ADDENDUM TO 2014 PROVIDER MANUAL
Transcription
ADDENDUM TO 2014 PROVIDER MANUAL
ADDENDUM TO 2014 PROVIDER MANUAL Coventry Health Care of Louisiana, Inc. 3838 North Causeway Blvd. Suite 3350 Metairie, LA 70002 (504) 834-0840 (800) 245-8327 www.la.chcadvantra.com Table of Contents Advantra specific information has been added to the following Chapters. Chapter 1 Introduction 2 Chapter 2 Administrative Procedures 8 Chapter 3 Benefit Plan Options 11 Chapter 4 Provider Participation Information 20 Chapter 5 Authorizations 36 Chapter 6 Reimbursement & Claims 38 Chapter 7 Utilization and Quality Management 41 1 Chapter Introduction Coventry Health Care of Louisiana is committed to working with your office staff toward the success of both your provider practice and the plan. W elcome! The goal of Coventry Health Care of Louisiana Inc. (CHC) is to develop and sustain strong, mutually beneficial relationships with our providers and their office staff. We encourage your active participation in the Health Plan and appreciate your comments. By working together, we create a unique team of people to deliver the most appropriate health care in the most cost efficient manner. We share a common goal of preserving the quality of care for patients who seek the benefits and preventative care of a managed care plan within traditional physician/patient relationships. P R O V I D E R R E L A T I O N S D E P A R T M E N T 5 0 4 - 8 3 4 - 0 8 4 0 E X T 5 0 3 - 2 1 7 6 is to answer important questions about administering health care services specifically to Coventry Health Care of Louisiana’s Advantra Members. This addendum is to supplement the 2014 Coventry Health Care of Louisiana, Inc. Provider Manual. The two documents represent the entire Provider Manual for a participating CHC Advantra Provider. The manual is referenced as part of the Provider Agreement between you and Coventry Health Care. The manual describes administrative policies and procedures, as well as other pertinent information. If there is a conflict between this addendum and the 2014 Provider Manual, this addendum will rule. The purpose of this manual From time to time, it will be necessary to update this manual. When this happens, you will receive replacement pages, along with an explanation of the changes. For significant changes, you will also receive periodic fax blast updates, which will provide you with valuable information. Please add those updates to the back of this manual for future reference. Any updates, fax 3 blasts and other reference material can be found on our website at www.la.chcadvantra.com. M E D I C A R E A D V A N T A G E S E R V I C E Coventry Health Care of Louisiana’s Medicare Advantage product has two major service areas in the Metro New Orleans and Baton Rouge Markets. The Markets are comprised of 4 parishes. A R E A These Metro New Orleans parishes are: Orleans Jefferson The Metro Baton Rouge parishes are:: East Baton Rouge Ascension Who to Contact for More Information 4 Coventry Health Care W E B A C C E S S www.coventryhealthcare.com Coventry Health Care of Louisiana www.la.chcadvantra.com Advantra Coventry Health Care of Louisiana www.chcla.com Coventry Health Care Provider Portal www.directprovider.com Coventry Health Care of Louisiana Advantra Contact Information Department Contact Information When to contact Customer Service (888) 360-6626 Advantra Members Benefits/Eligibility inquiries 711 TTY/TDD Health Services Claims inquiries Authorization inquiries (800) 245-8327 Prior authorization requests (800) 459-5612 fax Concurrent Review Discharge planning Pharmacy Precertification (877) 215-4100 Provider Relations (800) 245-8327 Pharmacy authorization (866) 669-5575 fax (504) 834-0840 (800) 834-1308 fax Provider participation questions including reimbursement and contracts. Office orientation needs Sales/ Marketing (855) 879-8822 Information about Medicare product offerings. 5 A D V A N T R A C L A I M S Always confirm the mailing address for claims on the back of the Member identification card. Coventry Health Care of Louisiana Inc. P.O. Box 7819 London, KY 40742-7819 Electronic Payor Number: 25133 A P P E A L S Mail appeals to : For Part C: Coventry Health Care of Louisiana, Inc. Attn: Medicare Medical Appeals & Grievance Department P.O. Box 7776 London, KY 40742 For Part D Coventry Health Care of Louisiana, Inc. Attn: Medicare Part D Appeals & Grievance Department PO Box 7773 London, KY 40742 For updates on appeal status, contact Customer Service at (866) 613-4977. A L L O T H E R C O R R E S P O N D E N C E Mail all correspondence other than claims to: Coventry Health Care of Louisiana, Inc. 3838 North Causeway Blvd. Suite 3350 Metairie, LA 70002 6 2 Chapter Administrative Procedures This section details administrative procedures specific to Coventry Health Care of Louisiana, Inc. Advantra. Participating Providers P articipating providers include those physicians, hospitals, skilled nursing facilities, urgent care centers or other duly licensed institutions or health professionals that have a contract with Coventry Health Care of Louisiana. In order for a Member to be eligible for the highest level of covered services, participating providers must be utilized unless non-participating providers are specifically authorized by CHC before services are rendered. Please be aware that our Directory is subject to change. You should verify the participation status of a provider with Customer Service or via the web before referring a patient. They can be reached at (888) 360-6626 or www.la.chcadvantra.com 7 An identification card does not guarantee that the patient is eligible for services. Therefore, verifying the Member’s eligibility is essential. Member Identification All Coventry Health Care of Louisiana Members receive a CHC identification card shortly after enrollment. Members must present their card to their Provider at the time services are rendered. If the Member is a recent enrollee who has not yet received a card, he/she must present a copy of the enrollment form. The ID card will list the Member’s name, Member number, Primary Care Physician (PCP), group name and number, the benefit plan type, as well as copayments or coinsurance for office visits, prescriptions, outpatient and inpatient services. Benefits vary among our different product lines. Therefore, it is important to reference the Member ID card for the correct copayment or coinsurance amount. The ID card will also contain important Customer Service phone numbers for CHC, our Pharmacy Vendor, and our Mental Health Vendor. To verify a Member’s eligibility: Check the Member’s ID card, enrollment form, or other identification card. Eligibility can then be confirmed by calling Customer Service or by logging onto www.directprovider.com. . How to Read a Coventry Health Care of Louisiana Identification Card When you receive an identification card, it will contain the following key items: Logo(s)- Look for the Coventry Health Care of Louisiana Advantra Logo to identify that the Member will be accessing the CHC Advantra contracts. Member Name and Identification Number Group Name- The group name refers to the type of benefit plan that the Member has. PCP Name- The Member’s PCP’s name will be displayed in this field. 