Provider Manual ATRIO Medicare Advantage Plans 1/1/2014

1/1/2014
Provider Manual
ATRIO Medicare Advantage Plans
Table of Contents
Service Areas .............................................................................................................. 6
Contact Information ......................................................................................................... 7
Douglas County ........................................................................................................... 7
Klamath County ........................................................................................................... 7
Marion & Polk County .................................................................................................. 8
Pre-Authorizations ....................................................................................................... 8
Referrals and Medical or Equipment............................................................................ 8
All Pharmacy Pre-Authorization Requests ................................................................... 8
Claims Submission for Douglas, Klamath, Marion and Polk County ............................ 8
Customer Service for both Douglas County and Klamath County SACs ..................... 9
Contracting & Credentialing ............................................................................................ 9
Termination ................................................................................................................ 10
Provider Rights & Responsibilities ............................................................................. 11
Role of Specialty Care Physicians ............................................................................. 12
Well-Woman Examinations ........................................................................................ 12
Specialist-To-Specialist Referral ................................................................................ 12
Office Visit Accessibility ............................................................................................. 13
ATRIO Health Plans Responsibilities......................................................................... 13
Member Rights and Responsibilities.......................................................................... 14
Medicare Advantage Guidelines ................................................................................... 16
CMS Required Provisions .......................................................................................... 16
Claims Submission ........................................................................................................ 18
Paper Claims Submissions ........................................................................................ 18
Paper Claims Submission Address ........................................................................ 19
Provider Log In, Clinical Integration Manager ............................................................ 19
Requirements for CMS-1500 Electronic Print Image Claims ..................................... 19
Electronic Claims Submission-(EDI) Electronic Data Interchange ............................. 20
What are the Advantages of Billing Electronically? .................................................... 20
Timely Billing/Filing .................................................................................................... 20
Prior Authorization on Claim Form ............................................................................. 21
Resubmission of Corrected Claims............................................................................ 21
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Medicare Overpayment Recovery ............................................................................. 21
Balance Billing ........................................................................................................... 21
Hold Harmless Dual Eligible ...................................................................................... 22
Coordination of Benefits ............................................................................................ 22
Non-Covered Services, Hospital Acquired Conditions & Surgical Never Events ....... 23
Grievance & Appeal Process, Provider Appeal ............................................................. 24
When Can a Contracted Provider Request a Reconsideration? ................................ 24
How Often Can a Contracted Provider Request a Reconsideration? ........................ 24
Reversal of Denial ..................................................................................................... 24
Affirmation of Denial .................................................................................................. 24
Member Appeal ......................................................................................................... 25
Standard Appeal process .......................................................................................... 25
Reversal of Denial of a Standard Pre-Service Appeal ............................................... 25
Affirmation of Denial of a Standard Pre-Service Appeal ............................................ 25
Expedited Appeals Process ....................................................................................... 26
Denial of an Expedited Request ................................................................................ 26
Resolution of an Expedited Appeal ............................................................................ 27
Reversal of Denial of an Expedited Appeal ............................................................... 27
Affirmation of Denial of an Expedited Appeal ............................................................ 27
Appeal Levels ............................................................................................................ 28
Grievance Process .................................................................................................... 28
Provider .................................................................................................................. 28
Member .................................................................................................................. 28
Grievance Resolution, Expedited .............................................................................. 29
Standard .................................................................................................................... 29
Utilization Management ................................................................................................. 30
Prior Authorization/Organization Determination ......................................................... 30
Concurrent Review .................................................................................................... 31
Discharge Planning.................................................................................................... 32
Retrospective Review ................................................................................................ 32
Prior Authorization ..................................................................................................... 33
Organization Determination (Prior Authorization) Timelines ...................................... 34
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Standard Organization Determination .................................................................... 34
Expedited Organization Determination ................................................................... 34
Medicare QIO Review Process of SNF/HHA/CORF Terminations ............................ 35
Case Management ........................................................................................................ 35
SNP Model of Care .................................................................................................... 36
Action Required ......................................................................................................... 36
Health Risk Assessment (HRA) ................................................................................. 36
Transitions of Care (TOC) ......................................................................................... 37
Chronic Care Improvement Program (CCIP) ............................................................. 37
Quality Improvement Programs ................................................................................. 38
Member Programs ..................................................................................................... 38
Disease Management ................................................................................................ 38
Diabetes Prevention Program (DPP) ..................................................................... 38
Smoking Cessation Classes ...................................................................................... 39
Practice Guidelines .................................................................................................... 39
HEDIS ........................................................................................................................... 40
Advance Directives .................................................................................................... 41
Risk Adjustment Program.............................................................................................. 41
Background ............................................................................................................... 41
Documentation and Coding Requirements for All Medical Documents...................... 41
In-Home Comprehensive Health Evaluations ............................................................ 42
Retrospective Chart Reviews .................................................................................... 42
2014 ATRIO Prescription Drug Reference Guide .......................................................... 42
Prior Authorization Guidelines ................................................................................... 43
Step Therapy Guidelines ........................................................................................... 43
Quantity Limit Guidelines ........................................................................................... 44
Exception Requests ................................................................................................... 44
To Request Prior Authorization, Exception or Override ............................................. 44
Douglas County Oregon members ......................................................................... 45
Klamath County Oregon members ......................................................................... 45
Marion & Polk County members............................................................................. 45
Authorization Request Forms .................................................................................... 45
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Grievances and Appeals ............................................................................................... 45
Covered Drugs .......................................................................................................... 46
New Covered Drugs for 2014! ................................................................................... 46
Covered OTC Drugs .................................................................................................. 46
Excluded Drugs ......................................................................................................... 47
Day Supplies Available .............................................................................................. 47
Transition Fills ........................................................................................................... 48
Transition Fill Reference Chart .................................................................................. 48
Diabetic Testing Supplies .......................................................................................... 52
Part B vs.D Coverage ................................................................................................ 52
Part B and Part D Vaccines ................................................................................... 53
Part D Vaccines ..................................................................................................... 53
Part B Vaccines:..................................................................................................... 53
Low Income Subsidy and Co-Pays ............................................................................ 53
Medication Therapy Management ............................................................................. 53
E-Prescribing ............................................................................................................. 53
Corporate Code of Conduct .......................................................................................... 54
I. Code of Conduct ..................................................................................................... 54
II. Standards of Conduct ............................................................................................ 54
Confidentiality/Privacy ............................................................................................ 55
Fraud/Waste/Abuse ............................................................................................... 55
III. Reporting/Investigation and Response ................................................................. 56
IV. Delegated Entity Responsibilities ......................................................................... 56
Medical Record Accessibility and HIPAA ...................................................................... 58
Reporting Fraud, Waste and Abuse .............................................................................. 59
HIPAA Violations and other Non-Compliance............................................................ 59
Chief Compliance Officer ....................................................................................... 59
ATRIO Website ...................................................................................................... 59
Anonymous Mailbox ............................................................................................... 59
Chairman of the Board Audit Committee ................................................................ 59
Office of Inspector General .................................................................................... 59
Center for Medicare and Medicaid Services (CMS) ............................................... 59
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Notice of Privacy Practices ............................................................................................ 60
Our Privacy Commitment ........................................................................................... 60
How ATRIO May Use Your Information ..................................................................... 60
Your Privacy Rights ................................................................................................... 61
How to Contact ATRIO to Review, Correct or Limit Your Protected Health Information
(PHI) .......................................................................................................................... 62
How to File a Complaint or Report a Problem ........................................................... 63
Changes to this Notice............................................................................................... 63
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History of ATRIO Health Plans
ATRIO Health Plans incorporated in 2004, is a fully licensed Health Service Contractor
(HSC) by the State of Oregon. Collaboratively formed by the mutual efforts of three
individual physician and hospital organizations contracted with the State of Oregon to
administer the Oregon Health Plan; Cascade Comprehensive Care, Inc. (CCC) (CCC)
in Klamath County, Douglas County Individual Practice Association (DCIPA), and
Doctors of Oregon Coast South (DOCS) in Coos County. A primary goal of ATRIO is to
keep local attention and control with the provision of member care.
ATRIO achieved approval from the Centers for Medicare & Medicaid Services (CMS) to
offer a Medicare Advantage Plan beginning June 1, 2005. The insurance plan offered to
all Medicare eligible beneficiaries in the original three county service areas including
individuals who were dually eligible for Medicare and Medicaid services. With the
introduction of Part D on January 1, 2006, ATRIO also began offering Part D
prescription drug coverage.
Effective November 1, 2011, Marion Polk Community Health Plans Advante (MPCHPA)
joined the ATRIO Health Plans Medicare Advantage Service area.
Starting in January 2014 ATRIO Health Plan now offers individual insurance on and off
the Exchange through Cover Oregon. We also offer small group employer coverage off
the Exchange.
This manual provides critical information regarding provider and plan responsibilities.
The provider manual goes along with your provider agreement. If any information in this
manual is inconsistent with your contract terms, the provider agreement is primacy.
We hope you will find the information within this manual useful. Please let us know if
you have questions about any aspect of this manual or have suggestions regarding how
we can improve this document in the future by contacting our Provider Relations staff at
(541) 492-2154.
At ATRIO Health Plans, our goal is to link exceptional clinical focus with operational
excellence. The relationship with our providers demonstrates mutual respect and an
expectation that we will meet our commitment to our members and patients to provide
effective and excellent care.
ATRIO understands the needs and concerns of our contracted providers, and we want
to foster open communication to improve provider satisfaction while at the same time
improving the quality of patient care and service.
Service Areas
ATRIO’s approved service area began in Coos, Douglas, and Klamath Counties. Over
the years, there has been some change in the counties in which we offer our products
to Medicare eligible beneficiaries. We currently hold CMS approval to provide Medicare
Advantage benefits for enrollees in Douglas, Klamath, and Marion and Polk Counties.
Provider directories are in a service area format. The Provider Directory updated and
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produced monthly; but if changes occur between directory updates, the Utilization
Management Department will alert the provider and assist in the identification of
alternate Specialists. All Providers and Facilities listed in the ATRIO Provider Directory
are in-network for ATRIO members regardless of service area location.
ATRIOs website at www.atriohp.com has a useful provider search where you can find
specialists inside the network. If ATRIO is unable to locate a contracted provider within
the network, the Provider Relations Department will aid the member and their
physicians in identifying and contracting with an out-of-network provider for the care
needed. For information about contracting with ATRIO Health Plans, contact Charles
Wilson at (503) 967-7387 or Daina Williams at (503) 587-5140. You can also see the
section titled Contracts & Credentialing.
Contact Information
General Correspondence: All general correspondence (address changes, contracting
inquiries mail to
ATRIO Health Plans
ATTN: Karen Novak
2270 NW Aviation Dr., Suite 3
Roseburg, OR 97470
ATRIO Health Plans, Inc. is currently comprised of multiple Service Area Contractors
(SACs) with contact information specific to each:
Douglas County
Architrave Health, LLC
1813 W Harvard Ave., Suite 431
Roseburg, OR 97471

Medical Authorization Requests Fax: (541) 672-4318

Pharmacy Authorization Requests Fax: (541) 672-4318

Provider Relations: (855) 204-2964 PHTech

In-House Provider Relations: (541) 492-2154, Theresa Derby, Roseburg
Klamath County
Cascade Comprehensive Care, Inc. (CCC)
2909 Daggett Ave., Suite 200
Klamath Falls, OR 97601
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
Medical Authorization Requests Fax: (541) 882-6914

Pharmacy Authorization Requests Fax: (541) 883-6104

Provider Relations: (855) 204-2964 PHTech

In-House Provider Relations: (541) 273-0238, Brannon Kaefring, Klamath Falls
Marion & Polk County
*Provider Manual specific to WVP Health Authority SAC‘s Marion & Polk County
Members can be found at
http://www.wvphealthauthority.org/images/mpchp/WVPHA_provider_manual.pdf

Willamette Valley Community Health CCO

Provider Relations: 1-855-204-2964

Referrals and Medical or Equipment Fax: 503-581-7417
Pre-Authorizations

ATRIO Health Plan Medicare Product

Provider Relations: 1-855-204-2964
Referrals and Medical or Equipment

Fax: 503-581-7422 Pre-Authorizations

ATRIO Health Plan Exchange Products

Provider Relations: 1-855-204-2964

Referrals and Medical or Equipment

Fax: 503-485-3226 Pre-Authorizations
All Pharmacy Pre-Authorization Requests

Provider Relations: 1-855-204-2964

Fax: 503-581-7353

Customer Service:
(503) 584-4210
(888) 462-2708

In-House Provider Relations: (503) 967-7149, Jim Myers, Salem
Claims Submission for Douglas, Klamath, Marion and Polk County
ATRIO Health Plans
P.O. Box 5490
Salem, OR 97304
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Customer Service for both Douglas County and Klamath County SACs

(541) 672-8620

(877) 672-8620

Fax Number: (541) 672-8670
Contracting & Credentialing
ATRIO has contracted with three Service Area Contractors (SAC): Cascade
Comprehensive Care, Inc. (CCC) Inc. (CCC) in Klamath County, Douglas County
Individual Practice Association (DCIPA) in Douglas County and WVP Health Authority
(WVP) in Marion and Polk Counties, for use of their provider network. Each SAC is a
delegated party for credentialing the providers in their network. ATRIO, or a delegated
entity, credentials all contracted providers. Participating contracted providers providing
covered services to an ATRIO Health Plans’ member are credentialed upon initial
contracting with ATRIO and re-credentialed no less frequently than every three (3)
years, unless otherwise determined by ATRIO’s Credentialing Committee or the
applicable delegated entity’s credentialing committee.
Contracted Providers, ATRIO, and the SACs shall not refer members to or use
providers who have been identified during the credentialing process as having been
terminated from the Oregon Medical Assistance Program or excluded as
Medicare/Medicaid providers by CMS and/or by any lawful conviction by a Court for
which the provider could be excluded under 42 CFR 1001.101.
All medical providers and facilities go through a credentialing process. This includes, but
is not limited to, medical doctors, doctors of osteopathy, chiropractors, podiatrists,
optometrists, oral surgeons, physician assistants, nurse practitioners, and other nonphysician practitioners, such as durable medical equipment (DME) providers, hospitals,
skilled nursing facilities (SNF), who are applying for membership and/or a contracted
relationship with ATRIO or a SAC for the provision of covered services.
ATRIO or the SACs may delegate the responsibility for primary source verification of
credentialing information to an independent credentialing verification organization.
However, ATRIO or the SACs is ultimately responsible for the review of all
documentation and final approval or denial of providers.
A provider’s participation and credentialing status with ATRIO or the SACs are
determined after the ATRIO or SAC Credentialing Committee and Board has received
and reviewed the credentials and other required documentation of the provider. Provider
status will be effective the date of credentialing approval by ATRIO’s or the SACs
credentialing committee contingent upon final approval by the ATRIO Board of Directors
or applicable SAC board of directors, if required. Credentialing approval will be valid for
three (3) years thereafter so long as the provider remains contracted with ATRIO or the
applicable SAC.
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Termination
Conditions of denial, suspension, or termination of a provider’s credentialing/recredentialing may include, but are not limited to the following:

Intentionally incomplete application for admission or reappointment to ATRIO or
the SAC provider panel;

Misrepresentation of information on application;

A significant number of paid malpractice claims or settlements;

Unacceptable mortality or morbidity statistics;

Repeated failure to follow utilization rules;

Loss or suspension of license to practice;

Loss of malpractice insurance or inability to obtain coverage at levels required by
health plan;

Failure to follow plan rules as outlined in ATRIO or SAC signed provider
agreement;

Failure to maintain an office according to plan standards as outlined in the
physician provider agreements;

Issues related to non-professional behavior;

Refusal to cooperate with ATRIO or the SAC regarding a suggested corrective
action; or

Severe negligence in meeting expected quality requirements as outlined in the
physician provider agreements.
ATRIO will report to the National Practitioner Databank and the appropriate regulatory
bodies for all serious deficiencies including, but not limited to, quality of care issues that
result in suspension or termination of a practitioner.
Conditions for disciplinary action may include, but are not limited to the following:
Evidence of knowledge deficit in area of specialty
Failure of medical record documentation review
If ATRIO or a SAC terminate a provider, and later ATRIO or the SAC wished to reinstate
the provider, ATRIO or the SAC will credential the provider using the “initial”
credentialing process if the break in service is 30 days or more. ATRIO or the SAC will
re-verify credentialing factors that are no longer within the credentialing time limits.
ATRIO or the SAC Credentialing Committee will review all credentials and make a final
determination prior to the provider’s re-entry into the organization.
Failure to complete the re-credentialing application and/or to submit additional
information when requested after the expiration of their last credentialing effective date,
the provider would be subject to termination as an ATRIO or SAC provider. There will
be three reminder notices sent to providers at a minimum of 30 calendar days apart.
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Provider Rights & Responsibilities
ATRIO Health Plans is committed to providing the members of its various plans with
access to health care delivery systems that provide quality health care in a manner that
preserves the dignity, privacy, and autonomy of the individual member. In furtherance of
this goal, ATRIO employees and health care providers in the ATRIO network shall:

Treat all members with respect and courtesy;

Respond promptly to members’ questions and document communications with
members as appropriate

Protect the rights of members by publicizing such rights to members, ATRIO
employees and network providers;

Comply with all the legal and professional standards of care, ethics, conduct and
behavior applicable

to health maintenance organizations, their employees and their network
providers;

Provide all members with information concerning the benefits available to them
so that they may avail themselves of such benefits as appropriate;

Make sure that members have reasonable access to the services to which they
are entitled under their plans;

Make sure that member requests for access to their medical records and
information that pertains to their care are responded to in a timely manner;

Give members (or their legal guardians, when appropriate) the opportunity to
make informed decisions concerning their medical care, including giving them
information about withholding resuscitative service, forgoing or withdrawing lifesustaining treatment, or participating in investigation studies or clinical trials.
Health care providers, as required by law, shall obtain informed consent;

Preserve the integrity and independence of clinical decision-making by individual
providers in the ATRIO network. In making clinical decisions concerning a
member’s medical care, an ATRIO network provider shall not allow him/herself to
be influenced by how the provider or provider network is financially compensated
or by whether a particular treatment or course of care would be covered by the
member’s plan;

Agree to provide coverage seven days a week, 24 hours a day for members. The
provider, or call share provider, will be available to provide care or direct
members to the most appropriate treatment setting at all times;

Return telephone calls from members within a reasonable length of time. The
length of time should be appropriate to the members stated condition;

Provide call share group listing to ATRIO Health Plans including any updates to
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the call share group;

Meet ATRIO Health Plans’ credentialing requirements;

Meet Federal Fraud, Waste and Abuse requirements and be able to provide
documentation of completion at ATRIO Health Plans’ request;

Comply with provisions of the Americans with Disabilities Act (ADA). ADA
Accessibility Guidelines for Buildings and Facilities (ADAAG);

Be prepared to meet the special needs for members who are visually and
hearing-impaired; and

Ensure physical access to their offices. As a practitioner, you must ensure the
following provisions:

Street level access or accessible ramp into facility;

Wheelchair access to the lavatory;

Corridor railings; and

Elevators operable from a wheelchair.
Role of Specialty Care Physicians
Specialty care is those services that primary care providers have not trained and/or
approved to provide by the Quality Assurance/Utilization Management (QA/UM)
Committee. Specialists are required to provide written reports to the primary care
physicians regarding actions with patients requiring outpatient and inpatient procedures.
Since ATRIO Health Plans’ Special Needs Plan (SNP) for Dual Eligible members is an
HMO, this plan requires that non-contracted Specialists complete the Authorization
Request Form to provide services for a member. The Authorization Request Form is
valid for 90 days, unless request specifies longer.
ATRIO Health Plans’ PPO plans do not require an Authorization Request to see noncontracted Specialists. However, ATRIO contracted providers need to be utilized in
order that the Member receive the highest level of benefits. Please refer to the Provider
Directory for contracted providers.
Well-Woman Examinations
The Well-Woman examination is a self-referral benefit and performed by the patient’s
PCP or an ATRIO participating gynecologist. A referral to the participating gynecologist
is not required. Please verify that the member has not utilized this benefit before
rendering services.
Specialist-To-Specialist Referral
ATRIO Specialists are able to refer to other specialists within the network for the care of
a patient. Referrals made to ATRIO-contracted providers do not require prior
authorization. Please refer to the Provider Directory for contracted providers. Members
in the Special Needs HMO plan require authorization request forms for provider
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specialist not contracted with ATRIO.
Office Visit Accessibility
ATRIO Health Plans recommends the following standards for office visit access to our
members seeking medical services from participating providers:

Type of Service Time Standard

Non-urgent or routine care

Symptomatic: within 7 days

Asymptomatic: within 30 days

Urgent Care

Schedule as medically appropriate

Emergent Care

Immediate assessment or referral for treatment

Routine physical or preventive care within 45 days

Wait time for scheduled appointment not to exceed 45 minutes without an
explanation

Wait time for “walk-in” (if applicable) 2 hours

Access to advice nurse on the phone 2 hours

Return telephone call from provider’s office

Routine calls: by close of the business day

Urgent calls: within 4 hours
ATRIO Health Plans Responsibilities
ATRIO Health Plans is committed to giving both members and providers necessary and
important information regarding ATRIO benefits and services.
ATRIO Health Plans is responsible to:

Provide members with a Member Handbook (Also referred to as the Evidence of
Coverage), Provider Directory, Pharmacy Directory, Formulary and Member ID
Card within 10 days of confirmation of enrollment by CMS;

Provide members with an Advance Directive Form and instructions on the
purpose of this form;

Send all new members a Health Assessment Form;

Give members (or their legal guardians, when appropriate) the opportunity to
make informed decisions concerning their medical care, including giving them
information about withholding resuscitative service, forgoing or withdrawing lifesustaining treatment, or participating in investigation studies or clinical trials.
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Health care providers, as required by law, shall obtain informed consent;

Not screen potential members based on their health status, claims experience,
medical history or genetic information (only exception to this is beneficiaries with
End Stage Renal Disease);

Not discriminate against members based on race, ethnicity, religion, gender,
sexual orientation, disability, health status, financial status or geographic location
within the service area;

Provide culturally competent services to those who are in need of such services;

Not discriminate against any health care professional who is acting within the
scope of his or her license or certification under state law, solely on the basis of
the license or certification;

Provide information to contracted medical providers regarding ATRIO benefits,
claims processing and authorization requirements;

Process authorization requests in a timely and competent manner that is within
Medicare required timeframes and that uses Medicare required criteria; and

Process claims in a timely and accurate manner that is within Medicare required
timeframes, that uses Medicare required criteria and that meets contractual
obligations.
Provider offices that receive questions from members concerning benefits, limitations or
exclusions should refer the member to ATRIO Health Plans.
Member Rights and Responsibilities
ATRIO members have the right to:

Be treated with respect and in a manner that recognizes their need for privacy
and dignity;

Receive assistance in a prompt, courteous, responsible and culturally competent
manner;

Be provided with information about their health care benefits, exclusions, and
limitations of the plan, and any charges for which they may be responsible;

Receive a Notice of Privacy Practices regarding Protected Health Information
(PHI);

Refuse the release of identifiable personal information, except when such
release is required by law;

Have complete confidentiality involving medical diagnosis, treatment or care
received from any ATRIO contracted provider;

Be informed by their physician or other medical care provider of their diagnosis,
prognosis and plan of treatment in terms that are understood

A discussion with their physician regarding appropriate or medically necessary
P a g e 14 | 64
treatment options regardless of cost or benefits;

Expect ATRIO Health Plans not to interfere with any contracted health provider’s
discussion regarding treatment options whether covered or not;

Be provided with a directory of contracted providers, to select a Primary Care
Provider and to change the Primary Care Provider for any reason;

Be informed by their physician or other medical care provider about any
treatment they may receive;

Be given information on all alternate treatments available and their potential
values and risks;

Have their medical care provider request their consent for all treatment, unless
there is an emergency and they are unable to sign a consent form and their
health is in serious danger;

Refuse treatment, including any experimental treatment, and be advised of the
probable consequences of their decision;

Choose an advance directive to designate the kind of care they wish to receive
should they be unable to express their wishes;

Express a complaint about ATRIO’s notification, their provider(s) or the care they
have received and to receive a response in a timely manner;

Initiate the grievance procedure if they are not satisfied with ATRIO’s decision
regarding a complaint; and

Receive timely access to the records and information that pertains to the member
including medical records.
ATRIO members have the responsibility to:

Select a Primary Care Provider from the list of contracted providers within 30
days of the effective enrollment date;

Know and confirm their benefits prior to receiving treatment;

Show their ATRIO identification card before receiving services and to protect
against the wrongful use of the identification card by another user;

Verify that the provider they receive services from is participating within the
ATRIO network;

Keep scheduled appointments with medical providers or notify the provider when
unable to keep the appointment

Pay all necessary copayments and fees at the time of service;

Keep current on monthly premium payments;

Provide complete and accurate information about medical conditions and history
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when seeking medical assistance;

Ask questions and seek clarification until they understand the care they are
receiving;

Follow the treatment plan and advice of their medical care provider and be aware
of the possible consequences if they do not;

Notify ATRIO Health Plans immediately of any changes in address, phone
number or membership status; and

Express their opinions, concerns and complaints to ATRIO Health Plans.
Medicare Advantage Guidelines
The Centers for Medicare & Medicaid Services (CMS) introduced the Medicare
Advantage Program (formerly known as Medicare+Choice plans) and released
regulations for health plans, as well as their contracted network of participating
providers. Your contract with ATRIO Health Plans outlines these regulations and
requirements and includes but is not limited to
ATRIO Health Plans members can only be out of the service area for up to six months
or risk disenrollment from the plan.
Emergent/urgent care and renal dialysis are covered benefits that do not require
authorization while members are temporarily outside of the service area.
Contracted providers, including physicians and professional providers, may not deny,
limit or condition the coverage or offered services to an ATRIO member based on any
condition related to the member’s health status.
Contracted providers have agreed to accept ATRIO Health Plans as payment in full for
services and have agreed to bill ATRIO for all services rendered. ATRIO member’s
charges are coinsurance, deductibles, copayments and non-covered services.
You must “write off” and hold the member harmless of any other balances.
CMS Required Provisions
ATRIO Health Plans is responsible for including certain CMS Medicare Advantage
related provisions in the manuals, policies and procedures and contracts distributed to
the providers that constitute ATRIO Health Plans’ health services delivery network. The
following table summarizes these provisions:
CMS Requirement
CFR 42 Section
Safeguard privacy and maintain records accurately and
timely
422.118
Prohibition against discrimination based on health status
422.110(a)
Pay for emergency and urgently needed services
422.100(b)
P a g e 16 | 64
CMS Requirement
CFR 42 Section
Pay for renal dialysis for those temporarily out of service
area
422.100(b)(1)(iv)
Direct access to in-network mammography and influenza
vaccinations
422.100(g)(2)
No co-payment for Medicare-covered preventive services
ACA Section 4104
Agreements with providers to demonstrate adequate access
422.112(2)(1)
Direct access to women’s specialists for routine and
preventive services
422.112(a)(3)
Services available 24hrs/day, 7 days/week
422.112(a)(7)
Adhere to Medicare balance billing rules
422.214
Adhere to CMS marketing provisions
422.80(a),(b),(c),(d),(e)
Ensure services are provided in a culturally competent
manner
422.112(a)(8)
Maintain procedures to inform members of follow-up care or
provide training in self-care as necessary
422.112(b)(5)
Document in a prominent place in medical records if
individual has executed an Advance Directive
422.128(b)(1)(ii)(E)
Provide services in a manner consistent with professionally
recognized standards of care
422.504(a)(3)(iii)
Continuation of benefits provisions
422.504(g)(2),(3)
Payment and incentive arrangement specified
422.208
Subject to applicable Federal laws
422.504(h)
Disclose to CMS all information necessary to administer and
evaluate the program
422.64(a)
Disclose to CMS all information necessary to establish and
facilitate a process for current and prospective beneficiaries
to exercise choice in obtaining Medicare services
422.504(a)(4),(f),(2)
Must make good faith effort to notify all affected members of
the termination of a provider contract 30 calendar days
before the termination by plan or provider
422.111(e)
Submission of data, medical records and certify
completeness and truthfulness
422.310(d),(e);
Comply with medical policy, Quality Improvement and
Medical Management
422.202(b);
422.504(a)(5)
422.504(d),(e),(i),(l)
P a g e 17 | 64
CMS Requirement
CFR 42 Section
Disclose to CMS quality and performance indicators for plan
benefits and health outcomes
422.504(f)(2)(iv)(B),(C)
Notify providers in writing for reason for denial, suspension
and termination
422.202(c)(1)
Provide 60 days’ notice for terminating without cause
422.202(c)(4)
Comply with federal laws and regulations to include, but not
limited to the federal criminal law, the False Claims Act (31
U.S.C. 3729 et.Seq.) and the anti-kickback statute
422.504(h)(1) and
section 1128B(b) of
the False Claims Act
Prohibition of use of excluded providers
422.752(a)(8)
Adhere to appeals and grievance procedures
422.562(a)
Provide a written advance coverage determination when
requested
422.566
Claims Submission
ATRIO pays clean claims according to contractual requirements and CMS guidelines. A
clean claim is a claim for a covered service that has no defect or impropriety. A defect
or impropriety includes, without limitation, lack of data fields required by ATRIO or
substantiating documentation, or a particular circumstance requiring special handling or
treatment, which prevents timely payment on the claim. The term clean claim shall not
include a claim from a provider that is under investigation for fraud or abuse regarding
that claim. The term shall be consistent with the clean claim definition set forth in
applicable federal or state law, including lack of required substantiating documentation
for non-participating providers and suppliers, or particular circumstances requiring
special treatment that prevents timely payment on the claims. If additional substantiating
documentation involves a source outside of ATRIO, the claim is not a clean claim.
Paper Claims Submissions
Paper claims must follow these guidelines:

CMS-1500: Original red ink version claim forms with black barcode in the upper
left corner of form. Machine printed with dark black ink.

