Transcription
Buckeye Health PlanProvider ManualBuckeyeHealthPlan.com
PROVIDER MANUAL (Revised February 2020)Buckeye Health Plan . 5Goals of Buckeye. 5Mission Statement . 5Buckeye Guiding Principles . 5Buckeye Approach . 6Summary . 6Guidelines for Providers . 8Primary Care Provider (PCP) . 8Covered Physician Services . 8PCP Availability and Accessibility . 9PCP Coverage . 9Appointment Availability. 9Telephone Arrangements . 10Self Referrals. 11Referrals . 11Healthchek. 12Member Panel Capacity . 13Provider Termination. 13Other PCP Responsibilities . 13Specialist Responsibilities . 13Hospital Responsibilities . 14Advance Directives. 14Provider Assistance with Public Health Services . 15Additional Reporting Requirements . 16Clinical Practice and Preventive Health Guidelines . 16Medical Records . 17Required Information. 17Medical Records Release. 18Medical Records Transfer for New Patients. 19Medical Records Audits . 19Medical Management. 20
Overview . 20Prior-Authorization . 21Referral Process . 22Inpatient Notification Process . 22Admission Notification. 22Peer to Peer Review . 23Delivery Information . 23Concurrent Review . 23Hospital-To-Hospital Transfers . 24Discharge Planning . 24Observation Bed Guidelines. 24Utilization Management Criteria . 25Affirmative Statement for Utilization Management (UM). 25Second Opinion . 26Continuity of Care. 26Complex Care Management Services . 26Disease Management . 33New Technology . 35Routine, Urgent and Emergency Services . . 36Routine, Urgent and Emergency Care Services Defined . 36Eligibility. . 37Eligibility for the Buckeye Program . 37Verifying Enrollment. 37Newborn Enrollment. 38Enrollment Guidelines for Buckeye Providers . 39Non-compliant Patients. 40Benefits Available to Buckeye Members. . 41Dental Services. . 42Vision Services. . 42Pharmacy Services . 42Enhanced Benefits for Buckeye Members . 45Healthchek. 46
Ohio Healthchek Program. 46Newborn Testing. 47Immunizations. 47Vaccines for Children (VFC) . 47Blood Lead Screening . 48Domestic Violence . 48General Billing Information and Guidelines. . 49Clean Claim Definition. 50Non-Clean Claim Definition. 50Claims Submissions. 50Electronic Claims Submission . 50Ohio Medicaid Identification Number . 51NPI and Tax ID. 51Paper Claim Submission. 52Abortion, Sterilization, and Hysterectomy Billing . 52Common Billing Errors. 54Billing Codes. . 54Code Auditing. . 55Claims Mailing Information . 55Unsatisfactory Claim Payment . 56Billing the Patient. 56Provider Complaints and Appeals. . 56Inquiry, Dispute and Appeal of Claim Payment. . 57Informal Claim Payment Dispute. 57Administrative Claim Appeal . 57Medical Management Appeals. 58Medical Management Appeal Definitions for Appeals and Denials . 58Resubmitted Claims . 60Claim Payment Audits . 60Credentialing. . 61Credentialing Requirements . 61Credentialing Committee . 62
Criteria for Provider Participation . 62Recredentialing . 63Mid-level Practitioner Credentialing . 64Credentialing and Recredentialing of Health Delivery Organizations . 65Right to Review and Correct Information . 66Provider Directory . 66Quality Improvement Program. . 67Buckeye Quality Improvement Plan. 67Billing Error Abuse and Fraud System . 73Authority and Responsibility . 74Member Services . 75MemberConnections Program. 75Member Materials . 76Member Rights & Responsibilities. 76Membership Rights. 79Member Grievances and Appeals . 81Members Right to a State Fair Hearing. 82Special Services to Assist with Members . 83Transportation Services. 83Interpreter/Translation Services. 84NurseWise . 85Provider Relations Assistance. . 86
Provider ManualBuckeye Health PlanBuckeye Health PlanBuckeye Health Plan, Inc. (Buckeye) is a managed care plan (MCP)contracted with the Ohio Department of Medicaid (ODM) to serve Medicaidand other government services program members. Buckeye has developedthe expertise to work with Medicaid members to improve their health statusand quality of life. Our number one priority is the promotion of healthylifestyles through preventive healthcare. Buckeye works to accomplish thisgoal by partnering with the primary care providers (PCP) who oversee thehealthcare of Buckeye members.Goals of BuckeyeBuckeye has been designed to achieve the following goals: Ensure access to primary and preventive care servicesImprove access to all necessary health care servicesEncourage quality, continuity, and appropriateness ofmedical careProvide medical coverage in a cost-effective mannerBuckeye strives to provide members with an improved health status.Buckeye continually seeks to improve member and provider satisfaction.All of our programs, policies and procedures are designed with these goalsin mind. We hope that you will assist Buckeye in reaching these goals.Buckeye Mission StatementBetter health outcomes at lower costs.Buckeye Guiding Principles High quality, accessible, cost-effective healthcare for ourmembersIntegrity and the highest ethical standardsMutual respect and trust in our working relationshipsCommunication that is open, consistent and two-wayDiversity of people, cultures and ideas5