8 Member Responsibility Section (Copay)- This section will show the Member’s responsibility at the time of service. Point of Service Benefit. – This will give the Member’s benefit when accessing care from noncontracted providers. For plans without out of network benefits such as HMO, this line will be omitted. ID Card Template 9 3 Chapter Benefit Plan Options Coventry Health Care of Louisiana offers a Medicare Advantage benefit plan for Medicare eligible Members to choose from. This section will assist you in determining the benefits of our Advantra Members. What is Medicare? M edicare is a Federal Health Insurance Program established in 1965 as an amendment to the Social Security Act. It provides hospital (Part A) and supplemental medical (Part B) coverage for people 65 years of age and older, certain disabled people, and those of any age with End Stage Renal Disease (ESRD). The Medicare Program is administered by The Center for Medicare & Medicaid Services (CMS), formerly Health Care Financial Administration (HCFA), of the U.S. Department of Health and Human Services (DHHS). C O V E N T R Y M E D I C A R E A D V A N T A G E P L A N S Coventry Health Care of Louisiana, Inc. (CHC) has entered into a contract with the CMS that authorizes CHC to provide comprehensive health services to persons who are entitled to Medicare benefits and who choose to enroll in the Medicare Advantage (MA) Health Management Organization (HMO), called Advantra. Advantra Plans are not Medigap policies or Medicare Supplement Plans. Advantra is a MAPD Plan that includes Medicare Part A and B benefits and Part D pharmacy benefits as well as enhanced benefits not covered by traditional Fee for Service Medicare. Enhanced benefits may include preventive care, and under some benefit plan options, vision, hearing, dental and wellness programs. 10 W H A T I S A D V A N T R A ? Advantra Members must obtain all of their medical care through Advantra contracted providers to receive the highest level of benefits. The exception to this requirement includes emergency services within the service area and emergency or urgently needed services outside the service area. Advantra Members must choose a Primary Care Physician (PCP). Members should have their medical care provided or arranged by their Primary Care Physician to ensure that services are covered. H O W T H E D O E S P R O G R A M W O R K ? The Advantra HMO offers a new approach, with greater flexibility, freedom and savings. Members on an HMO plan, do not have coverage when accessing care from a nonparticipating provider except for emergency services or when authorized by CHC. Advantra Members pay zero or low monthly premiums to Coventry for their coverage, must be eligible for Medicare Part A and are required to continue paying their Medicare Part B premium. U N I Q U E S E R V I C E S Advantra offers a more comprehensive benefit package for its Members compared to original Medicare. Examples of these service enhancements are described below. Please note that Advantra products have coverage limitations that are different from the Coventry commercial HMO & POS products. In most cases, the coverage limitations follow Medicare Fee-for-Service coverage guidelines. Please note: Members are subject to the copayment indicated on their identification card for certain services. Outpatient Services Preventive Care Routine Physicals are covered once per year. Benefits may vary per plan. Diagnostic X-Ray These services need to be coordinated by the Primary Care Physician Mammograms are covered annually. As required by CMS, Members may self-refer to a contracted facility for the annual screening mammogram. Coventry does remind each Member that they should also have a breast 11 exam by their Primary Care Physician or a contracted gynecologist in conjunction with obtaining a mammogram. Durable Medical Equipment (DME) and Prosthetic Appliances Coventry follows Medicare guidelines for coverage of DME, Prosthetics and Orthotic devices. Prosthetic devices must be on Medicare’s list of approved prosthetic devices. A copayment or coinsurance may apply. Diabetic Supplies Diabetes and self-monitoring training and supplies includes coverage for glucose monitors (Lifescan Models), test strips, lancets and self-management training. A copayment or coinsurance may apply. Gynecological Visit Members are entitled to one office visit per year for a routine annual exam including a pap smear without a referral from the PCP when using an Advantra contracted gynecologist. A copayment may apply. Immunizations and Vaccinations Members have direct access (through self-referral) for influenza and pneumococcal vaccines and their administration and are covered in full. Mammography Screening Members have direct access (through self-referral) to screening mammography 12 Oral Surgery Members have coverage for initial treatment received within 24 hours of an accidental injury. Benefits also include non-dental treatment relating to medically diagnosed congenital defects, birth abnormalities, or treatment for tumors and cysts (including pathological examination) of jaw, cheeks, lips, tongue, roof and floor of mouth. Outpatient Rehabilitation Services Medically necessary Physical Therapy, Occupational Therapy, and Speech and Language Therapy services are covered. A copayment will apply for Medicare covered visits. Cardiac and Pulmonary Rehabilitation services will require a prior authorization. o Cardiac Medicare covered rehabilitation o Intensive Cardiac Rehabilitation o Pulmonary rehabilitation services Podiatry Members have access to Medicare covered podiatric services. A copayment may apply. Chiropractic Care Advantra follows Medicare guidelines for Chiropractic services. Inpatient Services Inpatient Hospital Services Inpatient hospital services include substance abuse and rehabilitation services. A copayment will apply. 