Provider Manual - Bridgeway Health Solutions

Transcription

Provider Manual
1-866-475-3129
BridgewayHS.com
Bridgeway Health Solutions
Assigned Representative Name
Network Email Address:
[email protected]
Network Phone Number:
1.866.475.3129
Network Fax Number:
1.866.687.0514
Bridgeway Health Solutions (Bridgeway) contract providers are required to
comply with applicable federal and state laws and regulations and Bridgeway’s
policies and procedures. The contents of Bridgeway’s provider manual are
supplemental to the provider contract and its addenda. When the contents
of Bridgeway’s provider manual conflict with the contract, the contract takes
precedence.
Provider Services Network:
1.866.475.3129
[email protected]
1
Table of Contents
INTRODUCTION ..........................................................5
AHCCCS ........................................................................5
ELIGIBILITY..................................................................7
TELEPHONE AND FAX REFERENCE GUIDE ....................8
BRIDGEWAY LONG TERM CARE ................................... 11
ATTENDANT CARE SERVICES ......................................13
PROVIDER REQUIREMENTS FOR ASSISTED LIVING
FACILITIES ................................................................. 16
PROVIDER REQUIREMENTS ........................................20
LEVELS OF CARE ........................................................ 22
REFERRALS AND AUTHORIZATION FOR
MEDICAL SERVICES .................................................. 22
LONG TERM CARE (LTC) CASE MANAGEMENT ............ 24
MEDICAL MANAGEMENT ........................................... 25
NETWORK MANAGEMENT DEPARTMENT ....................31
MEDICAL PROVIDER RESPONSIBILITIES ..................... 33
PROVIDING MEMBER CARE .............................................. 34
PRIMARY CARE PROVIDER (PCP) ....................................... 37
SPECIALISTS ................................................................ 39
HOSPITALS ................................................................... 39
ROUTINE, URGENT AND EMERGENCY SERVICES ...................40
APPROPRIATE USE OF EMERGENCY SERVICES ........... 41
REFERRALS ............................................................... 41
DOCUMENTING MEMBER CARE.................................. 42
ADVANCE DIRECTIVES ...............................................44
TELEMEDICINE .......................................................... 45
LANGUAGE LINE SERVICES ........................................ 45
CULTURAL COMPETENCY ...........................................46
MEMBER RIGHTS & RESPONSIBILITIES .......................49
CONFIDENTIALITY AND PRIVACY ...............................49
COVERED AND NON COVERED MEDICAL SERVICES ... 53
COVERED SERVICES ....................................................... 53
NON COVERED SERVICES ................................................ 54
1.866.475.3129
[email protected]
DENTAL SERVICES ..................................................... 55
PROVIDER GUIDELINES AND PLAN DETAILS ............... 55
March 2016
2
MARKETING...............................................................60
HEALTH CARE ACQUIRED CONDITIONS AND ABUSE ..60
WEB PORTAL .............................................................60
EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND
TREATMENT (EPSDT) ................................................. 61
SCREENINGS ............................................................. 62
STATE PROGRAMS......................................................66
BEHAVIORAL HEALTH ................................................68
COURT ORDERED TREATMENT AND PETITION PROCESS ..........71
BEHAVIORAL HEALTH TREATMENT PLANS AND DAILY
DOCUMENTATION .......................................................... 73
WELL-WOMAN PREVENTIVE CARE ............................. 73
FAMILY PLANNING .................................................... 74
MATERNITY ............................................................... 76
CASE MANAGEMENT AND DISEASE MANAGEMENT ...80
PHARMACY................................................................ 81
QUALITY IMPROVEMENT ............................................86
GENERAL BILLING INFORMATION AND GUIDELINES .. 88
EMERGENCY MEDICAL CONDITION (EMC)...........................99
RESUBMITTED CLAIMS ................................................... 101
CLAIM DISPUTE AND APPEALS PROCESS ...........................102
FRAUD WASTE AND ABUSE .......................................106
MEMBER RESOURCES ...............................................109
ARIZONA LONG TERM CARE SYSTEM (ALTCS) OFFICE
LOCATIONS ................................................................109
DOMESTIC VIOLENCE .................................................... 110
MEMBER ADVOCACY RESOURCES .................................... 110
HEALTH CARE DIRECTIVES AND LEGAL RESOURCES .............112
EXPLANATION OF PAYMENT REFERENCE SHEETS ................ 116
1.866.475.3129
[email protected]
3
1.866.475.3129
[email protected]
March 2016
4
INTRODUCTION
AHCCCS
The Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s
Medicaid agency that offers health care programs to eligible Arizona residents.
Individuals must meet certain income and other requirements to qualify for
services.
Who We Are – Bridgeway Health Solutions
Bridgeway Health Solutions, Inc. (Bridgeway) is one of the managed care
organization (MCO) contracted with AHCCCS to provide services to the ALTCS
population. Bridgeway is locally managed and administered and headquartered
in Tempe, Arizona. Bridgeway serves members in the following counties:
• Pinal
• Gila
• Cochise
• Graham
• Greenlee
• Maricopa
Bridgeway is a Centene company. Centene and its wholly-owned health plans
have a long and successful track record offering Medicaid managed care
services. For more than 20 years, Centene has provided comprehensive managed
care services to the Medicaid population and currently operates multiple health
plans in Arizona, Arkansas, California, Florida, Georgia, Illinois, Indiana, Kansas,
Louisiana, Massachusetts, Mississippi, Missouri, New Hampshire, Ohio, South
Carolina, Texas, Washington, and Wisconsin. Bridgeway serves our Arizona
members consistent with our core philosophy that quality healthcare is best
delivered locally. We are an organization committed to building interactive
partnerships with providers.
Since October 2006, Bridgeway has been providing care for Arizona’s long term
care population and is dedicated to promoting healthy outcomes and improve
the quality of life for our members. Bridgeway is responsible for the delivery of
acute care, long term care, behavioral health and case management services to
members via arrangements with selected providers to furnish comprehensive
services including formal programs for quality and medical management and
the coordination of care. We at Bridgeway strive to provide members with an
improved health status and continually work to improve member and provider
satisfaction.
A partial list of Bridgeway’s covered services includes:
• Nurse hotline 24 hours a day
• Behavioral health programs
• Home modifications
• Attendant care
• Emergency alert systems
• Equipment to assist with mobility
• Assisted Living Services
• Skilled Nursing Facilities
1.866.475.3129
[email protected]
Please refer to the section titled “Covered Services” in this manual for more
details.
5
Bridgeway Guiding Principles
• Provide high quality, accessible, cost-effective healthcare for our members
• Integrity and the highest ethical standards
• Mutual respect and trust in our working relationships
• Communication that is open, consistent and two-way
• Diversity of people, cultures and ideas
• Teamwork and meeting our commitments to one another
Bridgeway allows open practitioner/member communication regarding
appropriate treatment alternatives, including medication treatment options,
regardless of benefit coverage limitations. Bridgeway does not penalize
practitioners for discussing medically necessary or appropriate care with the
member.
All of our programs, policies and procedures are designed with these goals in
mind. We hope that you will assist Bridgeway in reaching these goals.
Bridgeway Approach
Recognizing that a strong health plan is predicated on building mutually
satisfactory associations with providers, Bridgeway is committed to:
• Working as partners with participating providers
• Demonstrating that healthcare is a local issue
• Performing its administrative responsibilities in a superior fashion
Bridgeway programs, policies and procedures are designed to minimize the
administrative responsibilities in the management of care, enabling you to focus
on the healthcare needs of your patients, our members.
Bridgeway Summary
Bridgeway’s philosophy, for our LTC Medicaid members, is to provide access to
high quality, culturally sensitive healthcare services by combining the talents of
PCPs and specialty providers with a highly successful, experienced managed care
administrator. Bridgeway believes that successful managed care is the delivery of
appropriate, medically necessary services - not the elimination of such services.
It is the policy of Bridgeway to conduct its business affairs in accordance with the
standards and rules of ethical business conduct and to abide by all applicable
federal and state laws.
At Bridgeway, we take the privacy and confidentiality of our members’ health
information seriously. We have processes, policies and procedures to comply
with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
state privacy law requirements. If you have any questions about Bridgeway’s
privacy practices, please contact our Vice President of Compliance & Regulatory
Affairs (Privacy Official) at 1.866.475.3129.
1.866.475.3129
[email protected]
March 2016
6
ELIGIBILITY
ALTCS Eligibility
The Arizona Long Term Care System (ALTCS) program is for individuals who are
elderly and/or have physical disabilities (E/PD) who require an institutional level
of care. However, program participants do not have to reside in a nursing home.
Many ALTCS participants live in their own homes or an assisted living facility and
receive needed in-home services.
All members on Bridgeway Health Solutions must meet eligibility requirements
set forth by the State of Arizona in order to receive benefits under the ALTCS
program. Bridgeway is not involved in the eligibility determination or the
enrollment/disenrollment process.
In counties where multiple program contractors are available to provide
ALTCS services, a member will have the opportunity to choose which program
contractor they want to enroll with to receive ALTCS services. If a member does
not choose, they will be auto-assigned to a program contractor by AHCCCS.
Members interested in applying for Long Term Care, should call or visit an
Arizona Long Term Care office.
Hospital Presumptive Eligibility
Based on provisions in the Affordable Care Act and effective January 1, 2015,
Arizona has developed a Hospital Presumptive Eligibility (HPE) process that
allows qualified hospitals to temporarily enroll persons who meet specific
federal criteria for full Medicaid benefits in AHCCCS immediately. Hospitals will
use special features in Arizona’s electronic application, Health-e-Arizona Plus
(HEAplus), to process HPE applications.
Hospitals that choose to participate in HPE must meet performance standards
for continued participation. Details about performance standards are included in
the Hospital Presumptive Eligibility Agreement.
HPE provides eligible persons with temporary full Medicaid coverage. Persons
who are approved for HPE may receive Medicaid services from any registered
AHCCCS provider.
For additional detail regarding Hospital Presumptive Eligibility, please review
AHCCCS’ Hospital Presumptive Eligibility web page.
1.866.475.3129
[email protected]
7
TELEPHONE AND FAX REFERENCE GUIDE
For your ease, we have included this Reference Guide to assist you in the day-today operations of your office.
How to Reach Us
BRIDGEWAY HEALTH SOLUTIONS, INC.
1850 W. Rio Salado Parkway
Suite 201
Tempe, AZ 85281
1.866.475.3129
www.bridgewayhs.com
MEMBER SERVICES
1.866.475.3129
Fax 1.866.687.0519
AZ TDD/TTY 711
PROVIDER SERVICES (CLAIMS ISSUES)
1.866.518.6843
Fax: 1-866.638.6124
NETWORK MANAGEMENT (NON CLAIMS ISSUES)
1.866.475.3129
Fax: 1.866.687.0514
Email: [email protected]
PAPER CLAIMS SUBMISSION
Attention: Claims Department
PO Box 3040
Farmington, MO 63640-3814
1.866.518.6843
Fax: 1.866.472.4568
ELECTRONIC CLAIMS SUBMISSION
C/O Centene EDI Department
1.800.225.2573 Ext. 25525
[email protected]
ELECTRONIC FUNDS TRANSFER
PaySpan
To register and obtain PIN Code
1.877.331.7154
www.payspanhealth.com
1.866.475.3129
[email protected]
CLAIM DISPUTES
Attention: Provider Claim Disputes
Suite 201
Tempe, AZ 85281
March 2016
8
MEDICAL MANAGEMENT/CASE MANAGEMENT
1.866.475.3129
Fax: 1.866.687.0509
NURSEWISE
NurseWise Nurse Advice Line
24-hour Nurse Line
1.866.475.3129
PHARMACY – US SCRIPT
The plan’s Pharmacy Benefit Manager (PBM) is US Script
Help Desk 1.800.460.8988
TTY: 1.866.492.9674
Prior Authorization Department
1.866.399.0928
Fax: 1.866.399.0929
PHARMACY CLAIM SUBMISSION
US Script, Inc.
Attn: Pharmacy Networks Department
5 River Park Place E, Suite 210
Fresno, CA 93720
DENTAL
Envolve Benefit Options Dental
Dental Health & Wellness
1.888.278.7310
Fax: 262.834.3589
http://www.dentalhw.com/
VISION
Envolve Benefit Options Vision
Envolve Benefit Options Vision
112 Zebulon Court
PO Box 7548
Rocky Mount, NC 27804
1.800.334.3937
Fax: 1.877.940.9243
http://www.opticare.com/
TRANSPORTATION
Total Transit
1.877.986.7420
DME & INFUSION
Preferred Home Care
480.446.9010
Fax: 480.446.7695
J&B Medical Supply (Incontinence Supplies)
1.800.737.0045
Fax: 1.800.737.0012
9
1.866.475.3129
[email protected]
LABORATORY
Sonora Quest
602.685.5050
Fax: 602.685.5903
LabCorp
800.788.9743
Theranos
855.843.7200
INTERPRETATION SERVICES
Bridgeway Member Services
1.866.475.3129
Hearing Impaired (TTY)
1.877.613.2070
BEHAVIORAL HEALTH
1.866.475.3120 ext. 26845
BRIDGEWAY COMPLIANCE DEPARTMENT
866.475.3129 Ext. 26818
1.866.475.3129
[email protected]
March 2016
10
BRIDGEWAY LONG TERM CARE
Overview
Bridgeway Long Term Care members are eligible for:
• Home and Community Based Services
• Residential Skilled Nursing Facilities (SNF) – For additional information
please review our Skilled Nursing Facilities (SNF) Guide. (http://www.
bridgewayhs.com/files/2016/03/2016-SNF-Billing-Reference-Guide.pdf)
Below is a partial list of services specific to the LTC program:
• Adult Day Health Care: supervision, assistance with medication, recreation
•
•
•
•
•
•
•
•
•
•
•
and socialization or personal living skills training. Health monitoring and/
or other health related services such as preventive, therapeutic and
restorative health care services are also included.
Attendant Care Services: assistance with a combination of services in
the member’s home, which may include homemaking, personal care, and
general supervision.
Community Transition Service (CTS): is a fund to assist ALTCS
institutionalized members to reintegrate into the community by providing
financial assistance to move from an ALTCS Long Term Care (LTC)
institutional setting to their own home or apartment.
Emergency Alert System: Monitoring devices/systems for ALTCS members
who are unable to access assistance in an emergency situation and/or live
alone. Habilitation: Services are designed to assist individuals in acquiring,
retaining and improving the self-help, socialization and adaptive skills
necessary to reside successfully in Home and Community Based (HCB)
settings.
Home Delivered Meals: Nutritious meals, prepared and delivered to a
member’s home.
Home Health Services: include home health skilled nursing visits, private
duty nursing, home health aide services, medically necessary supplies, and
therapy services in the member’s home.
Homemaker: assistance in the performance of activities related to
household maintenance. The service is intended to preserve or improve the
safety and sanitation of the member’s living conditions and the nutritional
value of food/meals for the member.
Home Modification: physical modifications to the home that enable the
member to function with greater independence in the home and that have a
specific adaptive purpose.
Hospice Services: Provide palliative and support care for terminally ill
members and their family members or caregivers during the final stages
of illness and during dying and bereavement. These services may be
provided in the member’s own home, a Home and Community Based (HCB)
approved alternative residential setting
Medical/Acute Care Services: Services provided to ALTCS members
are the same as those provided to members enrolled in the acute care
program, with the exception of certain therapies.
Member-Directed Options: (Agency With Choice (AWC) and Self-Directed
Attendant Care (SDAC) allows members to have more control over how
certain services are provided, including services such as attendant care,
personal care, homemaker and habilitation. The options are not a service,
but rather define the way in which services are delivered.
Personal Care: Assistance to meet essential personal physical needs to
members who reside in their own home.
11
1.866.475.3129
[email protected]
• Private Duty Nursing:
•
For members who need more individual and
continuous care.
Respite: A service that provides an interval of rest and/or relief to a family
member or other person(s) caring for the ALTCS member. It is available for
up to 24-hours per day and is limited to 600 hours per benefit year.
LTC Program Contractor Changes
Bridgeway has a transition coordinator to assist with all program contractor
changes. All members have the option of changing program contractors
during their annual enrollment choice month. AHCCCS distributes a packet of
information to each member prior to their annual enrollment choice including
information on how to change program contractors and the due dates for
selection. Members may also change program contractors at other times if the
circumstance meets AHCCCS criteria such as:
• moving to another county
• moving to another program contractor to maintain continuity of medical
care, or
• residing in a facility that no longer contracts with their current program
contractor
In these situations the member’s Case Manager will put together a packet of
information and the transition coordinator will send it to the requested program
contractor. If the requested program contractor grants the request, a transition
date is determined and AHCCCS is notified and makes the change.
Until the actual date of enrollment Bridgeway is not financially responsible
for services the prospective member receives. In addition, Bridgeway is not
financially responsible for services members receive after their coverage has
been terminated. However, Bridgeway is responsible for those individuals who
are Bridgeway members at the time of a hospital inpatient admission and change
health plans during that period of time.
Home & Community Based Services (HCBS)
Gap in Critical Services
All Home and Community Based providers who provide attendant care,
housekeeping, personal care, and respite care are required by AHCCCS to
complete a monthly Critical Services Gap Log for critical services. Your Network
Representative is available to assist in coordinating initial and ongoing training.
A gap in critical services is defined as the difference between the number of
hours of critical services scheduled in each member’s HCBS care plan and the
hours of scheduled type of critical service that are actually delivered to the
member.
1.866.475.3129
[email protected]
March 2016
Critical services received in the member’s home are inclusive of tasks such as
bathing, toileting, and dressing, feeding, and transferring to or from bed or
wheelchair, and assistance with similar daily activities. Types of critical services
include:
• Attendant care, including spouse attendant care
• Personal Care
• Homemaker
• In-home respite
12
Please refer to Chapter 1200, Arizona Long Term Care System Services and
Settings for Members Who Are Elderly and/or have Physical Disabilities
and/or have Developmental Disabilities in the AHCCCS Medical Policy Manual
(AMPM) for additional Home and Community Based Services information.
Critical Service Gap Log
The Critical Service Gap Log includes information to identify differences
between the number of hours of critical services scheduled and the hours of the
scheduled type of critical services that are actually delivered to the member.
Providers are required to complete the Critical Service Gap Log each month even
if there are no critical service gaps for the month. The Critical Service Gap Log
must be completed and submitted to Bridgeway by the fifth business day of each
month.
Telephone accessibility standards also apply. Bridgeway conducts after-hour
phone audits to assure providers have 24-hour coverage available for unforeseen
gaps in service. Please note that the AHCCCS standard is to allow HBCS providers
15 minutes to return a call addressing a gap in service. To allow an agency more
than 15 minutes to return a phone call when a gap in service is being reported
would make it exceptionally difficult for the service to be filled within the two (2)
hour requirement.
ATTENDANT CARE SERVICES
Interruption in Service
There may be times where an interruption in service may occur due to an
unplanned hospital admission for the member. While services may have been
authorized for attendant care during this time, attendant care agencies should
not be billing for any days that fall between the admission date and the discharge
date or any day during which services were not provided.
Each attendant care agency is responsible for following this process. If any
hours are submitted when a member has been hospitalized for the full 24
hours, the attendant care agency will be required to pay back any monies paid
by Bridgeway. In accordance with AHCCCS requirements, Bridgeway conducts
periodic audits to verify this is not occurring.
AHCCCS requires the use of specific codes/modifiers for attendant care as
follows:
Attendant Care:
Non-Family: S5125-No modifier
Family Non-Resident: S5125-U4
Family Resident: S5125-U5
Spouse: S5125-U3
Agency with Choice
Non-Family: S5125-U7
Family Non-Resident: S5125-U7 U4
Family Resident: S5125-–U7 U5
Spouse: S5125-U7 U3
Self-Directed Attendant Care
Non- Family: S5125-U2
Family Non-Resident: S5125-U2U4
Family Resident: S5125-U2U5
Skilled Self-Directed Attendant Care
Non-Family: S5125-U6
Family Non-Resident: S5125-U6U4
Family Resident: S5125-U6U5
13
1.866.475.3129
[email protected]
Prior Period of Coverage HCBS
“Prior Period of Coverage” for an HCBS member refers to HCBS in place prior to
enrollment with Bridgeway (during the Prior Period of Coverage period). Services
were previously provided by another AHCCCS plan.
Prior Period eligibility dates are determined by AHCCCS. LTC case manager
performs a retrospective assessment to determine the medical necessity of
services, along with determination that the services previously delivered were
provided by a registered AHCCCS provider in the most cost effective manner.
If the LTC case manager determines that the services are covered,
reimbursement will be made to the provider.
Case Manager Responsibilities
Each member is assigned to a LTC case manager. The case manager works
with the member’s PCP to coordinate and authorize the provision of medically
necessary services for the member. The case manager is also the member’s
advocate and works to facilitate the member’s care.
The LTC case manager authorizes LTC support services and home & community
based services, providing information about room and board or share of cost to
providers and members, and assisting members with coordination of appropriate
services.
The LTC case manager is the primary point of contact for providers when there
are issues or questions about a member. Providers must also contact the LTC
case manager whenever there are changes in a member’s health status.
Service Authorizations
The following table illustrates LTC and HCBS services provided to members that
require PCP orders and/or authorization by the contractor.
NOTE: The LTC case manager only authorizes long term care services, not
medical services. Medical service authorization procedures are outlined in
Chapter 16 – Referrals and Authorizations for Medical Services.
LTC Service Authorization Table
LTC Service
1.866.475.3129
[email protected]
March 2016
Bridgeway LTC Case
Manager
PCP Orders
Authorization
X
Acute Hospital Admission
(Non-Medicare Admission)
Adult Day Health Services
X
Assisted Living Facility
Attendant Care
X
X
X
Behavioral Health Services
X
X
DME/Medical Supplies
X
Emergency Alert
Habilitation
X
X
Home Delivered Meals
X
Home Health Agency
X
14
X
X
LTC Service
Home Modifications
Homemaker Services
Bridgeway LTC Case
Manager
X
X
Hospice Services (HCBS and
Institutional – Non-Medicare
Medical Care Acute Services
Nursing Facility
PCP Orders
Authorization
X
X
X
Personal Care
Respite Care (In-Home)
Respite Care (Institutional)
Therapies
Transportation
X
X
X
X
X
X
X
X
Alternative Residential Setting
Bridgeway offers different types of medically necessary living arrangements
for eligible members. These different types of settings provide supervisory
care, personal care or directed care, and are delivered by licensed or certified
facilities. Members are required to pay room and board fees in these settings.
The LTC case manager will assess the member’s need for the appropriate type of
setting.
LTC Service Types Table
Setting Description
LTC Setting
Adult Foster Care
Description
This setting includes up to 4 residents. The
owner of the home must live in the home and
provide the care.
Adult Therapeutic Home Care Provides behavioral health and ancillary
services for a Minimum of 1 and a maximum
of 3 people.
Child Therapeutic Home Care Provides services by those licensed with DES
as a professional foster care home.
Assisted Living Home
This setting provides care and supervision for
up to 10 people.
Assisted Living Center
This setting provides resident rooms or
residential units and services to 11 or more
residents. Three meals /day are provided
in the main dining hall. Personal care and
medication monitoring/administration
provided as needed.
1.866.475.3129
[email protected]
15
PROVIDER REQUIREMENTS FOR ASSISTED
LIVING FACILITIES
Assisted Living Home and Assisted Living Center Requirements
• The provider at an Assisted Living Facility must collect room and board fees
•
•
•
•
•
•
•
from the member. Room and board is the amount the member pays each
month for the cost of food and/or shelter.
Bridgeway does not pay the member’s room and board cost when the
member is in an alternative residential setting. Bridgeway room and board
agreement identifies the level of payment for the setting, placement date,
and room and board amount the member must pay and is determined by
the LTC case manager at the time of placement.
The room and board agreement is used for all alternative residential
settings. The amount of room and board periodically changes based on a
member’s income.
The Room and Board agreement form is completed at least once a year or
more often if there are changes in income.
Payment issued to the provider is always the contracted amount minus the
member’s room and board.
Provider must notify Bridgeway in writing immediately if a change in
location of the Assisted Living Home or Assisted Living Center is being
considered. LTC Case Management will communicate with members and
their representatives to determine whether or not a location change is in
their best interest.
Level of Care for Assisted Living Home or Assisted Living Center are
determined by the LTC Case Manager and contracted tier levels.
Provider must notify Bridgeway in writing immediately if an ownership
change is being considered. LTC Case Management and Network will decide
if a contract with the new owner will be offered. In order to be considered
for a contract, a new owner must be licensed by Arizona Department of
Health Services (ADHS), have an AHCCCS Provider Identification number
and have proof of required liability insurance.
Assisted Living Home Requirements
• Providers must obtain written authorization from the Bridgeway LTC Case
•
1.866.475.3129
[email protected]
•
March 2016
Manager who is the sole authorizing agent for placement and level of care
prior to admission. Providers must maintain member case records with
information that includes, but is not limited to:
o Member’s name and identification number
o Emergency contact name and phone number
o Member’s primary care provider address and phone number
o Member’s current medications and pharmacy phone number
o Member’s guardian, grantee of power of attorney, or healthcare
decision maker, as applicable.
Provider must maintain policies and procedures specific to the
management and organization of Assisted Living Homes, which include but
are not limited to a residency agreement; personnel policies and staffing
ratios; house standards; medication dispensing and home furnishings
and repairs. Provider must submit copies of policies and procedures to
the Bridgeway Network Department upon request. Provider must be
and remain in compliance with applicable state and federal rules and
regulations.
All deposits paid prior to Bridgeway enrollment date must be refunded to
the member or member’s power of attorney designee immediately.
16
• All private agreements with members cease on the effective enrollment
•
•
•
•
date with Bridgeway. Following Bridgeway enrollment, the Bridgeway Room
& Board Residency Agreement will govern.
Provider shall not charge members for any item(s) or service(s) which are
covered under their contract or the AHCCCS Medical Policy Manual.
Provider shall arrange for or provide recreational and social activities on a
regular basis designed to maintain or improve skills to members.
Provider must report to the Bridgeway LTC Case Manager all member
emergency room visits, hospitalizations, observation bed admissions and
expirations within twenty-four (24) hours of the occurrence.
Must maintain in full force and effect and be covered at all times throughout
the term of the Bridgeway contract by (a) professional liability (malpractice)
insurance which covers all acts of omissions of the provider in providing or
arranging for covered Assisted Living Home Services under their contract,
and (b) general liability insurance. The terms and limits of such insurance
coverage shall be subject to Bridgeway approval. The general liability
policy shall have limits of not less than One Million dollars ($1,000,000) per
occurrence, and an annual aggregate of Three Million dollars ($3,000,000),
unless a lesser amount is accepted by Bridgeway or where State Law
mandates otherwise. Failure to secure and maintain such professional
liability and general liability insurance coverage shall constitute a material
breach of Provider’s contract with Bridgeway. Provider will provide
Bridgeway with at least fifteen (15) day notice of such cancellation, nonrenewal, lapse, or adverse material modification of coverage.
Assisted Living Center Requirements
•
•
•
•
•
•
•
•
•
•
Provider must ensure that each new center staff completes an orientation
within ten (10) days from the date of employment which includes, but is
not limited to, orientation to the characteristics and needs of Assisted
Living Center members; promotion of member dignity, independence, selfdetermination, and privacy, choice and rights.
Provider must ensure that each staff member completes ongoing training
that includes but is not limited to promoting dignity, independence,
self-determination, privacy, choice and rights; fire, safety and emergency
procedures; and assistance in self-administration of medications.
Provider must obtain written authorization from the LTC Case Manager and/
or BH Care Manager for placement and level of care.
Upon admission, there must be documentation/evidence that the member
is free from infectious tuberculosis. Annual testing is to be completed and
documented in the member’s medical record.
Provider must report to LTC Case Manager all member emergency room
visits, hospitalizations, observation bed admissions and expirations within
twenty-four (24) hours of the occurrence.
There must always be staff member(s) on duty who speak and read English
(fluently), twenty-four (24) hours per day, three hundred sixty five (365)
days per year.
Provider must provide shampoo, hand soap, toilet paper and laundry
detergent for each resident.
One (1) staff member certified in CPR must be on duty at all times.
All deposits paid prior to LTC enrollment date must be refunded to the
member or member’s power of attorney designee immediately.
All private agreements with members cease on the effective enrollment
date with Bridgeway. Following Bridgeway enrollment, the Room & Board
Residency Agreement will govern.
17
1.866.475.3129
[email protected]
• Provider must collect the Room and Board amount determined by the LTC
Case Manager from the Member.
• Provider must maintain member case records with information that
•
•
•
•
includes, but is not limited to:
o Member’s name and LTC identification number
o Member’s relative name(s) address(es) and phone number(s)
o Emergency contact name and phone number
o Member’s primary care provider address and phone number;
o Member’s current medications and pharmacy phone number; and
decision maker, as applicable
Provider must maintain policies and procedures required by applicable
law which are specific to the management and organization of assisted
living centers, which include, but are not limited to admission agreements,
personnel policies and staffing ratios, house standards, medication
dispensing, and home furnishings and repairs. Providers must submit
copies of its policies and procedures to Bridgeway upon request.
Provider must maintain policies and procedures specific to a member’s
personal needs allowance according to applicable law; provider must
submit such policies to Bridgeway upon request.
Provider must not charge members for any item(s) or service(s) which are
covered under their contact or the AHCCCS Medical Policy Manual.
Must maintain in full force and effect and be covered at all times throughout
the term of the Bridgeway contract by (a) professional liability (malpractice)
insurance which covers all acts of omissions of the provider in providing or
arranging for covered Assisted Living Home Services under their contract,
and (b) general liability insurance. The terms and limits of such insurance
coverage shall be subject to Bridgeway approval. The general liability
policy shall have limits of not less than One Million dollars ($1,000,000) per
occurrence, and an annual aggregate of Three Million dollars ($3,000,000),
unless a lesser amount is accepted by Bridgeway or where State Law
mandates otherwise. Failure to secure and maintain such professional
liability and general liability insurance coverage shall constitute a material
breach of Provider’s contract with Bridgeway. Provider will provide
Bridgeway with at least fifteen (15) day notice of such cancellation, nonrenewal, lapse, or adverse material modification of coverage.
