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Travis Service Area – Bastrop, Burnet, Caldwell,Hays, Lee, Fayette, Travis and Williamson countiesDell Children’s Health PlanMEDICAID/CHIPPROVIDER MANUALNovember -0002-17

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November 2017Table of ContentsCHAPTER 1: INTRODUCTION AND OBJECTIVES . 5Introduction . 5Program Objectives . 5Nondiscrimination Statement . 6CHAPTER 2: QUICK REFERENCE INFORMATION . 8CHAPTER 3: PROVIDER ROLES . 11Role of the Primary Care Provider or Medical Home . 11Role of the Specialty Care Provider . 11Role of the CHIP Perinatal Provider . 11Role of the Pharmacy . 11Role of the Main Dental Home . 11Network Limitations. 12CHAPTER 4: STAR COVERED SERVICES . 13Texas Health Steps Services: STAR (Medicaid) Members Only. 13Telemedicine, Telehealth and Telemonitoring Access . 16Ambulance Transportation Services . 16Medical Transportation Program . 17Dental Services . 18Vision Services. 19STAR (Medicaid) Managed Care Covered Services . 19CHAPTER 5: COORDINATION WITH NON-MEDICAID MANAGED CARE COVERED SERVICES FOR STARMEMBERS. 22Overview . 22CHAPTER 6: CHIP AND CHIP PERINATAL COVERED SERVICES . 23CHIP Covered Services . 23CHIP Perinatal Covered Services . 23CHIP Member Prescriptions . 34Coordination With non-CHIP Covered Services . 35Value-Added Services – All Products . 35CHAPTER 7: BEHAVIORAL HEALTH FOR CHIP AND STAR MEMBERS . 36Overview . 36Behavioral Health Covered Services . 36Behavioral Health Care Provider Responsibilities . 39Care Continuity and Coordination Guidelines . 40Emergency and Urgent Behavioral Health Services. 40Precertification and Referrals for Behavioral Health . 41Court-Ordered Commitment . 41CHAPTER 8: QUALITY MANAGEMENT . 43Overview . 43Quality Improvement Committee . 43Quality Management Committee . 44Medical Advisory Committee. 44Credentialing Committee . 45Clinical Practice Guidelines . 46ii

Focus Studies and Utilization Management Reporting Requirements . 46New Technology. 46CHAPTER 9: UTILIZATION MANAGEMENT . 47Overview . 47Medical Review Criteria . 47Precertification/Notification Process. 49Health Insurance Portability and Accountability Act . 56CHAPTER 10: MEMBER MANAGEMENT SUPPORT . 58Appointment Scheduling . 58Case Management . 58Members with Special Health Care Needs (MSHCN) . 60Communicable Disease Services . 60Health Promotion. 61Women Infants and Children Program . 61Taking Care of Baby and Me Program . 61CHAPTER 11: STAR AND CHIP SPECIAL ACCESS REQUIREMENTS . 63General Transportation and Ambulance/Wheelchair Van . 63Interpreter/Translation Services . 63MCO/Provider Coordination . 63Reading/Grade Level Consideration and Cultural Sensitivity . 64CHAPTER 12: DISEASE MANAGEMENT PROGRAMS . 65Overview . 65Disease Management Centralized Care Unit Provider Rights and Responsibilities. 66CHAPTER 13: PROVIDER RESPONSIBILITIES . 67Provider Rights and Responsibilities . 67Appointments . 69Continuity of Care . 71Credentialing and Recredentialing. 72Cultural Competency . 74Early Childhood Intervention (ECI) Services. 76Eligibility Verification . 77Emergency Services . 77Fraud, Waste and Abuse . 78ImmTrac . 81Laboratory Services (Outpatient). 81Locum Tenens . 82Member Record Standards . 82Member’s Right to Designate an OB/GYN . 85Noncompliant Dell Children’s Health Plan Members . 85Primary Care Providers . 86Provider Disenrollment Process. 90Provider Marketing . 90Provider Quality Incentive Programs . 90Radiology. 90Second Opinions . 91Referrals . 91Specialty Care Providers . 91Texas Vaccines for Children Program . 94iii

How to Help a Member Find Dental Care . 94Cancellation of Product Orders. 94Reading/Grade Level Consideration . 94CHAPTER 14: PHARMACY PROVIDER RESPONSIBILITIES . 95Overview . 95Prescription Limits . 95Covered Drugs . 96Excluded Drugs. 96Process for Requesting a Prior Authorization . 97Emergency Prescription Supply . 97Durable Medical Equipment/Other Products Normally Found in a Pharmacy . 98CHAPTER 15: TEXAS DEPARTMENT OF FAMILY AND PROTECTIVE SERVICES . 99Coordination with the Texas Department of Family and Protective Services (DFPS) . 99CHAPTER 16: PROVIDER COMPLAINTS AND APPEALS PROCESS. 100Provider Complaint Resolution . 100Provider Payment Appeals. 100CHAPTER 17: MEMBER COMPLAINT AND APPEAL PROCESS . 104Overview . 104Definitions . 104Member Complaint Resolution. 105Member Medical Appeal Process and Procedures . 107CHAPTER 18: MEMBER ELIGIBILITY . 115Overview . 115Verifying Member Medicaid Eligibility . 115Service Responsibility . 117Member Enrollment and Disenrollment from Dell Children’s Health Plan . 119CHAPTER 19: MEMBER RIGHTS AND RESPONSIBILITIES . 124Medicaid Member Rights and Responsibilities. 124CHIP Member Rights and Responsibilities . 126CHIP Perinate Member Rights and Responsibilities . 127Member’s Right to Designate an Obstetrician/Gynecologist . 128CHAPTER 20: BILLING AND CLAIMS ADMINISTRATION . 130Overview . 130Timely Filing . 130Coding . 130Clean Claim . 131Claim Submission . 132Provider Reimbursement . 134Provider-Preventable Conditions . 135Claim Audits . 135Coordination of Benefits . 136Billing Members . 136Cost Sharing . 139CHIP Perinatal Postpartum Billing . 140Out-of-Network Providers . 140APPENDIX A . 142Community First Choice . 142iv

