement, must be
used to define all services.
•
Up to 4 ICD-9 codes (will change to ICD-10 as of October 1, 2015) may be
submitted, and all relevant codes should be included. Professional services without
at least one ICD code will be denied.
•
Affix the proper postage when mailing bulk documentation. NVA does not accept
postage due mail. This mail is returned to the sender and will result in delay of
payment.
Paper claims for routine services should be mailed to the following address:
NVA - Claims
P.O. Box 2187
Clifton, NJ 07015
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2.03
Coordination of Benefits (COB)
When NVA is the secondary insurance carrier, a copy of the primary carrier's
Explanation of Benefits (EOB) must be submitted with the claim. The payment made by
the primary carrier must be indicated in the appropriate COB field, on a CMS 1500 Form.
When a primary carrier's payment meets or exceeds a provider's contracted rate or fee
schedule, NVA will consider the claim paid in full and no further payment will be made
on the claim. Examples of Coordination of Benefits may include no fault insurance
carriers and worker’s compensation claims. Only paper (CMS-1500) claim forms may be
utilized to report a claim with COB information.
2.04
Filing Limits
Any claim received beyond the timely filing limit of 90 days will be denied for "untimely
filing." If a claim is denied for "untimely filing", the provider cannot bill the member. If
NVA is the secondary carrier, the timely filing limit begins with the date of payment or
denial from the primary carrier. Claims that are initially denied for timely filing may be
resubmitted if it can be demonstrated that they could not have been submitted within the
90 days. In no case will these claims be considered if submitted more than 365 days from
the date of service.
2.05
Receipt and Audit of Claims
In order to ensure timely, accurate remittances to each participating Provider, NVA
performs an audit of all claims upon receipt. This audit validates Member eligibility,
procedure codes and provider identifying information. When potential problems are
identified, your office may be contacted and asked to assist in resolving the problem.
Please contact our Provider Services Department with any questions you may have
regarding claim submission or your remittance.
3.00
Health Insurance Portability and Accountability Act (HIPAA)
As a healthcare provider, your office is required to comply with all aspects of the HIPAA
regulations in effect as indicated in the final publications of the various rules covered by HIPAA.
NVA has implemented various operational policies and procedures to ensure that it is compliant
with the Privacy, Administrative Simplification and Security Standards of HIIPAA. One aspect of
our compliance plan is working cooperatively with our providers to comply with the HIPAA
regulations. In relation to the Privacy Standards, NVA has previously modified its provider
contracts to reflect the appropriate HIPAA compliance language. These contractual updates
include the following, in regard to record handling and HIPAA requirements:
•
Maintenance of adequate vision/medical, financial and administrative records related to
covered services rendered by Provider in accordance with federal and state law.
•
Safeguarding of all information about Members according to applicable state and federal
laws and regulations. All material and information, in particular information relating to
Members or potential Members, which is provided to or obtained by or through a
Provider, whether verbal, written, tape, or otherwise, shall be reported as confidential
information to the extent confidential treatment is provided under state and federal laws.
•
Neither NVA nor Provider shall share confidential information with a Member’s
employer absent the Member’s consent for such disclosure.
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•
Provider agrees to comply with the requirements of the Health Insurance Portability and
Accountability Act (“HIPAA”) relating to the exchange of information and shall
cooperate with NVA in its efforts to ensure compliance with the privacy regulations
promulgated under HIPAA and other related privacy laws.
Provider and NVA agree to conduct their respective activities in accordance with the applicable
provisions of HIPAA and such implementing regulations.
In relation to the Administrative Simplification Standards, you will note that the benefit tables
included in this Provider Manual reflect the most current coding standards (CPT-5 and HCPCS).
Effective the date of this manual, NVA will require providers to submit all claims with the proper
CPT-5 or HCPCS codes listed in this manual. In addition, all paper claims must be submitted on
the current approved claim form. ICD-9 diagnosis codes must be provided (ICD-10 once
mandated).
Note: Copies of NVA’s HIPAA policies are available upon request by contacting NVA’s
Provider Services Department at 888-830-5630, or via e-mail at [email protected].
4.0 Participant Complaints/Grievances and Appeals CMS and the State of New York have
developed a fully integrated grievance and appeals process for the FIDA program in an effort
to mitigate the complexity and confusion of having separate processes for Medicaid and
Medicare. Note: the FIDA demonstration defines a “complaint” as being equivalent to a
“grievance,” so to enhance clarity this section will employ the term grievance.
Participants and their authorized representatives (including the participant’s provider ) may
file grievances directly with any PHP staff member either orally or in writing within 60
calendar days of the incident or period of dissatisfaction (if there is more than one specific
incident). Please refer any participant wishing to submit a grievance to PHP directly at the
contact information shown on their individual ID Card. Providers wishing to submit a
grievance should contact NVA Professional Relations directly at 1-877-865-9981
email [email protected]
.
PHP staff will assist participants and/or their authorized representatives with completing
forms and taking other procedural steps, if requested. This includes, but is not limited to,
providing interpreter services and toll-free numbers that have adequate TTY/TTD and
interpreter capability. Participants and their representatives will also be informed about the
availability of assistance from the state’s FIDA Participant Ombudsman program.
PHP will ensure that the personnel who make determinations on grievances were not
involved in any previous level of review or decision-making. In addition, if the grievance
relates to the denial of an expedited resolution of an appeal or involves clinical issues, PHP
will ensure that the persons making the determination are health care professionals who have
the appropriate clinical expertise, as determined by the state agency, in treating the
participant’s condition or disease.
If a grievance determination overturns an initial denial, PHP staff will authorize or provide
the disputed services promptly and as expeditiously as the participant’s health condition
requires.
PHP will not initiate disenrollment because of a participant’s or a participant’s authorized
representative’s attempt to exercise his or her rights under the grievance system. PHP will
A-21
likewise not initiate punitive actions against a provider who files and/or supports a
participant’s grievance.
In keeping with regulatory requirements, PHP will cooperate with NYSDOH and/or CMS
grievance investigations.
Grievance Process
All grievances must be filed within 60 calendar days of the incident or whenever the
participant’s unsatisfactory experience took place (if the grievance involves more than a
single incident).
Same-day Grievance
To the extent possible, PHP’s goal is to resolve grievances to the participant’s satisfaction
immediately (same day). Same-day grievances are acknowledged and resolved verbally and
do not require a written response. All same-day grievances are documented for quality
improvement purposes. Grievances that cannot be resolved the same day are referred to
PHP’s Grievances and Appeals (G&A) Coordinator for processing.
Standard Grievance
If a participant’s oral or written standard grievance cannot be resolved immediately, PHP
will resolve it as quickly as the participant’s condition requires but no later than thirty (30)
calendar days following receipt. The G&A Coordinator will send a written acknowledgment
of the grievance within fifteen (15) calendar days following receipt unless a determination is
reached beforehand, in which case no written acknowledgement will be sent.
The 30-day timeframe may be extended by up to 14 calendar days if the participant, the
participant’s authorized representative, or a provider acting on the participant’s behalf
requests an extension or if PHP justifies a need for additional information and can document
that the delay is in the participant’s interest. If PHP requests an extension, the participant and
the participant’s authorized representative and treating provider (if applicable) will be
immediately notified in writing of the reason for the delay. Once a decision is reached, PHP
will provide the participant/representative with written notification within three (3) business
days, including instructions on how to file a grievance appeal.
Expedited Grievance
An expedited grievance is required when a standard decision would significantly increase the
risk to a participant’s health. Participants or their representatives must file an expedited
grievance within 60 calendar days of the date of the coverage decision and must include a
physician certificate of need. PHP will respond to an expedited grievance as quickly as the
participant’s condition requires, but no later than 24 hours following receipt of the grievance.
PHP must immediately notify the participant/representative of the decision by phone and
provide written notification within three (3) business days of the decision, including
instructions on how to file a grievance appeal.
The resolution time period may be extended up to fourteen (14) calendar days if:
•
The participant or the participant’s authorized representative, or a provider acting on the
participant’s behalf requests the extension
A-22
•
Partners Health Plan demonstrates that there is a need for additional information and
provides documentation that the delay is in the participant's best interest
If PHP requests an extension, the participant will be immediately notified in writing of the
reason for the delay. Once a decision is reached, PHP will provide the
participant/representative with written notification within three (3) business days. The
notification will include instructions on how to file an expedited grievance appeal if he or
she disagrees with PHP’s decision to grant an extension.
Grievance Acknowledgment
Partners Health Plan acknowledges all grievances types. Same-day grievances are acknowledged
verbally and all other grievances are acknowledged in writing within fifteen (15) business days
following receipt unless a determination is reached before the written acknowledgement is sent, in
which case it will be acknowledged verbally. The written acknowledgment will include:
•
The date that the grievance was received
•
Participant’s name and address
•
Type of grievance
•
Additional information requested
•
Name and contact information of the staff member processing the grievance
If a participant/representative requests an expedited grievance and PHP decides not to
expedite it, the acknowledgement will indicate that the grievance will be handled on a
standard basis.