Additional Requirements for Covered Behavioral Health Assisted
Living Center
• Must meet minimum training of didactic in-service training in behavioral
health topics and ongoing monthly training for all direct care staff.
• Must provide members with recreational and social activities on a daily
basis designed to maintain or improve physical and social interaction.
• Must provide service including, but not limited to psychosocial
1.866.475.3129
[email protected]
March 2016
•
•
rehabilitation; skills training and development; and assist member on a
daily basis to carry out specified goals and objectives as prescribed in the
member’s treatment plan.
Must provide a designated unit secured by locked or electronically
controlled doors (a wander guard-type system alone does not meet this
requirement for locked Behavioral Health Assisted Living Unit)
Daily documentation is required to reflect member behaviors and issues
that occur. This should include frequency of behaviors, frequency and type
of staff interventions required throughout the day, and the member’s level
of responsiveness to interventions/redirections.
18
• Must provide a designated unit secured by locked or electronically
•
•
•
•
•
•
•
•
controlled doors (a wander guard-type system alone does not meet this
requirement).
Must be staffed with the following ratios: (these staffing ratios exclude
facility directors, administrative, clerical and maintenance staff ).
o One (1) staff to ten (10) members from 6:00 am – 2:00 pm
o One (1) staff to ten (10) members from 2:00 pm – 10:00 pm
o One (1) staff to twenty (20) members from10:00 pm – 6:00 am
• Example: If provider has thirty-eight (38) members, provider is
required to have three (3) full time staff and then the fourth (4th)
staff would be required to work 6 hours and 40 minutes of the 8
hour shift during the hours of 6:00 am to 10:00 pm.
All staff newly assigned to work on the unit must receive two (2) hours of inservice training prior to actually providing care to members with dementia.
Training must include, but is not be limited to:
o Understanding members with dementia; and
o How to work with members with dementia.
All staff on the unit must attend a minimum of one (1) hour every month
of in-service education addressing the special needs of members with
dementia such as those with Alzheimer’s disease and related disorders,
Training must take place and be documented within than every thirty (30)
days.
o Off-site in service education may be included to meet this
requirement.
Topics for in-service sessions are to include, but are not limited to:
o Charting and documentation;
o Understanding persons with dementia;
o How to work with persons with dementia;
o Providing services to members based on individual needs;
o How to maximize independence for persons with dementia;
o Member rights;
o Appropriate verbal and non-verbal interaction with members;
o Pharmacological and physical restraints and their use;
o Facility protocol to manage/locate members who wander;
o Activities of daily living as part of the activity program;
o Fall prevention;
o Cultural diversity; and
o Using hospice for members with advanced dementia.
Must have activity staff programming ten (10) hours a week.
Must offer activities that are appropriate for persons with dementia seven
(7) days a week.
Must have buildings and furnishings that are designed for the member’s
safety.
Facilities must be designed to maximize comfort for the member’s physical
environment, personal, shared surroundings, demonstrate a balance of
sensory stimuli that are calming and soothing; and other sensory stimuli
that are pleasantly stimulating and engaging.
1.866.475.3129
[email protected]
19
PROVIDER REQUIREMENTS
Provider Requirements for Adult Foster Care Home
• Must obtain written authorization from the LTC Case Manager who is the
•
•
•
•
•
•
•
•
•
•
1.866.475.3129
[email protected]
•
sole authorizing agent for placement and level of care prior to admission.
Must provide shampoo, hand soap, toilet paper and laundry detergent for
each resident.
All deposits paid prior to the Bridgeway enrollment date must be refunded
to the member or member’s power of attorney designee immediately.
All private agreements with members cease on the effective enrollment
date of the member with Bridgeway. Following enrollment, the Bridgeway
Room and Board Residency Agreement will govern. Provider must notify
Bridgeway in writing within five (5) business days of changes that include,
but are not limited to a change in location, services, licensing, or ownership.
Referrals for specific covered Adult Foster Care services must be initiated
and obtained by the member’s primary care provider and/or the LTC Case
Manager. Services not authorized by Bridgeway will not be reimbursed.
Provider must maintain member case records with information that
includes at a minimum the following:
o Member’s name and ALTCS identification number
o Member’s emergency contact(s) name(s), address(es) and phone
number(s)
o Member’s primary care provider address and phone number
o Member’s current medications and pharmacy phone number
decision maker, as applicable.
Provider must maintain policies and procedures specific to advanced
directives according to applicable law and Bridgeway Policies.
o Provider must also provide education to staff and subcontractors
regarding advance directives.
Provider must maintain policies and procedures required by applicable law
specific to their management and organization including but not limited
to an admission agreement; personnel policies and staffing ratios; house
standards; medication dispensing; and home furnishings and repairs.
o Provider must submit copies of policies and procedures to Bridgeway
upon request.
Provider cannot charge Members for any item(s) or service(s) which are
covered under this Agreement by AHCCCS or Medicare.
Provider must maintain policies and procedures specific to Member’s
personal needs according to applicable law and submit them to Bridgeway
upon request.
Nursing care services may be provided by a nurse who is licensed by the
State of Arizona to provide covered Adult Foster Care Services according to
applicable law.
o Must keep a record of nursing services rendered and obtain prior
authorization
Provider must arrange for or provide recreational and social activities on a
regular basis designed to maintain or improve skills to members.
Report to LTC Case Manager all member emergency room visits,
hospitalizations, observation bed admissions and expirations within twentyfour (24) hours of the occurrence.
March 2016
20
• Must maintain in full force and effect and be covered at all times throughout
the term of the Bridgeway contract by professional liability (malpractice)
insurance and other insurance necessary to insure provider and any
other person providing services hereunder on Provider’s behalf, against
any claim(s) of personal injuries or death alleged or caused by Provider’s
performance under agreement. Such insurance coverage shall be subject
to Bridgeway approval. Provider must maintain in full force and effect and
be covered at all times throughout the term of this Agreement. Insurance
shall be through a licensed carrier, and of not less than One Million dollars
($1,000,000) per occurrence, and an annual aggregate of Three Million
dollars ($3,000,000), unless a lesser amount is accepted by Bridgeway or
where State Law mandates otherwise. Failure to secure and maintain such
professional liability and general liability insurance coverage shall constitute
a material breach of Provider’s contract with Bridgeway. Provider will
provide Bridgeway with at least fifteen (15) day notice of such cancellation,
non-renewal, lapse, or adverse material modification of coverage.
Provider Requirements for Skilled Nursing Facilities (SNFs)
Skilled Nursing Facilities (SNFs) provide services to members that need
consistent care, but do not have the need to be hospitalized or require daily care
from a physician. Many SNFs provide additional services or other levels of care to
meet the special needs of members. SNFs are responsible for making sure that
members residing in their facility are seen by their PCP in accordance with the
following intervals:
• For initial admissions to a nursing facility, members must be seen once
every 30 days for the first 90 days, and at least once every 60 days
thereafter.
• Members that become eligible while residing in a SNF must be seen within
the first 30 days of becoming eligible, and at least once every 60 days
thereafter.
Additional nursing facility visits are provided as medically necessary and
appropriate.
Covered services delivered to eligible members in accordance with a provider’s
contract include the following:
• Bridgeway is not responsible to pay for any otherwise covered services
rendered to LTC members prior to the date the member becomes enrolled
by the State Agency with Bridgeway or after the member loses eligibility or
otherwise is dis-enrolled from Bridgeway LTC.
• The per diem payment for ALTCS members includes over-the-counter
medications. Providers must use Bridgeway contracted pharmacies and
durable medical equipment companies for non-Medicare enrollees who are
on a custodial stay in the facility.
• Bridgeway should be billed for co-payments for members who have Fee for
Service Medicare and a Prescription Drug Program or who are on a Medicare
Advantage Program, which is not Bridgeway Health Solutions Advantage
HMO SNP.
• Bridgeway reimburses providers for covered therapy services on a fee for
service basis. Bridgeway updates internal payment systems in response to
additions, deletions and changes of this nature.
21
1.866.475.3129
[email protected]
LEVELS OF CARE
The appropriate level of care will be determined by the LTC case manager,
utilizing the AHCCCS/ALTCS Uniform Assessment Tool.
In the event the provider disagrees with the level of care authorized, you may
request a plan review by Bridgeway. The review request must be made in writing
to the LTC Case Management Team within thirty (30) days of the determination
of the plan review. In the event the original level of care is upheld, the decision
is final and not subject to further review by LTC. In the event the original level of
care is overturned during the review process, Bridgeway will adjust the level of
care in accordance with the date of the provider’s initial level of care notification.
Levels of care are listed below:
Level of Care Revenue Codes
• Sub-Acute Care Level I 0191
• Sub-Acute Care Level II 0192
• Sub-Acute Care Level III 0193
• Sub-Acute Care Level IV 0194
•
•
o
o
o
o
o
Respiratory
Behavioral Health
Dialysis
Bariatric
Dementia
Hospital Bed Hold 185
Therapeutic Bed Hold 183
Level of care changes authorized by Bridgeway will be effective on the day of
evaluation. Level of care changes may be retroactive to the date of documented
(phone, email or fax) notification to the Nursing Facility, but not prior to the date
of notification.
Covered Therapy Services are not included in the Bridgeway member per diem
rate, except where specified. Providers must arrange, or provide covered therapy
services, for Bridgeway members residing in its facility.
REFERRALS AND AUTHORIZATION FOR MEDICAL
SERVICES
Requirements for Specialty Rates
1.866.475.3129
[email protected]
Custodial levels of care are determined according to the AHCCCS Universal
Assessment Tool for Acuity Determinations. These levels are NOT for placements
that are Medicare funded by Bridgeway Health Solutions Advantage HMO SNP.
RUG rates are used for Advantage members whose care meets the Medicare
criteria for RUG rates. If providing specialty levels of care, they must meet the
requirements identified below, in accordance with the contract:
Sub-Acute
Level III - Intensive Sub-Acute. This includes any combination of the following:
• complex wound care/decubitus
• total parenteral nutrition or tracheotomy care
• or any therapy up to 3 hours per day (PT/OT/ST)
March 2016
22
An RN charge nurse is required to be on the station where Level III members
are located 24 hours a day. This level of care is authorized by a Bridgeway
Review Nurse. Daily documentation in the medical chart of continued need for
sub-acute level of care is required. Provider must notify Bridgeway staff within 24
hours of when a member no longer requires sub-acute level of care services.
Hospital Bed Hold
Bed holds require authorization by Bridgeway staff. Provider must notify the
LTC case manager within 24 hour of hospital admission if there is a request
for a hospital bed hold. There are a maximum of twelve (12) days that may be
authorized per member, per contract year (October 1- September 30).
Therapeutic Bed Hold
Bed holds require authorization by LTC staff. There are a maximum of nine
(9) days that may be authorized per member, per contract year (October 1September 30).
Respite
Respite placement in a nursing facility is authorized by LTC case manager
according to AHCCCS requirements. The purpose is to provide an interval of
rest and/or relief to a family member or other unpaid person caring for the
member, and to improve the emotional and mental well-being of the member.
There is a maximum of 25 respite days per member per contract year (October
1-September 30) provided the member has not used respite in any other setting
during the contract year.
1.866.475.3129
[email protected]
23
LONG TERM CARE (LTC) CASE MANAGEMENT
Overview
Bridgeway offers a case management system that incorporates several unique
strengths. It is fully integrated, through a team approach that involves nurse,
behavioral health clinician, and non-clinical case managers. Case managers will
have a mixed case-load so they will have experience with both institutional and
HCBS long term care. This will ensure continuity and comprehensive service
planning for members transitioning from one setting to another. Medical case
management is a collaborative process which assesses, plans, implements,
coordinates, monitors and evaluates the options and services to meet an
individual’s health needs, using communication and available resources to
promote quality, cost effective outcomes. Care coordination/management is
a member-centered, goal-oriented, culturally relevant and logically managed
process to help ensure that a member receives needed services in a supportive,
effective, efficient, timely and cost-effective manner.
For members that need behavioral health services, Bridgeway’s Case Managers
can assist you in finding the appropriate behavioral health provider to see the
member. You can reach Case Management at 1.866.475.3129. If you know
that the member is currently in treatment with a mental health specialist, call
Bridgeway. We will be happy to work with them to help them stay with their
behavioral health specialist. You may refer to the Behavioral Health chapter of
this manual for further information.
Bridgeway’s Case Manager supports the physician by tracking compliance with
the case management plan, and facilitating communication between the PCP,
member, and the case management team. The Case Manager also facilitates
referrals and linkages to community providers, such as local health departments
and school-based clinics. The managing physician maintains responsibility for
the patient’s ongoing care needs. The Bridgeway case manager will contact the
PCP and/or managing physician if the member is not following the plan of care or
requires additional services.
The Bridgeway case manager will work with all involved providers to coordinate
care, provide referral assistance and other care coordination as required.
LTC Case Management Process
1.866.475.3129
[email protected]
Bridgeway’s case management for ALTCS members contains the following key
elements:
• Notify the member and their PCP of the member’s assignment to a
Bridgeway LTC Case Manager
• Develop and implement a care plan that accommodates the specific
cultural and linguistic needs of the member
• Establishment of treatment objectives and monitoring of outcomes
• Refer and assist the member in ensuring timely access to Providers
• Coordinate medical, residential, social and other support services
• Monitor care/services
• Revise the care plan as necessary
• Track plan outcomes
Bridgeway utilizes a member centric approach to member care.
March 2016
24
Chronic and Complex Conditions
Bridgeway provides individual medical case management services for members
who have chronic, complex, high-risk, high-cost or other catastrophic
conditions. The Bridgeway Medical case manager will work with the LTC
Case Manager and all involved providers to coordinate care, provide referral
assistance, and other support as required.
Bridgeway also uses disease management programs and associated practice
guidelines and protocols for members with chronic conditions, including
conditions such as asthma and diabetes. Members who qualify for chronic or
complex case management services have an ongoing physical, behavioral or
cognitive disorder, including chronic illnesses, impairments and disabilities.
These limitations are expected to last at least twelve (12) months with a
resulting functional limitation, reliance on compensatory mechanisms such as
medications, special diet, or assistive device, and require service use or needs
beyond that which is normally considered routine.
The Bridgeway medical and LTC case managers will coordinate care needs
including behavioral health needs, assist in identifying and obtaining supportive
community resources, and arrange for long-term referral services as needed. The
case manager may identify (and a member may request) a specialist with whom
a member with a chronic condition has an on-going relationship who may serve
as the PCP and coordinate services on the member’s behalf.
Members determined to need a course of treatment or regular care monitoring
may have direct access to a specialist as appropriate for the member’s condition
and identified needs, such as through a standing referral or an approved number
of visits. A member’s PCP will develop a treatment plan with the member’s
participation and in consultation with any specialists caring for the member.
The Bridgeway Medical Director, or other qualified designee, oversees these
processes in accordance with state standards.
Bridgeway encourages all PCPs and physicians to notify Bridgeway Medical Case
Management when a member is identified that meets the criteria for a chronic or
complex condition.
MEDICAL MANAGEMENT
Overview
The Bridgeway Medical Management Department hours of operation are Monday
through Friday (excluding holidays) from 8:00 a.m. to 5:00 p.m. For priorauthorizations during business hours, the provider should contact:
Medical Management
1.866.475.3129
A Referral Specialist will enter the demographic information and will then
transfer the call to a Nurse for the completion of medical necessity screening.
1.866.475.3129
[email protected]
25
Medical Necessity:
Medically Necessary services are generally accepted medical practices provided
in light of conditions present at the time of treatment. These services are:
• Appropriate and consistent with the diagnosis of the treating provider and
the omission of which could adversely affect the eligible member’s medical
condition
• Compatible with the standards of acceptable medical practice in the
community
• Provided in a safe, appropriate, and cost-effective setting given the nature
of the diagnosis and severity of the symptoms
• Not provided solely for the convenience of the member or the convenience
of the healthcare provider or hospital
• Not primarily custodial care unless custodial care is a covered service or
benefit under the members evidence of coverage
• There must be no other effective and more conservative or substantially
less costly treatment, service and setting available
• In no instance shall Bridgeway cover experimental, investigational or
cosmetic procedures
Information necessary for authorization may include but is not limited to:
• Member’s name, ID number
• Physician’s name and telephone number
• Hospital name, if the request is for an inpatient admission or outpatient
services
• Reason for admission – primary and secondary diagnoses, surgical
procedures, surgery date
• Relevant clinical information – past/proposed treatment plan, surgical
procedure, and diagnostic procedures to support the appropriateness and
level of service proposed
• Admission date or proposed date of surgery, if the request is for an
inpatient admission
• Requested length of stay, if the request is for an inpatient admission
• Discharge plans, if the request is for an inpatient admission
• For obstetrical admissions, the date and method of delivery and
information related to the newborn or neonate, Baby’s Medicaid ID number
• If more information is required, the Nurse will notify the caller for the
specific information needed to complete the authorization process
• Failure to obtain authorization may result in payment denials
Communication with Medical Management (MM) Staff
1.866.475.3129
[email protected]
Providers may access the MM staff via toll-free phone lines that are open
for authorization requests and MM related questions and or issues calling
1.866.475.3129 from 8:00AM to 5:00PM, Monday through Friday (excluding state
holidays). After normal business hours, and on state holidays, calls to the UM
department are automatically routed to NurseWise (1.866.475.3129). NurseWise
does not make authorization decisions. NurseWise staff will take authorization
information for next business day response by the health plan. Bridgeway
will process all expedite authorization requests in accordance with AHCCCS
standards. Outbound communications regarding UM inquiries are conducted
during normal business hours, unless otherwise agreed upon. If you are initiating
or returning calls regarding UM issues, all UM staff will identify themselves by
name, title and organization.
March 2016
26
Prior-Authorization
Prior-authorization requires that the provider or practitioner make a formal
medical necessity determination request to Bridgeway prior to the service being
rendered. Upon receipt, the prior authorization request is screened for eligibility
and benefit coverage and assessed for medical necessity and appropriateness of
the health services proposed, including the setting in which the proposed care
will take place.
Bridgeway has developed a tool for providers to determine if plan prior
authorization is required. To access the LTC prior authorization tool please visit
our website at: http://www.bridgewayhs.com/for-providers/pre-auth-needed/
medicaid-pre-auth-needed/
Please note: All attempts are made to provide the most current information
on the Pre-Auth Needed Tool. However, this does NOT guarantee payment.
Payment of claims is dependent upon eligibility covered benefits, provider
contracts and correct coding and billing practices.
Prior authorization requests can be submitting on line via the provider web
portal:
https://provider.bridgewayhs.com/sso/login?service=http%3A%2F%2Fprovider.
bridgewayhs.com%2Fcareconnect%2Fj_spring_cas_security_check%3Bjsessioni
d%3DTN7LjF4AXhXivLHnJyUIjg__.nwebprodNode01
Please contact your Network Representative for access to the web portal.
Standard Service Authorization
Prior Authorization decisions for non-urgent services shall be made within
fourteen (14) calendar days of receipt of the request for services. An extension
may be granted for an additional fourteen (14) calendar days if the member or
the provider requests an extension or if Bridgeway justifies a need for additional
information and the extension is in the member’s best interest.
When the extension is granted, both the provider and member will be notified.
Bridgeway gathers all pertinent clinical information to support the authorization
request within the allotted fourteen (14) calendar days. If the clinical information
is not received and, or gathered within the fourteen (14) calendar days, a written
notification to member and provider will be generated. The Member receives
written notice (Notice of Action) including the reasons for the decision to extend
the timeframe and the right to file a Grievance if he or she disagrees with that
decision.
If the request for authorization is approved, Bridgeway notifies the requesting
provider of the approval by telephone, fax or mail within one business day
after the decision is made, not to exceed the original authorization timeframe.
Bridgeway documents the date and time of the notification in the authorization
system.
If the request for authorization is denied, or a limited authorization of a requested
service, including the type and level of service, is proposed, the requesting
provider will be notified orally within one business day, and the member
and provider will be notified in writing, within two (2) business days of the
verbal notification, not to exceed the original fourteen (14) day determination
timeframe.
27
1.866.475.3129
[email protected]
Expedited Service Authorization
In the event the Provider indicates, or Bridgeway determines following the
standard timeframe could seriously jeopardize the Member’s life or health,
Bridgeway makes an expedited authorization determination and provides notice
within twenty-four (24) hours. Bridgeway may extend the twenty-four (24)
hour time period for up to five (5) business days if the member or the Provider
requests an extension, or if Bridgeway justifies a need for additional information
and the extension is in the member’s interest.
For actions to terminate, suspend, or reduce previously authorized covered
services, the Plan mails the Notice of Action 10 calendar days before the date
of the proposed action or not later than the date of the proposed action in the
event of one of the following exceptions:
• Bridgeway has factual information confirming the death of a member
• Bridgeway receives a clear written statement signed by the member
that he or she no longer wishes services or gives information that
requires termination or reduction of services and indicates that he or she
understands that this must be the result of supplying that information
• The member’s provider prescribes a change in the level of medical care
• The date of action will occur in less than 10 calendar days in accordance
with 42 CFR 483.12(a)(5)(ii)
Bridgeway’s Medical Management Department may be contacted by phone at
1.866.475.3129.
Inpatient Notification Process
Inpatient facilities are required to notify Bridgeway for emergent and urgent
inpatient admissions by the next business day of the admission with clinical
information. Admissions made on the weekend require notification the next
business day.
Notification of newborn delivery is required by the discharge date. The following
information is required once the delivery is complete in order to receive the claim
reimbursement approval:
• Member name and Medicaid number (mother)
• Newborn name ( In the event, a name has not been selected at the time of
discharge, please submit with the newborn’s gender: Baby boy or Baby girl
and Last Name (ex. Baby boy Smith)
• Newborn’s Medicaid number
• Facility name, Physician name
• Admit date, delivery date, type of delivery
• Gender, weight, and Apgar score of the newborn, and gestational age of the
newborn
1.866.475.3129
[email protected]
Notification is required to track inpatient utilization, enable care coordination,
discharge planning, and ensure timely claim payment. To provide notification
and when applicable obtain prior authorization, please contact the Bridgeway
Medical Management Department by phone at 1.866.475.3129.
March 2016
28
Concurrent Review
Bridgeway ensures a consistent application of review criteria; and basis for
consistent decisions under its utilization management program.
Bridgeway has policies and procedures in place that govern the process for
proactive discharge planning when members have been admitted into an acute
care facility or skilled nursing facility. The intent of the discharge planning policy
and procedure is to increase the utilization management of inpatient admissions
and decrease readmissions within 30 days of discharge.
In addition, please note 42 CFR 447.26 prohibits payment for ProviderPreventable Conditions that meet the definition of a Health Care-Acquired
Condition (HCAC) or an Other Provider –Preventable Condition (OPPC) (refer to
AMPM Chapter 1000 requirements). If an HCAC or OPPC is identified, Bridgeway
reports the occurrence to AHCCCS and conducts a quality of care investigation.
Discharge Planning
Discharge planning activities are expected to be initiated upon admission. The
Bridgeway Medical Management Department will coordinate the discharge
planning efforts with the hospital’s Utilization and Discharge Planning
Departments and when necessary the member’s attending physician/PCP in
order to ensure that Bridgeway members receive appropriate post hospital
discharge care.
Retrospective Review
Retrospective review is an initial review of services that have been performed.
Routinely this process encompasses services performed by a provider when
there was no opportunity for concurrent review. However, retrospective review is
also performed on active cases where an appropriate decision cannot be made
concurrently within the required timeframe due to lack of clinical information.
Once all necessary information is received a decision is made within thirty (30)
calendar days. Medical records should be sent to the following address for
retrospective review:
The Medical Review Unit
PO Box 3000
Observation Guidelines
In the event that a member’s clinical symptoms do not meet the criteria for an
inpatient admission, but the treating physician believes that allowing the patient
to leave the facility would likely put the member at serious risk, the member may
be admitted to the facility for an observation period.
Observation Bed Services are those services furnished on a hospital’s premises,
including use of a bed and periodic monitoring by a hospital’s nurse or other
staff. These services are reasonable and necessary to:
• Evaluate an acutely ill patient’s condition
• Determine the need for a possible inpatient hospital admission
• Provide aggressive treatment for an acute condition
29
1.866.475.3129
[email protected]
An observation may last up to a maximum of forty-eight (48) hours. Outpatient
observation stays will not require notification. Outpatient observation stays
over 24 hours will require retrospective medical record review for payment
consideration. In those instances that a member begins their hospitalization in
an observation status and the member is upgraded to an inpatient admission,
all incurred observation charges and services will be rolled into the acute
reimbursement rate, or as designated by the contractual arrangement with
Bridgeway, and cannot be billed separately. It is the responsibility of the hospital
to notify Bridgeway of the inpatient admission by the next business of the
admission with clinical information. Providers should not substitute outpatient
observation services for medically appropriate inpatient hospital admissions.
Medical Management Criteria
Bridgeway has adopted utilization review criteria developed by McKesson
InterQual Products. InterQual appropriateness criteria are developed by
specialists representing a national panel from community-based and
academic practice. InterQual criteria cover medical and surgical admissions,
outpatient procedures, referrals to specialists, and ancillary services. Criteria
are established and periodically evaluated and updated with appropriate
involvement from physician members of the Bridgeway Medical Management
Committee.
InterQual is utilized as a screening guide and is not intended to be a substitute for
practitioner judgment. Utilization review decisions are made in accordance with
currently accepted medical or healthcare practices, taking into account special
circumstances of each case that may require deviation from the norm stated in
the screening criteria. Criteria are used for the approval of medical necessity but
not for the denial of services.
The Medical Director or qualified designee reviews all potential denials of medical
necessity decision. Providers may obtain the criteria used to make a specific
decision by contacting the Medical Management Department at 1.866.475.3129.
Providers and members have the right to request a copy of the review criteria or
benefit provision utilized to make a denial decision. Copies of the criteria can be
obtained by submitting your request in writing to:
Medical Management- Prior Authorization
Suite 201
Tempe, AZ 85281
Attn: Prior Authorization
Physicians can discuss denial decisions with the physician reviewer who made
the decision by calling the Medical Management Department at 1.866.475.3129,
Monday - Friday, between the hours of 8:00AM and 5:00PM.
1.866.475.3129
[email protected]
March 2016
30
NETWORK MANAGEMENT DEPARTMENT
Provider Support
The Network Management Department is designed around the concept of
making your experience with Bridgeway a positive one by being your advocate.
There are two provider service areas available to you as a contracted provider: 1)
the Network Department and 2) the Provider Services Department.
Network Department
The Network Department is responsible for providing the services listed below
via your assigned Network Representative and include but are not limited to:
• Contracting
o Including education on innovative contracting strategies and any
other contracting and contract questions
• Maintenance of the Provider Manual, orientation materials and reference
materials including the plan’s Network Newsletter: Click here to access:
Newsletter
• Development of alternative reimbursement strategies
• Network performance profiling. Data entry initiation of any demographic
information changes and oversee testing and completion of change
requests for the network
o Find a Provider Education
www.bridgewayhs.com/for-members/find-a-provider
• Sign up providers for EFT/ERA via PaySpan, http://www.bridgewayhs.com/
for-providers/payformance/
• Individual physician performance profiling
• Physician and office staff orientation
• Hospital and ancillary staff orientation
• Ongoing targeted provider education, updates, and training (in coordination
with the plan’s Claims Educator)
o Provider Conferences
• Receive and effectively respond to external provider related issues inservice upon contract execution
o In-service topics include but are not limited to:
• Member Eligibility
• Member Rights and Responsibilities
• Provider Responsibilities
• Medical Management
• Quality Management
o Billing and Claims submission- https://provider.bridgewayhs.com
• Claims submission requirements; including required National
Provider Identifier (NPI)
• Claims Dispute process
• Interpreter services
• Fraud, Waste, and Abuse Reporting
• Cultural Competency, including servicing people with disabilities
and Americans with Disabilities Act (ADA) regulations
• Authorization processes
• Case Management services available for members
• Behavioral Health Services and how to access them
• Provider rights and responsibilities
• Member rights and responsibilities, including performance
standards
• Provider complaint and appeal procedures
31
1.866.475.3129
[email protected]
The goal of this department is to furnish you and your staff with the necessary
tools to provide the highest quality of healthcare to Bridgeway members. To
contact the network representative assigned to you, please contact:
Network Department
1850 W. Rio Salado Parkway, Suite #201
Tempe, AZ 85281
1.866.475.3129
Provider Services Department
The Provider Services Department is responsible for the services listed below,
which include but are not limited to:
• Address provider claim inquiries (including initial claims, resubmission,
recoupments, etc.)
• Handling of special claims projects
• Researching of trends in claims inquiries to Bridgeway
• Ongoing provider education and updates(in coordination with the plan’s
Network Department)
The Provider Services toll free help line staff is available to you and your staff to
answer claims related questions.
Provider Services
1.866.475.3129
Member Services
Bridgeway is committed to providing its members with information about health
benefits that are available to them through the Bridgeway ALTCS program.
Bridgeway encourages members to take responsibility for their healthcare by
providing them with basic information to assist them with making decisions
about their healthcare choices.
As a Bridgeway contracted provider please remember that it is your obligation to
identify any member who requires translation, interpretation, or sign language
services. Bridgeway pays for these services whenever needed to effectively
communicate with our members. If you experience any issues accessing the
services, please notify your assigned Network Representative for assistance.
Member Materials
1.866.475.3129
[email protected]
March 2016
Members will receive various pieces of information from Bridgeway through
mailings and through face-to-face contact. Member materials are printed in
English and Spanish and pertinent materials and information can be requested in
Spanish or other languages and formats. Materials include but are not limited to:
• Member Newsletters
• Targeted Disease Management Brochures
• Provider Directory
• NurseWise information
• Emergency Room Information
• Member Handbook which includes
• Benefit information, including pharmacy network information
• Transportation information
Providers interested in receiving any of these materials may contact their
assigned Network Representative.