CHAPTER 1: INTRODUCTION AND OBJECTIVESIntroductionDell Children’s Health Plan is a health plan dedicated to serving Children’s Health Insurance Program(CHIP) and State of Texas Access Reform (STAR) members in the Travis Service Area. Dell Children’sHealth Plan has been an administrator of CHIP since 2000 and was selected to administer the CHIPPerinatal and STAR programs in Central Texas beginning March 1, 2012.Dell Children’s Health Plan provides health care to its members through a network of physicians,hospitals and other health care professionals. We are a licensed Texas managed care organizationdedicated to providing quality care to our members and offering information to assist providers intreating their patients. Our goal at Dell Children’s Health Plan is to keep the families enrolled in ourhealth plan healthy and to make sure that these members receive the proper treatment if they becomesick or injured.We believe hospitals, physicians and other providers play a pivotal role in managed care. We can onlysucceed by working collaboratively with you and other caregivers. Earning your loyalty and respect isessential to maintaining a stable, high-quality provider network.Dell Children’s Health Plan retains the right to add to, delete from and otherwise modify this providermanual. Material in this provider manual is subject to change. Please visit DellChildrensHealthPlan.comfor the most up-to-date information.Program ObjectivesThe STAR program is a Medicaid managed care program providing clients with acute care medicalassistance. The objectives of the program are to: Improve access to care for clients enrolled in the program. Increase quality and continuity of care for clients. Decrease inappropriate use of the health care delivery system, such as emergency rooms (ERs)for nonemergencies. Achieve cost effectiveness and efficiency for the state. Promote provider and client satisfaction.The Children’s Health Insurance Program (CHIP) provides health coverage for children age 18 andyounger in families that earn too much to qualify for Medicaid but cannot afford private health carecoverage. A child must be age 18 or younger, a Texas resident, and a U.S. citizen or legal permanentresident. Objectives of the CHIP program are to: Increase the number of insured children in Texas. Ensure children have access to a medical home – a physician or health care provider who servesthe physical, mental and developmental health care needs of a growing child through acontinuous and ongoing relationship.Texas residents who are pregnant, uninsured and not able to obtain Medicaid may be eligible for CHIPPerinatal benefits. Coverage starts before the child is born and lasts 12 months from the date theunborn child is enrolled. The objectives of CHIP Perinatal are to improve health status and birthoutcomes for Texas by ensuring pregnant women who are ineligible for Medicaid due to income orimmigration status receive prenatal care.-5-

Nondiscrimination StatementDell Children’s Health Plan does not engage in, aid or perpetuate discrimination against any person byproviding significant assistance to any entity or person that discriminates on the basis of race, color ornational origin in providing aid, benefits or services to beneficiaries. Dell Children’s Health Plan does notutilize or administer criteria having the effect of discriminatory practices on the basis of gender orgender identity. Dell Children’s Health Plan does not select site or facility locations that have the effectof excluding individuals from, denying the benefits of or subjecting them to discrimination on the basisof gender or gender identity. In addition, in compliance with the Age Act, Dell Children’s Health Planmay not discriminate against any person on the basis of age, or aid or perpetuate age discrimination byproviding significant assistance to any agency, organization or person that discriminates on the basis ofage. Dell Children’s Health Plan provides health coverage to our members on a nondiscriminatory basis,according to state and federal law, regardless of gender, gender identity, race, color, age, religion,national origin, physical or mental disability, or type of illness or condition.Members who contact us with an allegation of discrimination are informed immediately of their right tofile a grievance. This also occurs when a Dell Children’s Health Plan representative working with amember identifies a potential act of discrimination. The member is advised to submit a verbal or writtenaccount of the incident and is assisted in doing so, if the member requests assistance. We document,track and trend all alleged acts of discrimination.Members are also advised to file a civil rights complaint with the U.S. Department of Health and HumanServices Office for Civil Rights (OCR): Through the OCR complaint portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf By mail to: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room509F, HHH Building, Washington, DC 20201 By phone at: 1-800-368-1019 (TTY/TTD: 1-800-537-7697)Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.Amerigroup provides free tools and services to people with disabilities to communicate effectivelywith us. Amerigroup also provides free language services to people whose primary language isn’tEnglish (e.g., qualified interpreters and information written in other languages). These services can beobtained by calling the Member Services number on their member ID card.If you or your patient believe that Dell Children’s Health Plan has failed to provide these services, ordiscriminated in any way on the basis of race, color, national origin, age, disability, gender or genderidentity, you can file a grievance with our member advocate via: Mail: 823 Congress Ave., Suite 400, Austin, TX 78701 Phone: 1-888-596-0268 (TTY 711), and ask for a member advocate Email: dl-txdelladvocate@anthem.comEqual Program Access on the Basis of GenderDell Children’s Health Plan provides individuals with equal access to health programs and activitieswithout discriminating on the basis of gender. Dell Children’s Health Plan must also treat individualsconsistently with their gender identity and is prohibited from discriminating against any individual orentity on the basis of a relationship with, or association with, a member of a protected class (i.e., race,color, national origin, gender, gender identity, age or disability).Dell Children’s Health Plan may not deny or limit health services that are ordinarily or exclusivelyavailable to individuals of one gender, to a transgender individual based on the fact that a different-6-