CMS-1450 or UB-04: Original red ink version of claim forms. Machine printed
with dark black ink.

Proper alignment of the claim form so all information is contained within the
appropriate fields.

Attachments must be on standard 8½” x 11” white paper with black print
immediately following the claim. Please do not staple the attachment(s) to the
claim form.

Each claim need its own individual explanation of benefits (EOB) or attachment if
P a g e 18 | 64
required to process the claim.

Please use only yellow highlighting on claims, EOBs or attachments. Other
colors will scan black thereby obscuring any detail.
Paper Claims Submission Address
ATRIO Health Plans
Claims Administration
PO Box 5490
Salem, OR 97304
Provider Log In, Clinical Integration Manager
ATRIO Health Plans uses the Clinical Integration Manager (CIM) to manage all of their
members. When a provider office signs up to receive a provider log in username and
password, they will be able to access their patients’ information.
Access for provider offices are as follows:

Authorizations; to enter authorization or check status

Eligibility for patients

Email nurse case managers

Claims

Messages

Vouchers
You may access the Provider Log In through www.atriohp.com, For Providers tab then
click Provider log in. Follow the Click here to log into the Provider Portal for 2014 link.
To receive access to the Provider Portal please email [email protected] or call
(503) 584-2169 option 2. Please provide email address, office name, address and
phone number to receive your username and password.
You may also contact your area provider relations representative.

Douglas County-Theresa M. Derby, 541-492-2154

Klamath County-Brannon Kaefring, 541-273-0238

Marion & Polk Counties-Jim Myers, 503-967-7149
Requirements for CMS-1500 Electronic Print Image Claims
Carrier Section (upper right corner of claim form) must read:
ATRIO Health Plans
Claims Administration
PO Box 5490
Salem, OR 97304
P a g e 19 | 64

Box 1A requires member’s identification number from their ATRIO ID card

The member’s name must appear exactly as it does on the ATRIO ID card in
Box 2.

Authorization number (if applicable) must appear in Box 23.

The provider’s NPI# must appear in Box 33a.

The provider’s individual Medicare ID must appear in Box 33b.

Each data field must have a space between it and the next data field.
Example: Procedure code must have a space between it and any modifier
(88305 26)
Electronic Claims Submission-(EDI) Electronic Data Interchange
ATRIO will facilitate the process for those providers interest in electronic claims
submission. This process meets all HIPAA requirements.
What are the Advantages of Billing Electronically?
Claim payments are faster: Claims submitted electronically in the HIPAA-compliant
format process upon receipt and require very little manual intervention.
Cost savings: Claims submitted electronically will reduce postage and other paper
related expenses.
Administrative benefits: Increased efficiency and reduced paperwork.
For providers submitting electronic claims, PhTech (ATRIO’s Third Party Administrator)
accepts electronic claims from the following clearinghouses:

Relay Health: Payer ID CPIS4799

Office Ally:
Payer ID MPCHPA

Availity:
Payer ID ATRIO
For direct electronic submission, contact PhTech at 503-584-2169, Option 1 or email
[email protected]
Standard CMS required data elements must be present for a claim to be a clean claim
and found in the CMS Claims Processing Manuals under:
Chapter 25 – Form CMS-1450 (UB-04)
http://www.cms.gov/manuals/downloads/clm104c25.pdf
Chapter 26 – Form CMS-1500 http://www.cms.gov/manuals/downloads/clm104c26.pdf
Chapter 31 – Electronic Claims http://www.cms.gov/manuals/downloads/clm104c26.pdf
Timely Billing/Filing
As an ATRIO Health Plans participating physician, other professional provider, or
healthcare facility, you have agreed to bill us directly for covered services provided to
P a g e 20 | 64
your ATRIO patients. In most circumstances, submit claims within 60 days from the
date(s) of service. After checking eligibility, ATRIO members (your patients) pay only
their copay/coinsurance for visits. Unless, the member is a dual eligible (member has
OHP as secondary), then there is no office visit copay/coinsurance.
Claims must be submitted with all required information within 365 days (one year) (or
the time-period specified in your Provider Agreement) of the date on which the service
was rendered.
Prior Authorization on Claim Form
Providers who render services that require prior authorizations without obtaining prior
authorizations will have their claims denied. See authorization grid for services that
require an authorization. Prior authorization numbers go in box 23 on the HCFA-1500 or
box 63 on the UB-04 claim form.
If appropriate, include the following additional attachments when sending in a claim:
If ATRIO is the secondary payer, please include the primary payer’s explanation of
payment.
Any additional documentation required under the terms of the provider’s contract.
Resubmission of Corrected Claims
When resubmitting corrected claims, you must stamp or write “Corrected Claim” at the
top of the CMS 1500 or UB04.
If CMS retroactively updates any pricer, it is the responsibility of the providers to
resubmit corrected claims according to the updated CMS pricer.
Medicare Overpayment Recovery
ATRIO strives for one-hundred percent (100%) payment quality but recognizes that a
small percent of financial overpayments will occur while processing claims. An
overpayment can occur due to reasons such as retroactive member termination,
inappropriate coding, duplication of payments, non-authorized services, erroneous
contract or fee schedule reimbursement and other reasons.
ATRIO will proactively identify and attempt to correct inappropriate payments. In
situations when the inappropriate payment caused an overpayment, ATRIO will follow
the same methodology used by the CMS Recovery Audit Contractor (RAC) program by
limiting its recovery to three years from the date of service. In all cases, ATRIO or one
of its business partners will provide a written notice to the provider explaining the
overpayment reason and amount, contact information and instructions on how to send
the refund. The standard request notification provides 45 calendar days for the provider
to send in the refund, request further information or dispute the overpayment. For more
information on the CMS RAC, refer to the CMS website.
Balance Billing
Participating providers may never balance bill because they have agreed to accept the
P a g e 21 | 64
Medicare allowed amount as payment in full.
A non-participating provider may accept assignment on a case-by-case basis and
indicates this by checking affirmatively field 27 on the CMS 1500 claims form; in such a
case, there is no balance billing allowed.
Providers may not bill, charge, or otherwise seek payment from ATRIO Health Plans
members for covered services (except as set forth below), including a failure by ATRIO
Health Plans to make payment to the provider.
Providers may collect copayments, coinsurance and deductibles as appropriate from
members. Providers will not bill or seek payment from ATRIO members for services
rendered except for non-covered services as long as the provider has informed the
member of the charges prior to performing the service(s).
Under no circumstances will providers bill or seek payments from an ATRIO Health
Plans member for a service for which payment is denied or reduced because failure of
the provider to comply with utilization management requirements.
Only services, which are not reasonable and necessary under original Medicare
program standards, are covered.
Providers and hospitals that balance bill for non-covered services are obligated to
provide prior written notice to ATRIO’s members detailing their potential liability. This
must include a good faith estimate of the costs.
Hold Harmless Dual Eligible
Do not bill dual eligible members whose Medicare Part A and B member expenses
identified and paid for at the amounts provided for in the State Medicaid Plan by the
applicable state Medicaid agency for Medicare Part A and B member expenses.
Regardless of whether the amount a provider perceives is less than the allowed
Medicare amount or provider charges reduced due to limitations on additional
reimbursement provided in the state Medicaid plan.
Providers shall accept ATRIO’s payment as payment in full or will bill the appropriate
state source.
Coordination of Benefits
Coordination of Benefits (COB) enables your patients to receive benefits for their
coverage from all health insurance plans. It ensures that the total combined payment
from all sources is not more than the total charge for the services provided. When your
patient has coverage under two or more insurance plans, the primary plan will pay
benefits first, with secondary and tertiary plans considering any remaining unpaid,
eligible balances. If you know which plan is primary, you should file the claim with that
plan first. If you are unsure, you may file claims simultaneously with all carriers taking
care to identify all insurance coverage information on each payer’s claim. ATRIO
Health Plans and the other carrier(s) will work together to determine which plan is
primary.
P a g e 22 | 64
Non-Covered Services, Hospital Acquired Conditions & Surgical Never Events
ATRIO follows CMS guidelines regarding Hospital Acquired Conditions and Surgical
Never Events. The hospital may not bill, attempt to collect from, or accept any payment
from ATRIO or the member for such events.
CMS requires hospitals identify and document secondary diagnoses that are present on
admission (“POA”) in order to differentiate between conditions present on admission
and conditions that develop during an inpatient admission. ATRIO will reject claims if
the POA value is not present. Medicare does not cover a surgical or other invasive
procedure to treat a medical condition when the practitioner erroneously performs:
(a) A different procedure altogether;
(b) The correct procedure but on the wrong body part, or;
(c) The correct procedure on the wrong patient.
Medicare will not cover hospitalizations and other services related to the non-covered
procedures, including:

All services provided in the operating room when an error occurs are considered
related and not covered;

All providers in the operating room when the error occurs, who could bill
individually for their services, are not eligible for payment;

No related services provided during the same hospitalization in which the error
occurred are covered.
Hospitals are required to bill two claims when a Never Event is reported, including:

One claim with covered services(s)/procedure(s) unrelated to the erroneous
surgery(ies) on a Type of Bill (“TOB”) 11X (with the exception of 110), and;

The other claim with the non-covered service(s)/procedure(s) related to the
erroneous surgery(s) on a 110 TOB (no-pay claim).
Each covered and non-covered claim must have matching “Statement Covers Period”.
TOB 110 must have one (1) of the following ICD-9-CM diagnosis code reported in
diagnosis position 2-9:

E876.5 – Performance of wrong operation (procedure) on correct patient

(existing code);

E876.6 – Performance of operation (procedure) on patient not scheduled for

surgery;

E876.7 – Performance of correct operation (procedure) on wrong side/body part.
Note: Do not report these codes in the External Cause of Injury (Ecode) outpatient,
ambulatory surgical centers, other appropriate bill types and practitioner claims are
required to bill one of the following modifiers to all lines related to the erroneous surgery
(ies):
P a g e 23 | 64

PA: Surgery Wrong Body Part;

PB: Surgery Wrong Patient;

PC: Wrong Surgery on Patient.
Grievance & Appeal Process, Provider Appeal
A provider may request a standard reconsideration on his or her own behalf by mailing
or faxing a letter of appeal and/or an appeal form with supporting documentation such
as medical records to ATRIO. Appeal forms are located on ATRIO’s website at:
http://www.atriohp.com/index.cfm?nav=Benefit Information&lev1=Grievances and
Appeals
When Can a Contracted Provider Request a Reconsideration?
When the Provider wants a second reviewer to make the determination. When the
Provider has additional information for making the determination.
How Often Can a Contracted Provider Request a Reconsideration?
A provider can only make the request once, when there is no additional information
provided for the request. ATRIO Health Plans must receive the request within 60
calendar days of the denial notification date.
Untimely filing is 61 or more days. If the provider feels they have filed their case within
the appropriate timeframe, they may submit documentation-showing proof. ATRIO has
30 calendar days to review the case for medical necessity and conformity to ATRIO
guidelines.
Necessary documentation is required for all cases. It is the responsibility of the provider
to provide the requested documentation within 60 calendar days of the denial to re-open
the case.
Reversal of Denial
ATRIO will make a determination within 30 calendar days if ATRIO has received the
relevant information. If it is determined during the review that the provider has complied
with ATRIO protocols and that the appealed services were medically necessary, the
denial will be overturned. We will notify the provider in writing of this decision.
The provider may file a claim for payment related to the appeal.
ATRIO will adjust for payment, overturned claims. ATRIO will ensure claims are
processed and comply with the federal and state requirements set forth in 42 CFR
447.45 and 447.46 and Chapter 641, F.S., whichever is more stringent.
Affirmation of Denial
Overturn decisions will not happen for providers that did not comply with ATRIO
protocols and or medical necessity was not established. Providers will get notice of
P a g e 24 | 64
decisions in writing. The criteria used to make the denial decision for medical necessity
is in the letter provided.
The provider may also request a copy of the clinical rationale used in making the appeal
decision by sending a written request to the Appeals addresses listed in the decision
letter.
Member Appeal
For a member appeal, the member, member’s representative, or a provider acting on
behalf of the member and with the member’s written consent, may file an appeal.
Providers do not have appeal rights through the member appeals process. If the
member wishes to use a representative, then s/he must complete an Appointment of
Representative (AOR) statement. The member and the person who will be representing
the member must sign the AOR statement. The form is located on ATRIO’s website.
Standard Appeal process
A member, provider on behalf of a member or a member’s representative may file an
appeal request either verbally or in writing within sixty calendar days of the date of the
adverse organization determination.
Appeals filed verbally through the customer service still require written signed appeal.
ATRIO’s reconsideration of the appeal begins with the receipt of the signed appeal
request. Reconsideration after sixty calendar days must show good cause in order for
ATRIO to accept the late request.
Examples of good cause include but are not limited to:

The member did not personally receive the adverse organization determination
notice or received it late;

The member was seriously ill, which prevented a timely appeal;

There was a death or serious illness in the member's immediate family;

An accident caused important records to be destroyed;

Documentation was difficult to locate within the time limits; and/or

The member had incorrect or incomplete information concerning the
reconsideration process.
Reversal of Denial of a Standard Pre-Service Appeal
If, upon standard reconsideration, ATRIO overturns its adverse organization
determination, then ATRIO will issue an approved authorization for the pre-service
request.
Affirmation of Denial of a Standard Pre-Service Appeal
If ATRIO affirms its initial action and/or denial (in whole or in part), it will:

Submit a written explanation for a final determination with the complete case file
P a g e 25 | 64
to the independent review entity (IRE) contracted by CMS. The IRE has thirty
calendar days from receipt of the case to issue a final determination.