Innovation and encouragement to challenge the status quoTeamwork and meeting our commitments to one anotherBuckeye allows open practitioner/patient communication regardingappropriate treatment alternatives. Buckeye does not penalize practitionersfor discussing medically necessary or appropriate care with the patient.Buckeye ApproachRecognizing that a strong health plan is predicated on building mutuallysatisfactory associations with providers Buckeye is committed to: Working as partners with participating providers;Demonstrating that healthcare is a local issue; andPerforming its administrative responsibilities in a superior fashion.All of Buckeye’s programs, policies and procedures are designed tominimize the administrative responsibilities in the management of care,enabling you to focus on the healthcare needs of your patients, ourmembers.Buckeye SummaryBuckeye’s philosophy is to provide access to high quality, culturallysensitive healthcare services to Ohio’s Medicaid eligibles, by combining thetalents of primary care providers and specialty providers with a highlysuccessful, experienced managed care administrator. Buckeye believesthat successful managed care is the delivery of appropriate, medicallynecessary services not the elimination of such services.It is the policy of Buckeye to conduct its business affairs in accordance withthe standards and rules of ethical business conduct and to abide by allapplicable federal and state laws. For specific detail related to topics withinthis handbook, please call Provider Services at 866-296-8731 to receive theadditional information upon request.At Buckeye we take privacy and confidentiality of our member’s healthinformation seriously. We have processes, policies and procedures tocomply with the Health Insurance Portability and Accountability Act of 1996(HIPAA) and state privacy law requirements. If you have any questionsabout Buckeye’s privacy practices, please contact the Privacy Official at 1866-246-4356.6
You may access most of Buckeye’s information/forms/etc. on our website atwww.buckeyehealthplan.com. Our website includes claims status andmember eligibility search capabilities; numerous forms; patient listings;Provider Directories; Provider Manual; Quality Improvement Standards; andour Drug List (DL), to name a few.7
Provider ManualGuidelines For providersPrimary Care Provider (PCP)The primary care provider (PCP) is the cornerstone of Buckeye. The PCPserves as the “medical home” for the patient. The “medical home” conceptassists in establishing a patient- provider relationship and ultimately betterhealth outcomes. The PCP may be a physician (M.D. or D.O.) or advancedpractice nurse. Acceptable specialty types include family/general practice,internal medicine, and pediatrics.The PCP is required to adhere to the responsibilities outlined below.Covered Physician ServicesThe PCP shall arrange for other participating providers to provide coveredpersons with covered physician services as stipulated in their contract. Thisenables them to provide the same care and attention that physicianscustomarily provide to all patients. Each participating provider shall provideall covered physician services in accordance with generally acceptedclinical, legal, and ethical standards in a manner consistent with physicianlicensure, qualifications, training and experience. These standards ofpractice for quality care are generally recognized within the medicalcommunity in which the physician practices.Covered services include: Professional medical services, both inpatient and outpatient,provided by the PCP, nurses, and other personnel employed by thePCP. These services include the administration of immunizations,but not the cost of biologicals.Periodic health assessments and routine physical examinations(performed at the discretion of the PCP, and consistent withnationally recognized standards recommended for the age and sex ofthe Enrollee).Vision and hearing screenings.All supplies and medications used or provided during a coveredpatient office visit. Injectable drugs costing over 100 require a PriorAuthorization, which can be obtained by calling 1-866-246-4359.Oncology drugs given in the office are excluded from PriorAuthorization requirements.All tests routinely performed in the PCP’s office during an office visit.8
The collection of laboratory specimens.Voluntary family planning services such as examinations, counseling,and pregnancy testing.Well-child care and periodic health appraisal examinations, includingall routine tests performed as customarily provided in a PCP’s office.Referral to specialty care physicians and other health providers withcoordination of care and follow-up after referral.PCP’s supervision of home care regimens involving ancillary healthprofessionals provided by licensed nursing agencies. Please note,these services are subject to prior authorization by Buckeye.Any other outpatient services and routine office supplies normallywithin the scope of the PCP’s practice.PCP Availability and AccessibilityEach participating provider shall maintain sufficient facilities and personnelto provide covered physician services and shall ensure that such servicesare available as needed 24 hours a day, 365 days a year. Eachparticipating provider shall offer hours of operation that are no less than thehours of operation offered to commercial members or comparable toMedicaid fee-for-service, if the provider serves only Medicaid members.PCP CoverageThe participating provider shall arrange for coverage with a physician whomust have executed a Participating Provider Agreement with the Buckeye.If the participating provider is capitated for professional services,compensation for the covering physician is considered to be included in thecapitation payment. If the participating provider is on a fee-for-serviceagreement with Buckeye, the covering provider is compensated inaccordance with the fee schedule in his/her Participating Agreement.Appointment AvailabilityThe following standards are established with regards to appointmentavailability: A full-time practice is defined as one where the provider is availableto patients at their practice site(s) in the specified county/region for atleast 25 hours a week. Routine appointments and physicals should be available within28 days of request Primary care urgent appointments (non life threatening) shouldbe available within 6 hours of request Urgent care should be available within 24 hours. Urgent Specialty care within 24 hours of referral. Referrals to Specialist should be made within 4 weeks ofrequest9
