PROVIDER POLICY AND PROCEDURE MANUAL MEDI-CAL TABLE OF CONTENTS

PROVIDER POLICY AND PROCEDURE MANUAL
MEDI-CAL
TABLE OF CONTENTS
INTRODUCTION
A.
B.
C.
1.
ORGANIZATIONAL STRUCTURE
A.
B.
C.
2.
General
Joint Powers Agency (JPA) Governing Board
IEHP Committees
Attachments
COMMITTEE OVERVIEW
A.
B.
C.
D.
E.
F.
G.
H.
3.
Manual Overview
IEHP Overview
Manual Updates
1. Policy and Procedure Manual
2. Benefit Manual
3. EDI Manual
4. Summary of Effected Changes
5. IEHP Code of Business Conduct and Ethics
6. Model of Care (MOC) Training
7. Distribution Letter
8. Acknowledgment of Receipt
Public Policy Participation Committee (PPPC)
Provider Advisory Committee (PAC)
Quality Management (QM) Committee
Peer Review Subcommittee
Pharmacy and Therapeutic (P&T) Subcommittee
Credentialing Subcommittee
Utilization Management (UM) Subcommittee
Persons with Disabilities Workgroup (PDW)
Attachment
ENROLLMENT AND ASSIGNMENT
A.
B.
Enrollment and Eligibility
Medi-Cal Enrollment Process
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C.
D.
E.
F.
G.
H.
4.
ELIGIBILITY AND VERIFICATION
A.
B.
C.
5.
Eligibility Verification
Eligibility Verification Methods
(1) Eligibility Files
(2) Interactive Voice Response (IVR)
(3) Online Eligibility Verification System (OEVS)
(4) Other
Member Co-Payments
Attachments
CREDENTIALING AND RECREDENTIALING
A.
B.
C.
D.
E.
F.
6.
Eligible Members
IEHP Service Area
Primary Care Physician (PCP) Assignment
Member Identification Cards
Identifying IPA and Hospital Affiliation
Post Enrollment Kit
Attachments
IEHP Practitioner Guidelines
Practitioner Credentialing Requirements
IEHP Quality Oversight of Participating Practitioners
Hospital Privileges
Subcontracted Organizational Providers
Credentialing Appeals Process
Attachments
SITE REVIEW
A.
B.
C.
D.
E.
F.
G.
H.
Site Review and Medical Records Review Survey Requirements and Monitoring
Physical Accessibility Review Survey (PARS)
PCP Sites Denied Participation or Removed from the IEHP Network
Residency Teaching Clinics
Rural Clinics
Non-Physician Practitioner Requirements
Primary Care Physician (PCP) Referral Audits
Interim FSR Monitoring for Primary Care Physicians (PCP)
Attachments
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7.
MEDICAL RECORDS REQUIREMENTS
A.
B.
C.
D.
8.
INFECTION CONTROL
A.
9.
PCP and Delegate Medical Records Requirements
Information Disclosure and Confidentiality of Medical Records
Informed Consent
Durable Power of Attorney for Healthcare
Attachments
Infection Control
Attachments
ACCESS STANDARDS
A.
B.
C.
D.
E.
F.
G.
Access Standards
Missed Appointments
Non-Emergency Transportation Services
Access to Care for People with Disabilities
(1) Members who are Deaf or Hard-of-Hearing
Access to Sensitive Services
Open Access to Obstetrical or Gynecological Services
Cancer Screening and Treatment Services
Attachments
10. MEDICAL CARE STANDARDS
A.
B.
C.
D.
E.
Initial Health Assessment
Adult Preventive Services
Pediatric Preventive Services
(1) Well Child Visits
(2) PM 160 Information Only Reporting
(3) Immunization Services
(4) School-Linked Services
Obstetrical Services - PCP Role in Care of Pregnant Members
(1) Guidelines for Obstetrical Services
(2) Obstetric Care by Certified Nurse Midwives
(3) Multi-Disciplinary Perinatal Services
(4) PCP Provision of Obstetric Care
(5) Guidelines for Maternal Transport for High Risk Pregnancies
Referrals to the Supplemental Food Program for Women, Infants, and Children (WIC)
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F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
Sterilization Services
Family Planning Services
Sexually Transmitted Disease (STD) Services
HIV Testing and Counseling
Tuberculosis Services
Reporting Communicable Diseases to Public Health Authorities
Vision Examination Level Standards
Mandatory Elder or Dependent Adult Abuse and Neglect Reporting
Mandatory Child Abuse and Neglect Reporting
Mandatory Domestic Violence Reporting
Attachments
11. PHARMACY
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Formulary Management
Prior Authorization For Non-Formulary Medications
Medication Handling Requirements at PCP Sites
Code 1 Medications
Physician Profiling Program
Pharmacy Reports
Emergency Department and Hospital Inpatient Discharge Medication Requirement
Pharmacy and Provider Policies and Procedures Summary
Insulin Administration Devices and Diabetes Testing Supplies
Member Request for Pharmacy Reimbursement
Pharmacy Audit Program
Pharmacy Credentialing and Re-Credentialing
Attachments
12. COORDINATION OF CARE
A. Case Management Requirements
(1) IEHP Monitoring and Oversight
(2) Delegate Responsibilities
(3) Reporting Requirements
(4) PCP Role
(5) Identifying and Reporting Potential Abuse of IEHP Members
B. California Children’s Services (CCS)
C. Early Start Services and Referrals
D. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental
Services
E. Genetically Handicapped Persons Program (GHPP)
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F.