32
MEDICAL PROVIDER RESPONSIBILITIES
GENERAL PROVIDER RESPONSIBILITIES
Provider Responsibilities Overview
These responsibilities are minimum requirements to comply with contract terms
and all applicable laws. Providers are contractually obligated to adhere to and
comply with all terms of the plan, provider contract and requirements in this
manual. Bridgeway Health Solutions may or may not specifically communicate
such terms in forms other than the contract and this manual. This section
outlines general provider responsibilities; however, additional responsibilities are
included throughout the manual.
Contracted providers must ensure the following described below in detail:
• Adhere to AHCCCS appointment standards (Refer to Appointment
Standards section in the manual)
• Provide service coverage on a 24/7 basis (including on call)
• Respect AHCCCS member rights
• Provider services in a culturally sensitive manager
• Adhere to Americans with Disability Act (ADA) requirements
• Provide services in a non-discriminatory manner
• Report suspected fraud, waste and abuse
• PCPs must utilize the AHCCCS approved EPSDT tracking form
• PCPs must provide clinical information regarding a member’s health and
medication to a treating physician (including behavioral health) within ten
(10) business days of the request
• If treating children, enroll as a “Vaccines for Children (VFC)” provider
• Provider complaint and appeal procedures
Contracted providers must complete initial, annual and ongoing Bridgeway
trainings that include, but are not limited to the following topics:
• Member Appeals & Grievances
• Appointment Standards and Wait Times
• Language Line Services
• Proper Emergency Department (ED) Usage
• Fraud, Waste and Abuse/ False Claims Act Training
• Contacting the Health Plan
• Where to file claims and claim disputes
1.866.475.3129
[email protected]
33
PROVIDING MEMBER CARE
AHCCCS Registration
Each provider must first be registered with AHCCCS and obtain an AHCCCS
provider ID number. An active Medicare number must also be obtained
if providing service for Bridgeway Health Solutions Advantage. For more
information on the AHCCCS registration process, please visit:
https://www.azahcccs.gov/PlansProviders/NewProviders/registration.html.
Appointment Availability Standards
The following schedule should be followed regarding appointment availability:
Provider
PCP
Specialty
Referrals
Dental
Care
Maternity
Behavioral
Health
Emergent
Care
Same day
or Within
24 hours
Within 24
hours
Within 24
hours
3rd
Trimester
– Within
3 days of
request
Within 24
hours
Urgent
Care
Within 2
days
Routine
Care
Within 21
days
Within 3
days
Within 3
days
2nd
Trimester
– Within
7 days of
request
Within 45
days
Within 45
days
1st
Trimester
– Within
14 days of
request
Within 30
days
Transportation
(Non-Urgent/
Non-Emergent
High
Risk
Within 3
days of
request, or
immediately
Office Wait
Time
<45
Minutes
<45
Minutes
<45
Minutes
<45
Minutes
<45
Minutes
<1 hour
before
or after
Waiting Times
Bridgeway actively monitor and ensure that a member’s waiting time for a
scheduled appointment at the PCP’s or specialist’s office is no more than 45
minutes, except when the provider is unavailable due to an emergency.
For medically necessary non-emergent transportation, Bridgeway schedules
transportation so that the member arrives on time for the appointment, but
no sooner than one hour before the appointment; nor have to wait more than
one hour after the conclusion of the treatment for transportation home; nor be
picked up prior to the completion of treatment.
1.866.475.3129
[email protected]
March 2016
Bridgeway has developed and implemented a quarterly performance auditing
protocol to evaluate compliance with the standards above and uses the results of
appointment standards monitoring to assure adequate appointment availability
in order to reduce unnecessary emergency department utilization
Bridgeway has established processes to monitor and reduce the appointment
“no-show” rate by provider and service type. As best practices are identified
and required by AHCCCS, Bridgeway educates its provider network about
appointment time requirements. Bridgeway will coordinate with providers to
develop a corrective action plan when appointment standards are not met.
34
Provider Response Time For After Hour Calls
• Urgent Calls: Shall not exceed 20 minutes
• Other Calls: Shall not exceed one hour
Telephone Arrangements
Providers are required to develop and use telephone protocol for all of the
following situations:
• Answering the members telephone inquiries on a timely basis
• Prioritizing appointments
• Scheduling a series of appointments and follow-up appointments as
needed by a member
• Identifying and rescheduling broken and no-show appointments
• Identifying special member needs while scheduling an appointment
(e.g., wheelchair and interpretive linguistic needs, or for noncompliant
individuals or those people with cognitive impairments)
• Response time for telephone call-back waiting times:
o after hours telephone care for non-emergent, symptomatic issues
within thirty (30) to forty-five (45) minutes
o same day for non-symptomatic concerns
o crisis situations within fifteen (15) minutes
• Scheduling continuous availability and accessibility of professional, allied,
and supportive personnel to provide covered services within normal
working hours; Protocols shall be in place to provide coverage in the event
of a provider’s absence
• After-hour calls should be documented in a written format in either an
after-hour call log or some other method, and then transferred to the
member’s medical record
Note: If after-hour urgent care or emergent care is needed, the PCP or his/
her designee should contact the urgent care center or emergency department
in order to notify the facility. Notification is not required prior to member
receiving urgent or emergent care. Bridgeway monitors appointment and
after-hours availability on an on-going basis through its Quality Improvement
Program.
Covering Physicians
The Network Department must be notified if a covering provider is not
contracted or affiliated with Bridgeway. This notification must occur in advance
of providing coverage to obtain prior authorization. Reimbursement to covering
physicians is based on the Medicare and Medicaid Fee schedule. The covering
physician must bill under their own Tax Identification Number. Failure to notify
Bridgeway of covering physician affiliations may result in claim denials and the
provider may be responsible for reimbursing the covering provider. For additional
information please contact your Network Representative.
Locum Tenens
AHCCCS requires credentialing of individual providers or those through
an organization such as a Federally Qualified Health Center (FQHC) who is
contracted with a health plan. This includes the credentialing of Locum Tenens.
Locum Tenens will be provisionally credentialed in order to expedite the
credentialing process.
35
1.866.475.3129
[email protected]
Verifying Enrollment
Providers are responsible for verifying eligibility every time a member schedules
an appointment, and when they arrive for services. PCPs should also verify that a
member is their assigned member.
A member’s assigned provider must also be verified prior to rendering primary
care services. Bridgeway does not reimburse providers for services rendered to
members that lost eligibility or were not assigned to the primary care provider’s
panel (unless, s/he is physician covering for a provider).
Member eligibility may be verified through one of the following ways:
• Provider Portal: http://www.bridgewayhs.com/login/. *You must have
a confidential password to access. To register contact your Network
representative
• MediFax: MediFax is an electronic product available through AHCCCS
that stores key member information. Use to verify member eligibility for
pharmacy, dental, transportation and specialty care.
• AHCCCS Interactive Voice Response (IVR): To use, dial 602.417.7200. For
providers outside of Maricopa County only please dial 800.331.5090.
• Bridgeway Telephone Verification: Use as a last resort. Call Member
Services to verify eligibility at 1.866.475.3129. To protect member
confidentiality, providers are asked for at least three pieces of identifying
information such as member identification number, date of birth and
address, before any eligibility information can be released. When calling use
the prompt for the providers.
Missed or Cancelled Appointments
Providers must:
• Document and follow-up on missed or canceled appointments.
• Notify Member Services
Bridgeway reserves the right to request documentation supporting follow up
with members related to any missed appointments. Providers may also notify
Bridgeway Quality Management of missed appointments for QM staff to followup with members.
Member Panel Capacity
All PCPs reserve the right to state the number of members they are willing to
accept into their practice. Member assignment is based on the member’s choice
and auto assignment, therefore, Bridgeway DOES NOT guarantee that any
provider will receive a set number of members. If a PCP does declare a specific
capacity for his/her practice and wants to make a change to that capacity, the
PCP must contact the Bridgeway Network Department at 1.866.475.3129. A PCP
shall not refuse to treat members as long as the physician has not reached their
requested panel size.
1.866.475.3129
[email protected]
Provider shall notify Bridgeway at least forty-five (45) days in advance of his or
her inability to accept additional Medicaid covered persons under Bridgeway
agreements. Bridgeway prohibits all providers from intentionally segregating
members from fair treatment and covered services provided to other nonMedicaid members.
March 2016
36
Non-compliant Members
There may be instances when a PCP feels that a member should be removed
from his or her panel. All requests to remove a member from a panel must be
made in writing, contain detailed documentation directed to:
Attention: Case Management
Suite 201
Tempe, AZ 85281
1.866.475.3129
Fax: 1.866.687.0509
TDD/TTY: 711
Upon receipt of such request, Bridgeway may:
• Interview the provider or their staff that are requesting the disenrollment,
as well as any additional relevant providers
• Interview the member
• Review any relevant medical records
• Involve other Bridgeway departments as appropriate to resolve the issue
An example of a reason that a PCP may request to remove a member from their
panel includes, but is not limited to a member is disruptive, unruly, threatening,
or uncooperative to the extent that the member seriously impairs the provider’s
ability to provide services to the member or to other members and the member’s
behavior is not caused by a physical or behavioral condition.
A PCP should never request a member be disenrolled for any of the following
reasons:
• Adverse change in the member’s health status or utilization of services
which are medically necessary for the treatment of a member’s condition
• On the basis of the member’s race, color, national origin, sex, age, disability,
political beliefs or religion
• Previous inability to pay medical bills or previous outstanding account
balances prior to the member’s enrollment with Bridgeway
PRIMARY CARE PROVIDER (PCP)
The primary care provider (PCP) is a cornerstone of care for Bridgeway members.
The PCP serves as the “medical home” for the member. The “medical home”
concept assists in establishing a member-provider relationship and ultimately
better health outcomes. Members are given the option to select a PCP at
time of enrollment. If a member fails or declines to select a PCP, a PCP will be
automatically assigned to the member. Members are able to make changes to
their PCP selection by calling Member Services at 1.866.475.2129. The PCP is
required to adhere to the responsibilities outlined below.
Covered PCP Services
The PCP is responsible for supervising, coordinating, and providing all
primary care to each assigned member. In addition, the PCP is responsible for
coordinating and/or initiating referrals for specialty care, maintaining continuity
of each member’s healthcare and maintaining the member’s Medical Record,
which includes documentation of all services provided by the PCP as well as any
specialty services, including behavioral health. The PCP shall arrange for
37
1.866.475.3129
[email protected]
other participating physicians to provide members with covered physician
services as stipulated in their contract. Each participating PCP shall provide
all covered physician services in accordance with generally accepted clinical,
legal, and ethical standards in a manner consistent with practitioner licensure,
qualifications, training and experience. These standards of practice for quality
care are generally recognized within the medical community in which the PCP
practices.
PCP Availability and Accessibility
The availability of the Bridgeway network is central to member care and
treatment outcomes. In order to ensure appropriate care, Bridgeway has
adopted geographic accessibility standards. Bridgeway appreciates your efforts
to comply with our standards and for providing the highest quality care for our
members.
Performance data may be used by the plan for the development of quality
improvement activities. Each participating provider is required to maintain
sufficient facilities and personnel to provide covered services and shall ensure
that such services are available as needed twenty-four (24) hours a day, 365 days
a year. Bridgeway requires the hours of operation that network providers offer
Bridgeway Medicaid Members services no less than those offered to commercial
members. Bridgeway encourages PCPs to offer services after hours and on the
weekends.
Bridgeway monitors through scheduled and un-scheduled visits.
PCP Responsibilities
PCP responsibilities and expectations include:
• Educate members on how to maintain healthy lifestyles and prevent serious
illness
• Provide culturally competent care, treating all members with respect and
dignity
• Provide follow up on emergency care
• Maintain confidentiality of medical information to comply with all applicable
federal and state laws
• Obtain authorizations for all inpatient and selected outpatient services as
listed on the current Prior Authorization List, except for emergency services
up to the point of stabilization
• Maintain malpractice insurance acceptable to Bridgeway.
• Maintain vaccines safely and in accordance with specific guidelines, to
provide members immunizations and up-to-date records.
• Coverage 24 hours a day, 7 days a week.
Providers should refer to their contract for complete information regarding PCP
obligation and mode of reimbursement.
1.866.475.3129
[email protected]
Bridgeway does not restrict or prohibit a provider from advocating on behalf of a
member.
March 2016
38
SPECIALISTS
Specialist Responsibilities
Selected specialty services require a formal referral from the PCP. The specialist
may order diagnostic tests without PCP involvement by following Bridgeway’s
referral guidelines. The specialist must abide by the prior authorization
requirements when ordering diagnostic tests. However, the specialist may not
refer to other specialists or admit to the hospital without the approval of a PCP,
except in a true emergency situation.
All non-emergency inpatient admissions require prior authorization from
Bridgeway.
The specialist provider must:
• Maintain contact with the PCP
• Obtain referral or authorization from the member’s PCP and/or the
Bridgeway Medical Management Department as needed before providing
services
• Coordinate the member’s care with the PCP
• Provide the PCP with consult reports and other appropriate records within
five (5) business days
• Be available for or provide on-call coverage through another source twentyfour (24) hours a day for
Providers should refer to their contract for complete information regarding
providers’ obligations and mode of reimbursement.
Second Opinion
A member, a member’s representative or healthcare professional with member’s
consent may request and receive a second opinion from a qualified professional
within Bridgeway’s network. If there is not an appropriate provider to render the
second opinion within the network, the member may obtain the second opinion
from an out-of-network provider at no cost to the member. Out-of-network and
in-network specialty provider types on the prior authorization list will require
prior authorization.
HOSPITALS
Hospital Responsibilities
Bridgeway utilizes a network of hospitals to provide services. Hospitals must:
• Notify Bridgeway’s Medical Management Department of all inpatient
hospital admissions by the next business day of the admission with clinical
information.
• Outpatient observation stays will not require notification. Outpatient
observation stays over 24 hours will require retrospective medical record
review for payment consideration.
Hospitals should refer to their contract for complete information regarding the
hospitals’ obligations and mode of reimbursement.
39
1.866.475.3129
[email protected]
ROUTINE, URGENT AND EMERGENCY SERVICES
Members are encouraged to contact their PCP prior to seeking care, except in
an emergency. The following are definitions for routine, urgent, and emergency
services.
Routine - Services to treat a condition that would have no adverse effects if not
treated within twenty-four (24) hours or could be treated in a less acute setting
(e.g., physician’s office) or by the patient. Examples include treatment of a cold,
flu, or mild sprain.
Urgent* - Services furnished to treat an injury, illness, or another type of
condition, including a behavioral health condition, usually not considered life
threatening which should be treated within twenty-four (24) hours.
Emergency* - Services furnished to evaluate and/or stabilize an emergency
medical condition that is found to exist using the prudent layperson standard.
An Emergency Medical Condition is a medical or mental health condition
manifesting itself by acute symptoms of sufficient severity (including severe pain)
that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention
to result in:
• Placing the physical or mental health of the individual (or, with respect to a
pregnant woman, the health of the woman or her unborn child) in serious
jeopardy
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part
• Serious harm to self or others due to an alcohol or drug abuse emergency
• Injury to self or bodily harm to others; or
• With respect to a pregnant woman having contractions; (i) that there is not
adequate time to effect a safe transfer to another hospital before delivery,
or (ii) that transfer may pose a threat to the health or safety of the woman
or unborn child An emergency medical condition shall not be defined or
limited based on a list of diagnoses or symptoms.
Post-Stabilization Services: Covered services, related to an emergency medical
condition that are provided after a member is stabilized in order to maintain
the stabilized condition or to improve or resolve the member’s condition. Post
stabilization services will be considered complete when the following occurs:
• A plan physician with privileges at the treating hospital assumes
responsibility for the enrollee’s (member) care
• A plan physician assumes responsibility for the enrollee’s (member) care
through transfer
• Or the enrollee (member) is discharged.
Stabilized: With respect to an emergency medical condition; that no material
deterioration of the condition is likely, within reasonable medical probability, to
result from or occur during the transfer of the individual from a facility.
1.866.475.3129
[email protected]
March 2016
Discharge: Point at which member is formally released from hospital, by treating
physician, an authorized member of the physician’s staff or by the member after
they have indicated in writing, their decision to leave the hospital contrary to the
advice of their treating physician.
*Urgent, Emergency, or/and Post Stabilization Services does not require prior
authorization or pre-certification. Emergency and Post Stabilization Services can be
provided by a qualified Provider regardless of network participation. Bridgeway is
financially responsible for emergency and post stabilization regardless of network
participation. Notification is require by next business day for members admitted in to the
hospital, no prior authorization is required.
40
APPROPRIATE USE OF EMERGENCY SERVICES
The PCP plays a major role in educating Bridgeway members about appropriate
and inappropriate use of hospital emergency rooms. The PCP is responsible to
follow up on members who receive emergency care from other providers.
The attending emergency room physician, or the Provider actually treating
the member, is responsible for determining when the Member is sufficiently
stabilized for transfer. Bridgeway may establish arrangements with a hospital
whereby Bridgeway may send one of its own physicians with appropriate
emergency room privileges to assume the attending physician’s responsibilities
to stabilize, treat, and transfer the member, provided that such arrangement
does not delay the provision of emergency services.
Bridgeway will not retroactively deny a physician claim for an emergency
screening examination because the condition, which appeared to be an
emergency medical condition under the prudent layperson standard, turned
out to be non-emergency in nature. However, the prudent layperson test will
be applied to the payment to the facility for charges which fall outside of the
diagnoses codes identified as an emergency.
When a member is admitted from the emergency room, notification and clinical
information is required by the next business day of the admission. For specific
necessary information to submit, see the Inpatient Notification section of this
manual.
REFERRALS
Self-Referrals
It is Bridgeway’s preference that the PCP coordinates healthcare services.
However, members are allowed to self-refer for certain services (see above).
PCPs are encouraged to refer a member when medically necessary care is
needed that is beyond the scope of the PCP. Those referrals which require
authorization by the plan are listed below under prior authorization.
Providers are required to notify Bridgeway promptly when they are rendering
prenatal care to a Bridgeway member.
The following services do not require PCP authorization or referral:
• Prescription drugs, including certain prescribed over-the-counter drugs
• Emergency services including emergency ambulance transportation
• OB/GYN Services, including those of a Certified Nurse Midwife
• GYN Services, including those of a Certified Nurse Midwife
• Women’s health specialist covered services provided by a Federally
Qualified Health Center (FQHC) or Certified Nurse Practitioner
• Mental Health and Chemical Dependency/Substance Abuse services
• Family Planning Services and supplies from a qualified family planning
provider
• Except for emergency services, the above services must be obtained
through network providers or prior authorized out-of network providers
41
1.866.475.3129
[email protected]
If the PCP is capitated, referrals from a capitated PCP to another PCP will not be
authorized or covered except for the following circumstances:
• Members who are auto-assigned to another PCP in the third trimester of
•
•
their pregnancy when they become eligible for services under Bridgeway
(Medicaid members who are pregnant and not in the third trimester are
subject to plan review and approval)
Members having chronic medical conditions with ongoing healthcare
needs that require continuity of care transition; Examples include, but not
limited to, hemophilia, HIV/AIDS, sickle cell anemia, neoplasm, and organ
transplant
Members who have other insurance coverage in which their primary
provider is different from their Bridgeway assigned PCP
No paper referral is required for a referral or prior-authorization.
Referral requests can be made by phone, fax or web access.
To verify if an authorization is necessary or to obtain a prior authorization, call:
Bridgeway Prior Authorization
1.866.475.3129
Bridgeway has the capability to perform the ANSI X 12N 278 referral certification
and authorization transaction through Centene. For more information on
conducting this transaction electronically contact:
C/o Centene EDI Department
1.800.225.2573, extension 25525
DOCUMENTING MEMBER CARE
Member’s Medical Record
1.866.475.3129
[email protected]
Bridgeway providers must keep accurate and complete medical records.
Such records will enable providers to render the highest quality healthcare
service to members. They will also enable Bridgeway to review the quality and
appropriateness of the services rendered. To ensure the member’s privacy,
medical records should be kept in a secure location. Bridgeway requires
providers to maintain all records for members in accordance with the following
requirements:
• All records shall be maintained to the extent and in such detail as required
by Arizona Medicaid Rules and policies
• Records shall include but not be limited to financial statements, records
relating to the quality of care, medical records, prescription files and other
records specified by Medicaid
• Network providers must make available at all reasonable times during the
term of the contract any of its records for inspection, audit or reproduction
by any authorized representative of Bridgeway
• Network providers must preserve and make available all records for a
period of five years from the date of final payment under the contract
unless a longer period of time is required by law
• For retention of patient medical records, network providers must ensure
compliance with A.R.S. §12-2297 which provides, in part, that a health care
provider shall retain patient medical records according to the following:
March 2016
42
o If the patient is an adult, the provider shall retain the patient medical
•
records for at least six years after the last date the adult patient
received medical or health care services from that provider
o If the patient is under 18 years of age, the provider shall retain the
patient medical records either for at least three years after the child’s
eighteenth birthday or for at least six years after the last date the child
received medical or health care services from that provider, whichever
date occurs later
Network providers must comply with the record retention periods specified
in HIPAA laws and regulations, including, but not limited to, 45 CFR
164.530(j)(2)
Required Information in Medical Record
Medical records means the complete, comprehensive records of a member
including, but not limited to, x-rays, laboratory tests, results, examinations and
notes, accessible at the site of the member’s participating primary care physician
or provider, that document all medical services received by the member,
including inpatient, ambulatory, ancillary, and emergency care, prepared in
accordance with all applicable AHCCCS rules and regulations, and signed by the
medical professional rendering the services.
Providers must maintain complete medical records for members in accordance
with the following standards:
• Member’s name, and/or medical record number on all chart pages
• Personal/biographical data is present (i.e. spouse, home telephone
number, employer etc.)
• All entries must be legible
• All entries must be dated and signed, or dictated by the provider rendering
the care
• Significant illnesses and/or medical conditions are documented on the
problem list
• Medication, allergies, and adverse reactions are prominently documented
in a uniform location in the medical record; if no known allergies, NKA or
NKDA are documented
• An immunization record is established for pediatric members or an
appropriate history is made in chart for adults
• Evidence that preventive screening and services are offered in accordance
with Bridgeway’s practice guidelines
• Appropriate subjective and objective information pertinent to the member’s
presenting complaints is documented in the history and physical
• Past medical history (for members seen three or more times) is easily
identified and includes any serious accidents, operations and/or
• illnesses, discharge summaries, and ER encounters; for children and
adolescents (18 years and younger) past medical history relating to prenatal
care, birth, any operations and/or childhood illnesses
• Working diagnosis is consistent with findings
• Treatment plan is consistent with diagnosis
• Unresolved problems from previous visits are addressed in subsequent
visits
• Laboratory and other studies ordered as appropriate
• Abnormal lab and imaging study results have explicit notations in the
record for follow up plans; all entries should be initialed by the ordering
practitioner to signify review
43
1.866.475.3129
[email protected]
• Referrals to specialists and ancillary providers are documented, including
follow-up of outcomes and summaries of treatment rendered elsewhere
• Health teaching and/or counseling is documented
• For members ten (10) years and over, appropriate notations concerning use
•
•
•
•
•
•
of tobacco, alcohol and substance use (for members seen three or more
times substance abuse history should be queried)
Documentation of failure to keep an appointment
Encounter forms or notes have a notation, when indicated, regarding follow
up care calls or visits
Evidence that the member is not placed at inappropriate risk by a
diagnostic or therapeutic problem
Confidentiality of member information and records are protected
Evidence that an advance directive has been offered to adults 18 years of
age and older
Records are organized and easily accessible each visit and kept in a secure
location
Medical Records Release
All medical records of members shall be confidential and shall not be released
without the written authorization of covered person or a responsible covered
person’s legal guardian. When the release of medical records is appropriate,
the extent of that release should be based upon medical necessity or on a need
to know basis. Written authorization is required for the transmission of the
medical record information of a current and past members to any physician not
connected with Bridgeway.
Medical Records Transfer for New Members
All PCPs are required to document in the member’s medical record attempts to
obtain old medical records for all new members. If the member or member’s
guardian is unable to remember where they obtained medical care or are unable
to provide an appropriate address, then this should also be noted in the medical
record.
Medical Records Audits
Medical records may be audited to determine compliance with Bridgeway’s
standards for documentation. The coordination of care and services provided to
members including over/under utilization of specialists as well as the outcome of
such services may also be assessed during a medical record audit.
ADVANCE DIRECTIVES
Bridgeway is committed to ensuring that its members know of and are able
to avail themselves of their rights to execute advance directives. Bridgeway
is equally committed to ensuring that its providers and staff are aware of and
comply with their responsibilities under federal and state law regarding advance
directives.
1.866.475.3129
[email protected]
PCPs and physicians delivering care to Bridgeway members must ensure adult
members 18 years of age and older receive information on advance directives
and are informed of their right to execute advance directives. Providers must
document such information in the permanent medical record. Bridgeway
recommends to its PCPs and physicians that:
March 2016
44
• The first point of contact in the PCP’s office ask if the member has executed
•
•
•
•
•
•
an advance directive; the member’s response should be documented in the
medical record
Ask the member to bring a copy of the advance directive to the PCP’s office
and document this request
An advance directive should be included as a part of the member’s medical
record, including mental health directives
If an advance directive exists, the physician should discuss potential
medical emergencies with the member and/or family member/significant
other (if named in the advance directive and if available) and with the
referring physician, if applicable. Discussion should be documented in the
medical record
If an advance directive has not been executed, the first point of contact
within the office should ask the member if they desire more information
about advance directives.
If the member requests further information, member advance directive
education/information should be provided
Case Management and Member Services representatives will assist
members with questions regarding advance directives
If you have any questions regarding advance directives contact:
Case Management Department
1.866.475.3129
If the member feels the advance directive is not being followed, they may file a
complaint to:
Secretary of State
Attn: Advance Directive Dept.
1700 W. Washington Street, Fl 7
Phoenix, AZ 85007
1-602.542.6187 or 1.800.458.5842
Online: http://www.azsos.gov/services/advance-directives
TELEMEDICINE
Bridgeway works to improve the availability and provision of specialized health
care services in rural and underserved parts of Arizona through the use of
telemedicine, health information exchange and TeleHealth technologies. The
program’s goal is to enable all rural Arizona members to access specialty care
within 30 mile of their homes.
The program provides Bridgeway members and providers with access to one of
the most comprehensive telemedicine networks in the nation, and enhances
the level of and access to care for the significant rural populations that
Bridgeway serves throughout the state of Arizona. For more information, contact
Bridgeway’s Prior Authorization Department: 1.866.475.3129.
LANGUAGE LINE SERVICES
Bridgeway is committed to ensuring that staff and subcontractors are educated
about, remain aware of, and are sensitive to the linguistic needs and cultural
differences of its members. In order to meet this need, Bridgeway is committed
to the following:
45
1.866.475.3129
[email protected]
• Having
•
•
•
•
•
•
individuals available who are trained professional interpreters
for Spanish and American Sign Language, and who will be available on site
or via telephone to assist providers with discussing technical, medical, or
treatment information with members as needed
Providing Language Line services that will be available twenty-four (24)
hours a day, seven (7) days a week in 140 languages to assist providers
and members in communicating with each other when there are no other
translators available for the language
In-person interpreter services are made available when Bridgeway is
notified in advance of the member’s scheduled appointment in order to
allow for a more positive encounter between the member and provider;
telephonic services are available for those encounters involving urgent/
emergent situations, as well as non-urgent/emergent appointments as
requested
Providing TTY access for members who are hearing impaired through 711
Bridgeway’s medical advice line, NurseWise®, provides 24-hour access,
seven days a week for interpretation of Spanish or the coordination of nonEnglish/Spanish needs via the Language Line
Providing or making available Bridgeway Member Services and Health
Education materials in alternative formats as needed to meet the needs
of the members, such as audio tapes or language translation; all
alternative methods must be requested by the member or designee
Call Member Services at 1.866.475.3129 if interpreter services are needed.
Please have the member’s ID number; date/time service is requested
and any other documentation that would assist in scheduling
interpreter services.
CULTURAL COMPETENCY
Overview
Cultural competency is defined as “A set of interpersonal skills that allow
individuals to increase their understanding, appreciation, acceptance, and
respect for cultural differences and similarities within, among and between
groups and the sensitivity to know how these differences influence relationships
with members”.
Bridgeway is committed to the development, strengthening and sustaining
of healthy provider/member relationships. Members are entitled to dignified,
appropriate and quality care. When healthcare services are delivered without
regard for cultural differences, members are at risk for sub-optimal care.
Members may be unable or unwilling to communicate their healthcare needs
in an insensitive environment, reducing effectiveness of the entire healthcare
process.
1.866.475.3129
[email protected]
Bridgeway will evaluate the cultural competency level of its network providers
and provide access to training and tool kits to assist provider’s in developing
culturally competent and culturally proficient practices. Network providers must
ensure the following:
• Members understand that they have access to medical interpreters,
signers, and TTY services to facilitate communication without cost to them
• Care is provided with consideration of the members’ race/ethnicity and
language and its impact/influence of the members’ health or illness
March 2016
46
• Office staff that routinely come in contact with members have access to and
•
•
•
•
participate in cultural competency training and development
Office staff responsible for data collection makes reasonable attempts to
collect race and language specific member information.
Staff will also explain race/ethnicity categories to a member so that the that
the member is able to identify the race/ethnicity of themselves and their
children
Treatment plans are developed and clinical guidelines are followed with
consideration of the members race, country of origin, native language,
social class, religion, mental or physical abilities, heritage, acculturation,
age, gender, sexual orientation and other characteristics that may result in
a different perspective or decision making process
Office sites have posted and printed materials in English, Spanish, and all
other prevalent non-English languages if required by AHCCCS.
Understanding the need for Culturally Competent Services
The Institute of Medicine report entitled “Unequal Treatment” along with
numerous research projects reveal that when accessing the healthcare system,
people of color are treated differently. Research also indicates that a person has
better health outcomes when they experience culturally appropriate interactions
with medical providers. The path to developing cultural competency begins
with self-awareness and ends with the realization and acceptance that the
goal of cultural competency is an ongoing process. Providers should note that
the experience of a member begins at the front door. Failure to use culturally
competent and linguistically competent practices could result in the following:
• Feelings of being insulted or treated rudely
• Reluctance and fear of making future contact with the office
• Confusion and misunderstanding
• Non-compliance
• Feelings of being uncared for, looked down on and devalued
• Parents resisting to seek help for their children
• Unfilled prescriptions
• Missed appointments
• Misdiagnosis due to lack of information sharing
• Wasted time
• Increased grievances or complaints
Preparing Cultural Competency Development
The road to developing a culturally competent practice begins with the
recognition and acceptance of the value of meeting the needs of your patients.