External Grievance
Participants and/or their authorized representatives may file an external grievance through 1800-Medicare or online by submitting a completed electronic grievance form on the
Medicare.gov website (PHP includes a link to this form on our main webpage). External
grievances filed through 1-800-Medicare are automatically entered into the CMS complaints
tracking module, which PHP can access. External grievances filed with NYSDOH are
forwarded to the FIDA Contract Management Team (CMT) and also entered into the CMS
Complaints tracking module.
Appeals Processes
Other than Medicare Part D appeals, which remain unchanged (see below), the FIDA
integrated appeals process includes the following features and processes:
Integrated Notice
PHP will provide participants and their authorized representatives with written notification
of any adverse actions and all applicable Medicare and Medicaid appeal rights, including the
availability of the FIDA Ombudsman to assist with appeals. The notice will specify:
•
The action PHP has taken or intends to take
•
The reasons for the action
•
The regulatory citation that supports the action
•
The participant’s or the participant’s authorized representative’s or provider’s right to file
A-23
an appeal
•
The procedures for the participant/representative to exercise his or her right to appeal
•
The circumstances under which an expedited resolution is available and how to request it
•
The participant’s right to have benefits continue pending a resolution of the appeal, if
applicable
Appeal Level One: Internal Appeal with PHP
•
Appeal Filing Deadline: Participants, their representatives, or providers acting on their
behalf must file a verbal or written appeal with PHP within the following timeframes:
− 60 calendar days from the postmarked date of PHP’s Notice of Action to file an
appeal related to a denial, reduction, or termination of a covered benefit if there is no
request to continue benefits while the appeal is pending.
− 10 calendar days from the postmarked date of PHP’s Notice of Action or by the
intended effective date of the Action (whichever is later) if there is a request to
continue benefits and the appeal involves the termination or modification of a
previously authorized service. The participant will continue to receive benefits while
the appeal decision is pending.
•
Acknowledgement of Appeal: PHP will send the participant/representative a written
acknowledgement of an appeal within fifteen (15) calendar days of receipt unless a
decision is reached beforehand, in which case no written acknowledgement will be sent.
•
Appeal Timeframe: PHP will decide an appeal and notify the participant, the
participant’s authorized representative, and the provider (as applicable) of the decision as
quickly as the participant’s condition requires, but no later than:
− Standard: No later than thirty (30) calendar days from the date of the receipt (seven
calendar days for Part D appeals). This may be a paper review unless the
participant/representative requests an in-person review. Benefits will continue
pending the appeal.
− Expedited: No later than seventy-two (72) hours following receipt of the appeal.
This may be a paper review unless the participant/representative requests an inperson review. Expedited reviews will be granted if a standard decision would
significantly increase the risk to a participant’s health. Benefits will continue pending
the expedited appeal.
− Appeal Extension: Appeal timeframes may be extended up to fourteen (14) calendar
days if a participant, the participant’s authorized representative, or a provider acting
on the participant’s behalf makes an oral or written request. PHP may also initiate an
extension if it can justify the need for more information and the extension is in the
participant’s interest. If PHP initiates an extension, the participant/representative will
be notified in writing of the reason for the delay, including the participant’s right to
file an expedited grievance if he or she disagrees with PHP’s decision. All extensions
must be well documented.
•
Notification of Appeal Decision: The written notification will include the results and the
date of the decision. In the case of adverse decisions (i.e., a decision that is not wholly in
the participant’s favor), the notification will also inform the participant and the
participant’s representative that the adverse decision will be automatically forwarded to
the Integrated Administrative Hearing Office at the FIDA Administrative Hearing Unit at
A-24
the New York State Office of Temporary and Disability Assistance (OTDA) and explain
the process and timeframe for the hearing. As applicable, the notice will further inform
the participant/representative that his or her benefits will continue pending the appeal and
that even if PHP’s action is upheld, the participant will not be liable for the cost of any
continued benefits. The notice will additionally indicate that once OTDA receives the
notice, it will contact the participant/representative regarding the date of the hearing and
state that the participant and/or the participant’s representative should contact OTDA in
the event that he or she does not hear from OTDA within:
− 24 hours for expedited appeals
− Five (5) calendar days for Medicaid prescription drug appeals
− 10 calendar days for all other appeals
•
Notification Timelines:
− Standard Appeals: PHP will provide written notice of its decision within two (2)
calendar days.
− Expedited Appeals: PHP will make a reasonable effort to provide prompt oral notice
to the participant/representative for expedited appeals (these efforts must be
documented) with a follow-up written notice within two (2) calendar days after
providing oral notice of PHP’s decision.
•
Continuation of Benefits Pending Appeal: Continuation of benefits for all previously
approved Medicare and Medicaid benefits will be provided throughout all four levels of
the appeals process if the original appeal is submitted to PHP within ten (10) calendar
days of the postmarked date of PHP’s Notice of Action or by the intended effective date
of the Action, whichever is later.
Appeal Level Two: Automatic Administrative Hearing
PHP’s G&A Coordinator will automatically forward any adverse decision that PHP renders
to the Integrated Administrative Hearing Officer at the Integrated Administrative Hearing
Unit within the State Office of Temporary and Disability Assistance (OTDA) by secure
email within two (2) business days of reaching a decision. A cover note will clearly indicate:
•
PHP’s identity
•
The type of appeal (i.e., expedited, Medicaid prescription drug, or other)
•
The name of the contact person at PHP that will participate in the Administrative Hearing
•
The participant’s name, address, phone number or other contact, social security number,
and Medicaid or CIN number
Benefits will continue pending an appeal, as applicable. Within 14 calendar days of
forwarding the administrative record, PHP will send the participant/representative an
Acknowledgement of Automatic Administrative Hearing and Confirmation of Aid Status
with a copy of the Integrated Administrative Hearing Office. If a decision is reached before
the acknowledgement is sent, PHP will not send an acknowledgement.
The Integrated Administrative Hearing Office will provide the participant/representative and
PHP with a Notice of Administrative Hearing at least 10 calendar days in advance of the
hearing date. PHP is required to participate in the hearing (needless to say, the staff member
designated to participate will be knowledgeable about the circumstances of the appeal),
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which will be conducted either by phone or in-person and a decision will be rendered as
expeditiously as the participant’s condition requires, but no later than seven (7) calendar days
for Medicaid drug coverage matters and within 90 calendar days from the date the participant
requested an appeal with PHP for all other matters.
In the case of expedited hearings, the Integrated Administrative Hearing Office will conduct
the hearing and issue a notification of decision within 72 hours after PHP forwards its
original appeal decision and review record. The notification will explain in plain language
the rationale for the decision and specify the next steps in the Appeal process, including
where to file the Appeal, the filing timeframes, and other information required by applicable
federal and state requirements. PHP will be bound by the decision and may not seek further
review and must implement the decision within one (1) business day.
Appeal Level Three: Medicare Appeals Council
If a participant/representative disagrees with the Integrated Administrative Hearing Officer’s
decision, he or she may appeal it to the Medicare Appeals Council within 60 calendar days
by submitting a request to the Integrated Administrative Hearing Office, which will in turn
forward the request to the FIDA Administrative Hearing Unit, which has responsibility for
submitting the appeal request and all related documents to the Medicare Appeals Council.
The Medicare Appeals Council will complete a paper review and issue a decision within 90
calendar days. Benefits will continue pending an appeal.
Appeal Level Four: Federal District Court
An adverse Medicare Appeals Council decision may be appealed to the Federal District
Court, which is the final level of appeal. Benefits will continue pending a decision.
If you have any questions or concerns about the FIDA integrated grievance and appeals
process, please do not hesitate to contact Participant Services at 1-855-PHP-LIVE (1-855747-5483)
6.00
Quality Improvement (QI) Program
NVA currently administers a Quality Improvement (QI) Program modeled after National
Committee for Quality Assurance (NCQA) standards. The NCQA standards are adhered to as the
standards apply to ancillary services. The Quality Improvement program includes:
•
•
•
•
•
•
•
•
Provider Credentialing and Re-credentialing.
Member Satisfaction Surveys.
Provider Satisfaction Surveys.
Random Chart Audits.
Member Complaint Monitoring and Trending.
Peer Review Process.
Site Reviews and Vision Record Reviews.
Quarterly Quality Indicator tracking (i.e., complaint rate, appointment waiting time,
access to care, etc.).
A copy of NVA’s QI Program is available, upon request, by contacting NVA’s Provider Services
Department at 877-865-9981 or via e-mail at [email protected].
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7.0 FRAUD, WASTE, AND ABUSE (FWA)
Health care fraud costs taxpayers tens of billions of dollars every year. State and federal laws are
designed to crack down on these crimes and impose strict penalties. There are several stages to
addressing fraudulent acts, including detection, prevention, investigation, and reporting. In this
section, NVA provides information on how to help prevent participant and provider fraud by
identifying the different types.
Many types of fraud, waste, and abuse have been identified, including:
•
Provider Fraud, Waste, and Abuse:
− Billing for services not rendered
− Billing for services that were not medically necessary
− Double billing
− Unbundling services
− Up coding services
Providers can prevent fraud, waste, and abuse by ensuring that services rendered are medically
necessary, accurately documented in the medical records, and billed according to NVA
guidelines.
