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Provider ManualMaryland HealthChoice om/mdMD-PM-0038-20
Copyright February 2021 Anthem, Inc.Amerigroup Corporation is a wholly owned subsidiary of Anthem, Inc. All rights reserved. Thispublication, or any part thereof, may not be reproduced or transmitted in any form or by any means,electronic or mechanical, including photocopying, recording, storage in an information retrieval systemor otherwise, without the prior written permission of the National Provider CommunicationsDepartment, 5800 Northampton Blvd., Norfolk, VA 23502, telephone 757-473-2737.This manual is a Maryland Department of Health template and is not wholly inclusive of all Amerigrouppolicies and procedures. For more information on Amerigroup policies and procedures, visit the providerself-service website at https://provider.amerigroup.com/MD or contact your Provider Relationsrepresentative.MD-PM-0038-20
HealthChoice Provider ManualTable of ContentsSECTION I. INTRODUCTION . 5Medicaid and the HealthChoice Program . 6Introduction to Amerigroup . 7Member Rights and Responsibilities . 7HIPAA and Member Privacy Rights . 9Anti-Gag Provisions . 10Assignment and Reassignment of Members . 10Credentialing Requirements . 11Credentialing Scope . 12Credentials Committee . 13Nondiscrimination Policy . 14Initial Credentialing . 14Re-credentialing . 15Health Delivery Organizations . 16Ongoing Sanction Monitoring . 16Appeals Process . 17Reporting Requirements . 17Amerigroup Credentialing Program Standards . 17HDO Type and Amerigroup Approved Accrediting Agent(s) . 30Provider Reimbursement . 31Self-Referral and Emergency Services . 38Maryland Continuity of Care Provisions . 40SECTION II. OUTREACH AND SUPPORT SERVICES, APPOINTMENT SCHEDULING, EPSDT, AND SPECIALPOPULATIONS. 42MCO Member Outreach and Support Services . 43State Nonemergency Medical Transportation Assistance . 43MCO Transportation Assistance . 43State Support Services . 43Scheduling Initial Appointments . 43Early and Periodic Screening, Diagnosis and Treatment Requirements . 44Special Needs Populations . 46Rare and Expensive Case Management Program . 52SECTION III. HEALTHCHOICE BENEFITS AND SERVICES . 53MCO Benefits and Services Overview . 54Additional Services Covered By Amerigroup . 63Medicaid Benefits covered by the State – Not Covered by Amerigroup . 65State-Covered Dental Services for Children and Pregnant Women . 65Additional Services Covered by the State . 65Noncovered Services and Benefit Limitations . 662
SECTION IV. PRIOR AUTHORIZATION AND MEMBER COMPLAINT, GRIEVANCE AND APPEALPROCEDURES . 69Services Requiring Prior Authorization . 70Services Not Requiring Preauthorization . 70Prior Authorization Procedures . 71Inpatient Admissions and Concurrent Review . 71Medical Necessity Criteria . 75Clinical Guidelines . 75Timeliness of Decisions and Notifications to Providers and Members . 76Out-of-Network Providers . 77Overview of Member Complaint, Grievance and Appeal Processes . 77State HealthChoice Help Lines . 81Amerigroup Provider Complaint Process . 81HealthChoice Provider Hotline. 81SECTION V. PHARMACY MANAGEMENT . 82Pharmacy Benefit Management . 83Mail-Order Pharmacy . 84Specialty Pharmacy . 84Prescription and Drug Formulary . 87Prescription Copays. 88Over-the-Counter Products. 88Injectables and Nonformulary Medications Requiring Prior Authorization . 89Prior Authorization Process . 90Step Therapy and Quantity Limits . 91Maryland Prescription Drug Monitoring Program . 91Corrective Managed Care Program/Lock-In Program. 92Maryland Opioid Prescribing Guidance and Policies . 93SECTION VI. CLAIMS SUBMISSION, PROVIDER APPEALS, QUALITY INITIATIVES, PROVIDERPERFORMANCE DATA AND PAY FOR PERFORMANCE . 95Facts to Know Before You Bill . 96Submitting Claims to Amerigroup . 96Provider Appeal of Amerigroup Claim Denial . 122State’s Independent Review Organization (IRO) . 126MCO Quality Initiatives . 126Provider Performance Data . 131Pay for Performance . 131SECTION VII. PROVIDER SERVICES AND RESPONSIBILITIES . 133Overview of Amerigroup Provider Services . 134Provider Web Portal . 134Information Changes . 134Recredentialing . 135Overview of Provider Responsibilities . 136Primary Care Providers . 137PCP Contract Terminations . 139Specialty Providers . 1393