Bridgeway is committed to helping you reach this goal. For information on
Bridgeway’s Cultural Competency Plan, please review the plan on our web
site, www.bridgewayhs.com, or request a free copy of the plan by calling
1.866.475.3129. Please visit our web site for links to free on-line learning
tools which address health literacy, cultural competency and limited English
proficiency. For additional information on developing and meeting cultural
competency standards within your practice, please review A Physician’s Practical
Guide to Culturally Competent Care at: https://cccm.thinkculturalhealth.org/.
• Take into consideration the following as you provide care to the Bridgeway
members:
• What are your own cultural values and identity?
• How do or can cultural differences impact your relationship with your
patients?
47
1.866.475.3129
[email protected]
• Does your understanding of culture take into consideration values,
•
communication styles, spirituality, language ability, literacy, and family
definitions?
Do you embrace differences as allies in your patients’ healing process?
Facts about Health Disparities 1
• Persons with lower income and less education face many to receiving timely
care.
• Households headed by Hispanics are more likely to report difficulty in
obtaining care
• Many minorities are more likely to experience long wait times to see
healthcare providers
• African Americans experience longer waits in emergency departments and
are more likely to leave without being seen
• Many racial and ethnic minorities of lower socioeconomic position are less
likely to receive timely prenatal care, more likely to have low birth weight
babies and have higher infant and maternal mortality.
• Racial and ethnic low-income minority children are less likely to receive
childhood immunizations
• Patient race, ethnicity, and socioeconomic status are important indicators
of the effectiveness of healthcare
• Health Disparities come at a personal and societal price
1 AHRQ “2003 National Healthcare Disparities Report”
1.866.475.3129
[email protected]
March 2016
48
MEMBER RIGHTS & RESPONSIBILITIES
Member Rights
Bridgeway members can expect to be treated fairly and with respect. We provide
covered services to all members without regard to:
• Age
• Disability
• Marital Status
• Race
• Sex
• Income
• Health Status
• Arrest or Conviction
• Religion
• Sexual Preference
• Color
• Birth Nation
• Military Participation
• Language
All services that are covered and medically necessary may be obtained. All
services are provided in the same way to all members. Bridgeway providers who
refer members for care do so the same way for all.
Translation services, including sign language, are available to members at no
cost to enable them to receive materials, educational information and medical
services in a language they best understand.
Respect and Dignity
Bridgeway members can expect to:
• Be treated fairly and with respect regardless of race, ethnicity, religion,
mental or physical disability, sex, age, sexual preference or ability to pay
• Get quality medical services that support your personal beliefs, medical
condition(s) and background in a language that you understand
• Get information in your own language, or have it translated
• Receive information in an alternative format
• Be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience or retaliation
CONFIDENTIALITY AND PRIVACY
Members have the right to:
• Have protected health information kept private
• Privacy and confidentiality of health care information
• Talk to health care professionals in a private manner
Personal Rights
Bridgeway members maintain the following personal rights:
• Receive services in a safe place
• For Nursing Home residents (or other alternative settings), the right to
choose to share a room with a spouse when appropriate
49
1.866.475.3129
[email protected]
• If residing in a Nursing Home (or other alternative setting), the right to keep
•
•
•
•
and use personal clothing and belongings (as long as there is room and the
items are not prohibited for medical reasons)
For Assisted Living Center residents, the choice to reside in a single
occupancy unit
Choose to remain in your home
To manage your own finances, or have someone trusted be responsible for
finances
To be free from any restraints or seclusion used as a mean of coercion,
discipline, convenience or retaliation
Member Participation in Treatment Decisions
1.866.475.3129
[email protected]
Bridgeway members are encouraged to participate in treatment decisions.
Members have the following rights:
• Privacy and confidentiality of health care information, including private
discussions with health care providers
• To know treatment choices or types of care available and the benefits and
drawbacks of each choice
• To have treatment options shared in a way they understand and is
appropriate for their medical condition.
• To decline treatments, services and PCP’s
• To be told what may happen by declining treatment (Member medical care
CANNOT depend on member agreement to follow a treatment plan.)
• To decline tasks that are NOT part of their care plan.
• To decline drugs or restraints, except for times when the treating doctor
determines these actions are necessary to protect the member or others
from harm
• To include family and/or caregivers in treatment
• To agree or refuse treatment services (unless they are court ordered)
• To refuse care from a doctor the member was referred to
• To have someone be with the member for treatments and exams
• To have a female in the room for breast and pelvic exams
• Information on how to get services and submit authorizations for services
• To choose or change a PCP
• To talk to the assigned PCP about current health condition(s)
• To receive information from PCP about current health condition(s)
• To receive information on medical procedures and who will perform them
• To receive a second opinion from a doctor outside of the Bridgeway network
at no cost to the member (if a Bridgeway network provider is not available
or appropriate)
• To transfer or leave a long-term care home because of medical reasons, for
members own good or the good of others, or for not paying
• To receive emergency health care services without the approval of the
assigned PCP or Bridgeway (members may go to any emergency room or
other setting for emergency care)
• To receive behavioral health services without the prior approval of a PCP or
Bridgeway
• To see a specialist with a referral from a PCP
Additionally, Bridgeway members, family, guardians or other authorized
representatives have the right to:
• Obtain the name of the member’s PCP
• Obtain the name of the member’s Case Manager
March 2016
50
• Receive one (1) copy of member’s medical records at no cost to the
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
member
Know the name, location and telephone numbers of currently contracted
providers in the member’s service area that speak a language other than
English (including identification of the languages spoken)
Know the amount, duration, and scope of all services, benefits, and service
providers available as part of the member’s enrollment with Bridgeway
Request to amend or correct medical records
To inspect medical records- note: members may not be able to get a copy
of medical records that contain psychotherapy notices put together for a
civil, criminal or administrative action
A copy of the Bridgeway Member Handbook
Be free from any restrictions on member freedom of choice among network
providers
A description of member rights and responsibilities
Information on how Bridgeway provides after hours and emergency care
Know the location of providers and hospitals that furnish emergency and
post stabilization services
Information on how Bridgeway pays providers, controls costs and uses
services (including whether or not Bridgeway has a Physician Incentive Plan
and associated information)
Request information on the structure and operation of Bridgeway and our
subcontractors
Request information on Physician Incentive Plans (PIP) that affect use of
referral services
Know the types of compensation arrangements used by Bridgeway
Know whether stop loss insurance is required
General grievance results
A summary of member survey results
Information on how Bridgeway evaluates new technology to include as a
covered service
Information on Advance Directives
Information on how medical decisions can be made for members when they
are not able to themselves
Actions to take if an assigned PCP leaves the Bridgeway network
Member costs to get a service that Bridgeway does not cover
Be informed in writing when any services are reduced, suspended,
terminated or denied (must follow instructions in the written notification)
Appeal denied or reduced services
Member Responsibilities
Bridgeway members have the following responsibilities:
• Not to lose or share their Member ID card with anyone
• To respect the doctors, pharmacists, office staff, facilities and Bridgeway
staff providing services
• To share all insurance information (such as Medicare) with case managers
and PCPs
• To present member ID card(s) before getting the services or prescriptions
• To notify AHCCCS, the assigned case manager and/or Member Services
about changes that could impact coverage eligibility (changes in address,
phone numbers, assists, etc.)
• To speak with doctors about all health problems (prior illnesses, hospital
admissions, medications and vaccinations)
51
1.866.475.3129
[email protected]
• To notify the PCP about changes in health conditions
• To ask the doctor for additional explanation if they do not understand a
health condition or care plan
Member Grievances
A grievance is an expression of dissatisfaction with any aspect of Bridgeway
Health Solutions’ or a provider’s provision operation, provision of healthcare
services, activities, or behaviors other than a Proposed Action.
Members have the right to:
• File an appeal and get a decision from Bridgeway within the required
timeframes
• Contact Bridgeway about any potential fraud, waste or abuse concerns
• Give Bridgeway feedback on policies and services
Members or a member’s authorized representative may file a grievance
either orally or in writing. Bridgeway will notify the member or authorized
representative that the grievance has been received in writing within ten
(10) business days of receipt of the grievance. Members or their authorized
representatives my file a grievance by contacting Member Services at
1.866.475.3129 or by submitting written notification to:
Attn: Grievances and Appeals
1850 W. Rio Salado Parkway, Suite 201
Tempe, AZ 85281
Bridgeway will respond to all issues raised by members within 90 calendar days
of receipt of the grievance. Should Bridgeway or the member request additional
time to resolve the grievance, Bridgeway will extend the resolution timeframe to
14 additional calendar days for resolution of the grievance.
Administrative Review (Member Appeal)
An Administrative Review (or Member Appeal) is the request for review of an
Action taken by Bridgeway. An Action is the denial or limited authorization
of a requested service, including the type or level of service; the reduction,
suspension, or termination of a previously authorized service; the denial, in
whole or part of payment for a service; the failure to provide services in a timely
manner, or the failure of Bridgeway to act within the time frames. The appeal may
be requested by telephone or in writing.
Who may file an Administrative Review:
• Bridgeway member
• Authorized representative of Bridgeway member
• Provider acting on behalf of member (with written member consent)
1.866.475.3129
[email protected]
Requests for an appeal must be made within sixty (60) calendar days from the
date of the Notice of Action. Under certain circumstances, members have the
right to request, within 10 days of the date of the Notice of Proposed Action, that
benefits be continued while an administrative review is pending. Bridgeway will
send a written decision within thirty (30) calendar days after the request for an
appeal is received by Bridgeway, subject to an authorized extension of up to 14
days.
March 2016
52
Expedited Administrative Review (Expedited Member Appeal)
If a decision on an appeal is required immediately due to the Member’s health
needs, an expedited appeal may be requested. If Bridgeway determines the
matter meets criteria for an expedited appeal, Bridgeway will provide a decision
within 72 hours of Bridgeway’s receipt of the request for the review, subject to an
authorized extension of up to 14 days.
Assistance Contacting Bridgeway
Bridgeway’s Appeals and Grievance Coordinator is available to assist members
who need help in filing a grievance or request for Administrative Review
or in completing any element in the grievance or Administrative Review
process. Members may seek assistance or initiate a grievance or request for
Administrative Review by calling 1.866.475.3129.
COVERED AND NON COVERED MEDICAL
SERVICES
COVERED SERVICES
For a combined listing of covered services please refer to Bridgeway Member
Handbook under the “Benefit Information” section:
http://www.bridgewayhs.com/files/2010/01/Bridgeway-MemberHandbook-2015-2016.pdf
For more detailed service descriptions including covered benefits, exclusions and
limitations, including behavioral health services, refer to the AHCCCS Medical
Policy Manual (AMPM) Chapters 300 and 1200 as well as the Behavioral Health
Services Guide.
https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap300.pdf
http://www.azdhs.gov/bhs/documents/covserv/covered-bhs-guide.pdf
Incontinence Briefs
In addition, Incontinence briefs (adult diapers and pull ups) are covered for
members on the Arizona LTC program when necessary to treat a medical
condition (like a rash or infection). For members under the age of 21 years,
incontinence briefs are also covered to avoid or prevent skin breakdown. Prior
authorization is required. Providers must indicate a clear medical condition
which causes incontinence and a prescription must be issued. Bridgeway can
cover up to 180 briefs per month. Prescribers must demonstrate any need
to have more than 180 briefs per month authorized. Bridgeway works with
J&B Medical Supply to meet the needs of incontinence supplies. J&B can be
contacted directly at:
J&B Medical Supply
1.800.737.0045
8:00AM-5:00PM
Monday-Friday
53
1.866.475.3129
[email protected]
Non Emergent Transportation
To arrange transportation for a Bridgeway member should contact the NonEmergency Transportation (NET) vendor that services all Bridgeway counties.
Urgent same day or next day transportation is available for an acute sick visit
to the primary care provider (PCP) or urgent care center, or if discharged
from the hospital. In situations where urgent transportation is needed and
cannot be coordinated with the NET vendor in a timely fashion please contact:
1.877.986.7420
NON COVERED SERVICES
• Services from a provider who is NOT contracted with Bridgeway (unless
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
prior approved)
Cosmetic services or items, unless medically necessary and prior
authorized
Personal care items such as combs, razors, soap etc.
Any service that requires prior authorization that was not prior authorized
Services or items given free of charge, or for which charges are not usually
made
Services of special duty nurses, unless medically necessary and prior
authorized
Routine circumcisions
Services that are determined to be experimental by the health plan medical
director
Abortions and abortion counseling, unless medically necessary, pregnancy
is the result of rape or incest, or if physical illness related to the pregnancy
endangers the health of the mother
Health services for incarcerated members
Experimental organ transplants, unless approved by AHCCCS
Sex change operations
Reversal of voluntary sterilization
Medications and supplies without a prescription
Treatment to straighten teeth, unless medically necessary and approved
Prescriptions not on Bridgeway’s list of covered medications, unless
approved
Diapers solely for personal hygiene
Physical exams for the purpose of qualifying for employment or sports
activities
Other Services that are Not Covered for Adults (age 21 and over)
• Hearing aids, including bone-anchored hearing aids.
• Cochlear implants;
• Microprocessor controlled lower limbs and microprocessor controlled
1.866.475.3129
[email protected]
•
•
•
•
•
•
March 2016
joints for lower limbs;
Percussive vests;
Services performed by a podiatrist (except for QMB members);
Routine eye examinations for prescriptive lenses or glasses;
Routine dental services and emergency dental services, unless related
to the treatment of a medical condition such as acute pain, infection, or
fracture of the jaw;
Chiropractic services (except for Medicare QMB members);
Outpatient speech and occupational therapy (except for Medicare QMB
members)
54
DENTAL SERVICES
Members Under the Age of 21
Bridgeway provides all members under the age of 21 with all medically necessary
dental services including emergency dental services, dental screening,
preventive services in accordance with the AHCCCS Dental Periodicity
Schedule, as well as therapeutic dental services, therapeutic services and
dental appliances in accordance with the AHCCCS Dental Periodicity Schedule.
Bridgeway monitors compliance with the AHCCCS Dental Periodicity Schedule
for dental screening services. The Contractor must develop processes to
assign members to a dental home by one year of age and communicate that
assignment to the member. Bridgeway regularly notifies oral health professionals
which members have been assigned to the provider’s dental home for routine
preventative care as outlined in AHCCCS Medical Policy Manual (AMPM) Chapter
400:
https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400.pdf.
Bridgeway ensures that members are notified in writing when dental screenings
are due, if the member has not been scheduled for a visit. If a dental screening is
not received by the member, a second written notice is sent. Members under the
age of 21 may request dental services without referral and may choose a dental
provider from the Bridgeway provider network.
Members Over the Age of 21
Pursuant to A.A.C. R9-22-207, for members who are 21 years of age and older,
Bridgeway covers medical and surgical services furnished by a dentist only to the
extent such services may be performed under state law either by a physician or
by a dentist. These services would be considered physician services if furnished
by a physician. Limited dental services are covered for pre-transplant candidates
and for members with cancer of the jaw, neck or head. Refer to the AMPM for
specific details.
PROVIDER GUIDELINES AND PLAN DETAILS
Credentialing
Bridgeway participates with other members of The Arizona Association of Health
Plans (AzAHP) in a credentialing Alliance that utilizes a contracted Credentialing
Verification Organization (CVO) as part of its credentialing and re-credentialing
process. The purpose of the Alliance is to lessen administrative burden for
providers that contract with multiple AHCCCS Contractors which often results in
duplicative submission of information used for credentialing purposes.
The CVO is responsible for receiving completed applications and attestations
and conducting primary source verifications. The CVO is also responsible
for conducting annual entity site visits to ensure compliance with AHCCCS
requirements. Once the CVO work is completed, Bridgeway credentialing
staff ensures that the providers are taken through the approval process and
appropriate updates are made within the Bridgeway provider system. Once
complete, notifications are sent out to the Providers who have completed the
Initial Credentialing process.
55
1.866.475.3129
[email protected]
Bridgeway conducts re-credentialing for providers at least every three (3) years
from the date of the initial credentialing decision. The purpose of this process is
to identify any changes in the practitioner’s licensure, sanctions, certification,
competence or health status, which may affect the ability to perform services
the provider is under contract to provide. This process includes all providers,
ancillary providers and/ or facilities previously credentialed to practice within the
Bridgeway network. Bridgeway includes utilization, performance, complaint, and
quality of care information as part of the approval process.
Notice: In order to maintain a current provider profile, providers are required
to notify Bridgeway of any relevant changes to their credentialing file in a
timely manner. A provider’s agreement may be terminated if at any time it is
determined by the Credentialing Committee that credentialing requirements are
no longer being met.
Providers must submit at a minimum the following information when applying for
participation with Bridgeway:
• Complete signed and dated Practitioner Credentialing Application Form
• Current Drug Enforcement Administration (DEA) registration Certificate,
when applicable
• Current malpractice insurance policy certificate that includes effective/
expiration date, amounts of coverage and the provider’s name
(Requirement $1mil/$3mil aggregate unless covered by some type of
Federal Tort)
• Signed attestation of history of loss of license and/or clinical privileges,
disciplinary actions, and/or felony convictions; lack of current illegal
substance and/or alcohol abuse; and mental and physical competence
• Copy of ECFMG certificate, if applicable
• Current Arizona Medical License
• Current copy of specialty/board certification certificate, if applicable
• Curriculum vitae listing, at minimum, a five-year work history
• Signed and dated release of information form
• National Provider Identification number (NPI)
• Valid Medicaid ID number
• Vaccines for Children (VFC) Letter (PCP’s only)
Credentialing Committee
The Bridgeway Credentialing Committee has responsibility for evaluating provider
credentials and making decisions to credential and or re-credential providers for
participation in to the Provider Network. This committee also performs oversight
of delegated credentialing activities and monthly ongoing monitoring. Committee
meetings are held monthly, no less than 10 times a year and reports to the
Bridgeway Quality Improvement Committee (QIC) quarterly.
Credentialing of Health Delivery Organizations
1.866.475.3129
[email protected]
March 2016
Prior to contracting with Health Delivery Organizations (HDOs), Bridgeway
verifies that the following organizations have been approved by a recognized
accrediting body or meet Bridgeway’s standards for participation, and are in
good standing with state and federal agencies:
• Hospitals
• Home Health Agencies
• Attendant Care Agencies
• Rehabilitation Centers
56
• Skilled Nursing Facilities
• Nursing Homes
• Free-Standing Surgical Centers
Bridgeway recognizes the following accrediting bodies:*
• AAAASF - American Association for Accreditation of Ambulatory Surgery
Facilities
• AAAHC - Accreditation Association for Ambulatory Healthcare
• ABCPO - American Board for Certification of Prosthetics and Orthotics
• AOA - American Osteopathic Association
• CAP - College of American Pathologists
• CARF - Commission on Accreditation of Rehabilitation Facilities
• CHAPS - Community Health Accreditation Program
• CCAC - Continuing Care Accreditation Commission
• CLIA - Clinical Laboratory Improvement Amendment certification-Please
note: Certification required not just CLIA license
• COLA - Commission on Office Laboratory Accreditation
• JCAHO - Joint Commission on Accreditation of Healthcare Organizations
• NCQA - National Committee for Quality Assurance
* This list may not be inclusive of all accrediting organizations. For those organizations
that are not accredited and licensed, an on-site evaluation will be scheduled to review
the scope of services available at the facility, physical plant safety, and the quality
improvement program. Current Centers for Medicare and Medicaid Services (CMS)
certificate will be accepted in lieu of a formal site visit, and can be utilized to augment
the information required to assess compliance with Bridgeway standards. HDOs are
re-credentialed at least every three (3) years to assure that the organization is in good
standing with state and federal regulatory bodies, has been reviewed and approved by
an accrediting body (as applicable), and continues to meet Bridgeway participation and
QI requirements.
Link to request an application (including credentialing):
http://www.bridgewayhs.com/for-providers/become-a-provider/
Right to Review and Correct Information
All providers participating with Bridgeway have the right to review information
obtained by Bridgeway to evaluate their credentialing and/ or re-credentialing
application. This includes information obtained from any outside primary source
such as the National Practitioner Data Bank- Healthcare Integrity and Protection
Data Bank, malpractice insurance carriers and the Arizona State Board of Medical
Examiners and Arizona State Board of Nursing for Nurse Practitioners. This does
not allow a provider to review references, personal recommendations or other
information that is peer review protected.
Should a provider believe any of the information used in the credentialing/ recredentialing process to be erroneous, or should any information gathered as
part of the primary source verification process differ from that submitted by a
practitioner, they have the right to correct any erroneous information submitted
by another party. To request release of such information, a written request
must be submitted to the Bridgeway Credentialing Department. Upon receipt
of this information, the provider will have fourteen (14) days to provide a written
explanation detailing the error or the difference in information.
57
1.866.475.3129
[email protected]
Denial of Initial Credentialing Application
The Credentials Committee (CC) may decide not to extend participation status
to a practitioner. The CC Chair or designee will notify the practitioner via certified
mail of the CC denial decision within sixty (60) calendar days of the CC’s
decision.
The letter of denial shall include information on the practitioner’s right to request
reconsideration
Practitioners who are denied participation for non-administrative reasons have
the right to request reconsideration of the decision within fourteen (14) calendar
days of the date of receipt of the denial letter. Should a provider believe any of
the information used in the credentialing process to be erroneous, or should
any information gathered as part of the primary source verification process
differ from that submitted by a practitioner, they have the right to correct any
erroneous information submitted by another party. To request release of such
information, a written request must be submitted to the Bridgeway Credentialing
Department.
All requests shall include:
1. Additional supporting documentation in favor of the applicant’s
consideration for network participation.
2. The provider will have additional time to provide a written explanation
detailing the error or the difference in information.
The request shall be presented to the CC at the next regularly scheduled meeting
but in no case later than sixty (60) calendar days from the receipt of additional
information. The CC may recommend:
a. Support the original denial recommendation by the CC and closure of the
file; OR
b. Support of the applicant’s ability to meet Bridgeway Health Solutions
minimum participation criteria and approval of the applicant for inclusion
in the Bridgeway Health Solutions network.
The Medical Director/CC Chair or designee, shall notify the applicant in
writing within sixty (60) calendar days of the CC decision. The decision of the
Credentials Committee is final and there are no appeal rights for initial credential
denials.
Providers who are denied initial participation may reapply for admission into the
network at a later date.
Recredentialing
Bridgeway Health Solutions formally recredentials providers at least every three
years. Application and attestation must be signed and dated within one hundred
and eighty (180) calendar days of the recredentialing decision, and verifications
must be completed within that period. Providers who voluntarily withdraw from
the Bridgeway Health solutions Network and then look to be reinstated must
complete the initial credentialing process if the break in service is thirty (30) days
or more, or if it has been more than three years since they were last credentialed.
Those providers will be subject to the initial credentialing guidelines.
1.866.475.3129
[email protected]
The information about the providers being considered for recredentialing is
brought to the Credentialing Committee for approval. If the provider has had no
adverse activity since their last credentialing, the file will be presented to the
committee for approval. In cases where there has been adverse activity such as
mal practice actions, performance monitoring and participation in a Corrective
March 2016
58
Action Plan, all relevant information is presented to the Credentials Committee
for discussion and approval or denial. The Credentials Committee has the final
authority for all Bridgeway Health Solution provider appointments.
Providers who are approved by the Credentials Committee will receive formal
written acknowledgement of that approval.
Denial of Recredentialing Application
Providers who are denied recredentialing by the Credentials Committee have
the right to appeal the Committee’s decision within fourteen (14) calendar days
of the date of receipt of the denial letter. Should a provider believe any of the
information used in the re-credentialing process to be erroneous, or should
any information gathered as part of the primary source verification process
differ from that submitted by a practitioner, they have the right to correct any
erroneous information submitted by another party. To request release of such
information, a written request must be submitted to the Bridgeway Credentialing
Department. All requests shall include additional supporting documentation in
favor of the applicant’s consideration for network participation and upon receipt
of this information, the provider will have additional time to provide a written
explanation detailing the error or the difference in information.
If after review of the new information, the Committee sustains their denial
decision, the provider will have the right to a Fair Hearing. (Reference Fair
Hearing Process in Bridgeway Health Solutions Policies and Procedures.)
Peer Review
Bridgeway has an established Peer Review Committee and Policy to address
issues related to Bridgeway providers’ quality of care/service. Composed
of licensed practitioners, committee participants conduct a peer review
in any situation where peers are needed to assess or monitor the medical
appropriateness or, aspect or pattern of care, behavior or practice, or other
areas which may be identified or deemed as inappropriate.
The Peer Review Committee is chaired by Bridgeway’s Chief Medical Officer,
and includes providers of the same or similar specialty as that of the case(s)
being reviewed. This may be accomplished through external consultation if the
specialty is not represented by the committee member. The proceedings of the
Committee are confidential, and participating members are required to sign a
confidentiality agreement prior to each meeting.
If the committee determines upon review to make a recommendation to deny,
limit, suspend, or terminate a practitioner’s privileges, the affected practitioner is
entitled to a Fair Hearing.
For more information please contact the Bridgeway Chief Medical Officer at:
Attention: Chief Medical Officer – Peer Review
1850 W. Rio Salado Parkway Suite 201
Tempe, AZ 85281
1.866.475.3129
59
1.866.475.3129
[email protected]
MARKETING
Providers may not market Bridgeway name, logo, or likeness without prior
approval.
HEALTH CARE ACQUIRED CONDITIONS AND
ABUSE
Organizational providers must have established policies and procedures that
meet AHCCCS requirements. The requirements must be met for all organizational
providers (including, but not limited to, hospitals, home health agencies,
attendant care agencies, group homes, nursing facilities, behavioral health
facilities, dialysis centers, transportation companies, dental and medical
schools, and free-standing surgi-centers). Processes must include reporting
incidences of Health Care Acquired Conditions, abuse, neglect, exploitation,
injuries and unexpected death to Bridgeway.
WEB PORTAL
Bridgeway provides a web-based platform enabling us to communicate
healthcare information directly with providers. Users can perform transactions,
download information, and work interactively with member healthcare
information (http://www.bridgewayhs.com/login/). The following information
can be reviewed and accessed on the provider portal:
• Member Eligibility Search – Verify current eligibility on one or more
members. Please note that eligibility may also be verified through the
AHCCCS website
• Panel Roster – View the list of members currently assigned to the provider
as the primary care provider (PCP)
• Provider List – Search for a specific health plan provider by name, specialty,
or location.
• Claims Status Search – Search for provider claims by member, provider,
claim number, or service dates. Only claims associated with the user’s
account provider ID will be displayed.
• Explanation of Payment (EOP) or “Remittance Advice” Search – Search
for provider claim payment information by member name, member ID,
provider name, provider ID, date of service, or date range or specific claim
number. Only remits associated with the user’s account provider ID will be
displayed.
• Authorization List – Search for provider authorizations by member, provider,
authorization data, or submission/service dates.
• Submit Authorizations – Submit an authorization request for a member
• HEDIS – Check the status of the member compliance with any of the HEDIS
measures
For registration information:
https://provider.bridgewayhs.com/careconnect/registration?execution=e1s1
1.866.475.3129
[email protected]
March 2016
60
EARLY AND PERIODIC SCREENING, DIAGNOSTIC
AND TREATMENT (EPSDT)
EPSDT Program Overview
The Early and Periodic Screening, Diagnostic and Treatment program (EPSDT) is
a comprehensive child health program of prevention, treatment, correction, and
improvement (amelioration) of physical and mental health problems for AHCCCS
members under the age of 21 as described in 42 USC 1396d (a) and (r). The EPSDT
program is governed by federal and state regulations and community standards
of practice. All PCPs who provide services to members under age 21 are required
to provide comprehensive health care, screening and preventive services,
including, but not limited to:
• Primary prevention
• Early intervention
• Diagnosis
• All services required to treat or improve a defect, problem or condition
identified in an EPSDT screening.
Requirements for EPSDT Providers
PCPs are required to comply with EPSDT regulatory requirements including:
• Document immunizations within 30 days of immunization to the Arizona
State Immunization Information System (ASIIS)
o Enroll every year in the Vaccine for Children Program
• Provide all screening services according to the AHCCCS Periodicity
Schedule and community standards of practice
o The Periodicity Schedule can be viewed by accessing the AHCCCS’
website: https://www.azahcccs.gov/shared/Downloads/
MedicalPolicyManual/Chap400.pdf
• Ensure all infants receive both the first and second newborn screening tests
o Specimens for the second test may be drawn at the PCP’s office and
mailed directly to the Arizona State Laboratory, or the member may be
referred to the contracted laboratory for the draw.
• Use current AHCCCS standardized EPSDT tracking forms to document
services provided and compliance with AHCCCS standards.
o EPSDT Tracking Forms are available on the AHCCCS website:
https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/
AppendixB.pdf
• Send copies of EPSDT tracking forms to Bridgeway on a monthly basis.
o Please fax forms to: MCH/EPSDT Coordinator 1.866.687.0515
• Use all clinical encounters to assess the need for EPSDT screening and/or
services
• Document in the medical record the member’s decision not to participate
in the EPSDT program, if appropriate
• Make referrals for diagnosis and treatment when necessary and initiate
follow-up services within 60 days
• Schedule the next appointment at the time of the current office visit for
children 24 months of age and younger
• Report all EPSDT encounters on required claim forms, using the Preventive
Medicine Codes
• Refer members to WIC, AzEIP and Head Start when appropriate
• Initiate and coordinate referrals to behavioral health providers as necessary
61
1.866.475.3129
[email protected]
An EPSDT screening includes the following basic elements:
• Comprehensive health and developmental history, including growth and
development screening (includes physical, nutritional and behavioral health
assessments)
• Developmental screening (using an AHCCCS approved developmental
screening tool) for members age 9, 18 and 24 months
• Comprehensive unclothed physical examination
• Appropriate immunizations according to age and health history
• Laboratory tests appropriate to age and risk for blood lead, tuberculosis
skin testing, anemia testing and sickle cell trait
• Health education and counseling about child development, healthy
lifestyles and accident and disease prevention
• Appropriate dental screening and referral
• Fluoride varnish application every six months (by providers who have
completed training) for members’ age 6-24 months with at least one tooth
eruption
• Appropriate vision and hearing/speech testing
• Obesity screening using the BMI percentile for children
• Preventive guidance
Health Education
PCPs are responsible for ensuring that health counseling and education are
provided at each EPSDT visit. Preventive guidance should be discussed so
that parents or guardians know what to expect with respect to the child’s
development. PCPs should also cover accident and disease prevention, and the
benefits of a healthy lifestyle.