•
Participant Fraud, Waste, and Abuse:
− Benefit sharing
− Collusion
− Drug trafficking
− Forgery
− Illicit drug seeking
− Impersonation
− Misinformation/misrepresentation
− Subrogation/third-party liability fraud
− Transportation fraud
One of the most important steps to help prevent participant fraud is as simple as reviewing the
participant's ID card. NVA will not accept responsibility for the costs incurred by providers
rendering services to a patient who is not a current PHP participant, even if that patient presents a
PHP participant ID card. Providers should take measures to ensure the cardholder is the person
named on the card and his or her participation in PHP is up-to-date, by obtaining an
authorization from NVA for the services.
Additionally, providers can assist in encouraging participants and their caregivers to protect their
cards as they would a credit card or cash, carry their participant ID card at all times, and report
any lost or stolen cards as soon as possible.
PHP encourages its participants, participants’ representatives, and providers to immediately
report any suspected instance of fraud, waste, and abuse. No individual who reports violations or
suspected fraud, waste, or abuse will be retaliated against, and PHP will make every effort to
maintain anonymity and confidentiality.
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You can contact NVA’s Fraud and Abuse Hotline at 888-328-0421.
8.00
Credentialing
NVA, in conjunction with the Plan, has the sole right to determine which Providers (O.D., M.D.,
D.O., or Opticians) it shall accept and continue as Participating Providers. Providers must be
enrolled with Medical Assistance, must be enrolled as Medicare providers, and have a valid
Medicaid number, or Medicaid ID meeting the requirements for NYS Medicaid, which shall be
verified by NVA. The purpose of the credentialing plan is to provide a general guide for the
acceptance, discipline and termination of Participating Providers. NVA considers each
Provider’s potential contribution to the objective of providing effective and efficient Vision and
Eye Care services to Members of the Plan.
NVA’s credentialing process adheres to National Committee of Quality Assurance (NCQA)
guidelines as the guidelines apply to ancillary services.
Nothing in this Credentialing Plan limits NVA’s sole discretion to accept and discipline
Participating Providers. No portion of this Credentialing Plan limits NVA’s right to permit
restricted participation by a vision office or NVA’s ability to terminate a Provider’s participation
in accordance with the Participating Provider’s written agreement, instead of this Credentialing
Plan.
The Plan has the final decision-making power regarding network participation. NVA will notify
the Plan of all disciplinary actions enacted upon Participating Providers.
Appeal of Credentialing Committee Recommendations
If the Credentialing Committee recommends acceptance with restrictions or the denial of an
application, the Committee will offer the applicant an opportunity to appeal the recommendation.
The applicant must request a reconsideration/appeal in writing and the request must be received
by NVA within 30 days of the date the Committee gave notice of its decision to the applicant.
Discipline of Providers
NVA believes in and works hard to maintain positive professional relations with our provider
network. In rare instances, it may become necessary to discipline a provider up to and including
termination from the program. NVA maintains the right to take such action under the terms of
the Provider Agreement that all providers are required to sign prior to beginning participation.
Re-credentialing
Network Providers are re-credentialed at least every 36 months as required by the plan.
Note: The aforementioned policies are available upon request by contacting NVA’s Provider
Services Department at 877-865-9981 or via e-mail at [email protected].
9.0 Transfer of Medical/Service Records
Providers/Practitioners are responsible for making participant records available to health plans to
which participants are transferring and/or to other providers/practitioners, upon request, and in
compliance with PHP’s internal confidentiality requirements as well as HIPAA/HITECH. At a
minimum, providers are requested to transmit medical/service records related to current
A-28
diagnostic tests and determinations, current treatment services, immunizations, recent
hospitalizations (within the past year) with concurrent review data and discharge summaries (if
data and summaries available), current medications list, recent specialist referrals, and
emergency care.
PHP will facilitate the transfer of pertinent medical/service records (as needed) and will transfer
other requested records that exceed the requirements of the policy if so directed or required.
Receiving providers/practitioners may request records directly from the relinquishing
provider/practitioner.
10.00
Standards of Care – Routine Care
9.01
Examination Standards
An intermediate or comprehensive eye examination shall include all of the following
items and all findings shall be completely and legibly documented in the patient’s record
with quantitative/numerical findings where appropriate.
Current Status
1. Patient demographics (age/DOB, gender, race).
2. Personal and family medical and ocular history.
3. All current medications and medication allergies.
Patient's assessment of current vision status, use of eyeglasses or contact lenses.
4. Chief complaint/reason for visit.
Vision Assessment
1. Visual acuities in each eye at distance and near with or without correction.
2. Objective and subjective refraction at distance and near with the best corrected
visual acuity at distance and near.
3. Gross and quantitative evaluation of color vision and the accommodative and
binocular abilities of the patient.
Eye Health Assessment
1. Evaluation of external structures: lids, lashes, conjunctiva, gross visual fields,
and pupil anatomy and responses (direct, indirect, accommodative, and afferent
defects).
2 Bio-microscopic examination of the cornea, iris, lens, anterior chamber, anterior
chamber angle estimation, and measurement of the intra-ocular pressure
(specifying instrument and time).
3 Ophthalmoscopic examination of the internal eye structures
including the
vitreous, retina, blood vessels, optic nerve head (including C-D ratios), macula
and peripheral retina.
4. Dilated/binocular indirect ophthalmoscopic, retinal examination should be
performed when professionally indicated.
Disposition
A-29
1. List all diagnoses, prescriptions and treatment recommendations including, but
not limited to:
a. Refractive and eye health diagnoses.
b. Eyeglass and contact lens prescriptions.
c. Medications prescribed and/or treatment plans.
d. Patient education on their ocular status and any increased risk factors for
any personal or family conditions.
e. Recall/re-examination/referral recommendations
2. Doctor’s signature and date
10.02
The Patient Record
A.
Organization
The patient record must have areas for documentation of the following
registration and administrative information:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Patient’s first and last name.
Parent of guardian’s name, if appropriate.
Date of Birth.
Gender.
Race.
Address.
Telephone number/numbers.
Emergency contact person and telephone number.
Primary care physician.
Medicaid ID Number or other identification number.
In addition to the patient registration information, the patient record must contain
the examination data from all prior visits, all ancillary test results, consultation
requests and reports, copies of all Prior Approval Requests and Non-Covered
Services Agreements, and all eyewear and/or contact lens specifications.
Each individual page of the patient record must contain the patient’s name and/or
identification number and the date the care recorded on that sheet was provided.
B.
Content
For every routine examination, the patient examination record should contain all
of the information including the recording of all of the detailed qualitative and
quantitative information as described in the examination standards, 8.01, above.
Emergency and non-routine examination visits should contain all of the relevant
clinical data and history to adequately describe the situation/condition at hand
and support the diagnoses and treatments provided as appropriate for the
situation.
C.
Compliance
All entries in the record are legible and located consistently within the record
Symbols and abbreviations used in the record must be uniform, easily understood
and are commonly accepted within the profession.
A-30
The entire patient record should be maintained as a unit for at least the most
recent seven (7) years or the time period required by the State Board of
Registration, whichever is greater. For minors, records must be maintained until
they reach majority (age 18), plus seven (7) years at minimum.
The patient record should be maintained in a format that will allow the doctor to
make the entire record available to NVA for routine Quality Assurance review
activities.
Electronic medical records (EMR) utilizing default settings must ensure that the
defaults are appropriate for the specific patient or are modified to present an
actual and accurate clinical picture.
11.00
Partners Health Plan – New York Utilization Management Section
11.01
Overview
The priority in NVA programs is to allow patients easy access to the care that they
require. This is best achieved by providing the doctors simple straightforward guidelines
to follow in rendering and billing for the care that the patients require.
Our full vision benefit will encompass both routine vision care (examination) as well as
dispensing of eyewear. Our program will allow access to both components for the
patients while allowing the providers to bill for the appropriate service provided. We also
appreciate the need for simplicity and consistency for the provider’s office and staff in
working with this program. For this reason, we have constructed a protocol that is
applicable to all patients, in all programs, and to all providers.
We will allow patients freedom of choice in the selection of their eye care provider.
Patients may self-refer to your office for care, without the need for a referral or ‘gatekeeper’. It is our belief, and practice at NVA, that optometrists should be treated as
trustworthy professionals. As such, we expect our doctors to provide the care that the
patients need and bill for their services appropriately (i.e. not attempt to make a routine
examination a medical service to receive higher reimbursements).
Members requiring additional services for medical reasons shall be directed to their Care
Manager at the number found on the front of their ID card, for approval or referral. In
emergency situations the provider shall render care as required or make immediate
referrals to another provider or facility (including Hospital Emergency Room) if necessary.
Professional Staff
Carl Moroff, O.D., Chief Vision Officer
Leonard Pine, O.D, Optometric Consultant
Barnet Shuman, O.D., M.P.H., F.A.A.O., Optometric Consultant
Daniel Townsend, M.D., F.A.A.O., Ophthalmology Consultant
Operational Protocols and Policies
All initial patient visits should be considered as a routine vision care visit, and a
comprehensive examination should be provided. A description of our comprehensive
examination is included as Section 8.01 of this manual. Temporary codes, local codes
and ‘S’ codes will not be allowed, and all claims with ‘S’ codes will be denied.
A-31
The comprehensive examination should be coded as one of the following: 92002, 92004,
92012, or 92014.