Out-of-Network Providers and Single Case Agreements . 140Appointment Scheduling and Outreach Requirements . 140Second Opinions . 140Provider Requested Member Transfer . 141Medical Records Requirements . 141Reporting Communicable Disease . 144Advance Directives . 145Health Insurance Portability and Accountability Act of 1996 (HIPAA) . 145Cultural Competency . 145Health Literacy — Limited English Proficiency (LEP) or Reading Skills . 146Access for Individuals with Disabilities . 147SECTION VIII. QUALITY ASSURANCE MONITORING PLAN AND REPORTING FRAUD, WASTE AND ABUSE. 148Quality Assurance Monitoring Plan . 149Fraud, Waste and Abuse Activities . 150Reporting Suspected Fraud and Abuse . 151Relevant Laws . 153APPENDIX A. ATTACHMENTS . 156Attachment 1: Rare and Expensive Case Management (REM) Program . 157Attachment 2: School-Based Heath Center Health Visit Form (DHMH 2015) . 166Attachment 3: Local Health ACCU and NEMT Transportation — Contact List . 168Attachment 4: Local Health Service Request Form (DHMH 4682) — Fillable Form . 169Attachment 5: Maryland Prenatal Risk Assessment Form (DHMH 4850) . 170Request for Fair Hearing Form . 172Screening Tools . 173Women, Infants and Children Referral Form . 174Maryland Uniform Consultation and Referral Form . 175Specialist as PCP Request Form . 177Living Will Form . 178Durable Power of Attorney Form. 179Provider Payment Dispute and Correspondence Submission Form . 180Practitioner Office Site Evaluation Tool . 181APPENDIX B. CLINICAL GUIDELINES . 1834
SECTION I. INTRODUCTION5
Medicaid and the HealthChoice ProgramMedicaid and HealthChoiceHealthChoice is the name of Maryland Medicaid’s managed care program. There are approximately 1.3million Marylanders enrolled in Medicaid and the Maryland Children’s Health Program (MCHP). Withfew exceptions, Medicaid beneficiaries under age 65 must enroll in HealthChoice. Individuals that do notselect a managed care organization (MCO) will be auto-assigned to an MCO with available capacity thataccepts new enrollees in the county where the beneficiary lives. Individuals may apply for Medicaid,renew their eligibility and select their MCO online at www.marylandhealthconnection.gov or by calling1-855-642-8572 (TTY: 1-855-642-8572). Members are encouraged to select an MCO that their PCPparticipates with. If they do not have a PCP, they can choose one at the time of enrollment. MCOmembers who are initially auto-assigned can change MCOs within 90 days of enrollment. Members havethe right to change MCOs once every 12 months. The HealthChoice program’s goal is to provide patientfocused, accessible, cost-effective, high quality health care. The state assesses the quality of servicesprovided by MCOs through various processes and data reports. To learn more about the state’s qualityinitiatives and oversight of the HealthChoice Program, go ages/Home.aspx.Providers who wish to serve individuals enrolled in Medicaid MCOs are now required to register withMedicaid. Amerigroup Community Care also encourages providers to actively participate in theMedicaid fee-for service (FFS) program. Beneficiaries will have periods of Medicaid eligibility when theyare not active in an MCO. These periods occur after initial eligibility determinations and temporarilylapses in Medicaid coverage. While MCO providers are not required to accept FFS Medicaid, it isimportant for continuity of care. For more information, go to:https://eprep.health.maryland.gov/sso/login.do. All providers must verify Medicaid and MCO eligibilitythrough the Eligibility Verification System (EVS) before rendering services.We do not prohibit or otherwise restrict a provider, acting within the lawful scope of practice, fromadvising or advocating on behalf of an enrollee who is his or her patient.HealthChoice EligibilityAll individuals qualifying for Maryland Medicaid or MCHP are enrolled in the HealthChoice program,with the exception of the following: Individuals enrolled in a Medicare Advantage program Individuals age 65 or older Individuals who are eligible for Medicaid under spend-down provisions Medicaid participants who have been or are expected to be continuously institutionalized for morethan 30 successive days in a long-term care facility or in an institution for mental disease (IMD) Individuals institutionalized in an intermediate care facility for persons with intellectualdisabilities/mentally retarded persons (ICF-MR) Participants enrolled in the Model Waiver Program Participants who receive limited coverage, such as individuals who receive family planning servicesthrough the Family Planning Waiver or Employed Individuals with Disabilities Program Inmates of public institutions, including state-operated institutions or facilities A child receiving an adoption subsidy who is covered under the parents’ private insurance A child under state supervision who receives an adoption subsidy and lives outside of the state A child who is in an out-of-state placement6