13 Skilled Nursing Medically necessary coverage is limited to 100 days per Medicare Benefit Period. The three (3) day hospital stay will be waived. No prior hospitalization is required. Inpatient Behavioral Health Mental Health: Members have a lifetime limit of 190 days for care in a psychiatric hospital. Benefit limitations follow Medicare guidelines. The telephone number for MHNet is 800-752-7242. For specific question regarding Medicare covered services and requirements, please contact Customer Service at (888) 360-6626. S U P P L E M E N T A L B E N E F I T S Coventry contracts with several ancillary providers for supplemental benefits such as mental health, pharmacy, and chiropractic.. The following services are not routinely covered by Original Medicare, but are covered under Coventry. Mental Health/Substance Abuse Services MHNet provides access to inpatient and outpatient mental health and substance abuse services for Members. Members have a lifetime limit of 190 days of care in a psychiatric hospital. Benefit limitations follow Medicare guidelines. Members can obtain a referral to a MHNet participating practitioner and/or facility by calling MHNet at (800) 752-7242. Pharmacy Services Individual Members have a pharmacy benefit that is subject to limitations. Members also have coverage for Medicare Part B drugs. Please refer to the Member Summary of Benefits and Evidence of Coverage for more specific information. Please contact the Customer Service Department at (888) 360-6626 for more information on prescription drug coverage for Advantra Members. Self-injectable medications are not covered unless it is a Medicare approved Part B drug. Express Scripts provides the administration of the drug benefit for Advantra Members. All prescriptions must be filled at a participating pharmacy. 14 Questions regarding general pharmacy benefits should be directed to Customer Service at (888) 360-6626.. Questions regarding pharmacy benefits and pharmacy and drug coverage should be directed to Express Scripts Customer Service at (800) 922-1557. All drug prior authorization requests should be directed to (877) 215-4100 or faxed to (866) 669-5575. CHC has developed a drug formulary to maintain that high quality costeffective pharmaceuticals are dispensed to Members. The formulary consists of a list of medications that are approved for use by the Coventry Health Care Pharmacy and Therapeutics Committee (P&T Committee). This committee is composed of physicians from various medical specialties and pharmacist. Periodic changes to the formulary occur based upon the decisions of the P&T Committee, and are published annually. Generic drugs provide cost-effective drug therapy. Most prescription benefit plans provide a lower copay for the Member when they receive generic medications along with coverage through the Gap. Providers are encouraged to prescribe generic products. If you prescribe medicines that are not included on the formulary, your patients may incur the cost of the medication. In some cases, dosage limitations and prior authorization requirements apply for certain drugs. Drugs requiring prior authorization can be found on our website at www.la.chcadvantra.com You can access the plan’s Web site http://LAformulary.coventrymedicare.com for the most current Drug List. Vision Services Members are entitled to vision coverage in accordance with Medicare guidelines. Members, regardless of the benefit plan selected are also entitled to benefits for eyeglasses or contact lenses after cataract surgery. This benefit follows the Medicare guideline for coverage. Chiropractic Coverage Advantra does provide chiropractic coverage in accordance with Medicare guidelines. 15 S P E C I A L S T A T U S M E D I C A R E M E M B E R S The Centers for Medicare & Medicaid Service (CMS) reimburses contractors at different rates for each Member based on age, sex, county of residence, and also on the classification into one of five special Status Categories. The Special Status Categories include: Institutional Status End Stage Renal Disease Medicare/Medicaid Dual Eligible Hospice Working Aged It is important that you understand the different Special Status Categories and take the actions defined below when you identify a Member who meets the Special Status definition. Institutional Status is defined as an individual enrolled in a Medicare Advantage who has been a resident in a skilled nursing facility, nursing facility, ICF/MR, psychiatric hospital, rehabilitation hospital, long-term care hospital, swing-bed hospital for at least 30 consecutive days. If you are making rounds on a Member in one of these facilities and the Member has been there for more than 30 days, please make sure your Utilization Management contact is aware of this Member. These types of Members must be submitted to CMS each month for CMS to provide the Plan with a higher reimbursement rate. End Stage Renal Disease (ESRD) is defined by CMS as the state of renal impairment that appears to be irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life. If 36 months or more has elapsed since a kidney transplant, the person is no longer considered to have ESRD status. It is very important that you inform your Utilization Management contact of any enrolled Members who now meet the ESRD definition. ESRD status is reported to CMS through the ESRD Network Organization located in 18 geographic areas in the United States. The provider, usually a contracted nephrologist or renal dialysis facility submits the completed CMS 2728-U4, “Medical Evidence Report Form,” to the applicable ESRD Network Organization. 16 The ESRD Network Organization reviews the form and transmits the data to CMS electronically. CMS will notify the Plan of Members who are ESRD. (NOTE: Coventry may be secondary payor for individuals who have both Medicare coverage and Employer Group Health Plan coverage.) Medicare/Medicaid Dual Eligible is an individual who is covered under both the Medicare and Medicaid programs. A qualified Medicare beneficiary (QMB), has the state Medicaid program pay for annual Medicare Part A deductible, Medicare Part A coinsurance, monthly Medicare Part B premium, annual Part B deductible and Medicare Part B coinsurance. Hospice is a Member who has selected Medicare certified Hospice coverage. Prospective Members are entitled to enroll in Advantra if they are receiving Hospice coverage. An Advantra Member becomes Medicare certified for Hospice when he/she completes a Hospice Election Form. This form is usually provided by a Medicare certified Home Health or Hospice provider. The provider then submits the form along with the provider bills to the fiscal intermediary. The fiscal intermediary pays the Hospice claims, not Coventry Advantra. Working Aged is defined as the CMS Medicare Advantage risk payment category for an individual who is defined as eligible for Medicare and (1) is either working for an employer with more than 20 employees or (2) has a spouse with coverage under an Employer Group Health Plan which covers the Advantra Member. If you identify a Member with Employer Group Health Plan coverage in addition to their Advantra coverage, please inform Advantra Customer Service. If a Member is Working Aged, you should bill the other carrier as primary and Coventry Advantra as the secondary payor. 