Referrals
All patient referrals for further evaluation or care must be made to an approved NVA or
Partners Health Plan panel provider. Any non-emergency referrals to a provider or
facility outside of the current approved NVA and Partners Health Plan provider network
will require Prior Approval. A copy of all referrals should be sent to the member’s
primary care physician (PCP).
Program Limitations
As with all health care programs, there are some limitations to coverage for which you
should be aware. Most are listed in the categories below.
1. Services which are the responsibility of another insurer and not the responsibility
of NVA or Partners Health Plan should be billed directly to the responsible party.
NVA or Partners Health Plan will not pay these claims.
o
Automobile accidents
o
Job-related/Workers Compensation claims
2. Services which are not covered by this program are the complete financial
responsibility of the patient. NVA and Partners Health Plan will not pay these
claims. These services, supplies, and materials include:
o
o
Refractive surgery, its complications, and post-operative care, including
but not limited to:

Lasik

PRK

Intacs

Clear lens extractions.

Implantable contact lenses.

Radial Keratotomy.
o
Services provided as part of clinical trials.
o
Experimental procedures.
o
Unspecified services (any CPT XX999).
Low Vision services or devices - While covered, prior to rendering care members requiring Low
Vision Services should be referred to their Care Manager at the telephone number found on the
front of their ID Card. Generally Low Vision Services:Low vision aids may be supplied to an enrollee
A-32
o
after a low vision examination and upon prescription by an ophthalmologist or specially certified
optometrist.
All acceptable types of low vision aids including microscopes and telescopes must be utilized in
selecting an appropriate low vision aid for an enrollee. Any necessary adjustments to the aid for
six months following the receipt of the aid by the enrollee must be performed by the dispenser
without additional reimbursement.
11.02
11.12 Vision Training/Orthoptics/Pleoptics – vision training is a covered service subject to the
following limitations. Prior to rendering care contact the members Care Manager at the telephone
number found on the front of the member’s ID Card for approval. Orthoptic training may be provided by
an optometrist only after receiving prior approval for a treatment plan. The maximum time period for which
approval of a treatment plan will be granted is six months.
At the end of the six month period, it is necessary to reapply for prior approval and supply information that details
the progress made, the anticipated treatment plan, and the prognosis.
In cases of strabismus, it may be determined when prior approval is requested, that surgery is required for proper
correction. The optometrist will then be advised to refer the enrollee to an ophthalmologist for an opinion and
recommendation.
12.00
MEDICAID UTILIZATION REVIEW PROCESS
Prior authorization is not a guarantee of payment. All services are subject to the plan
provisions, limitations/exclusions, and member eligibility at the time the services are rendered.
Services requiring prior authorization are not eligible for reimbursement by NVA if authorization
is not obtained and cannot be billed to the member. The decision to render medically necessary
services lies with the member and the treating provider.
Prior Authorization Determinations
NVA processes service requests in accordance with the clinical immediacy of the request. If
priority is not specified on the referral request, the request will default to routine status.
•
•
•
Routine – within three (3) business days of receipt of all the necessary information.
Urgent – within one (1) business day of receipt of all the necessary information.
Emergent – within one (1) hour of receipt of all the necessary information.
Medical Necessity Screening Criteria
In the event that criteria are not published in this provider manual for proposed services, other
resource guidelines (i.e., New York Medicaid Providers Manual, internally developed criteria,
etc.) are used to determine medical necessity and appropriate level of care. Criteria utilized in the
medical necessity review of a service request will be faxed to you upon request. The final
decision as to the approval or denial of any Medically Necessary Service(s) resides with the
Medical Director of Partners Health Plan.
Notices of Action
NVA must notify members and providers of any Action. An Action includes the denial or limited
authorization of a requested service, including the type or level of service; the reduction,
suspension, or termination of a previously authorized service; or the denial, in whole or in part, of
payment for a service. Only the Chief Medical Officer or designee of PHP, may render a denial
for lack of medical necessity (adverse determination).
A-33
Appeals
See Appeals information in Section X of this Manual
APPENDIX A
Attachments
General Definitions
The following definitions apply to this Office Reference Manual:
A.
Responsible Agency
a. For Members:
i. NYS Department of Health
B.
“Contract” means the document specifying the services provided by NVA
to:
•
•
C.
A Medicaid beneficiary, directly or on behalf of a Plan, as agreed upon
between the State or its regulatory agencies or Plan and NVA (a “Medicaid
Contract”).
A Medicare beneficiary, directly or on behalf of a Plan, as agreed upon
between the Center for Medicare and Medicaid Services (“CMS”) or Plan
and NVA (a “Medicare Contract”).
“Covered Services” is a Vision or Eye Care service or supply that satisfies all of
the following criteria:
•
•
•
Provided or arranged by a Participating Provider to a Member;
Authorized by NVA in accordance with the Plan Requirements; and
Submitted to NVA according to NVA’s filing requirements.
D.
“NVA” shall refer to NVA, IPA, L.L.C.
E.
"NVA Service Area" shall be defined as the covered counties in the State of
New York.
F.
“Medically Necessary” means a service or benefit is medically necessary if it is
compensable under the MA Program and if it meets any one of the following
standards:
•
•
•
•
The Service or benefit will, or is reasonably expected to, prevent the onset of
an illness, condition, or disability.
The service or benefit will, or is reasonably expected to, reduce or
ameliorate, the physical, mental, or developmental effects of an illness,
condition, injury, or disability.
The service or benefit will assist the individual to achieve or maintain
maximum functional capacity in performing daily activities, taking into
account both the functional capacity of the individual and those functional
capacities that are appropriate for individuals of the same age.
Determination of medical necessity for covered care and services must be
documented in writing.
A-34
The determination is based on medical information provided by the Member,
the Member’s family/caretaker and the Primary Care Practitioner, as well as
any other Providers, programs, and agencies that have evaluated the member.
All such determinations must be made by qualified and trained Health Care
Providers. A Health Care Provider who makes such determinations of
Medical Necessity is not considered to be providing a health care service
under this Agreement.
G.
“Member” means any individual who is eligible to receive Covered Services
pursuant to a Contract and the eligible dependents of such individuals. A
Member enrolled pursuant to a Commercial Contract is referred to as a
“Commercial Member.” A Member enrolled pursuant to a Medicaid Contract is
referred to as a “Medicaid Member.” A Member enrolled pursuant to a Medicare
Contract is referred to as a “Medicare Member.” A member pursuant to both a
Medicaid and Medicare contract is consider “Dual Eligible” under an authorized
FIDA Program.
H.
“Participating Provider” is a Vision or Eye Care professional or facility or other
entity, including a Provider that has entered into a written agreement with NVA,
directly or through another entity, to provide Vision or Eye Care services to
selected groups of Members.
I.
“Plan” is an insurer, health maintenance organization, or any other entity that is
an organized system which combines the delivery and financing of health care
and which provides basic health services to enrolled members for a fixed prepaid
fee.
J.
“Plan Certificate” means the document that outlines the benefits available to
Members.
K.
"Provider" means the undersigned health professional or any other entity that has
entered into a written agreement with NVA to provide certain health services to
Members. Each Provider shall have its own distinct tax identification number.
L.
or
“Vision Provider” is an Optometrist (O.D.), Doctor of Medicine (M.D. or D.O.),
Optician, duly licensed, as applicable and qualified under the applicable laws
who practices as a shareholder, partner, or employee of Provider, and who has
executed a Provider Vision Participation Agreement.
M
“Primary Care Practitioner (PCP)” is a specific physician, physician group, or a
CRNP operating under the scope of his/her licensure, and who is responsible for
supervising, prescribing, and providing primary care services; locating,
coordinating and monitoring other medical care and rehabilitative services; and
maintaining continuity of care on behalf of a Member.
A-35
NVA
P.O. Box 103, Grafton, WI 53024
Toll Free: 888-696-9551
Fax: 888-696-9552
A-37
A-39
Prior Approval for Services – Routine Vision & Materials
Patient Information
Member Identification Number
Patient Birth Date
/
Age
Auth # (if provided)
/
Patient Name (Last, First, Middle)
Sex (M/F)
Provider Information
Provider Number - NPI
Provider Name
NVA Provider Number
Office Name
Street Address
Telephone Number
(
City/State
)
Zip Code
Requested Services (Please list all applicable CPT or HCPCS codes):
_____________________
_____________________
_____________________
Reason for additional service(s) – (check one):
____
Replacement for Lost or Broken Frames
____
Replacement for Lost or Broken Lenses
Medically Necessary (Check specific reason below):
____
Contact Lenses:
Tint_________
UV Coating ___________
Press on Prisms ____
___ Change of Prescription
Please explain: ________________________________________________________________
Old Prescription
SPHERICAL
Distance
CYLINDRICAL
AXIS
PRISM
AXIS
PRISM
O.D.
O.S.
Additional Information
O.D.
Add
O.S.
New Prescription
SPHERICAL
Distance
CYLINDRICAL
O.D.
O.S.
O.D.
Additional Information
Add
O.S.