Notify the member of the decision to affirm the denial and send the case to the
IRE. The IRE will notify the member and ATRIO of the final determination.

In the event the IRE agrees with ATRIO, the IRE will provide the member further
appeal rights.
If the IRE overturns the denial, the IRE notifies the member or representative in writing
of the decision. ATRIO will also notify the member, member’s representative, and
provider on behalf of the member in writing about the services of approval and an
authorization number within fourteen calendar days from receipt of the IRE’s
termination.
Expedited Appeals Process
To request an expedited reconsideration, a member or a provider must submit an oral
or written request directly to ATRIO. A request to expedite a reconsideration of a
determination will be considered in situations where applying the standard procedure
could seriously jeopardize the member’s life, health, or ability to regain maximum
function, including cases in which ATRIO makes a less than fully favorable decision to
the member. In light of the short time frame for deciding expedited reconsiderations, a
provider does not need to be an authorized representative to request an expedited
reconsideration on behalf of the member. However, the provider must have the
member’s consent on file.
A request for payment of a service already provided to a member is not eligible to be
reviewed as an expedited reconsideration.
Denial of an Expedited Request
ATRIO will provide the member with prompt oral notification within twenty-four hours
regarding the denial of an expedited reconsideration and the member’s rights, and will
subsequently mail to the member within 3 calendar days of the oral notification, a
written letter that:

Explains that ATRIO will automatically transfer and process the request using the
thirty calendar day time frame for standard reconsiderations;

Informs the member of the right to file an expedited grievance if s/he disagrees
with the organization’s decision not to expedite the reconsideration and provides
instructions about the expedited grievance process and its time frames; and

Informs the member of the right to resubmit a request for an expedited
reconsideration and that if the member gets any provider’s support indicating that
applying the standard time frame for making a determination could seriously
jeopardize the member’s life, health or ability to regain maximum function, the
P a g e 26 | 64
request will be automatically expedited.
Resolution of an Expedited Appeal
Upon an expedited reconsideration of an adverse determination, ATRIO will complete
the expedited reconsideration and give the member (and the provider involved, as
appropriate) notice of its decision as expeditiously as the member’s health condition
requires, but no later than seventy-two hours after receiving a valid complete request for
reconsideration.
Reversal of Denial of an Expedited Appeal
If ATRIO overturns its initial action and/or the denial, it will notify the member verbally
within seventy-two hours of receipt of the expedited appeal request followed with written
notification of the appeal decision.
Affirmation of Denial of an Expedited Appeal
If ATRIO affirms its initial action and/or denial (in whole or in part), it will:

Submit a written explanation for a final determination with the complete case file
to the IRE contracted by CMS. The IRE has seventy-two hours from receipt of
the case to issue a final determination;

Notify the member of the decision to affirm the denial and that the case has been
forwarded to the IRE;
The IRE will notify decisions made to the member and ATRIO. In the event the IRE
agrees with ATRIO, the IRE will provide the member further appeal rights. If the IRE
overturns the denial, the IRE notifies the member or representative in writing of the
decision.
ATRIO will not take or threaten to take any punitive action against any provider acting
on behalf or in support of a member in requesting an appeal or an expedited appeal.
Examples of actions that can be appealed include, but are not limited to:

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;

The denial, in whole or in part, of payment for a service;

The failure to provide services in a timely manner, as defined by the state.
ATRIO ensures that decision-makers on appeals were not involved in previous levels of
review or decision-making. When deciding any of the following:
(a) An appeal of a denial based on lack of medical necessity;
(b) A grievance regarding denial of expedited resolution of an appeal; or
(c) A grievance or appeal involving clinical issues; the appeal reviewers will be
health care professionals with clinical expertise in treating the member’s
P a g e 27 | 64
condition/disease or have sought advice from providers with expertise in the field
of medicine related to the request.
Appeal Levels
There are five levels of appeals available to Medicare beneficiaries enrolled in Medicare
Advantage plans offered by ATRIO after an adverse organization determination. These
levels will be followed sequentially only if the original denial continues to be upheld at
each level by the reviewing entity:
1. Reconsideration of adverse organization determination by ATRIO;
2. Reconsideration of adverse organization determination by the Independent
Review Entity (IRE);
3. Hearing by an Administrative Law Judge (ALJ), if the appropriate threshold
requirements set forth in § 100.2 has been met;
4. Medicare Appeals Council (MAC) Review; and
5. Judicial Review, if the appropriate threshold requirements set has been met.
ATRIO gives members reasonable assistance in completing forms and other procedural
steps for an appeal, including but not limited to providing interpreter services and tollfree telephone numbers with TTY/TDD and interpreter capability. Members are also
provided reasonable opportunity to present evidence and allegations of fact or law in
person as well as in writing.
Grievance Process
This section describes the provider and member grievance process.
Provider
Medicare providers are not able to file a grievance per CMS guidance.
Member
The member or member’s representative acting on the member’s behalf may file a
grievance. Some examples of grievances are:

Provider Service including, but not limited to:

Rudeness by provider or office staff;

Refusal to see member (other than in the case of patient discharge from office);
P a g e 28 | 64
and/or

Office conditions.

Services provided by ATRIO including, but not limited to:

Hold time on telephone;

Rudeness of staff;

Involuntary disenrollment from ATRIO; and/or

Unfulfilled requests.

Access availability including, but not limited to:

Difficulty getting an appointment;

Wait time in excess of one hour; and/or

Handicap accessibility.
A member or a member’s representative may file a standard grievance request either
verbally or in writing within 60 calendar days of the date of the incident or when the
member was made aware of the incident.
If the member wishes to use a representative, then s/he must complete an Appointment
of Representative (AOR) statement. The form is located on ATRIO’s website.
Grievance Resolution, Expedited
A member or member’s representative may request an expedited grievance if ATRIO
makes the decision not to expedite an organizational determination, expedite an appeal,
or invoke an extension to a review. Expedited grievances are responded to within 24
hours of receipt. The grievance will be conducted to ensure that the decision to not
apply an expedited review period or extend a review period does not jeopardize the
member’s health.
Within three business days after the determination, ATRIO will contact the member or
the member’s representative, via telephone with the determination and will mail the
resolution letter to the member or the member’s representative. The resolution will also
be documented in the member’s record.
Standard
A member or member’s representative shall be notified of the decision as expeditiously
as the case requires, based on the member’s health status, but no later than thirty (30)
calendar days after the date ATRIO receives the oral or written grievance, consistent
with applicable federal law. ATRIO will send a closure letter upon completion of the
member’s grievance. The member or the member’s representative may request up to a
14-calendar day extension. ATRIO may also initiate an extension if it can justify the
need for additional information and if extension is in the member’s best interest. In all
cases, extensions require well documented. ATRIO will provide the member or the
member’s representative prompt written notification regarding ATRIO’s plan to take up
P a g e 29 | 64
to a 14-calendar day extension on a grievance case.
The Grievance Department will inform the member of the determination of the grievance
as follows:
All grievances submitted, either verbally or in writing, will be responded to in writing; and
All grievances related to quality of care will include a description of the member’s right
to file a written complaint with the Quality Improvement Organization (QIO).
For any complaint submitted to a QIO, ATRIO will cooperate with the QIO in resolving
the complaint. ATRIO will provide all members with written information about the
grievance procedures/process available to them, as well as the complaint processes.
ATRIO will provide written information to members and/or their appointed
representative(s) about the grievance procedure at:
(a) Initial enrollment
(b) Upon involuntary disenrollment initiated by ATRIO
(c) Upon the denial of an member’s request for an expedited review of a
determination or appeal
(d) Upon the member’s request and
(e) Annually thereafter. ATRIO will provide written information to members and/or
their appointed representatives about the QIO process at initial enrollment and
annually thereafter
The facts surrounding a complaint will determine whether the complaint is for coverage
determination, organization determination or an appeal for appropriately reviewing and
resolution.
Utilization Management
The Utilization Management program includes components of prior authorization as well
as prospective, concurrent and retrospective review activities, each designed to provide
for evaluation of health care and services based on member coverage and the
appropriateness of such care and services and to determine the extent of coverage and
payment to providers of care.
ATRIO does not reward its associates or any practitioners, physicians or other
individuals or entities performing utilization management activities for issuing denials of
coverage, services or care and financial incentives, if any, do not encourage or promote
under-utilization.
Prior Authorization/Organization Determination
ATRIO provides a process to make a determination of medical necessity and benefits
coverage for inpatient and outpatient services prior to services being rendered. Prior
Authorization requirements are applicable for pre-service decisions.
Authorization Request Forms are for the county in which the member resides and are
available located in ATRIO’s website.
P a g e 30 | 64
Providers may submit requests for authorization by:

Faxing a properly completed Inpatient, Outpatient, or Ancillary Services

Authorization Request Form;

Requesting, via telephone, selected services, including urgent requests;

Entering information into C.I.M.
It is necessary to include the following information in the request for services:

Member name and identification number;

The requesting provider’s demographics;

Diagnosis Code(s) and Place of Service;

Services being requested and CPT Code(s);

The recommended provider’s demographics to provide the service;

A history and any pertinent medical information related to the request, including
current plan of treatment, progress notes as to the necessity, effectiveness, and
goals.
Concurrent Review
ATRIO provides a process for the oversight and evaluation of member status when
admitted to hospitals, rehabilitation centers and skilled nursing facilities, including
continued inpatient stays to monitor appropriate utilization of health care resources and
promote quality outcomes for members.
ATRIO provides oversight for members receiving acute inpatient services in a hospital,
rehabilitation center or skilled nursing facility to determine the initial/ongoing medical
necessity, appropriate level of care, appropriate length of stay and to facilitate a timely
discharge.
Member’s medical condition is the basis for the concurrent review process. ATRIO
utilizes Evidence Based guidelines and Medicare Coverage guidelines for concurrent
review decisions.
These review criteria are utilized as guidelines and decisions that will take into account
the member’s medical condition and co-morbidities. The ATRIO Medical Director directs
the performance of the review process.
Clinical information is required to support the appropriateness of the admission,
continued length of stay, level of care, treatment plans and discharge plans.
Initial concurrent review is obtained the first business day following the admission to
determine appropriateness of the level of care.

Observation care may be appropriate when testing or re-evaluation is needed to
P a g e 31 | 64
determine the patient’s diagnosis and care needs, OR

Observation is needed to determine whether a patient’s response is adequate.

Inpatient admission or transition to inpatient from observation care is generally
indicated when:

A condition is diagnosed requiring a long- term stay (greater than 24-48 hours,
OR

Intensive monitoring is needed for a condition.

If the Nurse Case Manager is unable to make a determination, the case is
referred to the ATRIO or SAC (Service Area Contractor) Medical Director.

Notification to the providers and the members of approval status for observation
or inpatient is within 48 hours of receipt date (excluding weekends and holidays).
Discharge Planning
ATRIO identifies and provides the appropriate level of care as well as medically
necessary support services for members upon discharge from an inpatient setting.
Discharge planning begins upon notification of the member’s inpatient status to facilitate
continuity of care, post-hospitalization services, and referrals to a skilled nursing facility
or rehabilitation facility, evaluating for a lower level of care, and maximizing services in a
cost-effective manner. As part of the utilization management process, ATRIO will
provide for continuity of care when transitioning members from one level of care to
another. The discharge plan will include a comprehensive evaluation of the member’s
health needs and identification of the services and supplies required to facilitate
appropriate care following discharge from an institutional setting. This will be based on
the information received from the institution and/or provider caring for the member.
Some of the services involved in the discharge plan include but are not limited to:

Durable Medical Equipment (DME)

Transfers to an appropriate level of care (such as an Inpatient Nursing)

Rehabilitation (INR) Facility, Long Term Acute Care (LTAC) Facility or Skilled

Nursing Facility/SNF

Home Health Care

Medication Therapy Management (Comprehensive Medication Review/Patient
Education/Compliance Monitoring)

Physical, Occupational, or Speech Therapy
Retrospective Review
A retrospective review is any review of care or services that have already been
provided.
Services provided by ATRIO may require prior authorization for payment. However, if
P a g e 32 | 64
prior authorization is overlooked and submitted retroactively those requests for
authorization of payment will be reviewed as provided below. Retroactive requests not
meeting the criteria provided is cause for denial of payment by ATRIO.
Requests for retroactive approval should occur infrequently; providers are required to
seek approval in advance.
ATRIO will consider approval of retroactive requests due to other unique circumstances.
Documentation of the circumstances that reasonably prevented the provider from
seeking prior approval from ATRIO must accompany the retroactive request. Timeperiod for retroactive request is four months.
.
Prior Authorization

Facility Based Services- All Inpatient, SNF, Rehabilitation Admissions and
Ambulatory Surgery/ procedures

Epidural Injections

Infra-red Therapy

Botox Injections

Intra-articular Injections

B Codes- Enteral/Parenteral

Sleep Studies

Biofeedback

Hyperbaric Oxygen Therapy

Therapeutic Pheresis

Cardiac Rehab -After first 36 visits- 1 evaluation and 35 visits per event

PT, OT, ST, Pulmonary Rehab- After first 12 visits- 1 evaluation and 11 visits per
event for each therapy. ATRIO follows Medicare Billing practices- evaluation and
treatment cannot be done on the same day

Mental Health Services- outpatient- after the first 5 visits per event- cannot have
group and individual on same date of service- PCP's do not require
Authorizations

Chiropractic Services- must be referred by contracted provider- After1 evaluation
P a g e 33 | 64
and 11 visits per event must be authorized for continued services

Selected Radiology to include: MRI, MRA, PET, CT

Podiatry and Foot Care

Dental - must meet Medicare medical criteria

Home Health

Wound Care Clinic

Wound-Vac (nursing care, supplies and rental)

Clinical Trials

DME- All items with a purchase price exceeding $300.00 requires an
authorization,

All services that are billed as a "Rental item or service" requires an authorizationATRIO follows Medicare regulations for required documentation to be on file,
even if the item/service does not require an authorization.