17 4 Chapter Provider Participation Information In addition to the responsibilities outlined in the Coventry Health Care of Louisiana, Inc. Provider Manual, your participation in the Medicare Advantra product requires some additional requirements and responsibilities. This section outlines those Responsibilities. Responsibilities M E D I C A L R E C O R D S A N D R E C O R D R E T E N T I O N Providers should safeguard the privacy of the Member’s medical record. Original medical records should be released only in accordance with Federal or State laws, court orders or subpoenas. All records should be kept confidential and maintained for 10 years and in certain instances described in the Medicare Advantage regulation, periods in excess of 10 years or more. All Member information should be available to be transferred upon request by the Member, or authorized representative, to any organization with which the Member may subsequently enroll, or to a provider to ensure continuity of care. Ensure timely access by Member to pertinent records and information upon request. The provider must abide by all Federal and state laws regarding confidentiality, documentation on whether or not a Member has 18 executed an Advance Directive and disclosure for mental health records and medical records. As a requirement of Medicare, all providers must maintain for a period of 10 years books and in certain instances described in the Medicare Advantage regulation, periods in excess of 10 years for more records, documents and other evidence of accounting procedures and practices, physical facilities and equipment and records related to Medicare enrollees and any additional relevant information CMS may require. C M S R E Q U I R E M E N T S Please be advised that marketing material communications that promote, communicate or explain the Medicare health plan to Advantra Members require approval by the Center for Medicare & Medicaid Services (CMS). Health education materials are generally not under the purview of CMS marketing review. The Plan has various CMS-approved materials that we can make available to you for you to announce your participation with the Advantra program. Please contact the Advantra Marketing Department if you are interested in pursuing any communication to Members of your practice regarding the Advantra products. Laws and Regulations All Plan providers must comply with applicable Medicare laws and regulations, including Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, the Rehabilitation Act of 1973, and other laws applicable to recipients of Federal funds. Coventry's policy, as well as the Federal law, is that no form of discrimination prohibited by law will be permitted on the basis of sex, race, color, disability, age, religion or ethnic origin, and that all Members will have access to their medical services at all contracted provider facilities. Disclosure of Information At the request of the MA Organization or CMS, the provider shall disclose all information necessary to (1) administer and evaluate the program, to include quality performance indicators and information regarding Members’ satisfaction and health outcomes; and (2) establish and facilitate a process for current and prospective beneficiaries to exercise their right to choose Medicare services 19 Continuation of Benefits Provider shall continue to provide covered services to Advantra Members who are hospitalized on the date the CMS contract terminates or expires, of if Coventry Health Care of Louisiana becomes insolvent, through the date of each Advantra Member’s discharge or for the remainder of the period for which the Member’s Medicare premium has been paid. External Review Provider agrees to cooperate with all independent quality review and improvement organization activities required by CMS and/or Coventry Health Care of Louisiana pertaining to the provision of services for Advantra Members. Plan Provider Termination Notices The MA Organization must make a good faith effort to notify Members of the termination of a provider’s contract 30 days before the termination is effective. Providers must follow the termination provision as defined in their Physician Agreement to ensure timely notification. The MA Organization will notify physicians in writing of the reason(s) for any denial, suspension or termination of the physician’s participation in the provider network. When contracted providers choose to opt out of Medicare or sanctions are taken against that provider, the MA Organization will take immediate steps to terminate that provider’s contract with the Organization. Compliance with Medical Management Providers must agree to comply with the Plan’s Medical policies, QI and Medical Management Programs, and adhere to appeals/grievance procedures. Hold Harmless Provider shall only bill, charge, collect a deposit from, or seek compensation for services rendered under the Agreement. For purposes of this section, services rendered under the Agreement include those health care services delivered to Medicare Advantage Members by any and all health care professionals employed by or independently contracted with the Provider. This section shall not prohibit collection 20 of copayments, coinsurance, or deductibles in accordance with the Medicare Advantage Member’s Member Contract. Hold Harmless for Dual Enrollees As required by CMS, effective January 1, 2010 Provider shall look solely to Plan or the appropriate State source for payment of Covered Services furnished to Medicare Members who are eligible for both Medicare and Medicaid. Provider shall not seek to collect payment from the dual eligible member for any portion of the Medicare Part A and Part B Copayment/Coinsurance and Deductible when the applicable State program is responsible for paying such amounts. Provider shall not seek to collect any Copayment/Coinsurance and Deductible that exceeds the amount of Copayment/Coinsurance and Deductible that would be permitted to be paid by the individual under Title XIX (Medicaid) if the individual were not enrolled in the plan. Provider shall be responsible for determining the appropriate amount, if any, of Copayment/Coinsurance and Deductible that may be collected from the Medicare Member. With respect to any amount that the Provider is prohibited from collecting from the member, Provider shall either (i) accept payment from the Plan as payment in full or (ii) bill the appropriate State source for any remaining amount. CHC will assist Provider in locating information about Medicare and Medicaid benefits and rules for members eligible for Medicare and Medicaid. MEDICARE PROVIDER TRAINING & EDUCATION Coventry Health Care, Inc. (“Coventry”) is pleased to have the opportunity to work with you as a provider or provider organization in delivering high value services to our members. Our association, particularly in relation to our Medicare product lines, relies on a contracted relationship that establishes your entity as a first tier1 or related entity2. As a first tier or related entity, there are several requirements imposed upon you, some by federal law, some by federal regulations as promulgated by the Centers for Medicare & Medicaid Services (“CMS”), and other requirements in light of your contracted relationship with Coventry. As a result, you, your entity, any downstream entities3 and/or related entities under your direction, and in several cases your individual employees who are assigned to work on Coventry’s Medicare business, must complete a number of requirements. The requirements are summarized below and are applicable to your organization, as well as any of your downstream and/or related entity arrangements. 