___________________________________________________
Signature of Provider
____________________________
Date
Approval: Authorization # ______________________
Denial: __________________________
Type: Examination Only _____________________
Materials Only
_____________________
Examination and Materials ______________
Reason: _________________________
A-39
Approved by:________________________________
Date: ___________________________
Approved by:________________________________
Date: ___________________________
NON-COVERED SERVICES AGREEMENT FORM – Directions and Use
NVA has included the following non-covered services agreement form for use when members request services that are not
covered under the plan certificate. Members may be billed for non-covered services in the event that they willingly elect
to receive such non-covered services, understand the financial responsibility involved in receiving such services, and
agree to be financially responsible for such services.
As a provider, you have agreed to hold covered members harmless for covered services, and you should make best efforts
to minimize out-of-pocket expenses. In select circumstances, when the aforementioned requirements have been fulfilled,
members may be financially responsible for non-covered services. The disclosure and agreement form has been provided
as an option for securing member consent of financial responsibility. Examples of circumstances where members may be
billed include:
•
Non-Covered Frames
•
Non-Covered Lens Types or Options
•
Non-Covered Professional Services
•
Cosmetic Contact Lenses (Member must acknowledge that cosmetic contact lenses are in lieu of eyeglasses for the
current benefit period.)
A-39
A-39
Non-Covered Services Agreement
I, ____________________________________________________________, being a patient of Dr.
_______________________________________ located
at_____________________________________________________________, do hereby
acknowledge that it has been explained to me that a certain portion of my care will not be covered
under the terms of my Health Plan. The portion of care not covered is:
________________________________________________________________
___
.
I understand that acceptance of services or treatments not covered by Medicaid are voluntary and
that I may refuse the service or treatments. I acknowledge that I have been told in advance of
treatment what portion of my care I will have to self-pay for, and I agree to make financial
arrangements with the aforementioned Provider to pay for these services myself.
If Cosmetic Contact Lenses have been selected, I understand that they are in lieu of all other
eyeglass benefits for the current benefit period and that they may not be exchanged or returned.
________________________________________________________________
(Patient Name - Print)
________________________________________________________________
(Patient Name - Signature)
Date
Member I.D. # __________________________________________
Plan Name
Members: If you feel you have not been offered alternatives that are within the benefit limits and/or allowance amount, or
feel uncomfortable signing this agreement, please contact member services at the number listed below before signing.
Customer Service/Member Services
877-865-7925
A-39
Laboratory Order Form
To be Supplied by Classic Optical
A-9
APPENDIX B
Covered Benefits (See B-1 – B-3)
This section provides specific benefit information for Partners Health Plan:
877-865-9981
Upon request, by either the member or the participating Provider, NVA will supply a
copy of the review criteria utilized in determining a benefit.
Vision providers are not allowed to charge members for missed appointments. Plan
members are to be allowed the same access to treatment, as any other patients in the
practice.
The NVA claim system can only recognize services described using the current CPT,
HCPCS code list or authorized by NVA. All other service codes not contained in the
following tables will be rejected when submitted for payment.
Furthermore, NVA subscribes to the definition of services performed as described in
this manual.
The benefit description in B-1 is all-inclusive of covered services. Each category of
service is contained in a separate table and lists:
1.
2.
3.
4.
The approved CPT or HCPCS service code to submit when billing.
Brief description of the covered service.
Any age limits imposed on coverage.
A description of documentation that must be submitted when a claim, request
for authorization, or Medical Prior Approval is submitted.
5. An indicator of whether or not the service is subject to Medical Prior
Approval.
6. Lens and frame options, member charges, and additional dispensing fees.
7. Any other applicable benefit limitations.
Prior Approval
Services that require prior approval are noted in the benefit designs.
B-1
Appendix B-1 Medicaid – Medicare Dual Eligible
Covered Benefits: Where benefits differ between products, the coverage for each product
will be clearly labeled with the product description.
1.00
Examination
1.01
Members
Eligible members covered for one (1) routine eye examination, consistent with
CPT codes 92002, 92004, 92012 or 92014 once in each benefit period, which is
based on last Date of Service.
1.02
Additional Examinations
When an additional examination, within the same benefit period, is required due
to a referral from a physician, or due to a required change of prescription of at
least +/- 0.50 diopters or greater, in sphere or cylinder in one or both eyes, a prior
approval form (see page A-8) must be completed, signed, and submitted. If
approved by NVA’s professional staff, you will be notified and provided with a
PAS number for submission of your claim.
It is essential that this PAS number be submitted as part of your claim
(electronically or by paper) in order for the claim to process correctly.
2.00
Dispensing
In instances where a patient requires eyeglasses to correct vision with a minimum
prescription of +/- .50 or equivalent, use codes 92340, 92341, or 92342. This will
generate a dispensing fee payment to you in accordance with the fee schedule. You do
not need to include the code 92340, 92341, or 92342 on your claim as this will be
automatically generated by the laboratory system when using the provider portal.
Dispensing payments will be made for approved replacements provided that 60 days from
the original date of dispensing have past.
Dispensing Services Include:
•
•
•
•
•
Prescribing and ordering proper lenses.
Assisting in the selection of a frame.
Verifying accuracy of completed eyeglasses.
Proper fitting and adjustment.
Periodic re-adjustment – minor repairs (screws, nose pads, etc.).
Minor repairs, which will not require a replacement frame ordered from the laboratory,
but will involve your provision of additional materials such as pads, temples, or temple
covers from your own laboratory supplies, will be reimbursed once every 60 days for
B-2
children and once every 24 months for adults (age 21 or greater) with submission of code
92370.
3.00
Contact Lens Fitting – Medically Necessary Contact Lenses
Patients requiring contact lenses for the correction of certain qualifying medical
conditions (including Keratoconus, Anisekonia, Anisometropia (2.0 diopters minimum),
Aphakia, prescriptions =/> than +/- 12.0 diopters, or other conditions in which best acuity
cannot be corrected beyond 20/70 with conventional spectacles) may receive contact
lenses.
3.01
Prior Approval
You must obtain Prior Approval for the fitting of Contact Lenses. Follow the
same procedure as for additional examinations above and be sure to complete the
form found in A-6. Also be sure to include the PAS number on your claim form
or electronically. Prior Approval for fitting will also provide approval for
materials (see materials section).
Reimbursement for fitting will be in accordance with the Medicaid Fee Schedule
then in effect.
B-3
4.00
Payments
NVA believes that good provider relations demand rapid payment and has, therefore,
determined a bi-weekly payment process.
We process all claims on the 15th and last day of each month and checks are mailed
within 5-7 business days following.
5.00
Assistance
If further information or assistance is required, please contact the Provider Services
Department at 877-865-9981 or [email protected].
6.00
Materials
Contact lenses necessary for the correction of any of the above noted medically necessary
conditions may be provided once Prior Approval has been requested and authorized. Be
sure to include the PAS number in your claim (paper or electronic). Contact lenses are to
be supplied from your normal sources and will be reimbursed up to the Medicaid Fee
Schedule, then in effect for Medically Necessary Contact Lenses, or up to the schedule
found in paragraph 15.00 for Cosmetic Contact Lenses.
7.00
Contract Laboratory
The provision of materials (frames and lenses) is an essential part of this program. NVA
maintains a primary emphasis on providing quality services within budgetary constraints
and, for this reason, will utilize the services of a contract laboratory to provide plan
covered frames and spectacle lenses, as well as a range of lens options. The laboratory
has been selected on the basis of its professional reputation, volume production
capabilities, and economics.
8.00
Ordering
Accessing the laboratory to place your eyeglass order is easy. The most efficient way is
through the internet at www.e-nva.com. Once you log on with your Provider name and
password (first time Providers will need their TIN, zip code and location suffix which is
provided by provider relations, and an e-mail address to obtain a Provider name and
password) you will have a range of services available, including:
•
•
•
•
•
•
•
•
•
Verify member eligibility and receive authorizations.
Submit claims for payment.
Place eyeglass orders.
Track claims.
Track eyeglass orders.
Benefit Description – Covered Services.
Electronic copy of Provider Manual.
Forms.
Codes and Fees.
B-4
You may also fax eyeglass orders to the laboratory directly at 888-522-2022. To call the
laboratory directly, please use 888-522-2020 and select option #5. This number is
reserved for customer service contact as telephone orders are not accepted, except in
emergencies as defined in Section 12.00.
B-5
9.00
Frames
9.01
Samples
An initial set of sample frames has or will be sent prior to the plan
implementation date to each contracted office. Only one set per office will be
provided. Samples are sent at no cost and remain the property of the plan. The
samples will be reviewed as part of the office audit process, and your office will
be billed for missing samples.
9.02
Plan Covered Frames – No Charge to Members
The selection contains appropriate styles for patients of all ages, in a variety of
materials, colors, styles, and sizes, and it is your responsibility to ensure that all
applicable styles are shown to beneficiaries. The frames will result in the
standard dispensing fee paid to your office and should be billed with the code
V2020. You do not need to include the code V2020 on your claim as this will be
automatically generated by the laboratory system, when using the provider portal.
9.03
Plan Covered Frames
All Plan covered frames are to be ordered from the contract laboratory.
When utilizing the Provider Portal, frame and lens codes are generated
automatically.