SCREENINGS
Periodic Screenings
The AHCCCS EPSDT Periodicity Schedule specifies the screening services to be
provided at each stage of a child’s development. The AHCCCS EPSDT Periodicity
Schedule (Exhibit 430-1) can be viewed on the AHCCCS website. The schedule
follows Center for Disease Control (CDC) recommendations. Children may
receive additional inter-periodic screening at the discretion of the provider.
Bridgeway does not limit the number of well-child visits that members under age
21 receive.
Annual Well Child Visits are comprehensive and should include all of the services
required for sports or other activities. Physicals completed solely for the
purpose of sports activities are not covered by AHCCCS; therefore, no additional
payment would be made.
Nutritional Assessment & Nutritional Therapy
1.866.475.3129
[email protected]
March 2016
Nutritional therapy for EPSDT members on an enteral, parenteral or oral basis is
covered when determined medically necessary to provide either complete daily
dietary requirements, or to supplement a member’s daily nutritional and caloric
intake.
The following requirements apply:
• Needs must be reassessed at each visit
• Members in need of nutritional therapy should be identified and referred to
Bridgeway
62
• Nutritional therapy requires prior authorization and approval by the
•
Bridgeway Medical Director or other qualified health professional designee
Once prior authorization has been issued, provider must complete the
Commercial Oral Nutritional Supplements (EPSDT Members) form and
sent directly to the Durable Medical Equipment provider for handling
Developmental Screening Tools
The following developmental screening tools are available for members at their
9, 18 and 24 month EPSDT visit:
• Ages and Stages Questionnaires™ Third Edition (ASQ) is a tool used to
identify developmental delays in the first 5 years of a child’s life. The sooner
a delay or disability is identified, the sooner a child can be connected with
services and support that make a real difference.
• Ages and Stages Questionnaires®: Social-Emotional (ASQ: SE) is a tool
used to identify developmental delays for social-emotional screening.
• The Modified Checklist for Autism in Toddlers (M-CHAT) used only as a
screening tool by a primary care provider, for members 16-30 months of
age, to screen for autism when medically indicated.
• The Parents’ Evaluation of Developmental Status (PEDS) used for
developmental screening of EPSDT-aged members.
Payment for use of screening tools are covered when the following criteria is met:
• The member’s EPSDT visit is at either 9, 18, or 24 months;
• Prior to providing the service, the provider is required to complete the
required training for the developmental screening tool being utilized and
submit a copy of the training certificate to CAQH.
• The code is appropriately billed (96110-EP).
o Copies of the completed tools must be retained in the medical record
and submitted to the health plan with the completed EPSDT Tracking
Form.
PCP Application of Fluoride Varnish
Physicians who have completed the AHCCCS required training may be
reimbursed for fluoride varnish applications completed at the EPSDT visit for
recipients who are at least 6 months of age, with at least 1 tooth eruption.
Additional applications occurring every 6 months during an EPSDT visit, up until
the recipient’s 2nd birthday, will also be reimbursed.
EPSDT Oral Health Care
Physician, physician’s assistant or nurse practitioner must perform an oral health
screening as part of the EPSDT physical examination.
PCPs and attending physicians must refer EPSDT recipients to a dentist for
appropriate services based on the needs identified through the screening
process and for routine dental care based on the AHCCCS EPSDT Periodicity
Schedule (AMPM Exhibit 431-1). Evidence of the referral must be documented on
the ESPDT Tracking Form and in the recipient’s medical record.
Recipients must be assigned to a dental home by one year of age and seen by a
dentist for routine preventative care according to the AHCCCS EPSDT Periodicity
Schedule. The physician may refer EPSDT recipients for a dental assessment
at an earlier age, if their oral health screening reveals potential carious lesions
or other conditions requiring assessment and/or treatment by a dental
63
1.866.475.3129
[email protected]
professional. In addition to physician referrals, EPSDT recipients are allowed selfreferral to an AHCCCS registered dentist.
AHCCCS recommended training for fluoride varnish application is located
at the Smiles for Life website under Training Module 6 that covers caries risk
assessment, fluoride varnish and counseling. Upon completion of the required
training, providers should fax a copy of their certificate to Bridgeway’s Network
Department at 1-866-687-0514. This certificate will be used in the credentialing
process to verify completion of training necessary for reimbursement.
An oral health screening must be part of an EPSDT screening conducted by a
PCP. However, it does not substitute for examination through direct referral to
a dentist. PCPs must refer EPSDT members for appropriate services based on
needs identified through the screening process and for routine dental care based
on the AHCCCS EPSDT Periodicity Schedule. Evidence of this referral must be
documented on the EPSDT Tracking Form and in the member’s medical record.
Pediatric Immunizations/Vaccines for Children Program
EPSDT covers all child and adolescent immunizations. Immunizations must be
provided according to the Advisory Committee on Immunization Practices
(ACIP) guidelines and be up-to-date. Providers are required to coordinate with
the Arizona Department of Health Services’ (ADHS) Vaccine for Children Program
(VFC) to obtain vaccines for Bridgeway members who are 18 years of age and
under.
Additional information can be attained by calling Vaccine for Children at
1-602.364.3642 or by accessing their website.
Arizona law requires the reporting of all immunizations administered to children
under 19 years old. Immunizations must be reported at least monthly to ADHS.
Reported immunizations are held in a central database, the Arizona State
Immunization Information System (ASIIS) that can be accessed online to obtain
complete, accurate records.
Bridgeway requests that all primary care providers and pediatricians caring for
newborns review each member’s immunization records fully upon the initial visit,
and subsequent follow-up visits, regardless of where the child was delivered. It
is our intention to ensure that the newborns receive all required vaccines, and
that those who have not received the birth dose of the Hepatitis B vaccine in the
hospital be “caught up” by their primary care provider.
Body Mass Index (BMI)
Providers should calculate each child’s BMI starting at age three until the
member is 21 years old. Body mass index is used to assess underweight,
overweight, and those at risk for overweight. BMI for children is gender and age
specific. PCPs are required to calculate the child’s BMI and percentile. Additional
information is available at the CDC website regarding Body Mass Index (BMI).
1.866.475.3129
[email protected]
The following established percentile cutoff points are used to identify
underweight and overweight in children:
March 2016
64
Body Mass Index (BMI) Table
• Underweight - BMI for age <5th percentile
• At risk of Overweight - BMI for age 85th percentile to <95th percentile
• Overweight - BMI for age > 95th percentile
Blood Lead Screening
• All children are considered at risk of, and must be screened for lead
poisoning.
• Children at 12 months of age and at 24 months of age must receive a blood
lead test.
• Children between 36 months and 72 months of age must receive a blood
lead test if they have not been previously screened.
A verbal risk assessment must be completed at each EPSDT visit for children
six months through 72 months to determine risk category and the need for any
follow up services.
Providers must report blood lead levels equal to or greater than 10 micrograms of
lead per deciliter of whole blood to the ADHS.
Eye Examinations and Prescriptive Lenses
EPSDT includes eye exams and prescriptive lenses to correct or ameliorate
defects, physical illness and conditions. PCPs are required to perform basic
eye exams and refer members to the contracted vision provider for further
assessment.
Hearing/Speech Screening
Hearing evaluation consists of appropriate hearing screens given according
to the EPSDT schedule. Evaluation consists of history, risk factors, parental
questions and impedance testing.
• Pure-tone testing should be performed when medically necessary.
• Speech screening shall be performed to assess the language development
of the member at each EPSDT visit.
Behavioral Health Screening
Screenings for mental health and substance abuse problems are to be
conducted at each EPSDT visit. Treatment services are a covered benefit for
members under age 21. The PCP is expected to:
• Initiate and coordinate necessary referrals for behavioral health services.
• Monitor whether a member has received services.
• Keep any information received from a behavioral health provider regarding
the member in the member’s medical record.
• Initial and date copies of referrals or information sent to a behavioral health
provider before placing in the member’s medical record.
• If the member has not yet been seen by the PCP, this information may be
kept in an appropriately labeled file in lieu of actually establishing a medical
record, but must be associated with the member’s medical record as soon
as one is established.
65
1.866.475.3129
[email protected]
Dental Screening and Referrals
Oral health screenings are to be conducted at every EPSDT visit. The PCP must
screen children less than three years of age at each visit to identify those who
require a dental referral for evaluation and treatment.
In addition to the screening, members three years of age and older must
be referred to a dentist at least annually. American Association of Pediatric
dentistry recommends that the dental visits begin by age one but the referral
isn’t mandatory until age 3. Documented dental findings and treatment must
be included in the member’s medical record in the PCP’s office. Depending on
the results of the oral health screening, referral to a dentist should be made
according to the following timeframes:
• Urgent - (Within 24 hours) Pain, infection, swelling and/or soft tissue
ulceration of approximately two weeks duration or longer
• Early - (Within three weeks) Decay without pain, spontaneous bleeding of
the gums and/or suspicious white or red tissue areas
• Routine - (Next regular checkup) none of the above problems identified.
The member’s parent or guardian may also self-refer and schedule dental
appointments for the member with any contracted general dentist. They may
go directly to the dentist without seeing the PCP first and no authorization is
required.
Tuberculin Skin Testing
Tuberculin skin testing should be performed as appropriate to age and risk.
Children at increased risk of tuberculosis (TB) include those who have contact
with persons:
• Confined or suspected of TB;
• In jail during the last five years;
• Living in a household with an HIV-infected person or the child is infected
with HIV; and
• Traveling/emigrating from, or having significant contact with persons
indigenous to, endemic countries.
STATE PROGRAMS
Arizona Early Intervention Program (AzEIP)
AzEIP is an early intervention program that offers a statewide system of support
and services for children birth through three years of age and their families who
have disabilities or developmental delays. This program was jointly developed
and implemented by AHCCCS and the Arizona Early Intervention Program
(AzEIP) to ensure the coordination and provision of EPSDT and early intervention
services, such as physical therapy, occupational therapy, speech/language
therapy and care coordination under Sec. 1905 [42 U.S.C 1396d]. Concerns about
a child’s development may be initially identified by the child’s Primary Care
Provider or by AzEIP.
1.866.475.3129
[email protected]
Bridgeway coordinates with AzEIP to ensure that members receive medically
necessary EPSDT services in a timely manner to promote optimum child health
and development. For additional information, please contact the Bridgeway
EPSDT Coordinator.
March 2016
66
Head Start Program
Head Start programs are provided at no cost to families and help prepare young
children for kindergarten. These programs are for children ages 3 or 4 as of
September 1 of each year. They provide children with well-equipped classrooms,
nutritional snacks and meals, special services for the disabled, and handicapped
health services. For further information, please call Member Services at
1.866.475.3129.
AHCCCS Office of Special Programs
Children who have been diagnosed with the following genetic metabolic
conditions and who need medical foods may receive services directly through the
AHCCCS Office of Special Programs. AHCCCS covers medical foods, within the
limitations specified in the AHCCCS Medical Policy Manual (AMPM), Chapter 320H, Medical Foods, for any member diagnosed with one of the following inherited
metabolic conditions:
• Phenylketonuria
• Homocystinuria
• Maple Syrup Urine Disease
• Galactosemia (requires soy formula)
• Beta Keto-Thiolase Deficiency
• Citrullinemia
• Glutaric Acidemia Type I
• 3 Methylcrotonyl CoA Carboxylase Deficiency
• Isovaleric Acidemia
• Methylmalonic Acidemia
• Propionic Acidemia
• Arginosuccinic Acidemia
• Tyrosinemia Type I
• HMG CoA Lyase Deficiency
• Cobalamin A, B, C Deficiencies
Metabolic Disorder Medical Foods – Coverage Entity:
• Members receiving EPSDT services that have been diagnosed with a
metabolic disorder included in the AMPM, Chapter 320-H, Medical Foods,
are eligible for services.
• Members receiving EPSDT services must receive metabolic formula.
• Members receiving EPSDT services who require modified low protein foods
• Bridgeway is responsible for providing both necessary metabolic formula
and modified low protein foods for members 21 years of age and older who
have been diagnosed with one of the inherited metabolic disorders included
in the AMPM, Chapter 320-H, Medical Foods section.
• Bridgeway is responsible for initial and follow-up consultations by a
genetics physician and/or a metabolic nutritionist, lab tests and other
services related to the provision of medical foods for enrolled members
diagnosed with a metabolic disorder included in the AMPM, Chapter 320–H,
Medical Foods section.
Further information can be obtained by contacting the Office of Special Programs
at 1-602.417.4053 or by referring to the AHCCCS Medical Policy Manual and
referring to Chapter 320-H, Medical Foods.
67
1.866.475.3129
[email protected]
BEHAVIORAL HEALTH
Behavioral Health Overview
Comprehensive mental health and substance abuse (behavioral health) services
are available to Bridgeway members. A direct referral for a behavioral health
evaluation can be made by any health care professional in coordination with the
member’s assigned PCP and case manager. Bridgeway members may also selfrefer for all behavioral health services. The level and type of behavioral health
services will be provided based upon a member’s strengths and needs and will
respect a member’s culture. Behavioral health services include:
• Behavior management (personal care, family support/home care training,
peer support)
• Behavioral health nursing services
• Emergency behavioral health care
• Emergency and non-emergency transportation
• Evaluation and assessment
• Individual, group and family therapy/ counseling
• Inpatient hospital services
• Non-hospital inpatient psychiatric facilities services (Level I residential
treatment centers and sub-Acute facilities)
• Lab and radiology services for psychotropic medication regulation and
diagnosis
• Opioid Agonist treatment
• Partial care (supervised, therapeutic and medical day programs)
• Psychosocial rehabilitation (living skills training; health promotion;
supportive employment services)
• Psychotropic medication
• Psychotropic medication adjustment and monitoring
• Respite care (with limitations)
• Rural substance abuse transitional agency services
• Home Care Training to Home Care Client
• Behavioral health/substance abuse screenings
• Wellness and recovery services
Behavioral Health Provider Types
1.866.475.3129
[email protected]
Several main provider types typically provide behavioral health services for
Bridgeway members. These may include, but are not limited to, the following
licensed agencies or individuals:
• Outpatient behavioral health clinics
• Psychiatrists
• Psychologists
• Certified psychiatric nurse practitioners
• Licensed clinical social workers
• Licensed professional counselors
• Licensed marriage and family therapists
• Licensed independent substance abuse counselors
• Residential treatment facilities
• Behavioral health residential facilities.
• Partial hospital programs
• Intensive outpatient programs
• Substance abuse programs
• Inpatient hospital facilities
• Community Service Agency
March 2016
68
Alternative Living Arrangements
Bridgeway includes the following alternative living arrangements:
• Behavioral Health Residential Facilities – these settings provide
behavioral health treatment with 24-hour supervision. Services may
include on site medical services and intensive behavioral health treatment
programs.
• Traumatic Brain Injury Treatment Facility – this setting provides treatment
and services for people with traumatic brain injuries.
Emergency Services
Bridgeway covers behavioral health emergency services for members. If a
member is experiencing a behavioral health crisis, please contact NurseWise at
1.866.475.3129.
During a member’s behavioral health emergency, a Behavioral Health Hotline
clinician may dispatch a behavioral health mobile crisis team to the site of the
member to de-escalate the situation and evaluate the member for behavioral
health services. All medically necessary services are covered by Bridgeway
Behavioral Health Screening
• Members should be screened by their PCP for behavioral health needs
during routine or preventive visits.
• Behavioral health screening by PCPs is required at each EPSDT visit for
members under age 21
Behavioral Health Appointment Standards
Bridgeway routinely monitors providers for compliance with appointment
standards. The minimum standard requirements are:
• Emergency - Within 24 hours of referral.
• Routine - within 30 days of referral.
• Post Hospitalization Visit – within 7 days of discharge
Behavioral Health Provider Coordination of Care Responsibilities
It is critical that a strong communication link be maintained with behavioral
health providers including:
• PCPs and other interested parties such as Adult Protective Services
• Public Fiduciary Department (if documentation is provided identifying the
Public Fiduciary Department as the member’s guardian)
• Veterans Office (when applicable)
• The court system (when completing paper work for all court ordered
treatments or evaluations)
• Other specialty providers involved in the care of the member.
Information can be shared with the other party that is necessary for the
member’s treatment. This process begins once a member is identified as
meeting medical necessity for seeing a behavioral health provider by the
behavioral health coordinator. Information can be shared with other parties with
written permission from the member or the member’s guardian.
69
1.866.475.3129
[email protected]
PCP Coordination of Care
The PCP will be informed of the member’s behavioral health provider so that
communication may be established. It is very important that PCPs develop
a strong communication link with the behavioral health provider. PCPs are
expected to exchange any relevant information such as medical history, current
medications, diagnosis and treatment within 10 business days of receiving the
request from the behavioral health provider.
Where there has been a change in a member’s health status identified by a
medical provider, there should be coordination of care with the behavioral health
provider within a timely manner. The update should include but is not limited
to; diagnosis of chronic conditions, support for the petitioning process, and all
medication prescribed.
The PCP should also document and initial signifying review receipt of information
received from a behavioral health provider who is treating the member. All efforts
to coordinate on care on behalf of the member should be documented in the
member’s medical record.
Medication
Assessing a member for psychotropic medication should include a review of the
recipients profile in the Arizona State Board of Pharmacy Controlled Substance
Prescription Monitoring Program (CSPMP) database when initiating a controlled
substance (i.e. amphetamines, opiates, benzodiazepines,etc.) that will be used
on a regular basis or for short term addition of agents when the client is known
to be receiving opioid pain medications or another controlled substance from a
secondary prescriber.
Prior Authorization Requirements and Process
Bridgeway requires prior authorization for certain outpatient behavioral health
services and continued hospital stays to assure medical necessity. A request for
authorization will be decided within 14 days of receipt for a standard request. An
expedited request for authorization will be responded to within three business
days of receipt of the request. Unauthorized services will not be reimbursed.
Authorization is not a guarantee of payment. To request an authorization:
• Contact the member’s LTC Case Manager for prior authorization prior to
delivery of services.
o Explain to the Case Manager the type of services to be delivered,
frequency of services to be delivered, and duration of services
provided.
Family Involvement
1.866.475.3129
[email protected]
Family involvement in a member’s treatment is an important aspect in recovery.
Studies have shown members who have family involved in their treatment tend to
recover quicker, have less dependence on outside agencies, and tend to rely less
on emergency resources. Family is defined as any person related to the member
biologically or appointed (step-parent, guardian, and/or power of attorney).
Treatment includes treatment planning, participation in counseling or psychiatric
sessions, providing transportation or social support to the member. Information
can be shared with other parties with written permission from the member or the
member’s guardian.
March 2016
70
COURT ORDERED TREATMENT AND PETITION PROCESS
At times a member may need to be petitioned through the Mental Health Court.
Court Order Definitions
A Mental Disorder is deemed by ARS Title 36 as follows: A substantial disorder
of the person’s emotional processes, thought, cognition or memory. Exclusions:
the person is primarily disabled due to drug abuse, alcoholism, or mental
retardation; declining mental abilities that accompany impending death; or
character and personality disorders characterized by life-long and deeply
ingrained anti-social behaviors that can be reasonably expected, on the basis of
competent medical opinion, to result in serious physical harm.
Danger to Others (DTO) [ARS § 36-501-4]: Judgment of a person having a
mental disorder is so impaired that he/she is unable to understand his need for
treatment and as a result of his/her mental disorder, his/her continued behavior
can reasonably be expected, on the basis of competent medical opinion, to
result in serious physical harm.
Danger to Self (DTS) [ ARS § 36-501-5 ]: Behavior which, as a result of a mental
disorder, constitutes a danger of inflicting serious physical harm upon oneself,
including attempted suicide or the serious treat thereof, or if the threat is
expected that it will be carried out in light of context and previous acts AND
which as a result of a mental disorder will, without hospitalization, result in
serious physical harm or serious illness to the person EXCEPT that behavior
which establishes only the condition of Gravely Disabled.
Gravely Disabled (GD) [ ARS § 36-501-15 ]: Condition evidenced by behavior
in which a person, as a result of a mental disorder, is likely to come to serious
physical harm or serious illness because he/she is unable to provide for his/her
basic physical needs.
Persistently or Acutely Disabled (PAD) [ ARS § 36-501-29 ]: Severe mental
disorder which, (1) if not treated has a substantial probability of causing the
person to suffer severe and abnormal mental, emotional or physical harm that
significantly impairs judgment, reason, behavior or capacity to recognize reality;
(2) substantially impairs the person’s capacity to the extent they are incapable
of understanding and expressing an understanding of the consequences of
accepting treatment as well as the alternatives to the particular treatment after
the advantages, disadvantages, and alternatives are explained; AND, (3) has a
reasonable prospect of being treatable by outpatient, inpatient, or combined
treatment.
Maricopa County
Urgent Psychiatric Care Center/ConnectionsAZ
602.416.7600
903 N. 2nd Street
Phoenix, AZ 85004
Psychiatric Recovery Center West/Recovery Innovations
602.416.7600
11361 N. 99th Avenue, Suite 402
Peoria, AZ 85345
71
1.866.475.3129
[email protected]
*Cochise/Graham/Greenlee
ACTS
520-226-9002
2039 E. Wilcox Drive
Suite A
Sierra Vista, AZ 85635
ACTS
928.792.4242
301 E. 4th Street
Suite A
Safford, AZ 85546
ACTS
928.792.2661
562 N. Coronado Blvd
Clifton, AZ 85533
Pinal/Gila
Horizon Health and Wellness
480.983.0065
625 N. Plaza Drive
Apache Junction, AZ 85120
Community Bridges
877.931.9142
803 W. Main Street
Payson, AZ 85541
877.931.9142
5734 E. Hope Lane
Globe, AZ 85501
Non-Emergent Petition
Non-Emergent Petitions are known as a Gravely Disabled or Persistently and
Acutely Disabled (PAD) and are defined: “As a result of a mental disorder is likely
to cause serious physical harm or illness because he/she is unable to provide for
their basic needs, or if not treated has probability of causing the person to suffer
severe mental, emotional, or physical harm, or impairs the person’s capacity
to extent they are incapable of understanding and expressing the consequence
of accepting treatment.”. The Non-Emergent Petitions are filed by calling the
EMPACT-SPC PAD line at 480.784.1514, extension 1158 (“Non-Emergent Petition
Team).
For members who are already under Court Ordered Treatment through the
Mental Health Court, Bridgeway is responsible for tracking the status of the
member’s treatment and reports to the Mental Health Court as necessary. As
such, treating providers must notify Bridgeway of any treatments.
1.866.475.3129
[email protected]
March 2016
Non-Emergent (PAD/GD) Petition
For members who are already under Court Ordered Treatment through the
Mental Health Court, Bridgeway is responsible for tracking the status of the
member’s treatment and reports to the Mental Health Court as necessary. As
such, treating providers must notify Bridgeway of any treatments.
72
BEHAVIORAL HEALTH TREATMENT PLANS AND DAILY
DOCUMENTATION
Behavioral Health Treatment Plan
A Behavioral Health Treatment Plan is developed and reviewed/updated at least
annually on each Bridgeway member, and should a change in the member’s
condition require a modification to the treatment plan. The treatment plan
includes strengths, measurable goals, presenting behavioral issues and
behavioral interventions to be utilized. Amended/renewed plans indicate goals
achieved or barriers interfering with success and recommendations to resolve.
WELL-WOMAN PREVENTIVE CARE
Overview
An annual well-woman preventive care visit is intended for the identification
of risk factors for disease, identification of existing medical/mental health
problems, and promotion of healthy lifestyle habits essential to reducing or
preventing risk factors for various disease processes. As such, the well-woman
preventative care visit is inclusive of a minimum of the following:
a. A physical exam (well exam) that assesses overall health.
b. Clinical breast exam.
c. Pelvic exam (as necessary, according to current recommendations and best
standards of practice).
d. Review and administration of immunizations, screenings and testing as
appropriate for age and risk factors. NOTE: Genetic screening and testing is
not covered.
e. Screening and counseling is included as part of the well-woman preventive
care visit and is focused on maintaining a healthy lifestyle and minimizing
health risks. Screening and counseling addresses at a minimum the
following:
i. Proper nutrition
ii. Physical activity
iii. Elevated BMI indicative of obesity
iv. Tobacco/substance use, abuse, and/or dependency
v. Depression screening
vi. Interpersonal and domestic violence screening, that includes
counseling involving elicitation of information from women and
adolescents about current/past violence and abuse, in a culturally
sensitive and supportive manner to address current health concerns
about safety and other current or future health problems
vii. Sexually transmitted infections
viii. Human Immunodeficiency Virus (HIV)
ix. Family planning counseling
x. Preconception counseling that includes discussion regarding a
healthy lifestyle before and between pregnancies that includes:
(a) Reproductive history and sexual practices
(b) Healthy weight, including diet and nutrition, as well as the use
of nutritional supplements and folic acid intake
(c) Physical activity or exercise
(d) Oral health care
(e) Chronic disease management
(f) Emotional wellness
(g) Tobacco and substance use (caffeine, alcohol, marijuana and
other drugs), including prescription drug use
(h) Recommended intervals between pregnancies
73
1.866.475.3129
[email protected]
NOTE: Preconception counseling does not include genetic testing.
f. Initiation of necessary referrals when the need for further evaluation,
diagnosis, and/or treatment is identified.
g. Immunizations - Bridgeway will cover the Human Papilloma Virus (HPV)
vaccine for female members 11 to 26 years of age. Providers must coordinate
with The Arizona Department of Health Services (ADHS) Vaccines for
Children (VFC) Program in the delivery of immunization services if providing
vaccinations to Early and Periodic Screening, Diagnostic and Treatment
(EPSDT) aged members less than 19 years of age. Immunizations must
be provided according to the Advisory Committee on Immunization
Practices Recommended Schedule. (Refer to the CDC website at http://
www.cdc.gov/vaccines/schedules/index.html where this information is
included). Providers must enroll and re-enroll annually with the VFC
program, in accordance with AHCCCS contract requirements in providing
immunizations for EPSDT aged members less than 19 years of age, and
must document each EPSDT age member’s immunizations in the Arizona
State Immunization Information System (ASIIS) registry. The VFC program
must be used for members under 19 years of age.
FAMILY PLANNING
Overview
Family planning services are provided by health professionals to eligible persons
who voluntarily choose to delay or prevent pregnancy. In order to allow members
to make informed decisions, counseling should provide accurate, up-to-date
information regarding available family planning methods and prevention of
sexually transmitted diseases.
Provider Responsibilities for Family Planning Services
1.866.475.3129
[email protected]
All providers are responsible for:
• Making appropriate referrals to health professionals who provide family
planning services.
• Keeping complete medical records regarding referrals.
• Verifying and documenting a member’s willingness to receive family
planning services.
• Providing medically necessary management of members with family
planning complications.
• Notifying members of available contraceptive services and making these
services available to all members of reproductive age using the following
guidelines:
• Information for members who are 17 years of age and younger must be
given the information through the member’s parent or guardian.
o Information for members between 18 and 55 years of age must be
provided directly to the member or legal guardian.
o Whenever possible, contraceptive services should be offered in a
broad-spectrum counseling context, which includes discussion
of mental health and sexually transmitted diseases, including AIDS.
o Members of any age whose sexual behavior exposes them to possible
conception or STDs should have access to the most effective methods
of contraception.
o Every effort should be made to include male or female partners in such
services.
March 2016
74
• Providing counseling and education to members of both genders that is
•
•
•
•
age appropriate and includes information on prevention of unplanned
pregnancies.
Counseling for unwanted pregnancies. Counseling should include the
member’s short and long - term goals.
Spacing of births to promote better outcomes for future pregnancies.
Preconception counseling to assist members in deciding on the advisability
and timing of pregnancy, to assess risks and to reinforce habits that
promote a healthy pregnancy.
Sexually transmitted diseases, to include methods of prevention,
abstinence, and changes in sexual behavior and lifestyle that promote the
development of good health habits.
Contraceptives should be recommended and prescribed for sexually active
members. Providers are required to discuss the availability of family planning
services annually. If a member’s sexual activity presents a risk or potential
risk, the provider should initiate an in-depth discussion on the variety of
contraceptives available and their use and effectiveness in preventing sexually
transmitted diseases (including AIDS). Such discussions must be documented in
the member’s medical record.
Covered and Non Covered Services
Full health care coverage and voluntary family planning services are covered.
The following services are not covered for the purposes of family planning:
• Treatment of infertility;
• Pregnancy termination counseling;
• Pregnancy terminations;
• Hysterectomies;
• Hysteroscopic tubal sterilization;
• Services to reduce voluntary, surgically induced fertilized embryos.
Prior Authorization Requirements
Prior authorization is required for Sterilization or Pregnancy Termination. Prior
authorization must be obtained before the services are rendered or the services
will not be eligible for reimbursement.
To obtain authorization for Sterilization or Pregnancy Termination:
• Complete applicable form(s):
o Sterilization- Permanent sterilization is only covered for members 21
years of age or older.
o For pregnancy termination per AHCCCS requirements
Fax completed prior authorization form and signed consent form prior to the
procedure to:
Prior Authorization
1.866.638.6129
1.866.475.3129
[email protected]
75
MATERNITY
Overview
Bridgeway assigns newly identified pregnant members to a PCP to manage
their routine non-OB care. The OB provider manages the pregnancy care for the
member and is reimbursed in accordance with their contract.