Some Part B medications (Injections)**see list below
**see list below
Special Needs Plan (007) members will need prior authorization to see any Out-ofNetwork PCP or Specialist.
Organization Determination (Prior Authorization) Timelines
This section describes the standard and expedited organization determination process.
Standard Organization Determination
An organization determination will be made as expeditiously as the member’s health
condition requires, but no later than 14 calendar days after ATRIO receives the request
for service. An extension may be granted for an additional fourteen calendar days if the
member requests an extension, or if ATRIO justifies a need for additional information
and documents how the delay is in the interest of the member.
Expedited Organization Determination
A member or any provider may request ATRIO to expedite an organization
determination when the member or his/her provider believes that waiting for a decision
under the standard timeframe could place the member’s life, health, or ability to regain
maximum function in serious jeopardy. The request will be made as expeditiously as the
member’s health condition requires, but no later than 72 hours after receiving the
member’s request.
ATRIO will provide the member with prompt oral notification within 24 hours regarding
the denial of an expedited organization determination and the member’s rights, and will
subsequently mail to the member within three calendar days of the oral notification, a
written letter that:
Explains that ATRIO will automatically transfer and process the request using the 14
calendar day period for standard organization determinations;
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Informs the member of the right to file an expedited grievance if s/he disagrees with the
organization’s decision not to expedite the organization determination and provides
instructions about the expedited grievance process and its time frames; and
ATRIO’s organization determination system provides authorization numbers, effective
dates for the authorization, and specifies the services being authorized. The requesting
provider will be notified verbally via telephone or via fax of the authorization.
In the event of an adverse determination, ATRIO will notify the member or the member’s
representative (if appropriate) in writing and provide written notice to the provider.
Medicare QIO Review Process of SNF/HHA/CORF Terminations
ATRIO will ensure members receive written notification of termination of service from
providers no later than two calendar days before the proposed end of service for Skilled
Nursing Facilities (SNF), Home Health Agencies (HHA) and Comprehensive Outpatient
Rehabilitation Facilities (CORFs). The standard Notice of Medicare Non-Coverage letter
required by CMS will be issued. This letter includes the date coverage of service ends
and the process to request an expedited appeal with the appropriate Quality
Improvement Organization (QIO). Upon notification by the QIO that a member has
requested an appeal, ATRIO will issue a Detailed Explanation of Non-Coverage (DENC)
that indicates why services are either no longer reasonable or necessary or are no
longer covered.
The standardized Notice of Medicare Non-Coverage (NOMNC) of Skilled Nursing,
Home Health and Comprehensive Rehabilitation services will be given to the member
or, if appropriate, to the member’s representative, by the provider of service no later
than two calendar days before the proposed end of services. If the member’s services
are expected to be fewer than two calendar days in duration, the provider should notify
the member or, if appropriate, the member’s representative, at time of admission. If, in a
non-institutional setting, the span of time between services exceeds two calendar days,
the notice should be no later than two services prior to termination of the service.
ATRIO is financially liable for continued services until two calendar days after the
member receives valid notice. A member may waive continuation of services if s/he
agrees with being discharged sooner than two calendar days after receiving the notice.
Members who desire a fast-track appeal must submit a request for appeal to the QIO.
The Fast-track appeal must be in writing or by telephone, by noon (12 p.m.) of the first
day after the day of delivery of the termination notice or, where a member receives the
NOMNC more than two calendar days prior to the date coverage is expected to end, by
noon (12 p.m.) of the day before coverage ends.
Upon notification by the QIO that a member has requested an appeal, ATRIO will issue
a Detailed Explanation of Non-Coverage (DENC) that indicates why services are either
no longer reasonable or necessary or are no longer covered. Coverage of provider
services continues until the date and time designated on the termination notice, unless
the member appeals and the QIO reverses ATRIO’s decision.
Case Management
Our case managers are experienced registered nurses that work out of our service area
P a g e 35 | 64
contractors (SACs). The nurse case managers can provide guidance and support for a
variety of disease and health related conditions. Our nurse case management services
may consist of answering a relatively simple question to developing a comprehensive
assessment of the member’s condition, determination of available benefits and
resources, and the development and implementation of a plan of care with performance
goals, monitoring and scheduled case management follow-up.
Registered nurses here at ATRIO work with the members telephonically and/or mail the
members information about health management, disease education and preventative
services.
ATRIO’s nurse case managers encourage the members to regularly follow up with their
primary care provider to discuss what is addressed during case management. ATRIO’s
nurse case managers defer interpretation, diagnosis, treatment and overall medical
management to the primary care provider.
The goal of ATRIO case management is to help our members maintain or regain
optimum health and wellness. If you would like to refer a member to case management
please call ATRIO Customer Service at 877-672-8620 to make that request.
SNP Model of Care
CMS requires Medicare Advantage plans with a SNP plan to develop and implement a
Model of Care (MOC) that provides the structure for care management processes and
systems that will enable them to provide coordinated care for the dual eligible special
needs population. All SNP MOCs must include the following elements:

MOC 1—Description of the SNP Population

MOC 2—Care Coordination

MOC 3—Provider Network

MOC 4—MOC Quality Measurement and Performance Improvement
Action Required
It is also a CMS requirement that all network and out-of-network providers who are
routinely seen by SNP beneficiaries complete initial and annual SNP MOC training.
Please access the training and associated attestation on our provider web portal. We
appreciate your corporation and assistance in this process and providing the highest
quality of care to our SNP members.
Health Risk Assessment (HRA)
The HRA is a CMS required comprehensive tool used by the Plan to identify the
specialized needs of its beneficiaries and to coordinate care that reflects the member’s
preferences. The HRA questionnaire assesses medical, psychosocial, cognitive, and
functional needs as well as the member’s medical and mental health history.
The ATRIO’s senior clinical staff and Chief Medical Officer annually reviews HRAs.
ATRIO’s QA Committee annually or more frequently, reviews and approves changes to
HRA’s.
P a g e 36 | 64
ATRIO’s HRA has the member’s health literacy, potential physical limitations and
unique copies for their personal health record so they can take to their health care
provider to discuss further. This sharing of the HRA seeks to foster health care decision
making and empowerment on the part of the member and their caregiver(s).
Information gathered in the HRA may be used to create an individualized care plan and
direct interdisciplinary care team involvement by one of our service area nurse case
managers.
ATRIO makes a good faith effort to conduct both an initial HRA for all new SNP
members within 90 days of the effective date of enrollment and annually thereafter.
PPO members are sent the HRA at the time of initial enrollment.
Transitions of Care (TOC)
ATRIO makes special effort to coordinate care when SNP members move from one
health care setting to another, such as when they are discharged from a hospital.
Without coordination, such transitions often result in fragmented and unsafe care for the
older or disabled and particularly vulnerable SNP beneficiary. ATRIO’s Transitions of
Care program is designed with the intent to minimize risks associated with health care
transitions.
ATRIO’s TOC program consists of the identification of planned or unplanned transitions
of care for our SNP members. The sending of a TOC program introduction letter to the
member and primary care provider including the nurse case manager point of contact
information as well as the sending of a TOC specific ICP (Individualized Care Plan) to
both the member and PCP and other ICT members as requested follows this. Case
management activities will follow as identified and most appropriate.
ATRIO’s TOC program reporting is conducted throughout the year and is presented to
the QA Committee on a regular basis. Quality improvement efforts revolve around the
identification of barriers and gaps in care and the implementation of mitigation plans and
corrective action strategies.
Chronic Care Improvement Program (CCIP)
Federal regulations (42 CFR §422.152) require all Medicare Advantage (MA)
organizations to conduct a Chronic Care Improvement Program (CCIP) as part of a
required Quality Improvement (QA) program. The focus for CCIPs is clinical areas and
to improve health outcomes and member satisfaction. ATRIO is required to conduct a
CCIP for all plans (HMO and PPO).
In 2012, CMS required the CCIP be focused on reducing and/or preventing
cardiovascular disease and span a 5 year period. The CCIP must support the National
HHS Initiative Million Hearts Campaign’s goal to prevent one million heart attacks and
strokes by 2017.
ATRIO Health Plan’s CCIP for 2012 – 2017 focuses on ACE inhibitor (ACEI) and/or
ARB use in diabetic members who have hypertension.
Per Standards of Medical Care in Diabetes – 2014, American Diabetes Association,
http://care.diabetesjournals.org/content/37/Supplement_1/S14.full.pdf+html
P a g e 37 | 64
Pharmacological therapy for patients with diabetes and hypertension should comprise a
regimen that includes either an ACE inhibitor or an angiotensin receptor blocker (ARB).
If one class is not tolerated, the other should be substituted.
Studies suggest that:

ACE inhibitors have been shown to reduce major CVD outcomes (i.e., MI, stroke,
death) in patients with diabetes, thus further supporting the use of these agents
in patients with elevated albuminuria in normotensive patients with type 1 or type
2 diabetes; However, ARBs have been shown to reduce the progression rate of
albumin levels from 30 to 299 mg/24 h to levels 300mg/24 h as well as ESRD in
patients with type 2 diabetes. Some evidence suggests that ARBs have a smaller
magnitude of rise in potassium compared with ACE inhibitors in people with
nephropathy.

ARBs have been shown to reduce major CVD outcomes in patients with CHF,
including diabetic subgroups

ARBs were superior in studies to calcium channel blockers for reducing heart
failure
In addition, treatment with ACEI/ARB therapy in members who have diabetes and
hypertension is a Medicare star ratings, one of several ways by which health plan
quality is measured by CMS. Medicare publically reports the star ratings and it directly
affects ATRIOs success.
Quality Improvement Programs
ATRIO implements a variety of quality improvement programs (QIPs) at any given time.
Some of the QIPs are designed for a short timeframe such as the organization of flu
vaccination clinics during peak flu season and other QIPs last for several years such as
the osteoporosis management QIP. Some of ATRIO’s QIPs are mandated by CMS and
others are created based on the identification of member’s needs and potential gaps in
care. QIPs commonly revolve around disease management, disease prevention and
progression control and seek to improve and/or maintain our member’s highest
achievable quality of life.
Member Programs
We offer programs as enhancements to the total benefit package. These programs help
our members live healthier lives and reinforce and support treatment plans with their
providers.
Disease Management
Our Disease Management program through our CCIP offers both early intervention and
long-term management of diabetes. Registered nurses manage members in the
Disease Management program.
Diabetes Prevention Program (DPP)
“I Can Prevent Diabetes!”
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ATRIO Health Plans, in collaboration with the Harold Schnitzer Diabetes Health Center
at OHSU, and the Central Douglas County Family YMCA, is proud to begin offering the I
CAN Prevent Diabetes! program in Douglas County.
Based on the original Diabetes Prevention Program trial1 and subsequent diabetes
prevention research2, I CAN Prevent Diabetes! is an evidence-based program proven
to lower the risk of patients transitioning from impaired glucose tolerance to type 2
diabetes.
To participate in the program patients simply need to have a BMI of greater than 25, as
well as a documented impaired glucose reading (fasting plasma glucose between 100125 mg/dL, two-hour [75 gram glucose load] plasma glucose between 140-199 mg/dL,
or hemoglobin A1C reading between 5.7-6.4%).
ATRIO will pay the entire cost of the program. If you feel that any of your patients would
benefit from participating in this program, please call customer service and ask for the
Quality Assurance Department. To learn more about the program, please call or visit
http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram.
Smoking Cessation Classes
ATRIO Health Plan’s Registered Nurse case managers will provide members with
support and guidance to several smoking cessation options that are available to ATRIO
Health Plan members including smoking cessation counselling services provided by a
qualified physician or other Medicare-recognized practitioner. There is $0 copay for the
smoking cessation counselling service (must meet Medicare guidelines; other cost
sharing may apply, e.g., office visit copay). SNP (HMO) members can receive assistive
medications (including OTCs) without copays. Commercial (PPO) ATRIO members can
receive assistive medications (e.g., Chantix, Nicotrol inhalers, bupropion—OTCs are
excluded on Part D) subject to applicable plan copay. ATRIO Health Plans’ Registered
Nurse Case Managers will also refer members to specific local, online or telephonic
classes or programs
Practice Guidelines
To promote quality care, patient safety and the most appropriate use of health care
resources, ATRIO follows the evidence-based Milliman Care Guidelines.
The Milliman Care Guidelines are developed using the industry’s most rigorous
evidence-based methodology. All content is reviewed annually and updated as
necessary by doctors and nurses who cite more than 15,000 unique references,
including peer review journals in the current seven-product Care Guidelines series.
Milliman Care Guidelines epidemiologists then examine databases that cover a
significant portion of the United States population to validate that these published
research results are achievable in real-life situations.
1NEJM
2
346: 393-403, 2002
Am J Prev Med 35 (4): 357-363, 2008
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ATRIO uses Medicare coverage criteria and Milliman Care Guidelines as the basis for
care management decisions. ATRIO medical directors and review nurses also consider
individual clinical circumstances and the capabilities of the local delivery system in care
management determinations.
HEDIS
ATRIO Health Plans is dedicated to providing the highest quality service and care for
members. In collaboration with ATRIO’s provider network, ATRIO scores above the
national average on quality ratings. Because of health care reform, quality standards
continue to rise and the Centers for Medicare and Medicaid Services (CMS) is requiring
ATRIO and other payers to provide continuous documentation of quality health care.
This documentation is used to publish quality ratings and affect reimbursement. The
results from various performance measures are combined to report scores in a five star
rating system known as the Medicare Health Plan Quality and Performance Ratings.
The ratings are used to assess the performance of Medicare Advantage plans by CMS
for oversight activities, reimbursement and give beneficiaries information to help them
choose among health plans offered in their area.
CMS rates plans on a one to five-star scale, with five stars representing the highest
quality and one star representing the lowest quality. A summary score is provided as an
overall measure of a plan’s quality determined by the quality of care, access to care,
health plan responsiveness, and beneficiary satisfaction with the plan. Plans scoring
four stars or higher are eligible for CMS payment incentives. These payment incentives
are critical for ATRIO to deliver high quality services.
The primary source for the star ratings is the Health Effectiveness Data and Information
Set (HEDIS) developed by the National Committee for Quality Assurance (NCQA) and
reported June 30th each year. In the United States, HEDIS evaluates more than 90
percent of health insurance plans. HEDIS rates are calculated in two ways;
administrative data and hybrid data. Administrator data requires the plan to identify the
eligible population and numerator using transaction data (i.e. claims) or other
administrative data. The hybrid method requires the plan to look for numerator
compliance in both administrative data and in a medical record.
In order to report HEDIS data each year, ATRIO Health Plans scan each medical record
for review. These scanned records are used for both HEDIS hybrid data and for Risk
Adjustment medical record reviews (see Risk Adjustment). In addition, by scanning the
medical record each year, ATRIO has immediate access to historical records for CMS
audits.
ATRIO expects providers to:

Maintain well-documented medical records at the clinic site in a manner that is
current, detailed, accurate, organized and readily accessible in order to permit
effective and confidential patient care and quality review of patient interactions.
See Documentation and Coding requirements under Risk Adjustment for further
detail.

Provide ATRIO access to the medical record for scanning or send copies upon
P a g e 40 | 64
request in a timely manner.

Participate with ATRIO’s quality improvement initiatives to improve quality
ratings.
HEDIS and the Health Information Portability and Accountability Act (HIPAA)
As a reminder, protected health information (PHI) that is used or disclosed for purposes
of treatment, payment or health care operations is permitted by HIPAA Privacy Rules
(45 CFR 164.506), and use or disclosure for these purposes does not require the
consent or authorization from the member/patient. For persons other than providers
who are participating in HEDIS activities, such as third party vendors and/or medical
record review staff, they sign a HIPAA-compliant Business Associate Agreement with
ATRIO Health Plans prior to accessing any PHI.
Advance Directives
ATRIO Health Plans sends out in every new member packet an Advance Directive
packet from Oregon Health Decisions.
Risk Adjustment Program
Risk Adjustment is a critical element in the success of ATRIO Health Plans and has a
significant role in the products and services offered to members.
Background
Risk adjustment is based on Hierarchical Condition Categories (HCC) defined by
Centers for Medicare & Medicaid Services (CMS), utilizing ICD-9-CM/ICD-10-CM
diagnostic codes submitted from physician and hospital inpatient and outpatient claims.
CMS uses these diagnosis codes, along with demographic data, to calculate a risk
score for each Medicare Advantage beneficiary that reflects his or her overall health
status on an annual basis. Payments from CMS to ATRIO Health Plans are based on
the risk scores for each health plan member. All ICD-9-CM/ICD-10-CM codes for
existing and chronic conditions should be documented at least once each calendar
year.
Documentation and Coding Requirements for All Medical Documents

Record the patient's name and date of service on each page of the chart.

Ensure the medical record is complete and legible.

Use subjective, objective, assessment, and plan (SOAP) note format when
applicable.

Clearly indicate that all diagnoses were addressed and reported.

Report codes only if they were actively addressed (not merely appearing on a
problem list).

Chronic conditions being medically managed should be reported, even if they are
not the principle reason for the patient's visit that day. This can be done when
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reviewing, updating or reconciling a patient's medication list.

Contributory and co-morbid conditions should be reported if they affect the
ongoing care for the patient and were addressed at the visit but not if the
condition is inactive or immaterial.

Update all acute and chronic diagnoses with the current status and treatment
plan in the progress notes.

On the claim, include the ICD-9-CM/ICD-10-CM code of every diagnosis
assessed, treated or considered in the medical decision making for the
encounter.

Include the provider's signature and credentials (either handwritten or electronic)
on each chart entry. Dictated/transcribed entries also require the provider's
signature (either handwritten or electronic). Stamped signatures are not
acceptable.

Use only standard medical abbreviations.
In-Home Comprehensive Health Evaluations
In an effort to ensure complete and accurate documentation of all medical conditions on
an annual-basis, ATRIO is pleased to offer in-home comprehensive health evaluations
for our members. These evaluations are performed by licensed medical providers
(physicians, nurse practitioners or physician assistants) trained to evaluate for all
current and chronic medical conditions. A copy of the report is optionally sent to the
Primary Care Provider (PCP) on record. Not only does this program provide the PCP
with a “birds-eye view” of their patient’s living environment but also serves as a detailed
summary of conditions sometimes treated by multiple specialists. Each report is
reviewed through a quality assurance process by a professional coder for accuracy and
documentation compliance prior to reporting diagnosis codes to CMS.
Retrospective Chart Reviews
ATRIO performs chart reviews of member records to ensure all relevant diagnoses
obtained from compliant documentation sources are reported to CMS. The purpose of
this initiative is to capture diagnoses that were either not reported via claims data or the
condition reported in claims data was not coded to the highest degree of specificity
based on compliant chart do
2014 ATRIO Prescription Drug Reference Guide
ATRIO Formularies are updated monthly and pdf versions are available at
http://www.atriohp.com.
To Access Formularies:
Click Learn More under ‘Medicare Advantage Plans’ >>>Already a Member>>> Choose
the county where the member resides>>>Go to the Benefit Information tab>>> Choose
the Plan>>>Formulary (Drug List)>>> Select the Comprehensive Formulary link for the
plan year to view the .pdf formulary
P a g e 42 | 64
The Index provides an alphabetical list of all of the drugs included in the formulary. Both
brand name drugs and generic drugs are listed in the Index. The Index is located at the
end of the formulary.
Brand name drugs are capitalized (e.g., COUMADIN and generic drugs are listed in
lower-case italics (e.g., warfarin sodium).
This listing means that generic Coumadin is covered, not Brand Coumadin.
warfarin sodium
(Coumadin)
1
This listing means that Brand Coumadin in a vial is covered.
COUMADIN
2
vial
If strengths/dosage forms are listed, only those strengths/dosage forms are covered.
prednisone
(Prednisone)
1
solution, tablet:
1mg, 2.5mg, 5mg,
10mg, 20mg, 50mg
If no strengths/dosage forms are listed, all strengths/dosage forms are covered.
prednisolone
(Prednisolone)
1
Prior Authorization Guidelines
ATRIO requires members or their prescribers to get Prior Authorization for certain
drugs. To determine if a drug has Prior Authorization requirements you can refer to the
formulary or use the search tool available at http://www.atriohp.com.You can also call
ATRIO to see if a drug has any restrictions or limits.
If a drug has Prior Authorization requirements, 'PA' will be listed to the right of the drug
name on the formulary.
To Access the Prior Authorization Search Tool:
Click Learn More under ‘Medicare Advantage Plans’ >>>Already a Member>>> Choose
the county where the member resides>>>Go to the Benefit Information tab>>>Choose
the Plan>>>Formulary Prior Authorization>>> Press Continue>>> on the bottom of the
page>>> Choose the Plan Year>>>Select a Prior Authorization Guideline to search or a
link to view a .pdf document>>> Use the Drug Name drop box to locate your drug, then
click Search. The results will then display below.
Step Therapy Guidelines
In some cases, ATRIO requires members to try certain drugs before we will cover
another drug for the same condition. To determine if a drug has Step Therapy
requirements you can refer to the formulary or use the search tool available at
http://www.atriohp.com.You can also call ATRIO to see if a drug has any restrictions or
limits.
If a drug has Step Therapy requirements, 'ST' will be listed to the right of the drug name
on the formulary.
To Access the Step Therapy Search Tool:
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Click Learn More under ‘Medicare Advantage Plans’ >>>Already a Member>>> Choose
the county where the member resides>>>Go to the Benefit Information tab>>> Choose
the Plan>>>Formulary Step Therapy>>> Press Continue>>> on the bottom of the
page>>> Choose the Plan Year>>>Select a Step Therapy Guideline to search or a link
to view a .pdf document>>> Use the Drug Name drop box to locate your drug, then click
Search. The results will then display below.
Quantity Limit Guidelines
For certain drugs, ATRIO limits the amount of the drug that ATRIO Health Plans will
cover in a certain time period. To determine if a drug has Quantity Limits you can refer
to the formulary available on our website. You can also call ATRIO to see if a drug has
any restrictions or limits.
If a drug has Quantity Limits, 'QL' will be listed to the right of the drug name on the
formulary. The Quantity and Day Supply limit will be indicated on the formulary.
Exception Requests
An Exception means that ATRIO may pay for a non-formulary drug or will make an
exception to the Prior Authorization restrictions, Step Therapy restrictions or Quantity
limits. Making an exception to these restrictions or limits means allowing coverage for
drugs even though the guidelines are not met. Other types of Exceptions include Tiering
or Copay Exceptions. These exceptions mean that we may place a drug on a lower tier
or approve a lower copay. We cannot approve Tier exceptions from a brand tier to a
generic tier or for drugs in the Specialty tier. Only those non-preferred brand or nonpreferred generic drugs that have a formulary preferred alternative that does not work
are allowed to be moved the preferred brand or preferred generic tier.
Exception requests require a supporting statement from prescriber. The period for
coverage determinations begins with the receipt of physician statement. Drugs excluded
from Part D cannot be covered, even by exception.
To Request Prior Authorization, Exception or Override
Prescribers and Members can request Prior Authorizations and Exceptions to Nonformulary status, Prior Authorization restrictions, Step Therapy restrictions and Quantity
Limits either by calling or by faxing the plan. Authorization request forms are available at
http://www.atriohp.com.
P a g e 44 | 64
Douglas County Oregon members

Fax: (541)672-4318

Phone: (541)672-8620

Toll Free: (877)672-8620
Klamath County Oregon members

Fax: (541)883-6104

Phone: (541)883-2947
Marion & Polk County members

Fax numbers:

Team 1 A-EM (503) 581-7353

Team 2 En-Led (503) 581-7417

Team 3 Lee-Roa (503) 485-3226

Team 4 Rob-Z (503) 581-7422

Phone: (503)316-3668

Toll Free: (855)204-2964
ATRIO will make coverage determinations within the following periods

Standard request - within 72 hours

Expedited request - within 24 hours (If standard timeframe could seriously
jeopardize the life or health of the enrollee or the enrollee’s ability to regain
maximum function)
Authorization Request Forms
Authorization Request Forms are available either by calling ATRIO or at ATRIO Health
Plans website. For prescription drug Authorization Request Forms, please use the
Pharmacy Authorization Request Form designated for the county in which the member
resides.
To Access Pharmacy Authorization Request Forms:
Click Learn More under ‘Medicare Advantage Plans’ >>>Go to the For Providers
tab>>>Select Provider Authorizations or Provider Forms>>>Select the Plan
Year>>>Select a link to view and print.
Grievances and Appeals
ATRIO Health Plan members have Grievance and Appeal rights. A grievance is any
complaint, other than one that involves a request for an initial determination or an
appeal. Grievances do not involve problems related to approving or paying for Part D
drugs. An appeal is a request for the plan to reconsider or make a redetermination
P a g e 45 | 64
about a Part D coverage determination. If a prescription drug coverage determination or
formulary exception is denied, in whole or in part, the member will be notified in writing
of their appeal rights and is entitled to appeal the Plan decision.
Members can submit written Grievances or request for an Appeal to:

Mail: ATRIO Health Plans, 3025 Ryan Drive SE, Salem, OR 97301

Email: [email protected]

Fax: 541-672-8670
Grievance and Appeal Request Forms are available either by calling ATRIO or at
http://www.atriohp.com.
To access Grievance and Appeal Request Forms: Click Learn More under ‘Medicare
Advantage Plans’ >>>Already a Member>>> Choose the county where the member
resides>>>Go to the Benefit Information tab>>>Select Grievance and Appeal
Information
Covered Drugs
ATRIO’s formularies ensure that at least two drugs represent every therapeutic class
used to treat the same medical condition (unless only one exists).We also cover nearly
“all or substantially all” drugs used in six classes:

Antidepressants,

Antipsychotics,

Anticonvulsants (epilepsy, etc.),

Antiretrovirals (for HIV/AIDS),

Immunosuppressant (for transplants)

Anticancer drugs.
New Covered Drugs for 2014!
Now covered under Part D:
Barbiturates
Covered OTC Drugs
ATRIO covers several generic OTC Allergy drugs at no cost to the member. These
drugs include the generic versions of popular OTC Allergy drugs and must be
prescribed by a doctor and dispensed at a pharmacy in order for members to receive
this valuable benefit. Members must have Part D benefits and must present their ATRIO
ID card to the pharmacy so the pharmacy can bill ATRIO directly. ATRIO will not
reimburse a member the cost of these drugs if purchased without using their ATRIO ID
card.
The list of Covered Over-the-Counter (OTC) Drugs can be located in the formulary
located at http://www.atriohp.com.
P a g e 46 | 64
To access formularies: Click Learn More under ‘Medicare Advantage Plans’ >>>Already
a Member>>> Choose the county where the member resides>>>Go to the Benefit
Information tab>>> Choose the Plan>>>Formulary (Drug List)>>> Select the
Comprehensive Formulary link for the plan year to view the .pdf formulary.
Excluded Drugs
ATRIO cannot cover certain “Excluded” drugs. Medicare has designated these drugs as
excluded from Part D coverage. Member’s with other insurance (Oregon Health Plan,
private insurance, etc.) may have coverage for these drugs. If member does not have
other insurance, they will have to pay out-of-pocket. These drugs include:
Drugs for anorexia, weight loss, or weight gain