Specialty frames (Miraflex™) will be available to patients for whom a
conventional frame may be dangerous or otherwise inappropriate. When ordering
Miraflex™, code V2025 would be used. These frames are automatically provided
with a head strap.
9.04
Member’s Frames
It is also possible that a patient will want to use their own frame. Although the
contract laboratory will accept member’s frames, please check them carefully as
the laboratory maintains the right to refuse a frame that is non-ophthalmic, old,
cracked, and shows signs of excessive wear or when it believes it is likely to
break during lens insertion. Please be sure that patients understand that the
contract laboratory is not responsible for breakage. A signed waiver is a good
practice to follow.
When placing the laboratory order for lenses, please indicate that a member’s
frame was selected. This will place the lens order and hold it for arrival of the
frame. It will also generate payment of the lens only dispensing fee to your office
although no frame allowance is paid. You do not need to include the code M2025
on your claim as this will be automatically generated by the laboratory system,
when using the provider portal.
9.05
Traceable Means – Shipping
B-6
When shipping to the laboratory (non-plan covered frames and member frames),
it is strongly advised that you use a traceable means. The contract laboratory is
not responsible for replacing frames lost in transit. The maximum amount for
which the laboratory will be responsible for lost or damaged frames is $50.00.
10.00
Lenses
As stated above all plan lenses will be provided by the contract laboratory and should be
ordered in the same manner as frames.
Standard single vision, bifocal, and trifocal (Flat top, round seg, or executive style) lenses
are covered and will be automatically filled in Polycarbonate material, unless it is
unavailable, in which case standard CR-39 will be utilized. As a reminder, only Flat top
28 and 35 bifocals and Flat top 7 x 28 trifocals are available as polycarbonate lenses.
Executive, Flat top 25, and round segment bifocals are available only in CR-39.
One of the advantages of utilizing a contract laboratory is the elimination of the need for
the provider offices to code claims with HCPCS for materials supplied by the laboratory.
As a result, you do not need to include the lens codes or option codes with this program,
as they will be automatically generated by the laboratory system if utilizing the provider
portal.
Standard single vision, bifocal, and trifocal (Flat top, round seg or executive style) lenses
are covered.
10.01
Lens options – Plan Paid
Certain lens options may be covered with Prior Approval, when medically or
professionally indicated not for cosmetic reasons. They include:
•
•
•
•
Tints
UV Coating
Press on prisms
High Index (10DS or greater)
Please submit for Prior Approval in instances when one of these services are
required. Following review by NVA’s professional staff, you will be provided
with a PAS number if approved. Please be sure to include this PAS number with
your claim information. Please remember that you do not need to include the
HCPCS code for options (see above) when utilizing the provider portal.
11.00
Contact Lenses
Members requiring contact lenses for medical necessity may receive a fitting, training,
and follow up care in conjunction with contact lens materials, consistent with the services
provided to your private patients.
Medical Necessity will be determined through the Prior Approval process described in
the Professional Services section of this manual. In general, the conditions requiring
medically necessary contact lenses are:
B-7
•
•
•
•
•
•
Keratoconus
Anisekonia
Anisometropia (> 2.00 diopters)
Aphakia
Rx =/> +/- 12.00 diopters
When BVA cannot be corrected to 20/70 with spectacles
Please use the appropriate HCPCS code for the materials provided (V2500-V2530) along
with the PAS number on your claim. You will need to include the HCPCS code(s) for
contact lenses as they are not ordered from the contract laboratory.
Payment will be made to you for the fitting as well as the materials, and you should order
the lenses from your usual sources.
Replacements for lost or damaged contact lenses, or with a significant change in RX (=/.50 diopters), may be made with Prior Approval.
12.00
Replacement Eyeglasses and Contact Lenses
Eyeglasses
Members who require replacement of lost or broken eyeglasses are eligible for
replacement under the New York Medicaid program.
Members who require replacement or repair of broken eyeglasses may receive such
replacement with prior approval.
Replacement will also be made when there is a change of prescription of + .50 diopters or
greater, in sphere or cylinder in one or both eyes. Prior Approval is also required.
Please complete the Prior Approval form and be sure to include the PAS number with
your claim. Payment for dispensing replacements will be made in full provided sixty (60)
days have passed between dispensing dates.
As referenced in Section 2.00 of this Appendix (B-1), dispensing payments will be made
for approved replacements provided that 60 days from the original date of dispensing
have past.
Contact Lenses – Medically Necessary
Members age 21 and above who require replacement of lost or damaged medically
necessary contact lenses are eligible for replacement with Prior Approval.
Members under 21 years of age who require replacement of lost or damaged medically
necessary contact lenses may receive such replacement with prior approval.
Replacement of medically necessary contact lenses for members will be as follows:
•
Replacement for lost or damaged lenses with Prior Approval.
B-8
Please complete the Prior Approval form and be sure to include the PAS number with
your claim.
13.00
Emergency Services
The contract laboratory has agreed to meet rigorous standards for quality and turnaround
time. In some cases, however, due to loss or breakage, a member may require more
immediate correction, and the laboratory has agreed to a process in these cases to
expedite handling.
Contact the laboratory by telephone at 888-522-2020 and select option #3. Identify your
office and the patient and request emergency processing.
Depending on the time of day, the laboratory will make every effort to ship the
eyeglasses the same day by overnight service.
This should be reserved for emergencies and only for significant prescriptions, which will
impact the child’s ability to perform critical tasks (i.e., school work). If more immediate
service is necessary, contact the NVA Provider Services Department at 888-830-5630.
14.00
Covered Codes and Associated Fees
Procedure Code
Description
Fee
Eye Examination
92002
Exam New Patient (Intermediate)
92004
Exam New Patient
92012
Exam Existing Patient (Intermediate)
92014
Exam Existing Patient
Spectacle Frames and Lenses
V2020
Vision Services Frames Standard
V2025
Vision Services Frames Specialty
V2100
Lens Sphere Single Plano 4.0
V2101
Single Vision Sphere 4.12-7.00
V2102
Single Vision Sphere 7.12-20.00
V2103
Spherocylinder 4.00D/12-2.00D
Procedure Code
Description
V2104
Spherocylinder 4.00D/2.12-4D
V2105
V2106
Spherocylinder 4.00D/>6.00D
V2107
Spherocylinder 4.25D/12-2D
V2108
V2109
V2110
Spherocylinder 4.25D/Over 6D
V2111
Spherocylinder 7.25D/.25-2.25
V2112
V2113
V2114
Spherocylinder Over 12.00D
V2115
Lens Lenticular Bifocal
B-9
$38.00
$38.00
$38.00
$38.00
Included
Included
Included
Included
Included
Included
Fee
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
V2118
V2121
V2200
V2201
V2202
V2203
V2204
V2205
V2206
V2207
V2208
V2209
V2210
V2211
V2212
V2213
V2214
V2215
V2218
V2219
V2220
V2221
V2300
V2301
V2302
V2303
V2304
V2305
V2306
V2307
V2308
V2309
V2310
V2311
V2312
V2313
V2314
Procedure Code
V2315
V2318
V2319
V2320
V2321
Dispensing Services
92340
92341
92342
92370
Lens Anisekonic Single
Lenticular Lens, Single
Lens Sphere Bifocal Plano 4.00D
Lens Sphere Bifocal 4.12-7.0
Lens Sphere Bifocal 7.12-20.
Lens Sphcyl Bifocal 4.00D/.1
Lens Sphcyl Bifocal 4.00D/2.1
Lens Sphcyl Bifocal 4.00D/4.2
Lens Sphcyl Bifocal 4.00D/Over
Lens Sphcyl Bifocal 4.25/7D/.
Lens Sphcyl Bifocal 4.25-7/2.
Lens Sphcyl Bifocal 4.25-7/4.
Lens Sphcyl Bifocal 4.25-7/OV
Lens Sphcyl Bifocal 7.25-12/.25Lens Sphcyl Bifocal 7.25-12/2.2
Lens Sphcyl Bifocal 7.25-12/4.2
Lens Sphcyl Bifocal Over 12.
Lens Lenticular Bifocal
Lens Anisekonic Bifocal
Lens Bifocal Seg Width Over
Lens Bifocal Add Over 3.25D
Lenticular Lens, Bifocal
Lens Sphere Trifocal 4.00D
Lens Sphere Trifocal 4.12-7.
Lens Sphere Trifocal 7.12-20
Lens Sphcyl Trifocal 4.0/.12Lens Sphcyl Trifocal 4.0/2.25
Lens Sphcyl Trifocal 4.0/4.25
Lens Sphcyl Trifocal 4.00/>6
Lens Sphcyl Trifocal 4.25-7/.
Lens Sphcyl Trifocal 4.25-7/2.
Lens Sphcyl Trifocal 4.25-7/4.