G.
In-Home Supportive Services (IHSS)
Organ Transplant
(1) H. Community Based Adult Services (CBAS) Unbundled Services
I.
Home and Community Based Services (HCBS)
(1) Department of Developmental Services (DDS)
(2) DHCS – Waiver Program
(3) DHCS - AIDS and AIDS Related Conditions (ARC) Waiver Program
(4) DHCS – Nursing Facility (NF) and Acute Hospital (AH) Waiver Program
J. Dental Services
K. Behavioral Health
(1) Behavioral Health Services
(2) Alcohol and Drug Treatment Services
L. Excluded Services (Chiropractic care, acupuncture, and healing by prayer or spiritual
means)
M. Vision Services
(1) Vision Exception Request (VER)
(2) Vision Provider Referrals
N. Developmental Disabilities
O. Disease Management Program
P. Open Access (Foster Care) Program
Q. Seniors and Persons with Disabilities (SPDs)
(1) Basic (General) Care Management
(2) Person-Centered Planning
(3) Health Risk Assessment
(4) Member Identification, Stratification and Interventions
R. Multipurpose Senior Services Program (MSSP)
Attachments
13. QUALITY MANAGEMENT
A.
B.
C.
D.
E.
F.
G.
H.
I.
IEHP Quality Management Program Description
IPA Quality Management Program Structure Requirements
Quality Management Reporting Requirements
Quality Studies Medical Records Access
Delegation Oversight Audit
Corrective Action Plan (CAP) Requirements
QM Program Overview for Members, Providers, and Practitioners
Delegated Activities
Chaperone Guidance
Attachments
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14. UTILIZATION MANAGEMENT
I.
J.
K.
Utilization Management Delegation and Monitoring
Utilization Management Reporting Requirements
Review Procedures
(1) Primary Care Physician (PCP) Referrals
a. PCP Referral Tracking Log
(2) Standing Referral/Extended Access to Specialty Care
L. Focused Referral and Denial Audits
M. Second Opinions
N. Emergency Services
O. Pre-Service Referral Authorization Process
P. Wheelchair Purchase Referral Procedure
Q. Long Term Care (LTC) – Custodial Level
R. Long Term Care (LTC) – Skilled Level
S. Hospice Services
Attachments
15. HEALTH EDUCATION
I.
J.
K.
Health Education
IEHP Child Safety Programs
Cultural and Linguistic Services
(1) Foreign Language Capabilities
(2) Spanish Language Competency Audits
(3) Non-Discrimination
L. IEHP Family Asthma Program
M. IEHP Diabetes Self-Management Program
N. IEHP Stop Smoking Program
O. IEHP Adult Weight Loss Program
P. IEHP “Healthy Babies” Pregnancy Program
Q. IEHP Healthy Heart Program
R. Individual Health Education Behavioral Assessment (IHEBA) and Staying Healthy
Assessment (SHA)
S. IEHP Pediatric Weight Loss Program
T. IEHP Blood Pressure Management Program
U. Cultural and Linguistic Services Program Description
V. IEHP Disease Management – BREATHE Program
W. IEHP Disease Management – JOURNEY Program
Attachments
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16. GRIEVANCE RESOLUTION SYSTEM
I.
J.
K.
Member Grievance Resolution Process
(1) Member Rights and Options
(2) Member Urgent Medical Grievances
Dispute and Appeal Resolution Process for Providers
(1) Initial
(2) Health Plan
(3) UM Decisions
IPA, Hospital, and Practitioner Grievance and Appeal Resolution Process
Attachments
17. MEMBER TRANSFERS AND DISENROLLMENT
I.
Primary Care Physician (PCP) Transfers
(1) Voluntary
(2) Involuntary
J. Disenrollment from IEHP
(1) Voluntary
(2) Involuntary Member Status Changes
K. Loss of Medi-Cal Eligibility - PCP Responsibilities
L. Continuity of Care
M. Episode of Care – Inpatient
18. PROVIDER NETWORK
I.
Primary Care Physician (PCP)
(1) Affiliation Numbers
(2) Enrollment Limits
J. Provider Directory
K. PCP and Vision Provider Network Changes
L. IPA Reported PCP Changes
(1) PCP Termination
(2) Specialty Practitioner Termination
M. Management Services Organization (MSO) Changes
N. Specialty Panel
O. Provider Resources
P. Hospital Affiliations
Q. Leave of Absence
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R.
S.
T.