21 1. General Compliance and Fraud, Waste and Abuse (“FWA”) Training You and/or your organization must complete general compliance training. In addition, you must complete the FWA portion of the training unless you are deemed to have met the FWA certification requirements through enrollment into Parts A or B of the Medicare program or through accreditation as a supplier of DMEPOS. You must provide general compliance training to all of your employees, downstream, and related entity arrangements who are assigned to work on Coventry Medicare business initially upon hire and annually thereafter. You must also provide FWA training, initially upon hire and annually thereafter, to all your employees, downstream, and related entity arrangements who are assigned to work on Coventry Medicare business unless these individuals are deemed to have met FWA certification requirements as described above. In addition, your organization must provide either Coventry’s Code of Conduct (“COC”) or your own equivalent COC to all of your employees, downstream, and related entities who are assigned to work on Coventry Medicare business initially upon hire or contract commencement and annually thereafter 2. Reporting Mechanisms You and/or your organization must report compliance concerns and suspected or actual misconduct to Coventry. 3. Exclusion/Debarment You and/or your organization must ensure that none of its employees or downstream and/or related entities that service Coventry Medicare business are on any of the following excluded persons, sanction and debarment lists: HHS Office of Inspector General (OIG); General Services Administration (GSA). 4. Downstream and Related Entity Oversight You and/or your organization must ensure that compliance is maintained by you and/or your organization as well as any of your contracted downstream and/or related entities that service Coventry Medicare business. 5. Offshore Operations 22 You and/or your organization must ensure that you do not engage in offshore operations for Coventry-related Medicare business without the express consent of an authorized Coventry representative. Offshore operations are usually contractually prohibited by Coventry. Any Coventry-approved offshore arrangements are subject to reporting requirements to alert CMS of these activities and therefore must be reported to Coventry before utilization. You must access the training and compliance materials mentioned above, along with additional information concerning these requirements, available for you on the Coventry Medicare FDR Training and Education Portal under Provider and Provider Group FDRs. This portal can be accessed through the following URL link www.CoventryMedicareFDRs.com. Further, if you and/or your organization utilizes downstream and/or related entities to perform Coventry Medicare work or serve Coventry Medicare members, that entity is also responsible for satisfaction of all of the above requirements. Due to the unique nature of the relationship between you and your downstream and/or related entities, Coventry expects that you ensure that they receive these requirements. You and/or your organization are responsible to ensure that evidence of the effectuation for all of the requirements is developed and maintained. This evidence may be in the form of attestations, training logs, or other means determined by you to best represent fulfillment of your obligations. Please be reminded that Coventry and CMS require records to be retained for a period of ten (10) years, and that your records must be available to Coventry and/or CMS upon request. A first tier entity is defined as any party that enters into a written arrangement acceptable to CMS with a Sponsor (i.e., Coventry) to provide administrative or health care services for a Medicare eligible individual under Part C or Part D. A related entity is defined as any entity that is related to the Sponsor by common ownership or control and a) performs some of the Sponsor’s management functions under contract or delegation; b) furnishes services to Medicare enrollees under an oral or written agreement, or c) leases real property or sells materials to the Sponsor at a cost of more than $2500 during a contract period. 42 CFR 423.501 23 M E M B E R R I G H T S Advantra Members have the right to: Timely, Quality Care A N D R E S P O N S I B I L I T I E S A downstream entity is defined as any party that enters into a written arrangement, acceptable to CMS, below the level of the arrangement between the Sponsor and the first tier entity. These written arrangements continue down to the level of provider of both health and administrative services. Choice of a qualified Contracting Primary Care Physician and Contracting Hospital. Candid discussion of appropriate of Medically Necessary treatment options for their condition, regardless of cost or benefit coverage. Timely access to Primary Care Physician and Referrals to Specialists when Medically Necessary. Timely access to all Covered Services, both clinical and nonclinical. To go to a women’s health specialist without a referral. Access to Emergency Services without prior authorization when they, as a prudent layperson, acting reasonably would have believed that an Emergency Medical Condition existed and payment will not be withheld in cases where they seek Emergency Services. Actively participate in decisions regarding their own health and treatment options. Receive urgently needed services when traveling outside the Plan’s service area or in Plan’s service area when unusual or extenuating circumstances prevent them from obtaining care from their Primary Care Physician. Treatment with Dignity and Respect Be treated with dignity, respect and fairness at all times, and to have their right to privacy of their medical records and personal health information recognized. 