Lens Sphcyl Trifocal 4.25-7/>6
Lens Sphcyl Trifocal 7.25-12/.25Lens Sphcyl Trifocal 7.25-12/2.25
Lens Sphcyl Trifocal 7.25-12/4.25
Lens Sphcyl Trifocal Over 12
Description
Lens Lenticular Trifocal
Lens Anisekonic Trifocal
Lens Trifocal Seg Width >28
Lens Trifocal Add Over 3.25D
Lenticular Lens, Trifocal
Fitting of Spectacles
Repair of existing Spectacles including
materials/supplies
B-10
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Fee
Included
Included
Included
Included
Included
$20.00
$20.00
$20.00
$7.00
Options
V2745
V2718
V2755
V2784
Medically Necessary
Contact Lenses
Services
CPT
Each of these options may be provided when Medically Necessary with Prior
Approval of Services (PAS)
Solid Tint
Included
Press On Prism
Included
UV Coating
Included
Polycarbonate Lenses (all children automatically
Included
and adults with -5.25 / +4.00)
(no PAS Required)
When contact lenses are provided, they are in lieu of eyeglasses. Medically
Necessary contact lenses require Prior Approval (PAS). Contact Lens fees are
global fees, including fitting, follow up, I and R Training, and Materials.
Service
92311
92312
92313
92071
92072
Medically necessary fit Aphakia Unilateral
Medically necessary fit Aphakia Bilateral
Medically necessary fit Aphakia cornea scleral
Medically necessary fit Ocular Surface Disease
Medically necessary fit - Keratoconus
Material
V2500
PMMA Spherical
Medicaid Fee Schedule
V2501
PMMA Toric
V2502
PMMA Bifocal
V2510
Gas Perm Spherical
V2511
Gas Perm Toric
V2512
Gas Perm Bifocal
V2513
Gas Perm Extended Wear
V2520
Soft Spherical
V2521
Soft Toric
V2522
Soft Bifocal
V2523
Soft Extended Wear
V2530
Scleral Lens – Gas Impermeable
V2531
Scleral Lens – Gas Permeable
HCPCS
B-11
PROVIDER ROLES AND RESPONSIBILITIES
Contracted providers and practitioners with Partners Health Plan (PHP) are obligated to
comply with the following rules, regulations, and guidelines:
•
Providers shall provide services that conform to accepted medical and surgical
practice standards in the community as well as applicable OPWDD standards. These
standards include, as appropriate, the rules of ethics and conduct as established by
medical societies and other such bodies, formal or informal, governmental or
otherwise, from which providers and practitioners seek advice or guidance or to
which they are subject for licensing and oversight.
•
Providers must immediately notify NVA's Chief Vision Officer, in writing, of any of
the following circumstances:
− If their ability to carry out their professional responsibilities is restricted or
impaired in any way
− If their license to practice their respective profession is revoked, suspended,
restricted, requires a practice monitor, or is limited in any way
− If any adverse action is taken
− If an investigation is initiated by any authorized local, state, or federal agency
− If there are any new or pending malpractice actions
− If there is any reduction, restriction, or denial of clinical privileges at any
affiliated hospital
•
Providers shall comply with all PHP administrative, participant referral, quality
assurance, utilization management, reporting, and reimbursement protocols and
procedures.
•
Providers shall not differentiate or discriminate in the treatment of participants on the
basis of race, sex, color, age, religion, marital status, veteran status, sexual
orientation, national origin, disability, health status, source of payment, or and any
other category protected by law.
•
Providers shall observe, protect, and promote the rights of participants.
•
Providers shall cooperate and participate in all PHP peer review functions, including
quality assurance, utilization review, administrative, and grievance procedures as
established by PHP.
•
Providers shall comply with all final determinations rendered by PHP peer review
programs or external arbitrators for grievance procedures consistent with the terms
and conditions of the provider's agreement with Partners Health Plan.
•
Providers shall notify PHP in writing of any change in office address, telephone
number, or office hours. A minimum of thirty (30) calendar days advance notice is
requested.
B-12
•
Providers shall notify NVA at least ninety (90) calendar days in advance, in writing,
of any decision to terminate their relationship with NVA or as required by the
provider's agreement with NVA.
•
Providers shall not under any circumstances, including non-payment by or insolvency
of the Plan or NVA, bill, seek, or accept payment from Plan participants for covered
services or benefits.
•
Providers agree to maintain standards for the confidentiality of and documentation of
participant medical/service records.
•
Providers agree to retain medical/service records for 10 years after the last date of
service or the length of time required by applicable law.
•
Providers shall maintain appointment availability in accordance with federal and state
requirements.
•
Primary Care Providers shall maintain 24-hour access in accordance with federal and
state standards. PCPs shall notify PHP of any extended coverage arrangements for
sick leave, vacation, etc.
•
Providers agree to continue care in progress during and after termination of a
participant’s enrollment in PHP for up to 60 days (so long as they maintain coverage
under Medicare and/or Medicaid), or such longer period of time required by state
laws and regulations, until a continuity of service plan is in place to transition the
participant to another network provider.
•
Providers must establish an appropriate mechanism to fulfill obligations under the
Americans with Disabilities Act (ADA).
Informed Consent
The provider must adhere to all federal and state requirements, including applicable
OPWDD requirements, for obtaining informed consent for treatment. Properly executed
consents must be included in the medical record for all procedures that require informed
consent. Providers must additionally provide participants/representatives with complete
information concerning their diagnosis, evaluation, treatment, and prognosis and grant
them the opportunity to take part in decisions involving their health care.
Confidentiality
All Protected Health Information (PHI), as this term is defined by the Health Insurance
Portability and Accountability Act (HIPAA) of 1996 (45 CFR § 164.501), related to
services provided to participants shall be confidential pursuant to federal and state laws,
rules, and regulations. PHI shall be used or disclosed by the provider only for a purpose
allowed by or required by federal or state laws, rules, and regulations.
Medical/Service records of all PHP participants shall be confidential and only be
disclosed to and by the provider’s staff in accordance with applicable laws and
regulations.
B-13
You Can Help Protect Patient Confidentiality
Protecting privacy is an essential part of building a physician/patient relationship. You
and your staff can help protect patient confidentiality by following these simple
measures:
•
Avoid discussing cases within earshot of other patients or visitors.
•
If voices can be heard easily through exam room walls, consider adding soundproof
panels or piping in soft music.
•
Make sure computer screens that contain patient information are protected from
general view.
•
Be sure all patient care is provided out of sight from other patients (e.g., taking body
weight, lab draws)
•
Have an Office Confidentiality Policy for staff to read and keep in your office
personnel files.
•
Ask your patients and/or their authorized representatives to sign an Authorization to
Release Information prior to releasing medical records to anyone.
•
Have a protocol for sending confidential information via fax.
Participant Complaints and Grievance Procedures
All providers and practitioners must respect Participant Rights as outlined in this Provider
Manual. In addition, providers should participate in, and are obligated to cooperate with,
the resolution of any participant complaint or grievance that may arise relating to the
services they provided to a Plan participant. Any concerns identified by participants
and/or their caregivers with NVA, a provider, or any of a provider's staff with respect to
the provision of services will be handled in accordance with NVA's complaint and
grievance procedures as described in this Manual.
Office Wait Times
PHP’s participants with a previously scheduled appointment must not be made to wait
longer than one (1) hour on a routine basis.
Missed Appointments
Participants and/or their caregivers may sometimes cancel or not appear for necessary
appointments and fail to reschedule the appointment. PHP encourages
practitioners/providers to attempt to contact participants/representatives who have not
shown up for or canceled an appointment without rescheduling. If you or your staff
experience difficulty in contacting the participant/representative or if a participant has a
pattern of missed or canceled appointments, please contact Participant Services or the
participant's care manager/coordinator for follow-up.
B-14
Second Medical or Surgical Opinion
Participants and/or their representatives may request a second opinion if they:
•
Dispute the reasonableness of a decision
•
Dispute the necessity of a procedure decision
•
Do not respond to medical treatment after a reasonable amount of time
Participants must obtain a second opinion from a network provider unless a network
provider with the necessary qualifications and experience is unavailable within a
reasonable timeframe. Participants may not visit out-of-network providers without prior
authorization.
Laws Relating to Federal Funds
The payments that providers receive for furnishing services to PHP participants are
derived in whole or in part from federal funds. Therefore, providers and any approved
subcontractors must comply with certain laws applicable to individuals and entities
receiving federal funds including, but not limited to:
•
Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR Part 84
•
The Age Discrimination Act of 1975 as implemented by 45 CFR Part 91
•
The Rehabilitation Act of 1973
•
The Americans with Disabilities Act
Cultural Competency
Cultural Competency is a process of developing and exercising proficiency in effectively
communicating in a cross cultural context. The word “culture” is used because it implies
the integrated pattern of human behavior that includes thoughts, communications,
actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social
group. The word “competence” is used because it implies having the capacity to function
effectively. Cultural competence in health care describes the ability of systems to provide
care to patients with diverse values, beliefs, and behaviors including tailoring delivery to
meet patients’ social, cultural, and linguistic needs.
The term ‘‘culturally competent', as defined by the Developmental Disabilities Bill of
Rights and Assistance Act of 2000 (DD Act), "means services, supports, or other
assistance that is conducted or provided in a manner that is responsive to the beliefs,
interpersonal styles, attitudes, language, and behaviors of individuals who are receiving
the services, supports, or other assistance, and in a manner that has the greatest likelihood
of ensuring their maximum participation in the program involved."