Fertility drugs

Erectile dysfunction drugs

Drugs for cosmetic purposes or hair growth

Cough and cold medicine **

Prescription vitamins (Except prenatal and fluoride preparations) **

Nonprescription drugs (over-the-counter drugs) †

Non-Insulin syringes

Bulk Chemical Compounded drugs, even if the main ingredient is a Part D drug

Drugs not listed with the FDA (may still have NDC)

Drugs not sold in the U.S.(drugs sold in Canada or Mexico are prohibited)

Drugs whose manufacturers have not agreed to provide Coverage Gap discounts
** These drug may be covered by the Oregon Health Plan
† ATRIO covers limited OTC Allergy Drugs (see above section)
Day Supplies Available
ATRIO allows day supplies of 0-31 or 84-90 days. ATRIO offers Retail and Mail Order
benefits, which allow up to a 90-day supply. For a 90 day (3 month) supply, members
pay a copay equaling a 60 day (2 month) supply. This saves the member one copay for
each 90 day supply they receive.
Members are not required to use the Mail Order benefit to obtain an extended supply of
maintenance drugs. Instead, they have the option of using a retail pharmacy in our
network to obtain an extended supply. Pharmacies that provide an extended day supply
can dispense up to a 90-day supply and are indicated as such in our Pharmacy
Directory.
Some retail pharmacies do not offer an extended supply. In this case, members would
be responsible for the difference in price.
P a g e 47 | 64
Transition Fills
For new members and current members transitioning from one plan year to the next,
ATRIO provides continued access to drugs. ATRIO’s Transition process allows for a
temporary supply of drugs and sufficient time for members to work with their health care
providers to select a therapeutically appropriate formulary alternative, or to request a
formulary exception based on medical necessity.
Medicare requires that we send a letter to the member and prescriber when a temporary
supply of drugs is provided.
Transition Fill Reference Chart
Transition Fill
PolicyNew Members
Transition Fill
PolicyCurrent
Members
Transition Fill
PolicyNew Members
(LTC)
Transition Fill
PolicyCurrent Members
(LTC)
Medications
Affected:
All Medications
except those
excluded from
Part D
coverage that
are not on the
formulary, or
have
PA/ST/QL
requirements.
Medications filled
in the last 180
days of the plan
year (filled
between August
1- December 31)
and that have
negative
formulary
changes in new
plan year (nonformulary,
PA/ST/QL
required, etc.).
All Medications
except those
excluded from
Part D coverage
that are not on the
formulary, or have
PA/ST/QL
requirements.
All Medications
except those
excluded from
Part D coverage
that are not on the
formulary, or have
PA/ST/QL
requirements.
Transition
Period:
The first 90
days of
enrollment.
The first 90 days
of the Plan year
(January 1 March 31).
The first 90 days
of enrollment.
After 90 days of
enrollment, As
long as they are
residents of a LTC
facility.
P a g e 48 | 64
Transition Fill
PolicyNew Members
Number of
Fills:
Transition Fill
PolicyCurrent
Members
One, maximum
One, maximum
supply of 30
supply of 30 days
days (or less if
(or less if the
the
prescription is
prescription is written for less).If
written for
prescription is
less).If
written for less
prescription is
than a 30 day
written for less
supply, multiple
than a 30 day
fills will be
supply,
allowed for a total
multiple fills
up to 30 day
will be allowed
supply.
for a total up to
30 day supply.
Transition Fill
PolicyNew Members
(LTC)
Transition Fill
PolicyCurrent Members
(LTC)
One (or more if
needed),
maximum supply
of 31 days (or less
if the prescription
is written for
less).If Multiple
fills are needed,
up to 93 day
supply may be
filled.
One (or more if
needed),
maximum supply
of 31 days (or less
if the prescription
is written for
less).If Multiple
fills are needed,
up to 93 day
supply may be
filled.
P a g e 49 | 64
Category
Part B or D
Antigens and Blood Clotting
factors
Always Part B
Diabetic Testing Supplies
(Monitor, Test Strips and
Lancets)
Always Part B
Drugs furnished “incident to” a
physician service (injectable/IV
drugs)
Pharmacies may not bill Part D for drugs purchased
directly by beneficiaries for administration furnished
“incident to” a physician service (injectable/IV drugs)
or for drugs purchased by a physician for
administration to a Medicare beneficiary. These
drugs are always Part B and must be an expense
incurred by the physician and billed by the
physician.
Erythropoietin (EPO)
B or D:
Part B for treatment of anemia due to dialysis
Part D for all other situations
Hospice Drugs
Part B for drugs used to treat symptoms and pain of
terminal illness only
Part D for all other drugs, including maintenance
drugs
Immunosuppressant Drugs
B or D:
Part B for Medicare Covered Transplant
Part D for all other situations
Infusible DME Supply Drugs
B or D:
Administered at Home with Infusion or Implantable
Pump- Part B
Administered at Home using other methods (e.g.IV
push, external pump)- Part D
Administered at LTC or SNF- Part D
Inhalation DME Supply Drugs
B or D:
Administered at Home with Nebulizer- Part B
Administered at Home using other methods (e.g.
metered dose inhaler or other non-nebulized
administration)- Part D
Administered at LTC or SNF- Part D
P a g e 50 | 64
Injectable Drugs
Part B covers some injectables provided “incident
to’ physician services, injectables prescribed by a
physician and dispensed by a pharmacy are Part D.
Insulin, Alcohol pads and
Syringes (Insulin and Insulin
delivery)
Always Part D
Intravenous Immune Globulin
(IVIG)
B or D:
Administered at HomePart B if diagnosis is Primary Immune Deficiency
Disease.
Part D for other diagnosis
Administered at LTC or SNF- Part D
Oral Anti-Cancer Drugs used in
cancer treatment for which there
is an infusible version of the drug
B or D:
Part B for Cancer treatment
Part D for all other indications
Oral Anti-Emetic Drugs used in
cancer treatment as a full
replacement for intravenous
treatment
B or D:
Part B for Cancer treatment and within 48 hours of
chemo (must be indicated on prescription)
Part D for all other indications
Parenteral Nutrition
B or D:
Part B for “permanent” dysfunction of digestive track
Part D for all other situations
Unique drugs never dispensed by
a pharmacy (Non-DME drugs
covered as supplies, including
radiopharmaceuticals (both
diagnostic and therapeutic and
low osmolar contrast media))
Always Part B
Vaccines (Prophylactic)
B or D:
Part B for Flu/Pneumonia and other vaccines for the
treatment of injury/exposure
Part B for Hep B for high risk individuals
P a g e 51 | 64
Part D for all other situations (see Part B and Part D
Vaccines section below)
ESRD Drugs that are separately
billable or included in Medicare’s
ESRD composite rate
Always Part B
Separately billable drugs in
HOPDs, CORFs
Drugs packaged under the OPPS
Osteoporosis drugs provided by
home health agencies under
certain conditions
Drugs furnished by CAH
outpatient departments
Drugs furnished by RHCs,
FQHCs, CMHCs and
Ambulances
Diabetic Testing Supplies
All ATRIO members are able to receive their Diabetic Testing Supplies at pharmacies.
All plans have $0 cost share for Diabetic Testing Supplies. Diabetic Testing Supplies
are covered under Part B and include Test Strips, Lancets and Glucometers. Insulin and
Insulin Syringes are covered under Part D and are only available to those members who
have Part D prescription coverage.
Insulin dependent, ATRIO allows 3 strips/day (#100 or #102/30d).Additional
requires PA.
Not insulin dependent, ATRIO allows 1 strip/day (#50 or #51/30d).Additional
requires PA.
Part B vs. D Coverage
As a Part D plan, ATRIO is ultimately responsible for making the Part B or D coverage
determination. In order to make this determination, certain drugs on our formulary
require Prior Authorization and we require the prescriber to provide information that will
assist us with making this determination. A few drugs are automatically determined to
be either Part B or D depending on how the claim is submitted or the member’s
demographic information.
Part B vs. Coverage Chart
P a g e 52 | 64
Part B and Part D Vaccines
Certain Vaccines are covered under Part B and some are covered under Part D. A large
number of vaccines are administered at local pharmacies. ALL ATRIO members, even
those without Part D prescription coverage, have access to Part D and Part B vaccines
at pharmacies by using their ATRIO ID Card (ID, BIN, GRP and PCN).
If covered, Vaccines are covered at 100% of Medicare allowable with no member cost
share. Important Flu and Pneumonia vaccine coverage and billing information is
available at http://www.atriohp.com.Visit the Important Health Information link on the
Home page and select the Flu Information icon next to the Syringe.
Part B Vaccines:
Flu, Pneumonia, Hepatitis B (for dialysis or immunosuppressed), Tetanus and
Diphtheria (not preventative) and Rabies (response to exposure)
Part D Vaccines
Included on ATRIO’s formulary are all commercially available vaccines (preventative).
Typhoid, Mumps, Polio, Tetanus, Diphtheria, Yellow Fever, Shingles, Whooping Cough,
Measles, Meningitis and Rubella
Low Income Subsidy and Co-Pays
Some ATRIO members are eligible for “Extra Help” from Medicare. These members
may get extra help to pay for their ATRIO premium and Part D drug copays. This help is
referred to as Low Income Subsidy (LIS) and Low Income Copay Subsidy (LICS). Some
Dual Eligible (eligible for Medicaid and Medicare) automatically qualify for extra help. If
you have a patient that may qualify for this extra help, please refer them to ATRIO.
Medication Therapy Management
As part of its mandated Quality Improvement Program, Medicare requires plans to
administer a Medication Therapy Management Program (MTMP).Medicare requires
plans to target enrollees who meet certain criteria.
Certain members are eligible to receive a Comprehensive Medication Review, Patient
Consultation and/or Monitoring/Education services. These services are FREE to the
member. Members who qualify must be taking at least two chronic/maintenance drugs
and have at least two chronic diseases (specific diseases apply).Their drug cost must
be at least $754.25 per quarter.
Certain members may be contacted by a consultant pharmacist and invited to receive
these MTM services. Members can also call ATRIO if they want to receive these
services. If members do not want to participate, they can OPT-Out.
E-Prescribing
ATRIO is compliant with Medicare E-Prescribing requirements. E-Prescribing or “E-Rx”
provides secure access to patient-specific prescription eligibility, medication history and
basic formulary for consenting patients through your practice’s qualified EMR, Practice
P a g e 53 | 64
Management System or standalone e-prescribing software, to allow you to make an
informed prescription choice.

A Clinician’s Guide to E-Prescribing

eHealth Initiative Organization

For more detailed information regarding ATRIO Health Plan’s Part D coverage,
see the Provider Manual on ATRIOs website, and see the Prescription Drug
Management section.
Corporate Code of Conduct
Delegated Entities
REVISION DATE:
October 25, 2013
I. Code of Conduct
ATRIO Health Plans will conduct its business in compliance with all federal, state, and
local laws, rules and regulations in a manner consistent with the highest standards of
business and professional ethics.
II. Standards of Conduct
In order to ensure company compliance with this code ATRIO Health Plans offers this
guidance to all Delegated Entities. ATRIO Health Plans recognizes that the successful
administration of this Health Plan relies upon the continued competence and integrity of
its Delegated Entities and that all policies and processes are committed to full
compliance with all federal and state rules and regulations. The Code and Standards of
Conduct are the products of this commitment and will provide guidelines that encourage
and promote a working environment of legal, ethical and professional standards.
These guidelines are for all Plan Delegated Entities to follow while acting and
representing ATRIO Health Plans in any capacity. These standards do not outline
individual Delegated Entity responsibilities but provide a framework in which Delegated
Entity may operate. Obviously – no one standard can be written to cover every possible
business situation which may arise in the complex regulatory environment in which we
operate. However the use of available resources, including all state and federal
regulations and guidance, honest behavior, personal integrity, common sense and good
judgment will help to identify appropriate action. If you have any doubts or concerns
please contact the Chairman of the Board or the designated Compliance Officer.
All Delegated Entities are asked to review this information carefully. If a Delegated
Entity is directed to do something that is or believed to be contrary to the ethical and
legal representations of this code, they are required to report the incident to the
designated Compliance Officer or directly to the Compliance Committee or the Board of
Directors. Failure of the corporation to adhere to these standards can result in criminal
and civil penalties and those actions found to defraud local and state health care
programs may be excluded from participation in these programs.
ATRIO Health Plans operates in a heavily regulated environment in which there are a
P a g e 54 | 64
variety of areas that may be considered at risk. An effective compliance program seeks
to mitigate these risks while providing a high standard of quality care and service to the
members that we serve. The various policies and procedures that describe Plan
operations represent our response to ensure that the day to day operational activity fully
complies with our legal, regulatory ethical and professional responsibilities.
Confidentiality/Privacy
When a member is enrolled into ATRIO Health Plans a substantial amount of medical,
personal and insurance information is collected and retained for purposes of Health
Plan enrollment, treatment and payment and other health care operations. This
information is also known as Protected Health Information (PHI) and the usage or
disclosure of this information is governed by state and federal law including the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). We are required by law to
make sure that this information is kept private and it is our legal responsibility to ensure
full compliance with these laws. Delegated Entities must never disclose or release any
PHI in a manner that violates the privacy rights of the member. Member information will
only be discussed in a manner that relates to the business at hand and no Delegated
Entity will have access to any information unless it is necessary to perform his/her
responsibilities as a Delegated Entity. Violation of this is subject to disciplinary action up
to and including termination of contract.
In addition, confidential information that is acquired during the course of your contract
with the Plan is not to be discussed except as needed to perform your responsibilities in
your contract as a Delegated Entity. Upon termination for any reasons, Delegated Entity
is prohibited from taking, retaining or copying any information that is related to ATRIO
Health Plans without express permission from senior management.
Each Delegated Entity will be required to sign a confidentiality pledge on an annual
basis and any violation of the company policy must be immediately reported to the
Chairman of the Board and/or the Compliance Officer for further action.
Fraud/Waste/Abuse
ATRIO Health Plans is committed to the detection and prevention of potential fraud and
abuse activities.