24 Exercise these rights regardless of their race, physical or mental ability, ethnicity, gender, sexual orientation, creed, age, religion or their national origin, cultural or educational background, economic or health status, English proficiency, reading skills, or source of payment for their care. Expect these rights to be upheld by both Coventry and its contracted providers. Confidential treatment of all communications and records pertaining to their care. They have the right to access their medical records. Coventry must provide timely access to your records and any information that pertains to them. Written permission from them or their authorized representative shall be obtained before medical records can be made available to any person not directly concerned with your care or responsible for making payment for the cost of such care. Know how their health information has been given out and used for non-routine purposes. Be involved in decisions to withhold resuscitative services, or forgo or withdraw life-sustaining treatment. Extend their rights to any person who may have legal responsibility to make decisions on their behalf regarding their medical care. Refuse treatment or leave a medical facility, even against the advice of physicians (providing they accept the responsibility and consequences of the decision). Complete an Advance Directive, Living Will or other directive to their Contracting Medical Providers. Advantra Information To be informed of Medicare Advantage policies and procedures regarding services, benefits, providers, and our Member Rights & Responsibilities and be notified of any significant changes. Information about Medicare Advantage and Covered Services written in a manner that truthfully and accurately provides information in a format that is easy to read and understand. Know the names and qualifications of physicians and health care professionals involved in their medical treatment. Receive information about an illness, the course of treatment and prospects for recovery in terms that they can understand. 25 Information regarding how medical treatment decisions are made by the Contracting Medical Group or Coventry, including payment structure. Information about their medications – what they are, how to take them and possible side effects. To receive a notice that tells about their privacy rights and explains how we protect the privacy of their health information. To ask Plan providers to make corrections or additions to their medical records. Receive as much information about any proposed treatment or procedure as they may need in order to give an informed consent or to refuse a course of treatment. Except in cases of Emergency Services, this information shall include a description of the procedure or treatment description, the medically significant risks involved, any alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. Reasonable continuity of care and to know in advance the time and location of an appointment, as well as the physician providing care. Be advised if a physician proposes to engage in experimentation affecting their care or treatment. They have the right to refuse to participate in such research projects or experimental treatment. Be informed of continuing health care requirements following discharge from inpatient or outpatient facilities. Examine and receive an explanation of any bills for Non-Covered Services, regardless of payment source. General coverage and Plan comparison information. Utilization control procedures. Summary of statistical data on grievances and appeals that Members have filed against the Medicare Advantage Program. The financial condition of Coventry. Summary of provider compensation agreements. To make recommendations regarding the organization's Member Rights & Responsibilities Policies. 26 Timely Problem Resolution Make complaints and appeals without discrimination and expect problems to be fairly examined and appropriately addressed. Responsiveness to reasonable requests made for services. Receive a detailed explanation from Coventry if you believe that a Plan provider has denied care that you believe you are entitled to receive. As a Member of Advantra, they have the responsibility to: A D V A N C E D I R E C T I V E Provide their physicians or other care Providers the information needed in order to care for them. Do their part to improve their own health condition by following treatment plans, instructions and care that they have agreed on with their physician(s). Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible. Behave in a manner that supports the care provided to other patients and the general functioning of the facility. Accept the financial responsibility for any Copayment or Coinsurance associated with covered services received while under the care of a physician or while a patient at a facility. Accept the financial responsibility for any premiums associated with Membership in Medicare Advantage Plans. Review information regarding Covered Services, policies and procedures as stated in their Evidence of Coverage Information. Ask questions of their Physician or Coventry. If they have a suggestion, concern, or a payment issue, we recommend they call Advantra Customer Service. (number of located on back of ID Card) An Advance Directive is a written formal document, written by the Member in advance of an incapacitating illness or injury. 27 When an Advantra Member visits your office, we ask that you discuss Advance Directives and document in the medical records whether or not the Member has executed an Advance Directive. COVENTRY HEALTH CARE MEDICAL CARE ADVANCE DIRECTIVE POLICY Coventry believes in the right of the patient to make the appropriate decisions concerning his/her care. We also understand that in some medical situations that power may not be within the patient’s realm of physical or mental capacities. As a Health Maintenance Organization, we believe in and support a patient’s right to make advance arrangements for the direction of his/her medical care in these instances. The state of Louisiana recognizes and enforces the provisions of the Patient SelfDetermination Act of 1990. In response to this legislation the state of Louisiana recognizes two forms of medical care Advance Directive. “Living Will” Health Care Agent Designation (Durable Power of Attorney) To download and print the Living Will Declaration Form, and for additional information regarding End of Life Registry Programs, go to the Louisiana Secretary of State website at: http://www.sos.la.gov/OurOffice/EndOfLifeRegistries/Pages/default.a spx Coventry requires our network and contracted providers to notify and educate the Member/patient about his/her rights and how to exercise them. The following is the policy followed by Coventry. 1. The Member’s primary care physician will be responsible for asking whether the Member has executed an Advance Directive. This discussion must be documented in the Member’s medical record. If the Attending Physician is not the Member’s primary care physician, the Attending Physician shall also document the Member’s Advance Directive information in the Member’s medical record. 28 2. Members shall be advised of their responsibility to inform outside providers/facilities that they have executed an Advance Directive 3. The existence of a medical care Advance Directive will not cause or create a change in the provision of care provided or result in any discrimination against the individual because of this choice. This provision shall, not, however, be construed to require care in conflict with the medical care Advance Directives. 