IEHP Termination of PCPs, Specialists, and Vision Providers
Hospital Network Participation Standards
Providers Charging Members
Attachments
19. FINANCE AND REIMBURSEMENT
I.
Financial Viability
(1) IPA
(2) Hospital
J. Capitation
K. Pay For Performance Program (P4P)
L. Pre-Existing Pregnancy Program
M. AIDS Reimbursement
N. IPA Financial Supervision
Attachments
20. CLAIMS PROCESSING
I.
J.
K.
D.
E.
F.
G.
H.
21.
Claims Processing
(1) Provider Dispute Resolution Process – Initial Claims Disputes
(2) Health Plan Claims Appeals
Billing of IEHP Members
Claims Deduction from Capitation
(1) 14-Day Letter
Claims and Compliance Audits
Disputes Between Contracted Relationships
Coordination of Benefits
Third Party Liability
Claims and Provider Dispute Reporting
Attachments
ENCOUNTER DATA REPORTING
A.
B.
Encounter Data Submission Requirements
Encounter Data Submission Requirements for Directly Contracted PCPs
Attachments
22. RIGHTS AND RESPONSIBILITIES
A.
Members’ Rights and Responsibilities
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B.
Practitioners’ Rights and Responsibilities
23. COMPLIANCE
A.
B.
C.
IPA Performance Evaluation
Fraud, Waste and Abuse Program
HIPAA - Protected Health Information (PHI)
Attachments
24. QUICK REFERENCE
A. Quick Reference Guide
B. Glossary
C. Index
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INTRODUCTION
A.
Manual Overview
__________________________________________________________________
The Inland Empire Health Plan (IEHP) Provider Policy and Procedure Manual is designed to
help IEHP’s Contracted Entities (Providers) understand how IEHP works and understand the
rules and regulations IEHP must comply with, as governed by the California Department of
Health Care Services (DHCS), California Department of Managed Health Care (DMHC), and the
Centers for Medicare and Medicaid Services (CMS). The provisions of this Manual must be
adhered to by all of IEHP’s Providers.
This Manual is intended to incorporate the statutory, regulatory and contractual requirements
imposed by DHCS, DMHC, CMS and other agencies such as medical professional licensing
boards. It is not intended to replace or exclude any statutory, regulatory or contractual
requirement not stated herein.
In addition to the Provider Policy and Procedure Manual, a Benefit Manual is included in the
Annual Mailing to IEHP’s Contracted Entities. The Benefit Manual is offered as a guideline to
determine benefit eligibility and is not intended to be construed as or to serve as a standard of
medical care, or as a contractual agreement for payment.
The Managed Care Coordinator for each Provider has the responsibility of ensuring the
appropriate people in their organization review and understand the information contained in this
Manual. Additionally, periodic updates are sent to keep the Manual current and our Providers
informed of any policy changes.
IEHP holds training sessions for its Providers to assist in learning IEHP policies and procedures
as outlined in this Manual.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
September 1, 1996
Chief Title: Chief Executive Officer
July 1, 2013
Revision Date:
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INTRODUCTION
B.
IEHP Overview
Inland Empire Health Plan is a not for profit public entity that is a Health Maintenance
Organization (HMO) serving Medi-Cal, Healthy Kids, Medicare DualChoice (HMO SNP), and
IEHP DualChoice Cal MediConnect Plan (Medicare – Medicaid Plan) beneficiaries residing in
Riverside and San Bernardino Counties.
IEHP is a Knox-Keene licensed Health Plan and is regulated by the California Department of
Managed Health Care (DMHC), the California Department of Health Care Services (DHCS), and
as well as the federal government’s Centers for Medicare and Medicaid Services (CMS).
IEHP was formed on July 26, 1994 as a Joint Powers Agency (JPA) created by the two counties
to administer the Two-Plan Model as the Local Initiative Medi-Cal Managed Health Care Plan.
IEHP commenced operations on September 1, 1996.
Mission Statement
To organize and improve the delivery of quality, accessible
and wellness based healthcare services for our community.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
September 1, 1996
Chief Title: Chief Executive Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
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INTRODUCTION
C.
Manual Updates
__________________________________________________________________
The Inland Empire Health Plan (IEHP) Provider Policy and Procedure Manual (Provider Manual)
is reviewed and updated in its entirety at least once a year. IEHP maintains and issues manuals on
disk that are distributed externally to contracting entities in accordance with contractual and
regulatory requirements.
The Provider Manual annual update includes the following:
1. Policy and Procedure Manual
• Medi-Cal
• Healthy Kids
• Medicare DualChocie (HMO SNP) and IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan)
2. Benefit Manual
• Medi-Cal
• Healthy Kids
• Medicare DualChocie (HMO SNP) and IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan)
3. EDI Manual (IPA and Delegates only)
4. Summary of Effected Changes
5. IEHP Code of Business Conduct and Ethics
6. Model of Care (MOC) Training
7. Distribution Letter
8. Acknowledgment of Receipt
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
Chief Title: Chief Executive Officer
July 1, 2014
Revision Date:
IEHP Provider Policy and Procedure Manual
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