If a member chooses to have an OB as their PCP during their pregnancy,
Bridgeway will assign the member to an OB PCP. If an OB provider has been
assigned for OB services for a pregnant member, the member will remain with
their OB PCP until after their postpartum visit when they will return to their
previously assigned PCP.
High Risk Maternity Care
In partnership with OB providers, Bridgeway LTC case managers identify
pregnant women who are “at risk” for adverse pregnancy outcomes. Bridgeway
offers a multi-disciplinary program to assist providers in managing the care
of pregnant members who are at risk because of medical conditions, social
circumstances or non-compliant behaviors. Bridgeway also considers factors
such as noncompliance with prenatal care appointments and medical treatment
plans in determining risk status. Members identified as “at risk” are reviewed and
evaluated for ongoing follow up during their pregnancy by an obstetrical case
manager.
OB Case Management
Bridgeway’s OB case manager provides comprehensive care management
services to high risk pregnant members, for the purpose of improving maternal
and fetal birth outcomes. The OB case manager takes a collaborative approach
with all involved in the member’s prenatal care (OB PCP, LTC case manager, etc.)
to engage high risk pregnant members telephonically throughout their pregnancy
and post-partum period.
1.866.475.3129
[email protected]
March 2016
Members who present with high risk perinatal conditions should be referred to
perinatal case management. These conditions include:
• a history of preterm labor before 37 weeks of gestation
• bleeding and blood clotting disorders
• chronic medical conditions
• polyhydramnios or oligohydramnios
• placenta previa, abruption or accreta
• cervical changes
• multiple gestation
• teenage mothers
• hyperemesis
• poor weight gain
• advanced maternal age
• substance abuse
• mental illness
• domestic violence
• non-compliance with OB appointments
Referrals can be made by faxing the member information electronically to
Bridgeway MCH Coordinator 1.866.638.6126. Please include the provider group
and Tax ID Number.
76
Obstetrical Care Appointment Standards
Bridgeway has specific standards for the timing of initial and return prenatal
appointments. These standards are as follows:
Initial Visit
All OB providers must make it possible for members to obtain initial prenatal care
appointments within the time frames identified:
Category Appointment Availability
• First Trimester- within 14 days of the request for an appointment
• Second Trimester- within seven days of the request for an appointment
• Third Trimester- within three days of the request for an appointment
• Return Visits- return visits should be scheduled routinely after the initial
visit.
Members must be able to obtain return prenatal visits:
• First 28 weeks - every four weeks
• From 28 to 36 weeks - every two to three weeks
• From 37 weeks until delivery – weekly
• High Risk Pregnancy Care - within three days of identification of high risk
by Bridgeway or maternity care provider, or immediately if an emergency
exists.
General Obstetrical Care Requirements
All providers must adhere to the standards of care established by the American
College of Obstetrics and Gynecology (ACOG), which include, but are not limited
to the following:
• Use of a standardized prenatal medical record and risk assessment tool,
such as the ACOG Form, documenting all aspects of maternity care.
• Completion of history including medical and personal health (including
infections and exposures), menstrual cycles, past pregnancies and
outcomes, family and genetic history.
• Clinical expected date of confinement.
• Performance of physical exam (including determination and documentation
of pelvic adequacy).
• Performance of laboratory tests at recommended time intervals.
• Comprehensive risk assessment incorporating psychosocial, nutritional,
medical and educational factors.
• Routine prenatal visits with blood pressure, weight, fundal height (tape
measurement), fetal heart tones, urine dipstick for protein and glucose,
ongoing risk assessment with any change in pregnancy risk recorded and an
appropriate management plan.
• Antenatal and Postpartum Depression Screening
Additional Obstetrical Physician and Practitioner Requirements
• Educate members on healthy behaviors during pregnancy, including
proper nutrition, effects of alcohol and drugs, the physiology of pregnancy,
the process of labor and delivery, breast feeding and other infant care
information
• Offer HIV/AIDS testing and confidential post testing counseling to all
members.
• Ensure delivery of newborn meets Bridgeway criteria
77
1.866.475.3129
[email protected]
• Remind delivery hospital of requirement to notify Bridgeway on the date of
delivery
• Refer member to Bridgeway case management, and other known support
•
services and community resources, as needed
Encourage members to participate in childbirth classes at no cost to them.
The member may call the facility where she will deliver and register for
childbirth classes.
Providers may also consult with the Bridgeway medical director, or other
qualified designee for members with other conditions that are deemed
appropriate for perinatology referral.
In non-emergent situations, all obstetrical care physicians and practitioners must
refer members to Bridgeway providers. Referrals outside the contracted network
must be prior authorized. Failure to obtain prior authorization for non-emergent
OB or newborn services out of the network will result in claim denials. Members
may not be billed for covered services if the provider neglects to obtain the
appropriate approvals.
Provider Requirements for Medically Necessary Termination of
Pregnancy
The Bridgeway Medical Director or qualified designee reviews all requests for
medically necessary pregnancy terminations. Documentation must include:
• A copy of the member’s medical record;
• A completed and signed copy of the Certificate of Necessity for Pregnancy
Termination
• Written explanation of the reason that the procedure is medically
necessary. For example, it is:
o Creating a serious physical or mental health problem for the pregnant
member
o Seriously impairing a bodily function of the pregnant member
o Causing dysfunction of a bodily organ or part of the pregnant member
o Exacerbating a health problem of the pregnant member
o Preventing the pregnant member from obtaining treatment for a health
problem
• If the pregnancy termination is requested as a result of incest or rape, the
following information must be included:
o Identification of the proper authority to which the incident was
reported, including the name of the agency
o The report number
o The date that the report was filed
When termination of pregnancy is considered due to rape or incest, or because
the health of the mother is in jeopardy secondary to medical complications,
please contact Prior Authorization at 1.866.295.9729. All terminations requested
for minors must include a signature of a parent or legal guardian or a certified
copy of a court order.
1.866.475.3129
[email protected]
Reporting High Risk and Non-Compliant Behaviors
Obstetrical physicians and practitioners must refer all “at risk” members to
Bridgeway: contact Member Services at 1.866.475.3129. The following types of
situations must be reported to Bridgeway:
March 2016
78
• Members that are diabetic and display consistent complacency regarding
•
•
•
•
•
•
dietary control and/or use of insulin
Members that fail to follow prescribed bed rest
Members that fail to take tocolytics as prescribed or do not follow home
uterine monitoring schedules
Members that admit to or demonstrate continued alcohol and/or other
substance abuse
Members that show a lack of resources that could influence well-being (e.g.
food, shelter and clothing).
Members that frequently visit the emergency department/urgent care
setting with complaints of acute pain and request prescriptions for
controlled analgesics and/or mood altering drugs
Members that fail to appear for two or more prenatal visits without
rescheduling and fail to keep rescheduled appointment. Providers are
expected to make two attempts to bring the member in for care prior to
contacting the Bridgeway Case Management department
Outreach, Education and Community Resources
Bridgeway is committed to maternity care outreach. Maternity care outreach is
an effort to identify currently enrolled pregnant women and to enter them into
prenatal care as soon as possible. PCPs are expected to ask about pregnancy
status when members call for appointments, report positive pregnancy tests
to Bridgeway and to provide general education and information about prenatal
care, when appropriate, during member office visits. Pregnant members will
continue to receive primary care services from their assigned PCP during their
pregnancy.
Bridgeway is involved in many community efforts to increase the awareness of
the need for prenatal care. PCPs are strongly encouraged to actively participate
in these outreach and education activities, including the WIC Nutritional
Program - Please encourage members to enroll in this program.
Various other services are available in the community to help pregnant women
and their families. Please call Bridgeway’s Member Services at 1.866.475.3129 for
information about how to help your patients use these services.
Providing EPSDT Services to Pregnant Members under Age 21
Federal and state mandates govern the provision of EPSDT services for members
under the age of 21 years. The provider is responsible for providing these services
to pregnant members under the age of 21, unless the member has selected an OB
provider to serve as both the OB and PCP. In that instance, the OB provider must
provide EPSDT services to the pregnant member.
Additional Claims Information
While these services are already performed in the initial prenatal visit, additional
information is necessary for claims submission. The provider (PCP or OB)
providing EPSDT services for members 12-20 years of age, must submit the
medical claims for these members.
79
1.866.475.3129
[email protected]
Loss of AHCCCS Coverage during Pregnancy
Members may lose AHCCCS eligibility during pregnancy. Although members
are responsible for maintaining their own eligibility, providers are encouraged
to notify Bridgeway if they are aware that a pregnant member is about to lose
or has lost eligibility. Bridgeway can assist in coordinating or resolving eligibility
and enrollment issues so that pregnancy care may continue without a lapse
in coverage. Please call Member Services at 1.866.475.3129 to report eligibility
changes for pregnant members.
Pre-Selection of Newborn’s PCP
Prior to the birth of the baby, the mother selects a PCP for the newborn. The
newborn is assigned to the pre-selected PCP after delivery. The mother may elect
to change the assigned PCP at any time.
CASE MANAGEMENT AND DISEASE
MANAGEMENT
Overview
Case Management
Once an individual becomes a Bridgeway member, they are assigned a LTC
case manager. The LTC case manager is responsible for working with the
member’s PCP to coordinate and authorize the provision of necessary services
for that member. The case manager is also the member’s advocate and works
to facilitate the member’s care. Part of that responsibility involves developing
the authorizations necessary for long term care support services, providing
information about room and board or share of cost to providers and members,
and assisting members with coordination of appropriate services. The case
manager is the primary point of contact for providers when there are issues or
questions about a member. In addition, the case manager must be contacted
whenever there is a change in a member’s health status.
Bridgeway has a comprehensive case management program. The case
management team considers the medical, social and cultural needs of members
by targeting, assessing, monitoring and implementing services for members
identified as “at risk.”
A wide spectrum of services are available for members, providers and families
who need assistance in finding and using appropriate health care and community
resources. The LTC case management staff:
• Considers the medical, social and cultural needs of members in targeting,
assessing, monitoring and implementing services for members.
• Provides assistance to members and families in navigating through the
complex medical and behavioral health systems.
1.866.475.3129
[email protected]
March 2016
The following conditions are specifically included in Bridgeway’s Disease
Management programs and have associated Clinical Guidelines that are reviewed
annually.
• Congestive Heart Failure
• Diabetes
• Asthma
• COPD
• HIV/AIDS
• High Blood Pressure
• Behavioral Health
80
Link: http://www.bridgewayhs.com/for-providers/clinical-practice-guidelines/
Disease Management
The Bridgeway disease management program is intended to enhance the health
outcomes of members. Disease management targets members who have
illnesses that have been slow to respond to coordinated management strategies
in the areas of diabetes, respiratory (COPD, asthma), and cardiac (CHF). The
primary goal of disease management is to positively affect the outcome of care
for these members through education and support and to prevent exacerbation
of the disease, which may lead to unnecessary hospitalization.
The objectives of disease management programs are to:
• Identify members who would benefit from the specific disease management
program
• Educate members on their disease, symptoms and effective tools for selfmanagement
• Monitor members to encourage/educate about self-care, identify
complications, assist in coordinating treatments and medications, and
encourage continuity and comprehensive care
• Provide evidence-based, nationally recognized expert resources for both
the member and the provider;
• Monitor effectiveness of interventions.
PHARMACY
Preferred Drug List
Prescription drugs may be prescribed by any authorized provider, such as a
PCP, attending physician, dentist, etc. Prescriptions should be written to allow
generic substitution whenever possible and signatures on prescriptions must be
legible in order for the prescription to be dispensed. The “Preferred Drug List”
(PDL) also referred to as a Formulary, identifies the medications, selected by
the Pharmacy and Therapeutics Committee (P&T Committee) that are clinically
appropriate to meet the therapeutic needs of members in a cost effective
manner.
The Preferred Drug List is developed, monitored and updated by the Pharmacy
and Therapeutics Committee (P&T Committee). The P&T Committee continuously
reviews the drug list and medications are added or removed based on objective,
clinical and scientific data. Considerations include efficacy, side effect profile,
and cost and benefit comparisons to alternative agents, if available.
Key considerations:
• Preferred drugs on the AHCCCS Drug List for specific therapeutic classes.
To view or to print a hard copy of the AHCCCS drug list please go to
www.azahcccs.gov/Resources/GuidesManualsPolicies/pharmacyupdates.html
• Therapeutic advantages outweigh cost considerations in all decisions to
change drug lists. Market share shifts, price increases, generic availability
and varied dosage regimens may affect the actual cost of therapy.
• Products are not added to the list if there are less expensive, similar
products on the formulary.
• When a drug is added to the list, other medications may be deleted.
• Participating physicians may request additions or deletions for
consideration by the P&T Committee. Requests should include:
o Basic product information, indications for use, its therapeutic
advantage over medications currently on the list.
81
1.866.475.3129
[email protected]
• Which drug(s), if any, the recommended medication would replace in the
current drug list.
• Any published supporting literature from peer reviewed medical journals.
Bridgeway may invite the requesting physician to the P&T Committee to support
the addition to the Preferred Drug List and answer related questions. Bridgeway
does not permit pharmaceutical representatives to participate or attend P&T
Committee meetings. All drug list requested additions should be sent to:
Pharmacy Department
Suite 201
Tempe, AZ 85281
Notification Drug List Updates
Bridgeway will not remove a medication from the Drug List without first notifying
providers and affected members. Bridgeway will provide at least 60 days’ notice
of such changes. Bridgeway is not required to send a hard copy of the PDL each
time it is updated, unless requested. A memo may be used to notify members
and providers of updates and changes and may refer providers to view the
updated Drug List on the Bridgeway website (http://www.bridgewayhs.com/formembers/altcs/pharmacy/). Bridgeway may also notify providers of changes to
the Drug List via direct letter or the plan website. Bridgeway will notify members
of updates to the PDL via direct mail and by notifying the prescribing provider, if
applicable.
Providers and members can request a printed version of the Preferred Drug List
by calling Member Services at 1.866.475.3129.
Prior Authorization Required
Prior authorization may be required:
• If the drug is not included on the Preferred Drug List
• If the prescription requires compounding
• For injectable medications dispensed by a pharmacy, with the exception of
heparin and insulin
o Note: If the member has a primary insurance that reimburses
for injectable medications, Bridgeway will only coordinate benefits
as the secondary payer if the Bridgeway pharmacy prior
authorization process was followed.
• For injectable medications dispensed by the physician and billed through
the member’s medical insurance, please call 1.866.638.6126 This would be
medical management phone number to initiate prior authorization for the
requested specialty medication
• For medication quantities which exceed recommended doses
• For specialty drugs which require certain established clinical guidelines be
met before consideration for prior authorization.
• For certain medications that may require additional documentation, e.g.
Peg-Intron.
1.866.475.3129
[email protected]
March 2016
Allow up to 14 calendar days for the prior authorization review process.
In instances where a prescription is written for drugs not on the Preferred Drug
List, the pharmacy may contact the prescriber to either request an alternative
or to advise the prescriber that prior authorization is required for non-covered
drugs.
82
Prior authorization requests submitted for review must be evaluated for clinical
appropriateness based on the strength of the scientific evidence and standards
of practice that include, but are not limited, to the following:
• Food and Drug Administration (FDA) approved indications and limits,
• Published practice guidelines and treatment protocols,
• Comparative data evaluating the efficacy, type and frequency of side effects
and potential drug interactions among alternative products as well as the
risks, benefits and potential member outcomes,
• Drug Facts and Comparisons,
• American Hospital Formulary Service Drug Information,
• United States Pharmacopeia –Drug Information,
• DRUGDEX Information System,
• UpToDate, and/or
• Peer-reviewed medical literature, including randomized clinical trials,
outcomes, research data and pharmacoeconomic studies.
A non-FDA indication shall not be the sole basis of denial, as off-label prescribing
may be clinically appropriate as outlined above in b. through i. Prescribing
clinicians must submit a prior authorization request to the Contractor, or as
applicable to the Contractor’s Pharmacy Benefit Manager (PBM), for review and
coverage determination.
Over the Counter (OTC) Medications
A limited number of OTC medications are covered for members. OTC medications
require a written prescription from the physician that must include the quantity
to be dispensed and dosing instructions. Members may present the prescription
at any contracted pharmacy. OTCs are limited to the package size closest to a 30day supply. Some medications may require step therapy. Please refer to the Drug
List for more information.
Generic and Biosimilar Drug Substitutions
Contractors must utilize a mandatory generic drug substitution policy that
requires the use of a generic equivalent drug whenever one is available. The
exceptions to this requirement are:
• A brand name drug can be covered when a generic equivalent is available
when the Contractor’s negotiated rate for the brand name drug is equal to
or less than the cost of the generic drug.
• AHCCCS may require Contractors to provide coverage of a brand name drug
when the cost of the generic drug has an overall negative financial impact
to the state. The overall financial impact to the state includes consideration
of the federal and supplemental rebates
Prescribing clinicians must clinically justify the use of a brand-name drug over
the use of its generic equivalent through the prior authorization process. Generic
and biosimiliar substitutions shall adhere to Arizona State Board of Pharmacy
rules and regulations. AHCCCS Contractors shall not transition to a biosimilar
drug until AHCCCS has determined that the biosimilar drug is overall more costeffective to the state than the continued use of the brand name drug.
1.866.475.3129
[email protected]
Diabetic Supplies
Diabetic supplies are limited to a one-month supply (to the nearest package size)
with a prescription.
83
Injectable Drugs
The following types of injectable drugs are covered when dispensed by a licensed
pharmacist or administered by a participating provider in an outpatient setting:
• Immunizations
• Chemotherapy for the treatment of cancer
• Medication to support chemotherapy for the treatment of cancer
• Glucagon emergency kit
• Insulin; Insulin syringes
• Immunosuppressant drugs for the post-operative management of covered
transplant services
• Rhogam
• Rabies vaccine
Exclusions
The following items, by way of example, are not reimbursable:
• Anorexiants
• DESI drugs (those considered less than effective by the FDA)
• Non-FDA approved agents
• Rogaine
• Any medication limited by federal law to investigational use only
• Medications used for cosmetic purposes
• Non-indicated uses of FDA approved medications without prior approval by
Bridgeway
• Lifestyle medications (such as medications for erectile dysfunction)
• Medications used for fertility
Family Planning Medications and Supplies
1.866.475.3129
[email protected]
March 2016
The family planning benefit includes:
• Over-the-counter items related to family planning (condoms, foams,
suppositories, etc.) are covered and do not require prior authorization
o The member must present a written prescription, to the pharmacy
including the quantity to be dispensed. A supply for up to 30-days is
covered
• Injectable medications, administered in the provider’s office, such as DepoProvera are reimbursed at the Fee Schedule rate, unless otherwise stated in
the Provider’s contract.
• Oral contraceptives
• Use of the AHCCCS Clinical Guidelines for the treatment and prescribing
of medications for ADHD, Anxiety and Depression
• PCPs may prescribe behavioral health medications to treat selected
behavioral health disorders.
o including ADD/ADHD, mild depression or anxiety disorder
• Behavioral health must be:
• Included on the Preferred Drug List.
• Limited to a 30-day supply.
• Prescribed in generic forms and will be substituted with
generic as they become available unless otherwise
designated.
Pharmacy Lock-In Program
The Lock-In program is for the protection of our members. Bridgeway reviews
members that receive medical services. The purpose of the review is to ensure
that benefits are used properly. In our review, we look to see if members have any
of the following:
84
• Prescriptions written on a stolen, fake, or changed prescription blank
• Prescribed drugs that should not be used for the member’s medical
•
•
•
•
•
•
•
•
•
•
condition
Member has filled prescriptions at more than two pharmacies per month or
more than five pharmacies per year
Member receives more than five different drugs per month
Member receives more than three controlled drugs (examples: pain
medicine, medicine to help sleep, and medicine to control attention deficit
disorder) per month
Member gets two or more drugs that work the same way from different
providers
Member receives prescriptions from more than two doctors per month
Member has been seen in hospital emergency room more than two times
per year
Member has diagnosis of drug poisoning or drug abuse on file
Number of prescriptions for controlled drugs exceeds 10 % of total number
of prescriptions
Referrals from providers
Referrals from Pharmacies
If the member has one or more of the items above the member may be assigned
to one pharmacy to fill all drugs. The member may also be restricted to one
doctor to write for controlled drugs. Members placed into the Pharmacy Lock-In
Program will receive a certified letter detailing the pharmacy and or controlled
substance prescriber that is selected for them. A copy of this notice is also sent
to the Primary Care Physician on file, the Lock-In Pharmacy, and the Controlled
Substance Prescriber.
This program lasts at least one year. Having one pharmacy fill all prescriptions
can prevent a member from being harmed by drugs that do not work together.
We expect all pharmacies who manage lock-in patients to uphold the following:
• Verify controlled substance prescriptions by phone when multiple
physicians are involved in the patient’s care
• Do not allow early refills on controlled substances
• Make sure that all physicians writing prescriptions for controlled substances
know that other physicians are also writing prescriptions for controlled
substances for the same patient
• This may not apply if the member is restricted to one provider for controlled
substance prescriptions
• If a member has moved and their Pharmacy or Medical Provider is no longer
within driving distance from the new home, they should be sure AHCCCS
has updated their records with the new address
Members can call Member Services at 1.866.475.3129 and request a provider
change based on the new location.
The member or provider, acting with member’s written consent, may appeal this
decision or file a grievance pertaining specifically to the pharmacy or physician.
85
1.866.475.3129
[email protected]
QUALITY IMPROVEMENT
Bridgeway Quality Improvement Program
The scope of Bridgeway’s Quality Improvement (QI) Program is comprehensive,
addressing both the quality of clinical care and the quality of non-clinical aspects
of service. The scope of the QI Program ensures that all demographic groups,
care settings, and services are included in QI activities. The scope may include,
but is not limited to, monitoring of the following:
• Compliance with preventive health guidelines and clinical practice
guidelines
• Acute and chronic case management
• Behavioral healthcare
• Continuity and coordination of care
• Under and over utilization
• Appointment availability
• After hours telephone accessibility
• Member satisfaction
• Provider satisfaction
• Complaints and appeals
• Performance monitoring and improvement of clinical and service related
measures
• Departmental performance and service
Additional information on the QI Program is available online at
www.bridgewayhs.com.
Providers may also call 1.866.475.3129 to request hard copies of Quality
Improvement Program documents.
Performance Improvement Process
The Bridgeway Quality Improvement Program allows for continuous performance
of quality improvement activities, and has established mechanisms to track
issues over time.
1.866.475.3129
[email protected]
Annually, Bridgeway’s Quality Improvement Committee develops a Quality
Improvement (QI) Work Plan for the upcoming year. The QI Work Plan serves
as a working document to guide quality improvement efforts on a continuous
basis. The Work Plan integrates QI activities, reporting and studies from all areas
of the organization (clinical and service) and includes timelines for completion
and reporting to the Quality Management and Performance Improvement (QMPI)
committee as well as requirements for external reporting. Studies and other
performance measurement activities and issues to be tracked over time are
scheduled in the QI Work Plan. The QI Work Plan is used by the QI Department
to manage projects and by the clinical quality committees, sub-committees and
Bridgeway Board of Directors to monitor progress. The Work Plan is modified
and enhanced throughout the year with approval from the State and the QMPI
committee. Modifications are reported to the Board of Directors and other
appropriate QI committees.
Additionally, Bridgeway tracks open issues to ensure follow-up of specific issues
or corrective actions requiring tracking over time. The QI Work Plan is used by the
QI department to prepare agendas for the QMPI committee to ensure continued
follow-up of issues and corrective action plans.
March 2016
86
Provider Review
The Bridgeway Quality Improvement Program includes review of processes
followed in the provision of health services, through oversight of the Quality
Improvement Committee (QIC). The QMPI committees contains physicians from
varying specialty areas. The ad hoc members of the QIC include representatives
from other departments of Bridgeway.
Feedback on Physician Specific Performance
As part of the re-credentialing process, performance data on each provider is
reviewed and evaluated by the Credentialing Committee. This review of provider
specific performance data may include, but is not limited to:
• Site evaluation results including medical record audit, appointment
availability, afterhours access, cultural proficiency and in office waiting time
• Preventive care, including Health Check exams, immunizations, lead
screening, and screening for detection of kidney disease
• Prenatal care
• Complaint and appeal data
• Utilization management data including referrals/1000 and bed days/1000
reports
• Sentinel events and/or adverse outcomes
• Compliance with clinical practice guidelines
Feedback of Aggregate Results
Aggregate results of studies and guideline compliance audits are presented to
the QI Committee. Participating physician members of the QMPI committee
provide input into action plans and serve as a liaison with physicians in the
community.
At least annually, a network representative communicates with providers to
review policies, guidelines, indicators, medical record standards, and provide
feedback of audit/study results. These sessions are also an opportunity for
providers to suggest revisions to existing materials and recommend priorities
for further initiatives. When a guideline, indicator, or standard is developed in
response to a documented quality of care deficiency, Bridgeway disseminates
the materials through an in-service training program to upgrade providers’
knowledge and skills. The Bridgeway Medical Directors and Pharmacist also
conduct special training and meetings to assist physicians and other providers
with quality and service improvement efforts.
Quality Oversight Committees
The Bridgeway Board of Directors is the governing body for Bridgeway. The Board
of Directors has ultimate responsibility for quality improvement and meets
quarterly to review and act upon reports reflecting the status of QI Program
implementation.
Governing body responsibilities for monitoring, evaluating, and making
improvements to care and service include:
• Review, evaluate, and approve the QI Program description, the QI Work Plan
and the annual QI Program Evaluation
• Review regular reports delineating actions taken and improvements made
as part of the QI Program
87
1.866.475.3129
[email protected]
• Ensure that the QI Program and QI Work Plan are implemented effectively
and result in improvements in care and service
• Provide written feedback to the Plan as appropriate, when program goals
are not being met
The Quality Improvement Program is approved by the Board of Directors, Quality
Management Performance Improvement (QMPI) Committee, the Chief Medical
Officer and the Vice President of Medical Management.
The QMPI Program Description delineates the structure and personnel
responsible for performing QI functions within the organization. The Program’s
Committee structure consists of the following committees and subcommittees:
• Quality Improvement Committee (QIC)
• Credentialing Committee
• Medical Management Committee
• Pharmacy and Therapeutics Committee (P&T)
• Contract Review Committee (subcommittee of the Network/ Medical
Management Committee)
• Peer Review Committee
• Member Advisory Council
• Policy Committee
These committees meet on a regular basis in order to oversee QI Program
activities and allow sufficient follow-up on findings and required actions. The
Chairperson of each committee may increase or decrease the frequency based
on findings and resolutions.
GENERAL BILLING INFORMATION AND
GUIDELINES
Current and Accurate Provider Information
Physicians, other licensed health professionals, facilities, and ancillary provider’s
contract directly with Bridgeway for payment of covered services. It is important
that providers ensure Bridgeway has accurate billing information on file. Please
confirm with your Network Department that the following information is current
in our files:
• Provider Name (as noted on his/her current W-9 form)
• Valid, unique AZ Medicaid ID Number for each provider
• Physical location address (as noted on current W-9 form)
• Billing name and address (if different)
• Tax Identification Number
• Provider NPI
Providers must bill with either their AHCCCS ID number or NPI in box
24J. Bridgeway returns claims when billing information does not match the
information that is currently in our files. Claims missing the requirements in
bold will be returned, and a notice sent to the provider. Such claims are not
considered “clean” and therefore cannot be entered into the system.
1.866.475.3129
[email protected]
March 2016
Updating Billing Information
We recommend that providers notify Bridgeway in advance of changes pertaining
to billing information. Please submit this information on a W-9 form. Changes to
a Provider’s Tax Identification Number and/or address are NOT acceptable when
conveyed via a claim form.
88
Claims
Claims eligible for payment must meet the following requirements:
• The member is effective on the date of service
• The service provided is a covered benefit on the date of service
• Referral and prior authorization processes were followed
Unless a contract specifies otherwise, Bridgeway ensures that for each form type
Dental/ Professional/ Institutional) 95% of all clean claims are adjudicated within
30 days of receipt of the clean claim and 99% are adjudicated within 60 days of
receipt of the clean claim.
Bridgeway does not pay:
• Claims initially submitted more than six months after date of service
for which payment is claimed or after the date that eligibility is posted,
whichever date is later; or
• Claims that are submitted as clean claims more than 12 months after date
of service for which payment is claimed or after the date that eligibility is
posted, whichever date is later (A.R.S.§36-2904.G).
Regardless of any subcontract with Bridgeway, when one AHCCCS plan recoups
a claim because the claim is the payment responsibility of another plan; the
provider may file a claim for payment with the responsible plan. You must submit
a clean claim to the responsible plan no later than:
• 60 days from the date of the recoupment,
• 12 months from the date of service, or
• 12 months from date that eligibility is posted, whichever date is later
The responsible plan does not deny a claim on the basis of lack of timely filing if
the provider submits the claim within the timeframes above.
Claim payment requirements pertain to both contracted and non-contracted
providers.
Secondary Insurer
Bridgeway is the payer of last resort. It is critical that you identify any other
available insurance coverage for the patient and bill the other insurance as
primary. For example, if Medicare is primary and Bridgeway is secondary.
• File an initial claim with Bridgeway if you have not received payment or
denial from the other insurer before the expiration of your required filing
limit. Make sure you are submitting timely in order to preserve your claim
dispute rights.
• Upon the receipt of payment or denial by the other insurer, you should then
submit your claim to Bridgeway, showing the other insurer payment amount
or denial reason, if applicable, and enclosing a complete legible copy of the
remittance advice or Explanation of Payment (EOP) from the other insurer.
• When a member has other health insurance, such as Medicare, a Medicare
HMO or a commercial carrier, Bridgeway coordinates payment of benefits.
• In accordance with requirements of the Balanced Budget Act of 1997,
Bridgeway pays co-payments, deductibles and/or coinsurance for AHCCCS
Covered Services up to the lower of either Bridgeway’s fee schedule or the
Medicare/other insurance allowed amount.
89
1.866.475.3129
[email protected]
Claims should be submitted within six (6) months from the date of service for a
first submission to retain appeal rights, whether the other insurance explanation
of benefits has been received or not.