4. New Advantra Members will be provided written information regarding Louisiana law on Advance Directive rights which includes the right to make decisions concerning their medical care the right to accept or refuse medical or surgical treatment, their right to formulate Advance Directives. Members may receive information regarding Advance Directives through member newsletters or member handbooks. 5. Coventry will protect each Member’s right to accept or refuse medical or surgical treatment and to formulate Advance Directives. 6. The member has the right to file a complaint with Coventry or the state survey and certification agency if they find noncompliance with the Advance Directive requirements. 7. Coventry will strongly urge each provider to inform each adult Member about the medical care Advance Directive in the following situations: for hospital provider, at the time of the patient’s admission: for a SNF, at the time of admission; at the time of admission to a nursing facility as a resident at the time of arranging for home health care, before the patient comes under the care of the home health provider; or at the time of the initial advice on hospice care. 29 8. The Health Plan recognizes that an Advance Directive can be revoked at any time by the Member, regardless of physical or mental status. In order to be effective, the Member’s revocation must be communicated to the Attending Physician by the Member or by a person acting at the direction of the Member. The Attending Physician must record in the Member’s medical record the time, date, and place of the revocation, as well as the time, date, and place when the Attending Physician received notification of the revocation (if different). If the Attending Physician is not the Member’s primary care physician, the Attending Physician shall also notify the Member’s primary care physician of this revocation. If the member filed a Declaration with the Secretary of State’s office, they must file a written notice of revocation in that office. The revocation will not be honored until the Secretary of State indicates on the Declaration the date and time that the office received notice of the revocation. Coventry further believes in the rights of any provider to object to the implementation of medical care Advance Directive. Those providers are required to inform the patient of their objection, how that will impact the request for medical care Advance Directive and provisions for referral or reassignment to a primary care physician that has compatible beliefs with the patient. All Advantra Members receive an Advance Directive document as part of their Membership materials. Extra copies can be obtained through Advantra Customer Service Department at (888) 360-6626. For additional information pertaining to the Louisiana Physician Order for Scope of Treatment (LaPOST) go to: http://www.lhcqf.org/lapost-home. 30 5 Chapter Authorizations Coventry Health Care requires prior authorization and precertification for certain services. This section will outline those requirements which are specific to Advantra. A uthorizations are required for inpatient and some outpatient hospital admissions, certain medical, surgical, or diagnostic procedures, and care by nonparticipating providers. The Authorization list is updated periodically by Coventry Health Care. Please make sure an authorization for applicable services is issued prior to Members receiving the services unless it is an emergency. If you are unsure about a particular procedure or for more information, contact Customer Service or log onto www.chcla.com to access the current Prior Authorization List, or log onto www.directprovider.com for a code specific look up tool. Advantra authorization request can be accepted through several methods including: Via phone call to our Health Services Department at (800) 2458327 Via faxed authorization form to Health Service Department (800) 459-5612 Via submission through directprovider.com Prior Authorization List Prior authorization is the approval of services by Coventry Health Care as medically necessary before the services are actually rendered. Prior authorization is required for the payment of claims for certain services. If the service is approved, an approval letter is sent to the Advantra HMO Member 31 and the provider performing the service. Denial notices are sent if the services are not authorized. Providers may be held responsible for the cost of services when prior authorization is required but not obtained. The Member may not be billed for the applicable services. Retroauthorizations are not covered. The Prior Authorization list for Coventry is located on the Coventry Health Care of Louisiana website, www.chcla.com, Provider Portal under Document Library. All Medicare members will follow the Prior Authorization list with a few exceptions to include: Cardiac and Pulmonary rehabilitation Hemodialysis Those services will be identified by bolded print, so please refer to the Prior Authorization listing. D U R A B L E M E D I C A L E Q U I P M E N T A M D P R O S T H E T I C A P P L I A N C E S CHC providers are required to obtain prior authorization for Members for the rental of durable medical equipment or purchase of items greater than $500. Advantra follows Medicare guidelines for the coverage of DME, and prosthetic appliances. Prosthetics must be on Medicare’s list of approved prosthetic appliances. Equipment must be obtained from a participating provider. Please consult Customer Service to verify the Member’s benefits at (888) 360-6626.. 32 6 Chapter Reimbursement & Claims Providers are reimbursed through a fee for service arrangement. This section outlines the procedures for claims submission which are specific to Advantra. P hysician reimbursement under CHC is a fee for service arrangement. Fee for service reimbursement compensates the provider only for services rendered based on the CPT codes submitted. Physician allowances are set by CPT codes. When submitting claims, please include all applicable modifiers to ensure the claims proper payment. Claims submitted to Coventry should include your usual fee for services rendered by CPT code. Proper coding remains the responsibility of the billing provider. Fee charged for services provided to CHC Members should be the same as those charged to non-Coventry Members for the same services. Claims Filing Procedures Coventry Health Care has adopted the standard billing guidelines so that completion of the CMS Form is consistent with Medicare Guidelines. Providers should submit charges on an HCFA 1500 Health Insurance Claim form (or UB92 if applicable) directly to the Claims Address listed on the Member’s Identification Card. You must include your NPI number on each Claim Form submitted. All hospitals (inpatient & outpatient) services and physician services information are required to be submitted to CMS. 33 The mailing address for Advantra claims is: Advantra P.O. Box 7819 London, KY. 40742 - 7819 For Electronic submission, please use Payor ID #25133 IMPORTANT PROVIDER ENCOUNTER INFORMATION REGARDING MEDICARE ADVANTAGE RISK ADJUSTMENT