All Medicaid participants who are eligible for the HealthChoice program, without exception, are enrolledin an MCO or in the Rare and Expensive Case Management (REM) program. See the Rare and ExpensiveCase Management Program section and Attachment 1 for more information.Medicaid-eligible individuals who are not eligible for HealthChoice will continue to receive services inthe Medicaid Fee-For-Service (FFS) system.Members must complete an updated eligibility application every year to maintain their coveragethrough the HealthChoice program.HealthChoice members are permitted to change MCOs if they have been in the same MCO for 12months or more.HealthChoice providers are prohibited from steering members to a specific MCO. Providers are onlyallowed to provide information on which MCOs they participate with if a current or potential memberseeks their advice about selecting an MCO.Introduction to AmerigroupHealthChoice, which is overseen by the Maryland Department of Health (MDH), serves most Medicaidparticipants. These individuals are enrolled in one of the participating managed care organizations(MCOs). Amerigroup Maryland, Inc., doing business as Amerigroup Community Care, is a wholly ownedsubsidiary of Amerigroup Corporation. Amerigroup Corporation is a wholly owned subsidiary ofAnthem, Inc. and is an MCO that participates in the HealthChoice program.The purpose of this provider manual is to highlight and explain the program’s elements and to serve as auseful reference for providers who participate in the HealthChoice program.Member Rights and ResponsibilitiesMembers have rights and responsibilities when participating in an MCO. Member Servicesrepresentatives serve as advocates for Amerigroup members.Members have the right to: Be treated respectfully and with due consideration for dignity and privacy. Privacy during a visit with their doctor. Talk about their medical record with their PCP, ask for a summary of that record and request toamend or correct the record as appropriate. Be properly educated about and helped to understand their illness and available health careoptions, including a candid discussion of appropriate clinically or medically necessary treatmentoptions, including medication treatment options regardless of the cost or benefit coverage. Participate in decision-making about the health care services they receive. Refuse health care (to the extent of the law) and understand the consequences of their refusal. Be free from any form of restraint, seclusion as a means of coercion, discipline, inconvenience orretaliation as specified in other federal regulations on the use of restraints and seclusion. Decide ahead of time regarding the kinds of care they want if they become sick, injured or seriouslyill by making a living will. Expect their records (including medical and personal information) and communications will betreated confidentially.7
If under age 18 and married, pregnant or have a child, be able to make decisions about his or herown health care and/or his or her child’s health care.Choose their PCP from the Amerigroup network of providers.Make a complaint to Amerigroup and get a response within 30 days.Have information about Amerigroup, its services, practitioners, and provider and member rights andresponsibilities.Receive information on the Notice of Privacy Practices as required by the Health InsurancePortability and Accountability Act (HIPAA).Get a current member handbook and a directory of health care providers within the Amerigroupnetwork.Choose any Amerigroup network specialist.Change their doctor to another Amerigroup network doctor if the doctor is unable to refer them tothe Amerigroup network specialist of their choice.Be connected to health care providers for ongoing treatment of chronic disabilities.Have access to their PCP or a backup 24 hours a day, 365 days a year for urgent or emergency care.Receive care right away from any hospital when their medical condition meets the definition of anemergency.Receive poststabilization services following an emergency condition in some situations.Call the Amerigroup toll-free 24-hour Nurse HelpLine 24 hours a day, 7 days a week. English:866-864-2544; Spanish: 866-864-2545Call the Amerigroup toll-free Member Services telephone line from 8 a.m.