Cultural competency assists providers and participants to:
•
Acknowledge the importance of culture and language
B-15
•
Assess cross-cultural relations
•
Embrace cultural strengths with people and communities
•
Strive to expand cultural knowledge
•
Understand cultural and linguistic differences
The quality of the patient-provider interaction has a profound impact on the ability of a
patient to communicate symptoms to his or her provider and to adhere to recommended
treatment. Some of the reasons that justify a provider’s need for cultural competency
include, but are not limited to:
•
The perception that illness and disease and their causes vary by culture.
•
The understanding that belief systems relating to health, healing, and wellness are
very diverse.
•
The recognition that an individual’s cultural background influences help-seeking
behaviors and attitudes toward health care providers.
•
An acknowledgement that individual preferences affect traditional and non-traditional
approaches to health care.
PHP strongly encourages providers to recognize cultural factors that shape personal and
professional behavior and to accept that their own world views and those of the
participant and/or his or her caregiver may differ while avoiding stereotyping and
misapplication of scientific knowledge.
PHP staff will gladly assist providers who may have questions or require help in
accessing needed resources such as language translation services or other available
community-based resources for adults with IDD. In addition, PHP provides detailed
information about the provision of culturally competent care for adults with IDD on our
website at www.PHPcares.org.
Americans with Disabilities Act Requirements
The Americans with Disabilities Act of 1990 (ADA) is a federal civil rights law that
prohibits discrimination against individuals with disabilities in everyday activities,
including medical services. Section 504 of the Rehabilitation Act of 1973 is a civil rights
law that prohibits discrimination against individuals with disabilities in programs or
activities that receive federal financial assistance, including Medicare and Medicaid. This
legislation requires that medical providers offer individuals with disabilities:
•
Full and equal access to their health care services and facilities
•
Reasonable accommodations to policies, practices, and procedures when necessary to
make health care services fully available to individuals with disabilities, unless the
modifications would fundamentally alter the essential nature of the services
PHP's policies and procedures are designed to promote compliance with the ADA.
Providers are strongly encouraged to take actions to remove an existing barrier and/or to
B-16
accommodate the needs of PHP participants, many of whom have some degree of
physical disability. This action plan includes the following:
•
Providing reasonable accommodations to individuals with hearing, vision, cognitive,
and psychiatric disabilities
•
Utilizing waiting room and exam room furniture that meets the needs of all
participants, including those with physical and non-physical disabilities
•
Utilizing clear signage and way-finding throughout facilities
•
Clearly marking handicap parking unless there is street-side parking
•
Providing street-level access to provider offices
•
Providing elevators or accessible ramps into facilities
•
Providing wheelchair accessible entrances and restrooms
•
Providing access to an examination room that accommodates a wheelchair
•
Offering first and last appointment availability to accommodate special needs visits
All providers are strongly encouraged to complete the NYSDOH ADA Attestation form
that is included as Attachment A to this Provider Manual. If you should have further
questions about ADA provisions and provider responsibilities, please contact our
Provider Relations staff at 1-855-747-5483.
Policy of Non-Interference with Provider Advice to Participants
PHP will not prohibit or otherwise restrict providers from advising or advocating on
behalf of participants about the following topics:
•
The participant's health status, medical care, or treatment options (including any
alternative treatments that may be self-administered), including the provision of
sufficient information to provide an opportunity for the participant and his or her
authorized representative to decide among all relevant treatment options
•
The risks, benefits, and consequences of treatment or non-treatment
•
The opportunity for the participant and his or her authorized representative to refuse
treatment and to express preferences about future treatment decisions
Provider Site Visits
PHP's protocols require QM and/or Provider Relations staff to conduct regularly
scheduled and ad hoc site visits to provider/practitioner offices to ensure that network
providers maintain PHP's standards for accessibility, appearance, and adequacy of
equipment as well as for medical/service record documentation and privacy in
accordance with all state and federal rules and regulations, professional ethics, and
accreditation standards.
B-17
PHP uses a standardized tool to evaluate provider/practitioner offices. If staff identifies a
deficiency during an on-site visit, we will require the implementation of a corrective
action plan (CAP) and re-visit the provider in six (6) months to ensure that the CAP is
progressing properly. QM staff will be responsible for documenting all such corrective
actions and related activities, including their resolution, and entering them into providers’
confidential QM files. QM staff will further report this information to the Chief Medical
Officer and the Quality Oversight Committee and it may also be used in
provider/practitioner re-credentialing/certification evaluations. The Chief Medical Officer
is also responsible for overseeing the preparation and submission of summary reports to
the Quality Management Oversight Committee of the Board.
B-18
ADA ATTESTATION CHECKLIST
The Americans with Disabilities Act (ADA) Attestation
Provider Name (print):
Date:
Provider Signature:
Provider Address:
Specialty:
1) Does the office have at least one wheelchair-accessible path from an entrance to
an exam room? Yes No
2) Examination tables and all equipment are accessible to people with disabilities.
Yes No
3) If parking is provided, spaces are reserved for people with disabilities, pedestrian
ramps at sidewalks, and drop-offs? Yes
No
4) If parking is provided, are there an adequate number of parking spaces provided
(8 feet wide for a car and 5 foot access aisle)? Yes No
Total Spaces
1-25
26-50
51-75
76-100
Accessible Spaces
1
2
3
4
5) For a provider with a disability-accessible parking space, is there a path of travel
from the disability accessible parking space to the facility entrance that does not
require the use of stairs?
Yes No
− Is the path of travel stable, firm, and slip resistant?
Yes No
− Except for curb cuts, is the path at least 36 inches wide?
Yes No
6) Is there a method for persons using wheelchairs or that require other mobility
assistance to enter as freely as everyone else?
Yes
No
− Is that route of travel safe and accessible for everyone, including people with
disabilities? Yes
No
7) Does the main exterior entrance door used by persons with mobility disabilities to
access public spaces meet the following standards:
− 32 inches clear opening:
Yes
No
B-19
− 18 inches of clear wall space on the pull side of the door, next to the handle: Yes
No
− The threshold edge is no greater than ¼ inch high or if beveled, no greater than ¾
inches high: Yes No
− The door handle is no higher than 48 inches high and can be operated with a
closed fist: Yes
No
8) Are there ramps to permit wheelchair access?
Yes No
− If yes, complete the following 4 questions:
◊ Are the slopes of the ramp accessible for wheelchair access? Yes No
◊ Are the railings sturdy and high enough for wheelchair access? Yes No
◊ Is the width between railings wide enough to accommodate a wheelchair? Yes
No
◊ Are the ramps non-slip and free from any obstruction (cracks)? Yes No
9) If there are stairs at the main entrance, is there also a ramp or lift or is there an
alternative accessible entrance?
Yes No
10) Do any inaccessible entrances have signs indicating the location of the nearest
accessible entrance?
Yes No
11) Can the accessible entrance be used independently and without assistance? Yes
No
12) Are doormats ½ inch high or less with beveled or secured edges?
No
Yes
13) Are waiting rooms and exam rooms accessible to people with disabilities? Yes
No
14) The layout of the interior of the building allows people with disabilities to obtain
materials and services without assistance. Yes No
15) The interior doors comply with the criteria set forth above regarding the exterior
door. Yes No
16) The accessible routes to all public spaces in the facility are 31 inches wide.
Yes No
17) There is a five-foot circle or a T-shaped space for a disabled person using a
wheelchair to reverse direction in public areas where services are rendered.
Yes No
18) All buttons or other controls in the hallway are no higher than 42 inches. Yes
No
19) Elevators in the facility meet the following standards:
− There are raised and Braille signs on both door jambs on every floor.
No
− The call buttons in the hallway are not higher than 42 inches.
No
B-20
Yes
Yes
− The controls inside the cab have raised and Braille lettering.
Yes
No
20) Are sign language interpreters and other auxiliary aids and services provided in
appropriate circumstances?
Yes
No
21) Is the public lavatory wheelchair-accessible?
No
Yes
22) With respect to the public restroom, the accessible route, the exterior door, and
the interior stall doors comply with standards set forth above for exterior doors.
Yes No
23) There is at least one wheelchair accessible stall in the public restroom that has an
area of at least five feet by five feet, clear of the door swing; OR, there is at least
one stall that is less accessible but that provides greater access than a typical stall
(either 36 by 69 inches, or 48 by 69 inches).
Yes No
24) In the accessible stall of the public rest room there are grab bars behind and on the
side wall nearest the toilet.
Yes
No
25) There is one lavatory in the public restroom that meets the following standards:
− 30 inches wide by 48 inches; deep bar space in front. (A maximum of 19 inches
of the required depth may be under the lavatory.) Yes
No
− The lavatory rim is no higher than 34 inches.
Yes
No
− There is at least 29 inches from the floor to the bottom of the lavatory apron. Yes
No
− The faucet can be operated with a closed fist.
Yes
No
− The soap dispenser and hand dryers are within reach and usable with one closed
fist. Yes No
− The mirror is mounted with the bottom edge of the reflecting surface 40 inches
from the floor or lower.
Yes No
I, [First and Last Names, Title, Provider Name], hereby attest that we are a provider that
has a physical site at which FIDA Participants might possibly be physically present and
that the answers provided are accurate. Also, I do hereby attest that I hold the authority to
make these attestations.
Provider Name (print)_______________________________
Provider Signature __________________________________
B-21
Date:

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

Transcription

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