PAYMENT METHODOLOGY The Balanced Budget Act of 1997 specifically required implementation of a Risk Adjustment Method Payment methodology. Starting 2004, Medicare Advantage Organizations will receive a portion of their payment from CMS based on the “health status” of the Medicare beneficiary. The payment model recognizes diagnoses from inpatient hospital data and ambulatory settings. Based on the Balance Budget Act of 1997, Medicare Advantage Organizations must collect and submit all inpatient hospital, outpatient hospital and physician encounter data to the Center of Medicare & Medicaid Services (CMS) on all enrolled Medicare Advantage HMO & HMO/POS Members. Effective July 1, 2002, all encounters submitted to CMS must contain all relevant diagnoses noted during hospital inpatient stays and hospital outpatient and physician visits. All hospitals and physicians must use current valid International Classification of Diseases - 9th Edition - Clinical Modification (ECD-9CM) Codes; report all diagnoses related to service performed and justified by medical record documentation and following coding guidelines using the most specific code. All providers who participate in the Medicare-Choice Program are required to submit complete and accurate claims data and maintain clear, concise and complete medical record documentation practices. The following procedures have been identified to assist providers in complying with the regulatory requirements of submitting encounter information. Provider should provide ongoing training to staff regarding appropriate use of ICD-9-CM code set for reporting diagnoses. 34 Submit all diagnosis that impact the patient evaluation, care and treatment: o Main reason for a visit or admission o Co-existing acute condition o Chronic conditions o Permanent past conditions Providers should periodically review their claim/encounter data submission to ensure that they are accurate, complete and truthful and are supported by the medical record or other relevant documentation. Provider should fully communicate diagnosis details to coding staff, so that the visit or admission is coded to the highest level of specificity known. Importance of Medical Record Documentation Accurate risk adjusted payment relies on complete medical record documentation and diagnostic coding. CMS annually conducts risk adjustment data validation by Medical Record Review. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. Resources - ICD-9-CM Coding www.hcfa.gov/medlearn/cbticd9.htm for a computer-based course on ICD-9-CM www.cms.hhs.gov (Conduct a site search for ICD-9-CM) www.mcoservice.com 35 7 Chapter Utilization and Quality Management Utilization management tracks health care costs while assuring the quality of and access to health care, while quality management assures that all health care services provided to Members meet the highest standards of quality. This section details the processes of utilization and quality management at Coventry Health Care of Louisiana which is specific to Advantra. U tilization management occurs by reviewing how health care resources are utilized by Members and identifies and evaluates appropriateness, timeliness, medical necessity, utilization patterns and clinical outcomes. Utilization management at Coventry Health Care consists of the following functions: Preauthorization of hospital admissions and outpatient services to determine medical necessity. Concurrent review of inpatient care to ensure appropriate treatment and length of hospital stay. Retrospective review of health care service and costs Use of alternative resources and settings Case management 36 A D V A N T R A P E R S O N A L H E A L T H P R O F I L E S C A S E M A N A G E M E N T Disease management programs Oversight of delegated utilization management functions All new Members are sent an Advantra Personal Health Questionnaire within the first 90 days of enrollment. The questionnaire is completed by the Member and sent back to Coventry Health Care of Louisiana. Coventry requests that the Member discuss their Personal Health Questionnaire with their PCP. The information from the Personal Health Questionnaire will assist the PCP or Specialist in providing direction regarding the Member's health needs and potential treatment options. This will allow the Member to participate in the development of their own treatment plan. Coventry will also assist in the coordination of care for complex or serious disease cases with the PCP or Specialist and will inform Members of any follow-up care and provide training in selfcare through the Case Management or Disease Management Program. Case management provides high quality, cost effective service to Members who have encountered, or have the potential to utilize, significant medical services. Case management includes but is not limited to: Treating patients in the least restrictive setting or environment Providing services at the most appropriate site Providing support for Primary Care Physicians with complex cases Managing patient’s real and perceived needs Serving as a patient/family advocate Members may be referred to complex case management if they meet one or more of the following key indicators and one or more admissions or ER visits for the following conditions. If you have a Member who you would like to refer into the Case Management Program, please contact our Health Services department at (800) 245-8327 37 New stroke Diabetic ketoacidosis Hypoglycemia Uncontrolled Diabetes Cellulitis with diabetes Foot ulcer with diabetes Retinopathy or blindness Sepsis Hospital admission with primary diagnosis of malignancy, HIV or complications (dehydration, pain control, etc) Receiving home care Respiratory: (Asthma, Chronic Obstructive Pulmonary Disorder, Cystic Fibrosis, etc) Asthma Cystic Fibrosis Chronic Obstructive Pulmonary Disease Trauma/Medical Surgical/Miscellaneous: Burns greater than 25% of the body Myasthenia gravis Spinal cord injury/fracture Traumatic brain injury Multiple fractures Complex wounds Transplants: Any transplant evaluation Non-Diagnosis Related Indicators: Discharge planning: Home Care with Two (2) or more services required for longer than one month (i.e., physical, speech, respiratory therapy, nursing, Cardiovascular: Endocrinology: (Diabetes mellitus, renal, etc.) Oncology/Immunodeficiency Disorders: 38 infusion, durable medical equipment, etc.) Emergency Department visits: Three (3) or more visits within a 45 day period Hospital admissions: Greater than one hospital admission within six (6) months for the same diagnosis. Pharmacy: Poly-pharmacy with ten (10) or more prescriptions in thirty days A variety of providers consulting on a seemingly straightforward case A Member taking large quantities of pain medications or antidepressant medications Repeated falls Nursing home admission Dialysis PCPs will be informed for any interventions and any follow-up needs. 39
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