-6 p.m. Eastern time,Monday- Friday.Know what payment methodology Amerigroup utilizes with health care providers.Receive assistance in filing a grievance and/or appeal and appeal through the Amerigroup internalsystem.File a grievance or appeal if he or she is not happy with the results of a grievance and receiveacknowledgement within 10 days and a resolution within 30 days.Ask Amerigroup to reconsider previously denied coverage; upon receipt of the member’s medicalinformation, Amerigroup will review the request.Freely exercise the right to file a grievance or appeal such that exercising of these rights will notadversely affect the way the member is treated.Receive notification to present supporting documentation for their appeal.Examine files before, during and after their appeal.Request an administrative hearing when dissatisfied with the Amerigroup decision.Continue to receive benefits pending the outcome of an appeal decision or state administrativehearing if the appropriate rules are followed.Only be responsible for cost-sharing in accordance with 42 CFR 447.50-42 CFR 447.60 and MarylandMedicaid provisions.To make recommendations regarding the Amerigroup Rights and Responsibilities Policy.Members have the responsibility to: Treat their providers, their providers’ staff and Amerigroup employees with respect and dignity. Not behave in a disruptive manner while in the provider’s office. Respect the rights and property of all providers. Cooperate with people providing health care. Tell their PCP about their symptoms and problems and ask questions. Get information and consider treatments before they are performed.8
Understand their health problems and participate in developing mutually agreed upon treatmentgoals to the degree possible.Discuss anticipated problems with following their provider’s directions.Consider the outcome of refusing treatment recommended by a provider.Follow plans and instructions for care they have agreed on with their providers, to the best of theirability.Help their provider obtain medical records from the previous provider and help their providercomplete new medical records as necessary.Supply information (to the extent possible) the organization and its practitioners and providers needto provide care.Respect the privacy of other people waiting in providers’ offices.Call Amerigroup and change their PCP before seeing a new PCP.Make and keep appointments and arrive on time; members should always call if they need to cancelan appointment, change an appointment time or if they will be late.Discuss complaints, concerns and opinions in an appropriate and courteous way.Tell their provider how they want to receive their health information.Obtain medical services from their PCP.Learn and follow the Amerigroup policies outlined in the member handbook.Read the member handbook to understand how Amerigroup works.Notify Amerigroup when a member or family member who is enrolled in Amerigroup has died.Become involved in their health care and cooperate with their provider about recommendedtreatment.Learn the correct method by which his or her medications should be taken.Carry his or her Amerigroup ID card at all times and quickly report any lost or stolen cards toAmerigroup; members should contact Amerigroup if information on the ID card is wrong or if thereare changes to their name, address or marital status.Show their ID cards to each provider.Tell Amerigroup about any providers they are currently seeing.Provide true and complete information about their circumstances.Report change(s) in their circumstances.Notify his or her PCP as soon as possible after they receive emergency services.Go to the emergency room only when they have an emergency.Report suspected fraud and abuse.HIPAA and Member Privacy RightsThe Health Insurance Portability and Accountability Act (HIPAA) was signed into law in August 1996. Thelegislation improves the portability and continuity of health benefits, ensures greater accountability inthe area of health care fraud, and simplifies the administration of health insurance.Amerigroup strives to ensure both Amerigroup and contracted participating providers conduct businessin a manner that safeguards member information in accordance with the privacy regulations enactedpursuant to HIPAA. Contracted providers shall have the following procedures implemented todemonstrate compliance with the HIPAA privacy regulations: Amerigroup recognizes its responsibility under HIPAA privacy regulations to only request theminimum necessary member information from providers to accomplish the intended purpose;conversely, network providers should only request the minimum necessary member information9
required to accomplish the intended purpose when contacting Amerigroup. However, privacyregulations allow the transfer or sharing of member information, which may be requested byAmerigroup to conduct business and make decisions about care, such as a member’s medicalrecord, authorization determinations or payment appeal resolutions. Such requests are consideredpart of the HIPAA definition of treatment, payment or health care operations.Fax
6 Medicaid and the HealthChoice Program Medicaid and HealthChoice HealthChoice is the name of Maryland Med