Claims should be submitted within one year from the last date of service or six
months from the date of the other insurance Explanation of Payment, whichever
is later, once the other insurance explanation of benefits is received.
Dual Eligibility Cost Sharing and Coordination of Benefits
When Bridgeway members are enrolled in both programs (Bridgeway Medicaid
and Medicare Advantage), any cost sharing responsibilities are coordinated
between the two payers. In general, providers only need to submit one claim to
Bridgeway and benefits will be automatically coordinated.
When adjudicating Medicare Part A SNF claims, the payment of Medicare SNF
daily deductible for days 21-100 is required. Bridgeway coordinates benefits with
Original Medicare or by paying for coinsurance and copays for Part A and Part B
services provided in a SNF.
Injuries due to an Accident
In the event the member is being treated for injuries suffered in an accident,
the date of the accident should be included on the claim so that Bridgeway
can investigate the possibility of recovery from any third-party liability source.
This is particularly important in cases involving work-related injuries or injuries
sustained as the result of a motor vehicle accident.
Link to claim form instructions http://www.bridgewayhs.com/for-providers/
provider-resources/forms/.
Electronic Claims Submission
Network providers are encouraged to participate in Bridgeway’s Electronic
Claims/Encounter Filing Program through Centene. Centene has the capability
to receive an ANSI X12N 837 professional, institution or encounter transaction.
In addition, Centene has the capability to generate an ANSI X12N 835 electronic
remittance advice known as an Explanation of Payment (EOP). For more
information on electronic fi ling, contact:
c/o Centene EDI Department
1.800.225.2573, extension 25525
Or by e-mail at:
[email protected]
1.866.475.3129
[email protected]
Providers who bill electronically are responsible for filing claims within the
same filing deadlines as providers filing paper claims. Providers who bill
electronically must monitor their error reports and evidence of payments to
ensure all submitted claims and encounters appear on the reports. Providers are
responsible for correcting any errors and resubmitting the affiliated claims and
encounters.
March 2016
90
Bridgeway dental, vision and behavioral health claims should be submitted to:
PO BOX 3040
ATTN: CLAIMS DEPARTMENT
Dental Claims
Envolve Benefit Options Dental
1.888.278.7310
Fax: 262.834.3589
https://portal.dentalhw.com/Login.aspx?ReturnUrl=%2fpwp%2fdefault.aspx
Vision Claims
Vision Claims Department
P.O. Box 7548
Vision Provider Services – 866.458.2139
Paper Claims Submission
All claims and encounters, with the exception of those services listed as “carve
outs” i.e., routine dental services, routine vision services, outpatient mental
health services, outpatient chemical dependency and outpatient substance
abuse services should be submitted to:
PO BOX 3040
ATTN: CLAIMS DEPARTMENT
Dental claims should be submitted to:
Claims - AZ
PO Box 1888
Milwaukee, WI 53201
Vision claims should be submitted to:
Envolve
112 Zebulon Court
P.O. Box 7548
Imaging Requirements
Bridgeway uses an imaging process for claims retrieval. To ensure accurate and
timely claims capture, please observe the following claims submission rules:
Do’s
• Do use the correct PO Box number
• Do submit all claims in a 9” x 12”, or larger envelope
• Do type all fields completely and correctly
• Do use black or blue font color only
• Do submit on a proper form . . . CMS 1500 or UB 04
• Claim form MUST BE RED AND WHITE
91
1.866.475.3129
[email protected]
Don’ts
• Don’t submit handwritten claim forms
• Don’t use red font on claim forms
• Don’t circle any data on claim forms
• Don’t add extraneous information to any claim form field
• Don’t use highlighter on any claim form field
• Don’t submit photocopied claim forms
• Don’t submit carbon copied claim forms
• Don’t submit claim forms via fax
Clean Claim Definition
A clean claim is one that may be processed without obtaining additional
information from the provider of service or from a third party but does not
include claims under investigation for fraud or abuse or claims under review for
medical necessity, as defined by A.R.S. §36-2904.
A clean claim means a claim received by Bridgeway for adjudication, in a
nationally accepted format in compliance with standard coding guidelines and
which requires no further information, adjustment, or alteration by the provider
of the services in order to be processed and paid by Bridgeway. The following
exceptions apply to this definition: (a) a claim for payment of expenses incurred
during a period of time for which premiums are delinquent; (b) a claim for which
fraud is suspected; and (c) a claim for which a Third Party Resource should be
responsible.
Non-Clean Claim Definition
Non-clean claims are submitted claims that require further investigation or
development beyond the information contained therein. Errors or omissions
in claim submissions result in the request for additional information from the
provider or other external sources to resolve or correct data omitted from the
bill; review of additional medical records; or the need for other information
necessary to resolve discrepancies. In addition, non-clean claims may involve
issues regarding medical necessity and include claims not submitted within the
filing deadlines.
What is an Encounter Versus a Claim?
You are required to submit an encounter or claim for each service that you
render to a Bridgeway member. See the definitions below:
If you are the PCP for a Bridgeway member and receive a monthly capitation
amount for services, you must fi le a “proxy claim” (also referred to as an
“encounter”) on a CMS 1500 for each service provided. Since you will have
received a pre-payment in the form of capitation, the “proxy claim” or
“encounter” is paid at zero dollar amounts. It is mandatory that your office
submits all encounter data.
1.866.475.3129
[email protected]
Bridgeway utilizes the encounter reporting to evaluate all aspects of quality
and utilization management, and it is required by AHCCCS and by Centers for
Medicare and Medicaid Services (CMS).
March 2016
92
• A claim is a request for reimbursement submitted either electronically
or by paper for any medical service. A claim must be filed on the proper
form, such as CMS 1500 or UB 04. A claim will be paid or denied with an
explanation for the denial. For each claim processed, an Explanation of
Payment (EOP) will be mailed to the provider who submitted the original
claim
Claim Adjustment
Providers may resubmit a claim(s) to correct a simple billing error or to request
an adjustment if it is believed the payment made by the plan is incorrect.
In order to be considered for payment claims in this category must be received
within twelve (12) months from the date of service. Please include the word
“resubmission” and the claim number on the claim form to help us identify that
this is a resubmission of an existing claim.
• For a HCFA, field 22 is used for Resubmitted claims. It should include a
Resubmit code (7 or 8 see descript below), a previous Claim number and
the claim should also indicate that it is a Resubmission/Corrected Claim.
o 7 Replacement of prior claim
o 8 Void/cancel of prior claim
• For UB’s, Field 4 (TOB) should end with a 7 (ie. 117) and field 64 should have
a previous Claim number populated as well.
Claims will be reviewed and a decision rendered based on the information
provided.
Procedures for Filing a Claim/Encounter Data
Bridgeway encourages all providers to file claims/encounters electronically. See
“Electronic Claims Submission” in this manual for more information on how to
initiate electronic claims/encounters.
Please remember the following when filing your claim/encounter:
• All documentation must be legible.
• PCPs and all participating providers must submit claims or encounter data
for every member visit, even though they may receive a monthly capitation
payment
• Provider must ensure that all data and documents submitted to Bridgeway,
to the best of your knowledge, information, and belief, are accurate,
complete, and truthful
• All claims and encounter data must be submitted on either form CMS 1500,
UB 04, or by electronic media in an approved format
• Review and retain a copy of the error report that is received for claims that
have been submitted electronically, then correct any errors and resubmit
with your next batch of claims
• All claims must be received by the plan within six (6) months from the
month the service was provided in order to be considered for payment
• Claims received after this time frame will be denied for failure to file timely
Common Billing Errors
In order to avoid rejected claims or encounters always remember to:
Please remember the following when filing your claim/encounter:
• Use SPECIFIC CPT-4, HCPCS, or ICD codes
• Avoid the use of non-specific or “catch-all” codes (i.e. 99070)
93
1.866.475.3129
[email protected]
• Use the most current CPT-4 and HCPCS codes. Out-of-date codes will be
denied
• Submit all claims/encounters with the proper provider number
• Submit all claims/encounters with the member’s complete AHCCCS ID
number.
• Verify other insurance information entered on claim
• The 11 digit National Drug Code (NDC) must be reported on all qualifying
•
•
claim forms when injectable drugs are administered in the office/outpatient
setting; excluding applicable vaccines/ immunizations. Failure to submit
the exact applicable NDC (do not report 99999999999 to bypass edit)
administered to the member will result in front-end rejection and/or denial
of claims. When reporting a drug, enter identifier N4, the eleven-digit NDC
code, Unit Qualifier, and number of units from the package of the dispensed
drug for the specified detail line
Do not enter a space, hyphen, or other separator between N4, the NDC
code, Unit Qualifier, and number of units
If you are given an NDC that is less than 11 digits, add the missing digits as
follows:
o For a 4-4-2 digit number, add a 0 to the beginning
o For a 5-3-2 digit number, add a 0 as the sixth digit
o For a 5-4-1 digit number, add a 0 as the tenth digit
• Example: N412345678901UN2000
Code Auditing and Editing
Bridgeway uses HIPAA compliant code-auditing software to assist in improving
accuracy and efficiency in claims processing, payment, and reporting. The code
auditing software will detect, correct, and document coding errors on provider
claims prior to payment. Our software analyzes HCPCS Level 1/CPT-4 codes
(5-digit numeric coding system which applies to medical services delivered);
HCPCS Level II codes (alpha-numeric codes which apply to ambulance services,
medical equipment, supplies and prosthetics); CPT Category II (“F” codes used
for tracking purposes) and CPT Category III (“T” codes or temporary codes used
for new and emerging technologies) and healthcare industry standard modifiers
against correct coding guidelines. These guidelines have been established by the
American Medical Association (CPT, CPT Assistant, and CPT Insider View) and the
Centers for Medicare and Medicaid Services (CMS).
In order to maintain its high standard of clinical accuracy, credibility and
physician acceptance, our code-auditing software’s audit logic is reviewed on a
regular basis to keep current with medical practice, coding practices, revisions
to the CPT Manual, CMS updates and universally accepted specialty society
guidance.
1.866.475.3129
[email protected]
Inherent within the code auditing software product is the clinical knowledge
base or edit logic which is used to determine reimbursement recommendations.
The clinical knowledge base contains the definitions, rules, functions and
auditing logic which is based on generally accepted principles of coding medical
services for reimbursement. Our code auditing software is not designed to
make reimbursement or payment decisions. Instead, the software will offer a
recommendation (auditing action) that is applied to the claim when a provider’s
coding pattern is unsupported by a coding principle.
March 2016
94
Reimbursement/payment decisions will continue to be based on the fee
schedules and contract agreements between the provider and the Plan.
Furthermore, while the code-auditing software has been designed to assist
in evaluating the accuracy of procedure coding; it will not evaluate medical
necessity. Bridgeway may request medical records or other documentation to
assist in the determination of medical necessity, appropriateness of the coding
submitted, or review of the procedure billed.
When an edit recommendation is made, Bridgeway will provide a general
explanation of the reason for the edit which will be detailed on your Explanation
of Payment (or remittance advice). The following list gives examples of conditions
where the code-auditing software will make a recommendation on submitted
codes:
• Unbundling: Procedure unbundling occurs when a provider submits a global
CPT/HCPCS code along with other CPT/HCPCS codes that are considered
included in the global code billed
• Fragmentation: The separate billing of component codes of a procedure
without listing the more comprehensive code
• Modifier to Procedure Code Validation: Claim lines submitted with modifiers
invalid for the submitted procedure codes listed on the claim.
• Age/Gender: Submitting procedure codes inappropriate for the member’s
age or gender because of the nature of the procedure
• Assistant Surgeon: Procedure codes submitted with an assistant surgeon
modifier, 80, 81, and 82 or AS that typically do not require an assistant
surgeon
• Add on Without Base Code: Submitting an add-on procedure code as a
stand-alone code without the primary procedure code billed on the claim
or a historical claim
• Duplicate Procedure Edits: CPT codes that contain terminology that does
not warrant multiple submissions of the code (i.e., unilateral, unilateral/
bilateral, single/multiple) or procedure codes which would not normally be
reported in duplicate
• Bilateral: Identifies a claim line where a procedure code has been billed
with/without a modifier 50, where a historical claim was found that was
billed with the same procedure code, and with the modifier 50- the
software will recommend a denial of the second submission.
• Global Surgical Period (pre-op, post-op and same day rules): addresses
payment/non-payment of evaluation and management services billed
during the global surgical period of another procedure
• Evaluation and Management Editing: Identifies certain diagnostic tests/
studies which are a component of the E/M service billed and should not be
reported separately
• Modifier Additions: Identifies professional services that should have been
billed with the 26 modifier for the procedure performed and the place of
service
Knowledge Base Auditing and Rules
Bridgeway’s code-auditing software audits against both professional claims
and outpatient facility claims. The software’s “knowledge base” contains
auditing logic and rules based on accepted principles regarding the manner
by which medical services should be coded for reimbursement. If the software
recommends an auditing action (edit) against a claim line, an edit is applied
which corresponds to a coding principle. The code auditing software’s knowledge
95
1.866.475.3129
[email protected]
base contains coding principles based on coding standards developed by
the Center for Medicare and Medicaid Services (CMS); the American Medical
Association’s Current Procedural Terminology (CPT Manual, CPT Assistant,
CPT Insider View); specialty society guidelines such as the American College
of Surgeons, American College of Radiology, and the American Academy of
Orthopedic Surgeons. Using a comprehensive set of rules, the code auditing
software provides consistent and objective claims review by:
• Accurately applying coding criteria for the clinical areas of medicine,
surgery, laboratory, pathology, radiology and anesthesiology as outlined by
the American Medical Association’s (AMA) CPT-4 manual
• Evaluating the CPT-4 and HCPCS codes submitted by detecting, correcting
and documenting coding inaccuracies including, but not limited to,
unbundling, upcoding, fragmentation, duplicate coding, invalid codes, and
mutually exclusive procedures
• Incorporating Historical Claims Auditing (HCA) functionality which links
multiple claims found in a patient’s claims history to current claims to
ensure consistent review across all dates of service
Billing Codes
It is important that providers bill with codes applicable to the date of service on
the claim. Billing with obsolete codes will result in a potential denial of the claim
and a consequent denial in payment.
Submit professional claims with current, valid CPT-4, HCPCS and ICD-10 codes.
Submit institutional claims with valid Revenue codes and CPT-4 or HCPCS (when
applicable), ICD-10 and DRG codes.
Providers will also improve the efficiency of their reimbursement through proper
coding of a patient’s diagnosis. We require the use of valid ICD-10 diagnosis
codes, to the ultimate specificity, for all claims. The highest degree of specificity
or detail, can be determined by using the Tabular list (Volume One) of the ICD-10
code manual in addition to the Alphabetic List (Volume Two) when locating and
designating diagnosis codes.
Claim Payment
Non-clean claims will be adjudicated (finalized as paid or denied) within thirty
(30), business days from the date of the original submission. Non-clean claims
will be adjudicated (finalized as paid or denied) within thirty (30) days of receipt
of the electronic claim.
Bridgeway sends providers written notification via the Website or an Explanation
of Payment (EOP) for each claim that is denied, including the reason(s) for
the denial, the date contractor received the claim, and a reiteration of the
outstanding information required from the provider to adjudicate the claim.
Note: It is the provider’s responsibility to check their audit report to verify that
Bridgeway has accepted their electronically submitted claim.
1.866.475.3129
[email protected]
Providers may discuss questions with Bridgeway Provider Services
Representatives regarding amount reimbursed or denial of a particular service;
Providers may also submit in writing, with all necessary documentation, including
the EOP) for consideration of additional reimbursement.
March 2016
96
Any response to approved adjustments will be provided by way of check with
accompanying explanation of payment. All disputed claims will be processed
in compliance with the claims payment resolution procedure as described
herein. For an explanation regarding how to request an informal claim payment
adjustment or file a complaint refer to the process described herein.
Billing Forms
Providers submit claims using standardized claim forms whether filing on paper
or electronically. Submit claims for professional services and durable medical
equipment on a CMS 1500. The following areas of information on CMS 1500
claim forms are common submission requirements of a clean claim accepted for
processing:
• Full member name
• member’s date of birth
• A valid member identification number
• Complete service level information:
• Date of Service
• Diagnosis
• Place of Service
• Procedure Code (appropriate CPT-4, ICD-10 codes)
• Charge Information and units
• Servicing provider’s name, address, taxonomy code, and NPI number
• Provider’s federal tax identification number
• All mandatory fields must be complete and accurate
• Submit claims for hospital based inpatient and outpatient services as well
as swing bed services on a UB 04.
Completing a CMS 1500 Form
All medical claims are to be submitted on the CMS 1500.
The CMS 1500 claim form is required for:
• All professional services “including specialists”
• Individual practitioners
• Non-hospital outpatient clinics
• Transportation providers
• Ancillary Services
• Durable Medical Equipment
• Non-institutional expenses
• Professional and/or technical components of hospital based physicians and
Certified Registered Nurse Anesthetists (CRNAs)
• Home Health Services
The CMS 1500 must provide all requested information to receive payment
for services rendered. Failure to do so may result in delayed or denied
reimbursement.
Bridgeway requires all CAPITALIZED, BOLD TYPE FIELDS to be completed.
Failure to complete these fields may cause the claim or encounter to be
rejected. An asterisk next to a capitalized, bold type (required) field indicates
required if applicable. Listed below are the field numbers and names, along with
explanations of the fields.
• R=Required
• C=Conditionally required/if applicable
• Blank=Not required
97
1.866.475.3129
[email protected]
Bridgeway accepts all nationally approved and recognized coding as defined by
CMS national correct coding initiatives and guidelines.
Completing a UB 04 Claim Form
A UB 04 is the only acceptable claim form for submitting inpatient or outpatient
hospital (technical services only) charges for reimbursement by Bridgeway.
In addition, a UB 04 is required when billing for nursing home services, swing
bed services with revenue and occurrence codes, inpatient hospice services,
ambulatory surgery centers (ASC) and dialysis services.
Incomplete or inaccurate information will result in the claim/encounter being
rejected or denied for corrections.
• R=Required
• C=Conditionally required/if applicable
• Blank=Not required
UB 04 Inpatient Documentation
The following information should be submitted along with the UB 04:
• Consent forms for hysterectomies, abortions, and sterilizations
• Specific additional information upon request by Bridgeway
UB 04 Hospital Outpatient Claims/Ambulatory Surgery
The following information applies to outpatient and ambulatory surgery claims:
• Professional fees must be billed on a CMS 1500 claim form
• Include the appropriate CPT-4 code next to each revenue code
UB 04 Claim Instructions
Bridgeway requires all CAPITALIZED, BOLD TYPE FIELDS to be completed. Failure
to complete these fields may cause the encounter to be rejected. An asterisk
next to a capitalized, bold type (required) field indicates required if applicable.
Billing the Member
In accordance with State and Federal regulations providers are prohibited from
billing members for covered services. Arizona Administrative Code R9-22702 states in part, “an AHCCCS registered provider shall not do either of the
following, unless services are not covered or without first receiving verification
from the Administration [AHCCCS] that the person was not an eligible person on
the date of service:
1. Charge, submit a claim to, or demand or collect payment from a person
claiming to be AHCCCS eligible; or
2. Refer or report a person claiming to be an eligible person to a collection
agency or credit reporting agency”
1.866.475.3129
[email protected]
March 2016
Bridgeway members should not be billed, or reported to a collection agency for
any covered service your office provides. Claims should be submitted directly to
the Bridgeway Claims Department address: Bridgeway Health Solutions PO Box
3040 Farmington, MO 63640- 3814. Submission must include the appropriate
claim form. Providers must comply with the time submission requirements
of Arizona Revised Statute § 36-2904 H. All covered health care providers
must have a National provider Identifier (NPI) number. Claims cannot process
for covered health care providers who do not have a NPI. If providers do not
have the required NPI, necessary forms and instructions may be obtained by
contacting the National Plan and Provider Enumeration System (NPPES):
98
By phone:
1.800.465.3203 (NPI Toll-Free)
1.800.692.2326 (NPI TTY)
By e-mail at:
customerservice@
npienumerator.com
By mail at:
NPI Enumerator
PO Box 6059
Fargo, ND 58108-6059
Please note, any and all future billings of Bridgeway members for covered
services may result in a fraud referral regarding your billing practices to the
AHCCCS Office the Inspector General.
Emergency Department Hospital Claims Adjudication Process
This process describes the methodology to be used by Bridgeway for managing
the Emergency Services benefit in compliance with directives from Centers for
Medicare and Medicaid Services (CMS) AHCCCS. This process delineates only
adjudication of Emergency Department claims. Bridgeway intends to work with
physicians and hospitals to decrease the need for Emergency Services through
proactive strategies that address chronic conditions such as asthma and to
redirect, the member to their primary care provider (PCP). In addition, Bridgeway
provides Emergency Department (ED) post-discharge follow up and continuity of
care services.
Bridgeway is dedicated to providing its members with high-quality healthcare.
This includes immediate access to Emergency Services when required. At the
same time, Bridgeway recognizes that it is not in the member’s best interests to
receive routine (non-emergent) episodic care in the ED and that members are
best served by receiving such care from their PCP’s.
EMERGENCY MEDICAL CONDITION (EMC)
Background
The statute that established the definition of “Emergency Medical Condition
(EMC)” is as follows:
A medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) such that a prudent layperson who possesses an average
knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in: a) placing the patient’s health (or, with
respect to a pregnant woman, the health of the woman or her unborn child)
in serious jeopardy, b) serious impairment to bodily functions, or c) serious
dysfunction of any bodily organ or part [42 CFR 438.114(a)]
CMS has issued specific guidelines to State Medicaid Directors regarding that
agency’s expectations of how the Medicaid Emergency Services benefit is to be
administered utilizing the prudent layperson (PLP) standard as defined above.
These guidelines are contained in letters to the State Medicaid Directors dated
February 20, 1998, April 5, 2000 and April 18, 2000. The following statements
from the April 18, 2000 letter have a direct bearing on the Hospital Claims
Adjudication Process [edited by Bridgeway to reflect ICD10].
“The BBA requires that a Medicaid beneficiary be permitted to obtain emergency
services immediately at the nearest provider when the need arises. When the
prudent layperson standard is met, no restriction may be placed on access to
emergency care. Limits on the number of visits are not allowed.
99
1.866.475.3129
[email protected]
The determination of whether the prudent layperson standard is met must be
made on a case-by-case basis. The only exceptions to this general rule are that
payers may approve coverage on the basis of an
ICD-[10] code and payers may set reasonable claim payment deadlines (taking
into account delays resulting from missing documents from the initial claim).
Note that payers may not deny coverage solely on the basis of ICD-[10] codes.
Payers are also barred from denying coverage on the basis of ICD-[10] codes
and then requiring resubmission of the claim as part of an appeal process.
This bar applies even if the process is not labeled as an appeal. Whenever a
payer (whether an MCO or a State) denies coverage or modifies a claim for
payment, the determination of whether the prudent layperson standard has
been met must be based on all pertinent documentation, must be focused on
the presenting symptoms (and not on the final diagnosis), and must take into
account that the decision to seek emergency services was made by a prudent
layperson (rather than a medical professional).”
ICD-10 Diagnosis Code Auditing and Review
ICD-10 codes are reviewed and may be moved to different diagnosis categories
based on actual adjudication experience. For example, if it is discovered that
claims with an ICD-10 diagnosis code that is designated as a non-obvious
emergency is being paid 90 percent of the time, the ICD-10 diagnosis code
may be moved to a more appropriate classification. Bridgeway considers any
requests for reclassifying specific ICD-10 diagnosis codes if the hospital believes
Bridgeway has misclassified the diagnosis code. If after review, it is determined
that an ICD-10 diagnosis code qualifies for reclassification, the reclassification
will apply to all hospitals.
Third Party Liability and Coordination of Benefits (COB) Guidelines
Third Party Liability (TPL) refers to any other health insurance plan or carrier
(e.g., individual, group, employer-related, self-insured or self-funded, or
commercial carrier, automobile insurance and worker’s compensation) or
program, that is, or may be, liable to pay all or part of the health care expenses of
the member.
Coordination of Benefits (COB) refers to members with two or more types of
insurance coverage. The plan that is primary pays its full benefits first. The
primary insurance carrier’s explanation of benefits (EOB) is then sent to the
secondary carrier/ Bridgeway, for coordination of benefits.
The primary EOB information will explain the primary’s payment or denial
process. Medicaid is the payor of last resort, therefore Bridgeway makes every
effort to cost avoid claims or services that are subject to payment from a third
party health insurance carrier, and may deny a service if the third party health
insurance carrier provides the service. Cost avoidance applies to all covered
services except claims for EPSDT and non-institutional pregnancy related
services.
1.866.475.3129
[email protected]
Bridgeway complies with Arizona Medicaid COB policies and utilizes the “Pay and
Chase” approach as required.
• Providers must make reasonable efforts to determine the legal liability of
third parties to pay for services furnished Bridgeway members and must bill
the primary payor prior to billing Bridgeway
March 2016
100
• When a provider bills the claim to the primary carrier and files the claims
•
•
•
•
•
with the EOP, Bridgeway coordinates with the primary payor to pay the
claim up to the plan’s allowable amount, but we will not exceed the amount
we would have paid had we paid as the primary coverage
If a third party health insurance carrier requires the member to pay
cost-sharing amounts (e.g. co-payments, coinsurance, and deductible),
Bridgeway pays the cost sharing amount but we will not exceed the amount
we would have paid had we paid as the primary coverage
Providers will receive written notification along with primary payor
information prior to Bridgeway initiating a recoupment.
Information regarding the other liability coverage is available through our
call center, and via the secure web portal.
Claims originally fi led timely with a third party carrier must be received
within 180 days of the date of the primary carrier’s EOP, but never more
than twelve (12) months from the month of service.
To the extent permitted by state and federal law, Bridgeway uses cost
avoidance processes as required by AHCCCS.
Understanding the Bridgeway Explanation of Payment
Please see “Attachment A-Explanation of Payment Reference Sheets” at the end
of this manual. If you have additional questions regarding the plan’s EOP, please
contact Provider Services at 1.866.475.3129.
RESUBMITTED CLAIMS
Timely Resubmission
Claims that have been denied due to erroneous or missing information must
be received within twelve (12) months from the month in which the service was
rendered. In order to be considered the denied claim must be resubmitted with
corrected information via the website or via paper. When resubmitting a denied
claim on paper more than twelve (12) months after the month of service, a copy
of the EOP with the denial must be attached to demonstrate that the original
claim was submitted timely. Please include the word “resubmission” and the
claim number on the claim form to help us identify that this is a resubmission of
an existing claim.
Resubmitted claims should be sent to:
Claims Department
PO Box 3040
Resubmitted claims should be clearly marked at the top with the word
RESUBMISSION and the claim number.
Providers resubmitting claims must attach a statement along with
documentation, including the EOP explaining the reason for resubmission.
Reasons for resubmission include but are not limited to:
• Provider has corrected the claim (for example, previously submitted wrong
diagnosis, etc.)
• Denial for other insurance
• Problem with electronic filing, now sending paper claim
• No payment received within 30 days of initial filing of claim
101
1.866.475.3129
[email protected]
Providers must wait at least 30 days from the initial submission before
resubmitting the claim. The claim must be clearly marked as a resubmission and
have the claim number on it. This will help to ensure that the claim is not denied
as a duplicate.
Claim Adjustment
Providers may resubmit a claim(s) to correct a simple billing error or to request
an adjustment if you believe the payment made by the plan is incorrect. In order
to be considered for payment claims in this category must be received within
twelve (12) months from the month in which the service was rendered. Please
include the word “resubmission” and the claim number on the claim form to help
us identify that this is a resubmission of an existing claim. A Provider Adjustment
form must be completed for all resubmission requests along with the supporting
documentation. Your claim will be reviewed and a decision rendered based on
the information provided.
Unsatisfactory Claim Payment
If you have a question or is not satisfied with the information received related
to a claim, please contact: the Bridgeway Provider Services Department at
1.866.475.3129.
CLAIM DISPUTE AND APPEALS PROCESS
Claim Dispute
A claim dispute is a dispute involving the payment of a claim, denial of a claim,
imposition of a sanction or reinsurance. A provider may file a claim dispute based
on:
• Claim Denial
• Recoupment
• Dissatisfaction with Claims Payment
Prior to initiating a formal claim disputes please ensure the following:
• The claim dispute process should only be used after other attempts to
resolve the matter have failed.
• The provider should contact the Bridgeway Provider Services and/or
assigned Network Representative to seek additional information prior to
initiating a claim dispute.
• The provider must follow all applicable laws, policies and contractual
requirements when filing.
• According to the Arizona Revised Statute, Arizona Administrative Code and
AHCCCS guidelines, all claim disputes related to a claim for system covered
services must be filed in writing and received by the plan: within 12 months
after the date of service.
• Within 12 months after the date that eligibility is posted.
• Or within 60 days after the date of the denial of a timely claim submission,
whichever is later
1.866.475.3129
[email protected]
You may submit your claim dispute in writing through the mail or send
electronically to us through fax. If you choose to send via fax, please fax your
disputes to 1-866-687-0518.
March 2016
102
Written claim disputes must be submitted to the attention of:
Tempe, AZ 85281
Please include all supporting documentation with the initial claim dispute
submission. The claim dispute must specifically state the factual and legal basis
for the relief requested, along with copies of any supporting documentation,
such as the explanation of payment (EOP), medical records or claims. Failure to
specifically state the factual and legal basis may result in denial of the claim
dispute.
Bridgeway acknowledges claim dispute requests within five (5) business of
receipt. If you do not receive an acknowledgement letter within five (5) business
days, please contact the Provider Claim Disputes Department at 1.866.475.3129.
Once received, the claim dispute will be reviewed, and a decision will be
rendered within 30 days of receipt. Bridgeway may request an extension of up to
45 days, if necessary.
All overturned claim disputes (ruled in the provider’s favor) are adjusted within
fifteen (15) business days of the plan’s overturn notification.