Fraud is defined as an intentional deception or misrepresentation made by an
individual who knows that the information is false and could result in an
unauthorized benefit to him/herself, another person or the Plan

Waste is defined as the overutilization of services, or other practices that, directly
or indirectly, result in unnecessary costs to the Medicare program.

Abuse is an incident or practice that is not consistent with sound medical
business or fiscal practices which may result in unnecessary program costs,
improper payment for services and directly or indirectly results in unnecessary
costs to the programs that we administer.
Again, if you are asked to do something you believe is contrary to this Code, state and
federal law and the regulatory requirements in which we operate you should report the
incident/occurrence to The Chairman of the Board or the designated Compliance
P a g e 55 | 64
Officer. All reports will be handled confidentially and as expeditiously as possible.
Further action based on the investigation will be taken by the Board of Directors in
accordance with state and federal requirements.
III. Reporting/Investigation and Response
ATRIO Health Plans has a confidential disclosure program for all employees, delegated
entities and Board Members to report known or suspected conduct or activities by any
person engaged in the performance of duties for ATRIO that violates the
Code/Standards of conduct or any state or federal law. This program may also be used
for individuals who are uncertain whether an action violates the Code and would like to
communicate with the company on a confidential basis.
All reports will be treated with respect and held in the strictest of confidence. ATRIO will
not tolerate any retribution or retaliation against any person for reporting good faith
suspected violations of the code or of state or federal law. Any member of management
who takes retaliatory action against a Delegated Entity for reporting a compliance issue
will be subject to severe disciplinary action up to and including discharge.
Questions or concerns about potential compliance issues or violations may be
addressed to any of the following:

The designated Compliance Officer

The Compliance Committee

The CEO

Chairman of the Board of Directors

Website reporting at http://www.atriohp.com

Confidential mailbox – 3019 NW Stewart Pkwy, Suite 304, #PMB 184, Roseburg,
OR 97470
These reports may be made anonymously and will be investigated and acted upon in
the same manner as calls made by Delegated Entities who choose to identify
themselves.
Prompt, appropriate and confidential investigation will be conducted for any good faith
report. The designated Compliance Officer will coordinate any findings from the
investigations and will share the complaint and investigation with the Compliance
Committee to ensure a complete review. Once a reported violation is researched
through the investigation process the Compliance Committee will initiate any corrective
action.
IV. Delegated Entity Responsibilities

To act with honesty and integrity and in full compliance with the Code/Standards
of Conduct

Promote honest and ethical behavior within the company

Avoid conflicts of interest or if one is possible to disclose the potential conflict for
P a g e 56 | 64
further evaluation

To comply with all state and federal rules and regulations

Respect the confidentiality of all information acquired in the course of my work
and to not disclose information that violates the Confidentiality/Privacy policy of
the company

To report any violations of this Code/Standards of Conduct or any violations of
local, state or federal law.

To disclose any exclusions of the entity or its’ staff members by the Department
of Health and Human Services (DHHS) Officer of the Inspector General (OIG) or
General Services Administration (GSA).
This Compliance Program is a mandatory policy of ATRIO Health Plans. All Delegated
Entities will sign a form which indicates that they have received this policy, have read
and understand it. This will be affirmed on an annual basis.
ATRIO Health Plans endeavors to ensure that all business activity is conducted in full
compliance with all state and federal laws that govern the business activities of the
Plan. No policy will be created that undermines this intent and no activity by a
Delegated Entity will be tolerated that violates these provisions.
ACKNOWLEDGEMENT
I, _________________________________ at ________________________________,
(NAME)
(NAME OF DELEGATED ENTITY)
have received ATRIO Health Plans Code of Conduct and have read and understood the
contents.
I further realize that failure to report a known violation of state or federal law,
Code/Standards of Conduct or any violation of the Compliance Plan may be subject to
disciplinary action up to and including termination from the company.
Signature & Title
___________________________
Date
P a g e 57 | 64
Medical Record Accessibility and HIPAA
ATRIO Health Plans will conduct business in a manner that safeguards member
information in accordance with the Health Insurance Portability and Accountability Act
(HIPAA) of 1996. The enacted privacy regulations fully implemented throughout this
organization and we are fully committed to the protection of Personal Health Information
(PHI).
All medical records are considered confidential and any specific information obtained by
utilization review and/or exchanged for conducting utilization review is considered
confidential. ATRIO Health Plans will use this information solely for the purpose of
medical management of the member. ATRIO will share this confidential information with
only those third parties who have written or legal authority to receive this information.
Members will be provided timely access to their medical records upon request. ATRIO
Health Plans may not disclose medical, personal or confidential information about a
patient obtained in performance of utilization review without the written consent of the
patient or as otherwise required by law.
ATRIO recognizes that under HIPAA we may request only the minimum member
information necessary to accomplish the task at hand. Please note that the regulation
allows the provision, transfer and sharing of member information that the plan may need
in the normal course of the business activities to make decisions about care. The
requested information needed for payment or health care operations would include the
member’s medical record to make an authorization determination or to resolve a
payment issue.
Requested information may be mailed or faxed to ATRIO Health Plans. Only authorized
ATRIO personnel have access to the ATRIO secure fax system. Internet e-mail should
never be used to transfer member information unless it is encrypted and secured.
ATRIO Health Plans requires all providers to retain their medical records for no less
than ten (10) years.
The Privacy Notification Statement is available to all ATRIO Health Plans members. If
you have any questions or concerns about our policy, please contact us at
(541) 672-8620.
P a g e 58 | 64
Reporting Fraud, Waste and Abuse
HIPAA Violations and other Non-Compliance
Chief Compliance Officer
Jeff Dover
(503)-400-6208, [email protected]
ATRIO Website
http://www.atriohp.com/Who-We-Are/Report-Fraud-Waste-Abuse-orCompliance-Incident.aspx
Anonymous Mailbox
3019 NW Steward Pkwy Suite 304
PMB 184
Roseburg OR 97470
Chairman of the Board Audit Committee
Sam Porter
(541) 880-5462, [email protected]
Office of Inspector General
By Phone: 1-800-HHS-TIPS (1-800-447-8477)
By TTY: 1-800-377-4950
By E-Mail: [email protected]
Center for Medicare and Medicaid Services (CMS)
By Phone: 1-800-MEDICARE (1-800-633-4227)
By TTY/TDD: 1-877-486-2048
P a g e 59 | 64
Notice of Privacy Practices
Effective Date: August 28, 2013
This Notice Describes How Medical Information About You May Be Used And Disclosed
And How You Can Get Access To This Information. Please Review It Carefully.
Our Privacy Commitment
As your contractor for a Medicare Advantage plan, ATRIO Health Plans provides you
with health services. ATRIO staff must collect information about you to provide these
services. ATRIO understands that information we collect about you and your health is
private and we follow strict policies (in accordance with state and federal privacy laws)
to keep your information private. The information we collect is called Protected Health
Information (“PHI”). PHI is information about you, including demographic data, that can
reasonably be used to identify you and that relates to your past, present and future
physical or mental health, the provision of healthcare to you or the payment for that
care.
This Notice of Privacy Practices tells you how we protect the privacy of your PHI and
how ATRIO may use or disclose information about you. Not all situations will be
described. ATRIO is required to give you notice of our privacy practices for the
information we collect and keep about you. ATRIO is required to follow the terms of the
notice currently in effect.
How ATRIO May Use Your Information
In order to manage your health benefits effectively, ATRIO may use and disclose your
PHI in certain way, without your authorization. The following are the types of disclosure
we may make as allowed or required by law:

For Treatment. ATRIO may use or disclose information with health care
providers who are involved in your health care. For example, information may be
shared to create and carry out a plan for your treatment.

For Payment. To make sure that claims are paid correctly and you receive the
benefits you are entitled to, we may use and disclose your PHI to determine plan
eligibility and responsibility for coverage and benefits. For example, ATRIO may
use your information to facilitate payment for the care you receive from health
care providers, coordinate benefits with other plans and facilitate the adjudication
or subrogation of health care claims. We may also use or disclose PHI to review
health care services for medical necessity, appropriateness of care or justification
for charges, and to facilitate utilization review activities, including precertification
and preauthorization of services, concurrent and retrospective review.

For Health Care Operations. ATRIO may use or disclose information in order to
manage its programs and activities. For example, ATRIO may use PHI to review
the quality of services you receive.

Appointments and Other Health Information. ATRIO may send you reminders
for medical care checkups. ATRIO may send you information about health
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services that may be of interest to you.

For Public Health Activities. ATRIO may provide information to Oregon
Department of Human Services, the public health agency that keeps and updates
vital records, including births, deaths, and tracks some diseases.

For Health Oversight Activities. ATRIO may use or disclose information to
inspect or investigate health care providers.

As Required by Law and For Law Enforcement. ATRIO will use and disclose
information when required or permitted by federal or state law, or by court order.

For Abuse Reports and Investigations. ATRIO is required by law to receive
and investigate reports of abuse.

For Government Programs. ATRIO may use and disclose information for public
benefits under other government programs. For example, ATRIO may disclose
information for the determination of Supplemental Security Income (SSI) benefits.

To Avoid Harm. ATRIO may disclose PHI to prevent or lesson a serious and
imminent threat to your health or safety, or the health or safety of the general
public.

For Research. ATRIO may use your PHI to perform select research activities,
provided that certain established measures to protect your privacy are in place
and only according to and as allowed by state and federal law.

Disclosures to Family, Friends and Others Who Are Involved In Your
Medical Care. ATRIO may disclose information to your family or other persons
who are involved in your medical care. You have the right to object to the sharing
of this information.

Other Uses and Disclosures Require Your Written Authorization. For other
situations, ATRIO will ask for your written authorization before using or disclosing
information. You may cancel this authorization at any time in writing. ATRIO
cannot take back any uses or disclosures already made with your authorization.
Your Privacy Rights
You have the following rights regarding Protected Health Information that ATRIO
maintains about you:

Right to See and Get Copies of Your Records. In most cases, you have the
right to look at or get copies of your records. You must make the request in
writing. You may be charged a fee for the cost of copying your records. We may
deny your request to inspect and/or copy records in certain limited
circumstances. If you are denied copies of, or access to, PHI that we keep about
you, you may ask that our denial be reviewed. If the law gives you a right to have
our denial reviewed, we will select a licensed health care professional to review
your request and our denial. The person conducting the review will not be the
person who denied your request and we will comply with the outcome of the
review.
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
Right to Request a Correction or Update of Your Records. You may ask
ATRIO to change or add missing information to your records if you believe it is
inaccurate. You must make the request in writing and provide a reason for your
request. If we determine that the PHI is inaccurate, we will correct it if permitted
by law. If a health care facility or professional create the information that you
want to change, you should ask them to amend the information.

Right to Get a List of Disclosures. You have the right to ask ATRIO for a list of
disclosures made within six years of the date of your request. This list will include
disclosures made for purposes other than treatment, payment, health care
operations and in special circumstances involving national security, correctional
institutions and law enforcement. The list will also exclude any disclosures we
have made based on your written authorization. You must make the request in
writing and indicate the time period for the disclosures made. There is no fee for
the first list you request within a 12 month period however you may be charged
for additional lists.

Right to Request Limits on Uses or Disclosures of PHI. You have the right to
ask that ATRIO limit how your information is used or disclosed. Your must make
the request in writing and describe what information you want to limit and to
whom you want the limits to apply. ATRIO is not required to agree to the
restriction(s). You can request that the restriction(s) be terminated in writing or
verbally.

Right to Revoke Permission. If you are asked to sign an authorization to use or
disclose information, you can cancel that authorization at any time. You must
make the request in writing. This will not affect information that has already been
shared.

Right to Choose How We Communicate with You. You have the right to ask
that ATRIO share information with you in a certain way or in a certain place. For
example, you may ask ATRIO to send information to your work address instead
of your home address. You must make this request in writing. You do not have to
explain the basis for your request.

Right to File a Complaint. You have the right to file a complaint if you do not
agree with how ATRIO has used or disclosed information about you any time.
How to Contact ATRIO to Review, Correct or Limit Your Protected Health
Information (PHI)
You may contact ATRIO or the ATRIO Privacy Officer at the address listed at the end of
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this notice to ask:

To look at or copy your records

To limit how information about you is used or disclosed

To cancel your authorization

To correct or change your records

For a list of the times ATRIO disclosed information about you
ATRIO may deny your request to look at, copy or change your records. If ATRIO denies
your request, ATRIO will send you a letter that tells you why the request is being denied
and how you can ask for a review of the denial. You will also receive information about
how to file a complaint with ATRIO or with the U.S. Department of Health and Human
Services.
How to File a Complaint or Report a Problem
If you want additional information regarding our Privacy Practices, or if you believe we
have violated any of your rights listed in this notice, you may contact ATRIO at the
address or phone numbers listed below. If you have a complaint, you also may submit a
written complaint to the Secretary of the U.S. Department of Health and Human
Services. We will provide you with the address to file your complaint with the U.S.
Department of Health and Human Services upon request. Your benefits will not be
affected by any complaints you make. ATRIO cannot retaliate against you for filing a
complaint, cooperating in an investigation, or refusing to agree to something that you
believe to be unlawful.
Physical and Mailing Address
ATRIO Health Plans
2270 NW Aviation Drive Suite 3
Roseburg, Oregon 97470
Phone: 541-672-8620
Toll Free: 1-800-672-8620
TTY: 1-800-735-2900
Fax: 541-672-8670
You may contact our Privacy Officer, Jeff Dover at 503-400-6208 or
[email protected], for further information about ATRIO’s privacy practices or the
complaint process.
Changes to this Notice
In the future, ATRIO may change its Notice of Privacy Practices. Any changes will apply
to information ATRIO already has, as well as information ATRIO receives in the future.
A copy of the new notice will be posted at ATRIO as required by law. You may ask for a
copy of the current notice any time you visit, contact ATRIO, or visit our ATRIO Health
Plans Website.
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