State Fair Hearing
If you disagree with the Bridgeway Notice of Decision, the provider may request
a State Fair Hearing. The request for State Fair Hearing must be filed in writing
no later than 30 days after receipt of the Notice of Decision. Please clearly state
“State Fair Hearing Request” on your correspondence. All State Fair Hearing
Requests must be sent in writing to the follow address:
State Fair Hearing Request
Tempe, AZ 85281
An authorized representative, including a provider, acting on behalf of the
member, with the member’s written consent, may request a State Fair Hearing
on behalf of the member. The request for State Fair Hearing must be in writing,
submitted to and received by Bridgeway, no later than 30 days after the date
the member receives the Notice of Appeal Resolution. All State Fair Hearing
Requests must be sent in writing to the follow address:
Attention: Member Appeal
State Fair Hearing Request
Tempe, AZ 85281
1.866.475.3129
[email protected]
103
Appeal
An appeal is a request for review of an action by an enrollee (member) or their
authorized representative, such as a provider. An appeal can be filed for various
reasons including the denial or limited authorization of a requested service,
the type or level of service, or for the reduction, suspension or termination of a
previously authorized service. An authorized representative acting on behalf of
the member, with the member’s written consent, may file an appeal or request a
State Fair Hearing on behalf of a member.
• Standard Appeals – Can be filed either orally or in writing with Bridgeway.
•
•
•
1.866.475.3129
[email protected]
To be considered timely an appeal request must be filed within 60 days of
the date of the Notice of Action. A provider may assist a member in filing an
appeal. Bridgeway does not restrict or prohibit a provider from advocating
on behalf of a member.
Standard Appeal Resolution - Bridgeway resolves appeals and issues
a written Notice of Appeal Resolution to the member (and/or authorized
representative) within 30 days of receiving the appeal request.
Expedited Appeals - If a provider believes that the time for a standard
resolution appeal could seriously jeopardize the member’s life, health,
or ability to attain, maintain, or regain maximum function, the provider
can submit a request for an Expedited Appeal, with the member’s written
consent, along with supporting documentation. Bridgeway acknowledges
expedited appeals within one working day of receipt.
Expedited Appeal Resolution - Bridgeway resolves all expedited appeals
not later than three (3) business days from the date Bridgeway receives the
appeal (unless an extension is in effect) where Bridgeway determines (for
a request from the enrollee), or the provider (in making the request on the
enrollee’s behalf indicates) that the standard resolution timeframe could
seriously jeopardize the enrollee’s life or health or ability to attain, maintain
or regain maximum function. The Contractor shall make reasonable efforts
to provide oral notice to an enrollee regarding an expedited resolution
appeal.
o If a Notice of Appeal Resolution is not completed when the timeframe
expires, the member’s appeal shall be considered to be denied by the
Contractor, and the member can file a request for hearing.
o If Bridgeway denies a request for expedited resolution, Bridgeway
transfers the appeal to the 30-day timeframe for a standard appeal.
o Bridgeway makes reasonable efforts to give the enrollee prompt
oral notice and follow-up within two days with a written notice of the
denial of expedited resolution.
o Benefits continue until a hearing decision is rendered if: 1) the enrollee
files an appeal before the later of a) 10 days from the mailing of the
Notice of Action or b) the intended date of Bridgeway’s action,
2) a) the appeal involves the termination, suspension, or reduction of
a previously authorized course of treatment or b) the appeal involves
a denial and the physician asserts that the requested service/
treatment is a necessary continuation of a previously authorized
service, 3) the services were ordered by an authorized provider and
4) the enrollee requests a continuation of benefits.
March 2016
104
Each appeal should be filed separately. In order to file an appeal, please submit
in writing, along with all substantiating documentation to:
Attention: Member Appeals
Tempe, AZ 85281
Or Via Toll Free: 1.866.475.3129
Claim Payment Audits
Bridgeway audit review nurses will perform retrospective review of claims paid
to providers to ensure accuracy of the payment process. If a claim is found to be
overpaid, the amount will be recouped against future claim payments. A letter
will be sent to the provider notifying them of the reason for the recoupment
and the amount. When necessary and appropriate, Bridgeway will secure the
necessary AHCCCS approval for recoupment.
Post Processing Claims Audit
Bridgeway is contractually obligated to have procedures in place to detect waste,
fraud, and abuse achieved through:
• Claims editing
• Post-processing review of claims
• Provider profiling and credentialing
• Quality control
• Utilization management
As accountable and fiscally responsible stewards of public funds, we take the
prevention and detection of waste, fraud, and abuse very seriously. Bridgeway
has a management contract with its parent organization, Centene Corporation
(Centene). Centene conducts routine post-processing claims audits on behalf of
Bridgeway. These audits are designed to ensure that billing codes and practices
are correct and that Bridgeway has paid health care providers appropriately. In
addition to provider reviews, Centene also investigates members who appear to
be abusing the Medicaid and Advantage programs.
Post Processing Claims Audit
A post-processing claims audit consists of a review of clinical documentation
and claims submissions to determine whether the payment made was consistent
with the services rendered. To start the audit, Centene Auditors request medical
records for a defined review period. Providers have two weeks to respond to
the request; if no response is received, a second and final request for medical
records is forwarded to the provider. If the provider fails to respond to the
second and final request for medical records, or if services for which claims have
been paid are not documented in the medical record, Bridgeway will recover all
amounts paid for the services in question.
Centene Auditors review cases for potential unbundling, upcoding, mutually
exclusive procedures, incorrect procedures and/or diagnosis for member’s
age, duplicates, incorrect modifier usage, and other billing irregularities. They
consider state and federal laws and regulations, provider contracts, billing
histories, and fee schedules in making determinations of claims payment
appropriateness. If necessary, a clinician of like specialty may also review specific
cases to determine if billing is appropriate.
105
1.866.475.3129
[email protected]
Auditors issue an audit results letter to each provider upon completion of the
audit, which includes a claims report which identifies all records reviewed during
the audit. If the Auditor determines that clinical documentation does not support
the claims payment in some or all circumstances, Bridgeway will seek recovery of
all overpayments.
Providers who contest the overpayment methodology or wish to calculate an
exact overpayment figure may request a full, on-site chart audit of all services
rendered during the review period. A full chart audit may take four to eight weeks
to complete. On-site audits are performed by Bridgeway’s contracted vendor,
HMS. Per the terms of your contract, you may be liable for the cost of an on-site
audit.
Payment & Coverage Policies
The Centene Corporation Payment Integrity unit established a Payment &
Coverage Policy Initiative in an effort to incentivize improved quality of care and
enhance provider communication related to plan payment policies. The initiative
was designed to Increase claims processing efficiently and effectiveness to better
ensure payment of only correctly coded and medically necessary claims.
The Centene (Bridgeway) Payment & Coverage policies address coding
inaccuracies such as unbundling, fragmentation, up coding, duplication, invalid
codes and mutually exclusive procedures as well as statements of plan coverage
of items and services. Coding and billing rules applied are based on industry
standards and guidelines as published and defined In the Current Procedure
Terminology (CPT), Centers for Medicare and Medicaid Services (CMS), and
public domain specialty society edits. State contract and/or State specific
regulations will be accounted for in the policies.
As a Centene Corporation health plan, Bridgeway will post a robust policy
library on the website that will outline the payment and coverage rules related
to different procedures. Please check the website often as policies will be
reviewed and uploaded throughout the year.
If you require assistance in accessing policies, or require that polices be provided
in a different format, please contact your Provider Relations Representative at
1.866.475.3129.
Thank you for your continued partnership and commitment to payment Integrity
FRAUD WASTE AND ABUSE
Fraud Waste and Abuse (FWA) System
1.866.475.3129
[email protected]
Bridgeway takes the detection and reporting of suspected fraud and abuse
very seriously, and has a FWA program that complies with state and federal
laws. Bridgeway, in conjunction with its parent company, Centene Corporation,
successfully operates a billing errors/ waste, abuse and fraud unit. If you suspect
or witness a provider inappropriately billing or a member receiving inappropriate
services, please call our anonymous and confidential hotline at 1-866-685-8664.
Bridgeway and Centene take all reports of potential waste, abuse or fraud very
seriously and investigate all reported issues.
March 2016
106
FWA Authority and Responsibility
The Bridgeway Vice President of Compliance & Regulatory Affairs has overall
responsibility and authority for carrying out the provisions of the compliance
program. Bridgeway is committed to identifying, and reporting cases of
suspected fraud and abuse. Bridgeway is required to report cases of suspected
fraud or abuse to the Arizona Health Care Cost Containment System (AHCCCS)
Office of Inspector General (OIG). Other agencies may have involvement in cases
of criminal activity or abuse. The AHCCCS OIG is responsible for determining
if suspected fraud or abuse cases warrant referral to the State Attorney
General’s office. The AHCCCS Office of Inspector General has the authority to
levy civil monetary penalties, issue recoupment letters, and utilize other types
of sanctions if fraud, waste or abuse is substantiated. Anyone who suspects
member or provider fraud or abuse may report it either to the Bridgeway Vice
President of Compliance & Regulatory Affairs, the Centene hotline number at
1-866-685-8664 or directly to the State hotline at:
• In Maricopa County: 602.417.4045
• Outside of Maricopa County: 888-ITS-NOT-OK or 888.487.6686
Deficit Reduction Act and False Claims Act Compliance Requirements
Each Provider Agreement requires all providers to adhere to Deficit Reduction Act
(DRA) requirements. The DRA requires that any entity (which receives or makes
payments, under a state plan approved under Title XIX or under any waiver of
such plan, totaling at least $5 million annually) must establish written policies for
its employees, management, contractors and agents regarding the False Claims
Act (FCA). The FCA applies to claims presented for payment by federal health
care programs. The FCA allows private persons to bring a civil action against
those who knowingly submit false claims upon the government.
Activities for which one may be liable under the FCA:
• Knowingly presenting to an officer or employee of the United States
government a false or fraudulent claim for payment or approval
• Knowingly making, using, or causing a false record or statement to get a
false or fraudulent claim paid or approved by the government
• Conspiring to defraud the government by getting false or fraudulent claims
allowed or paid
• Having possession, custody, or control of property or money used, or to
be used by the government and, intending to defraud the government by
willfully concealing property, delivering, or causing to be delivered less
property than the amount for which the person receives
• Authorizing to make or deliver a document, certifying receipt of property
used by the government and intending to defraud the government and
making or delivering a receipt without completely knowing that the
information on the receipt is true
• Knowingly buying, or receiving as a pledge of an obligation or debt, public
property from an officer or employee of the government, or a member of
the Armed Forces, who lawfully may not sell or pledge the property
• Knowingly making, using or causing to be made or used, a false record or
statement to conceal, avoid, or decrease an obligation to pay or transmit
money or property to the government
The definition of “knowing” and “knowingly” as it relates to the FCA includes
actual knowledge of the information, acting in deliberate ignorance of the truth
or falsity of the information, and/or acting in reckless disregard of the truth or
falsity of the information. Proof of specific intent to “defraud” is not required for
reporting potential violations of the law.
107
1.866.475.3129
[email protected]
Examples of Fraud, Waste and Abuse
Examples of actions that are reportable to the state’s investigative agencies
include:
• Physical or sexual abuse of members
• Improper billing and coding of claims
• Pass through billing
• Billing for services not rendered
• Raising fees for Medicaid patients to allowable amounts if these fees are not
billed to other patients
• Unbundling and up coding may be construed as fraud if a pattern is found
to exist
In addition, member fraud is also reportable and examples include:
• Use of another member’s identification to obtain services
• Fraudulent application for eligibility
• Sale of durable medical equipment while on loan to members
• Prescription fraud
Network FWA Training & Education
All Bridgeway Network providers are required to complete the AHCCCS
e-learning seminar entitled “Fraud Awareness for Providers” that discusses
provider and member fraud on an annual basis. The training includes an
overview the False Claims Act (FCA). Providers can access the training course
directly at: http://www.azahcccs.gov/fraud/. Network providers must attest to
completion of the training course annually at: http://www.bridgewayhs.com/forproviders/training/provider-training/
FWA State References
To prevent and detect fraud, waste, and abuse, many states have enacted laws
similar to the FCA but with state-specific requirements, including administrative
remedies and relater rights. Those laws generally prohibit the same types of false
or fraudulent claims for payments for health care related goods or services as are
addressed by the federal FCA. Additional information on the Deficit Reduction
Act and FCA is available on the following websites:
• http://www.azleg.state.az.us/ArizonaRevisedStatutes.asp (ARS 13-1802
Theft; 13-2002 Forgery; 13-2310 Fraudulent schemes and practices/willful
concealment; 36-2918 Duty to report fraud)
• http://www.azsos.gov/rules/arizona-administrative-code (AAC R9- 22-1101
Civil Monetary Penalties and Assessments)
Please contact the Bridgeway Vice President of Compliance & Regulatory Affairs
for additional information or guidance.
1.866.475.3129
[email protected]
March 2016
108
MEMBER RESOURCES
ARIZONA LONG TERM CARE SYSTEM (ALTCS) OFFICE LOCATIONS
(Note: this is not a complete list, please visit AHCCCS website for complete
listing)
Casa Grande ALTCS Office
500 N. Florence Street
Casa Grande, AZ 85222
Phone: (520) 421.1500
FAX: (877) 666.0874
Toll Free: (855) 277.0260
Chinle ALTCS Office
Tseyi Shopping Center, Hwy. 191
P.O. Box 1942
Chinle, AZ 86503
Phone: (928) 674.5439
FAX: (877) 660.1450
Toll Free: (888) 800.3804
Globe/Miami ALTCS Office
Cobre Valle Plaza
2250 Highway 60, Suite H
Miami, AZ 85539-9700
Phone: (928) 425.3165
FAX: (877) 666.5219
Toll Free: (888) 425.3165
Kingman ALTCS Office
519 E. Beale Street, Suite 130
Kingman, AZ 86401
Phone: (928) 753.2828
FAX: (877) 667.5239
Toll Free: (888) 300.8348
Lake Havasu ALTCS Office
2160 N. McCulloch Blvd., Suite 105
Lake Havasu City, AZ 86403
Phone: (928) 453.5100
FAX: (877) 664.5264
Toll Free: (800) 654.2076
Phoenix ALTCS Office
801 E. Jefferson Street, MD 1600
Phoenix, AZ 85034
Phone: (602) 417.6600
FAX: (602) 253.6385
Sierra Vista ALTCS Office
NOTE: Sierra Vista ALTCS staff is sharing space at the DES office.
Street Address: 820 E. Fry Blvd, Sierra Vista
Mailing address: 1010 N. Finance Center, Suite 201, Tucson, AZ 85710
Phone: (520) 459.7050
FAX: (877) 660.5342
Toll Free: (888) 782.5827
109
1.866.475.3129
[email protected]
DOMESTIC VIOLENCE
Bridgeway members may include individuals at risk for becoming victims
of domestic violence. It is especially important that providers are vigilant in
identifying these members. Case Managers can help members identify resources
to protect them from further domestic violence.
You may refer victims of domestic violence to the Arizona Adult Protective
Services (APS) https://des.az.gov/services/aging-and-adult/adult-protectiveservices/file-aps-report-online.
Providers should report all suspected domestic violence as described. State law
requires reporting by any person if he or she has “reasonable cause to believe
that a child has been subjected to child abuse or acts of child abuse”. Such
reporting can be done anonymously. Report any injuries from fi rearms and
other weapons to the police. Please report any suspected child abuse or neglect
immediately to the Arizona Department of Child Safety (DCS): https://dcs.az.gov/
report-child-abuse-or-neglect.
MEMBER ADVOCACY RESOURCES
Community Resources
Arizona Health Care Cost Containment System (AHCCCS)
801 E. Jefferson Street
Phoenix, AZ 85034
(602) 417.4000
www.healthearizonaplus.gov
* Health-e-Arizona Plus (www.healthearizonaplus.gov) allows AHCCCS members
to view their active healthcare and health plan enrollment and provides the
following information:
• Two (2) year history of eligibility
• Enrollment information
• Link to active health plan websites
• Current member address
You can use Health-e-Arizona to apply on-line for medical assistance, Nutrition
Assistance, and cash assistance. https://www.healthearizonaplus.gov.
Arizona Department of Health Services
150 N. 18th Avenue
Phoenix, AZ 85007
(602) 542.1025
400 W. Congress
Suite 100
Tucson, AZ 85701
(520) 628.6965
1.866.475.3129
[email protected]
March 2016
Area Agency on Aging
1366 E. Thomas Rd.
Suite 108
Phoenix AZ, 85014
Phone: (602) 264.2255
FAX: (602) 230.9132 or Toll Free: (888) 783.7500
http://www.aaaphx.org/
110
Alzheimer’s Association Central Arizona Regional Office
The Alzheimer’s Association can provide the following resources: care finder,
helpline, library, workshops and support groups
1028 E. McDowell Road
Phoenix, AZ 85006
(602) 528.0545 or (800) 272.3900
www.ALZ.org/dsw
Arizona Head Start
Arizona Head Start is a program that helps to prepare preschoolers for
kindergarten. Preschoolers enrolled in Head Start get healthy snacks and meals
at no cost.
234 N. Central Avenue
Phoenix, AZ 85004
(480) 464.9669
http://www.hsd.maricopa.gov/headstart
Arizona Early Intervention Program (AzEIP)
AzEIP helps families of children ages birth to three (3) with disabilities or
development delays to support and work with their natural ability to learn.
3839 N. 3rd Street
Suite 304
Phoenix, AZ 85012
(602) 532.9960
Community Information and Referral (Community I & R)
Community I&R can assist with the following community services:
• Food banks, clothes, shelters
• Help to pay rent and utilities
• Health care
• Support groups when you or someone else is in trouble
• Support groups and counseling for help with drug or alcohol problems
• Financial help
• Job training
• Transportation
• Education Programs/ help with learning
• Adult day care
• Meals on wheels
• Respite Care
• Home health care
• Homemaker services
• Protective services
Call 2-1-1 or visit the website at www.cir.org
Centers for Medicare and Medicaid Services
Region 9
90 7th Street
Suite 5-300
San Francisco, CA 94103-6706
(415) 744.3501 or (800) 633.4227
111
1.866.475.3129
[email protected]
Center for Independent Living
AABILITY360- Maricopa County
5025 E. Washington Street
Suite 200
Phoenix, AZ 85034
(602) 256.2245
ABILITY360- Pima
1023 N. Tyndall Avenue
Tucson, AZ 85719
(520) 561.8862
WIC (Women, Infants and Children)
WIC services pregnant women, infants and children under five (5) years of age.
WIC provides food, breastfeeding education and information on eating healthy
diet.
www.fns.usda.gov/wic
Social Security Administration
250 N. 7th Avenue
Suite 200
Phoenix, AZ 85007
(800) 772.1213
www.ssa.gov
HEALTH CARE DIRECTIVES AND LEGAL RESOURCES
Health Directives Local Resources
Health Care Decisions
1510 E. Flower Street
Phoenix, AZ 85014
(602) 530.6900
http://www.hov.org/living-will-health-care-decisions
1366 E. Thomas Rd.
Suite 108
Phoenix AZ, 85014
Phone: (602) 264.2255
FAX: (602) 230.9132 or Toll Free: (888) 783.7500
Arizona Attorney General’s Office
1275 W. Washington Street
Phoenix, AZ 85007
(602) 542.5025
www.azag.gov
1.866.475.3129
[email protected]
March 2016
Arizona Attorney General’s Office-Tucson
400 West Congress
South Building, Suite 315
Tucson, AZ 85701-1367
(520) 628.6504
www.azag.gov
112
Department of Economic Security (DES)
Division of Aging and Adult Services
1789 W. Jefferson Street, Site Code 950A
Phoenix, AZ 85007
(602) 542.4446
https://www.azdes.gov/
Health Directives National Resources
AARP
601 E Street, N.W.
Washington, DC 20049
(888) 687.2277
www.aarp.org/states/az
Arizona Senior Citizens Law Project
1818 S. 16th Street
Phoenix, AZ 85034
(602) 252.6710
http://www.azlawhelp.org/resourceprofile.cfm?id=12
Community Legal Services
Community Legal Services
Central Phoenix Area
305 S. Second Avenue
Phoenix, AZ 85003
(602) 25.3434 or (800) 852.9075
www.clsaz.org
East Valley Office
1220 S. Alma School Road
#206
Mesa, AZ 85210
(480) 833.1442 or (800) 852.9075
Southern Arizona Legal Aid (SALA) Community Legal Services
2343 E. Broadway Boulevard
Suite 200
Tucson, AZ 85719-6007
(520) 623.9465 or (800) 640.9465
www.sazlegalaid.org
Southern AZ Legal Aid- Graham/ Greenlee/ Cochise
400 Arizona Street
Bisbee, AZ 85603-1504
(520) 432.1639 or (800) 231.7106
www.sazlegalaid.org
1.866.475.3129
[email protected]
113
Ombudsman
1366 E. Thomas Rd.
Suite 108
Phoenix AZ, 85014
Phone: (602) 264.2255
FAX: (602) 230.9132 or Toll Free: (888) 783.7500
LTC Ombudsman - Maricopa
Division of Aging and Adult Services
1789 W. Jefferson Street (Site Code 950A)
Phoenix, AZ 85007
(602) 542.4446
https://www.azdes.gov/daas/ltco
LTC Ombudsman - Pinal/ Gila
8969 W. McCartney Road
Casa Grande, AZ 85194
(520) 836.2758 or (800) 293.9393
www.pgcsc.org
LTC Ombudsman- Graham/ Greenlee/ Cochise
SouthEastern Arizona Governments Organization (SEAGO)
300 Collins Road
Bisbee, AZ 85603
(520) 432.2528
www.seago.org
Arizona Center for Disability Law- Maricopa County
Suite 202
Phoenix, AZ 85034
(602) 274.6287 or (800) 927.2260
http://www.acdl.com/contact.html
Center for Independent Living
ABILITY360- Maricopa County
Suite 200
Phoenix, AZ 85034
(602) 256.2245
http://ability360.org/
1.866.475.3129
[email protected]
ABILITY360- Main Office
Suite 200
Phoenix, AZ 85034
(602) 256.2245
March 2016
114
ABILITY360- Central Office
Phoenix, AZ 85034
(602) 296.0551
ABILITY360- Mesa Office
2150 S. Country Club Dr.
Suite #10
Mesa, AZ 85210
(480) 655.9750
ABILITY360- West Valley Office
6829 N. 57th Avenue
Glendale, AZ 85301
(602) 424.4100
ABILITY360 Pinal/ Gila Office
8969 W. McCartney Road
Casa Grande, AZ 85194-7432
(520) 424.2834
ABILITY360- Pima
1023 N. Tyndall Avenue
Tucson, AZ 85719
(520) 561.8862
Southern Arizona Legal Aid (SALA) Community Legal Services
Suite 200
Tucson, AZ 85719-6007
(520) 623.9465 or (800) 640.9465
www.sazlegalaid.org
Tohono O’odham Legal Services (division of SALA)
Suite 200
Tucson, AZ 85719-6007
(520) 623.9465 or (800) 248.6789
1.866.475.3129
[email protected]
115
KL:1005833^20431570^368796761^P^1^false^L:KL
Run Date: 10/13/2014
Page 1 of X
EXPLANATION OF PAYMENT
1850 W. Rio Salado Parkway,
Suite 201
Tempe, AZ 85281
1-866-475-3129
PAY TO:
PROVIDER NAME
PROVIDER STREET
CITY, ST ZIP
Alt Policy#: MEDA606462408 [appears only when used]
Alt Policy#: MDCB606462408
Insured Name: NAME, INSURED
Patient Name: NAME, PATIENT
Servicing Provider: PROVIDER NAME
Serv
Date
0100 dd/mm/yyyy
NPI: 000000000000
DRG: [appears only when used]
Claim/ Ctrl No: N000GHE00000
PatCtrl No: 00000000
Group: PLAN/PRODUCT ID
BusSeg: [appears only when used]
Charged
00000000
01 02 03 04
05 06 07 08
1
$ 0000000.00 $ 0000000.00
Allowed
Deduct/
CoPay
Disallow/
Discount
Interest
$ 0000000.00
$ 0000000.00
$ 0000000.00
Med Allow/
Med Paid
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00 $ 0000000.00 $ 0000000.00
$ 0000000.00 $ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
92
$000.00
MRN: [appears only when used]
Carrier: [appears only when used]
Days
Ct/ Qty
Explanation Code
Payment Amt:
Mbr No: U00000000000
SvcProv No: 000000
Mod
Total
10/13/2014
0000000000
Payee ID: 0000
000000000
IRS#:
Carrier Name: MEDICARE PART A [appears only when used]
Carrier Name: MEDICARE PART B
Proc#
Sub-total
Payment Date:
Payment #:
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
Third Party
Payer
Denied
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
EXPL
Codes
92 00 00
00 00 00
Claim Header
Alt Policy#: policy number for additional insurance plan(s) covering the
member
Carrier: name for additional insurance plan(s) covering the member
Insured Name: member
Patient Name: member or member's covered dependent who received the
service
Servicing Provider: practitioner or facility who performed the service
Mbr No: member's CNC plan identification number
SvcProv No: CNC identification number for provider
NPI: national provider number
MRN: patient medical record number (provider)
Carrier No: Additional plan number for product designation/differentiation
DRG: Diagnosis Related Group number
BusSeg: Business Segment designation where it is used
Claim/Ctrl No: Plan claim number
PatCtrl No: Provider claim number
Group: Plan and product designation
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
$ 0000000.00
Description
PAID ACCORDING TO CONTRACT PROCESSING GUIDELINES
Payment/
Withheld
$0000000.00
Payment Header
Payment Date: Date payment was disbursed
Payment #: Check number
Payment Amount: Amount disbursed to provider
Service Line Labels
Serv: service line number
Date: Date service was provided to member
Proc#: procedure identification number
Mod: modifiers to facilitate contracted pricing with providers
Days Ct/Qty: days of treatment or quantity of treatment or supply
Charged: amount billed by the provider
Allowed: amount contracted by plan network to pay for the treatment
Deduct/Copay: member deductible applied or copayment paid by the member
Disallow/Discount: Amount not paid per contracted rates, discount applied
Interest: interest paid by plan.
Med Allow/ Med Paid: amount medical plan allowed and paid
TPP: third party payer
Denied: plan has denied payment for a service
EXPL Codes: codes to denote reasons for denial and explanantions of factors
affecting the payment of the claim
Payment: amount of payment paid to the provider
Withheld: recoupment withheld from provider's payment
$ 0000000.00
Key of Terms for the Centene EOP
EOP Header
Run Date: Date of the check run
Payee ID: Provider entity receiving the check (Group practice or
individual provider/facility)
IRS#: IRS number of the provider being paid
1-866-796-0530
6/6/2014
RUN DATE:
PAYEE ID:
Statement Total section
Explanation of application of negative
balances and payment
XXXX
123456789
IRS #:
STATEMENT TOTAL
1,234,567.89
1,234,567.89
Beginning Negative Services Balance:
Beginning Prepayment Balance:
Claims Paid This Run
1,234,567.89
1,234,567.89
Check Amount:
1,234,567.89
Total Beginning Balance:
Remittance Advice and Explanation of Payment
Carrier Name: CARRIER A
Carrier Name: CARRIER B
Alt Policy#: XXXX000000000X
Alt Policy#: XXXX000000000X
Insured Name: XXXXX, XXXXXXX
Member ID: U0000000000
Patient Name:
MRN: [appears only when used]
Claim No:
PCN: 0000000
Carrier: [appears only when used]
Provider ID:
NPI: 0000000000
DRG: [appears only when used]
Group: PLAN/PRODUCT ID
XXXXX, XXXXXXX
Service Provider:
Serv Date
100
51414
PROVIDER NAME
Procedure
Modifiers
12345678
01.02.03.04
05.06.07.08
Days
Ct/Qty
1.00
Charged
Allowed
1234567.89
1234567.89
Sub-total
1234567.89
1234567.89
BusSeg: [appears only when used]
Med Allow/
Disallow/
Interest
Deduct/
Discount
Med Paid
CoPay
1234567.89 1234567.89 1234567.89 1234567.89
1234567.89
1234567.89
1234567.89 1234567.89
1234567.89
TOTAL
1234567.89
1234567.89
1234567.89 1234567.89
Third Party Denied
Payment
1234567.89 1234567.89
N000MPE00000
P0000000000
Payment
Codes
91 Y1 XX
91 Y1 XX
Payment
1234567.89
1234567.89 1234567.89 1234567.89 1234567.89
1234567.89
1234567.89 1234567.89
1234567.89
1234567.89
1234567.89 1234567.89
1234567.89
1234567.89
Payment Code Description
91
REIMBURSEMENT OF FEE SCHEDULE AND/OR CONTRACTED RATES
CLAIM APPLIED TO OUT OF NETWORK DEDUCTIBLE
1Y
DENY: DUPLICATE CLAIM SERVICE
18
Claim Header
Alt Policy#: policy number for additional insurance
plan(s) covering the member
Carrier: name for additional insurance plan(s) covering
the member
Insured Name: member
Patient Name: member or member's covered
dependent who received the service
Member ID: member's plan identification number
Service Provider: practitioner or facility who performed
the service
PCN: patient account number
NPI: national provider number
Claim No: plan claim number
Provider ID: internal plan provider identification number
Group: plan coverage group
MRN: Patient Medical Record Number
DRG: Diagnosis Related Group
BusSeg: Business Segment designation where it is used
Service Line Labels
Serv: service line number
Proc#: procedure identification number
Mod: modifiers to facilitate contracted pricing with providers
Days or Ct/Qty: days of treatment or quantity of treatment
or supply
Charged: amount billed by the provider
Allowed: amount contracted by plan network to pay for the
treatment
Deduct/Copay: member deductible applied or copayment
paid by the member Coinsur/Discount: member
coinsurance applied or discount applied
Interest/ Penalty: interest paid by plan. Penalty not currently
being used.
Med Allow/ Med Paid: amount medical plan allowed and
paid
TPP: third party payer
Denied: plan has denied payment for a service
Payment Codes: codes to denote reasons for denial and
explanantions of factors affecting the payment of the claim
Payment: amount of payment paid to the provider
1.866.475.3129
[email protected]
March 2016
118
Suite 201
Tempe, AZ 85281
BridgewayHS.com
© 2016 Bridgeway Health Solutions. All rights reserved.

Provider Manual - Bridgeway Health Solutions

Transcription

Similar documents