Emergency care should be received immediately and available 24hours a day.Persistent symptoms must be treated no later than the end of thefollowing working day after initial contact with the PCP.Referrals to a specialist should be scheduled within four (4) weeks ofa request or shorter as medically indicated.Non urgent care – sick calls should be available within 72 hoursof request. Prenatal Care patients should be seen within thefollowing timeframes:1. Three (3) weeks of a positive pregnancy test (home or laboratory)2. Three (3) weeks of identification of high-risk3. Seven (7) days of request in first and second trimester4. Three (3) days of first request in third trimesterBehavioral healthcare must be provided within 6 hours for non-lifethreatening emergencies, within 48 hours of the request for urgentcare and within ten (10) days of the request for routine care. Followup routine care visits will be specified at a later date.Telephone ArrangementsProviders are required to develop and use telephone protocol for all of thefollowing situations: Answering the enrollee telephone inquiries on a timely basis.Prioritizing appointments.Scheduling a series of appointments and follow-up appointments asneeded by an enrollee.Identifying and rescheduling broken and no-show appointments.Identifying special enrollee needs while scheduling an appointment,e.g., wheelchair and interpretive linguistic needs for non-compliantindividuals who are mentally deficient.Response time for telephone call-back waiting times:o after hours telephone care for non-emergent, symptomaticissues within 30 to 45 minutes;o same day for non-symptomatic concerns;o crisis situations within 15 minutes;Scheduling continuous availability and accessibility of professional,allied, and supportive medical/dental personnel to provide coveredservices within normal working hours. Protocols shall be in place toprovide coverage in the event of a provider’s absence.After hours calls should be documented in a written format in eitheran after-hour call log or some other method, and transferred to thepatient’s medical record.10
Note: If after hours urgent care or emergent care is needed, the PCP orhis/her designee should contact the urgent care or emergency center tonotify the facility.Buckeye will monitor appointment and after-hours availability on an ongoing basis through its Quality Improvement Program.Self ReferralsThe following services do not require PCP authorization or referral: Emergency services including ambulance transportationOB/GYN ServicesServices provided by a Federally Qualified Health Center (FQHC)Services provided by a Rural Health Center (RHC)Services provided by a contracted Certified Nurse Midwife or NursePractitionerFamily Planning Services and supplies from a qualified familyplanning providerRoutine Dental Services from a contracted providerNon-surgical routine vision care from a contracted providerRoutine Podiatry Services from a contracted providerChiropractic Services from a contracted providerPlease visit our website at www.BuckeyeHealthPlan.com/providers fordetailed list of services requiring prior authorization.ReferralsIt is Buckeye’s preference that the PCP coordinates healthcare services.However, members are allowed to self-refer for certain services (seeabove). Providers are encouraged to refer members when medicallynecessary care is needed beyond the scope of the PCP. Those referralswhich require authorization by the plan are listed below under priorauthorization. A provider is also required to notify Buckeye when theyare rendering prenatal care to a Buckeye member, using the form onlineat: fo/forms.ispTo verify if an authorization is necessary or to obtain a prior authorization,call:Medical Management Department1-866-246-4359No paperwork is required for a referral or prior-authorization. AReferral Specialist will issue the referral authorization number immediately11
upon approval. Requests may be made by phone, fax or online atwww.buckeyehealthplan.com.Buckeye has the capability to perform the ANSI X 12N 278 referralcertification and authorization transaction through Centene Corporation.For more information on conducting this transaction electronically contact:Centene EDI Department1-800-225-2573, extension 6075525or by e-mail at:EDIBA@centene.comHealthchekHealthchek, otherwise known as the Early and Periodic Screening,Diagnosis, and Treatment (EPSDT) program, is a program ofcomprehensive preventive health services available to Medicaid recipientsfrom birth through 20 years of age. The program is designed to maintainhealth by providing early intervention to discover and treat health problems.Healthchek is a preventive program that combines diagnostic screening andmedically necessary follow-up care for: dental, vision and hearingexaminations for eligible Ohio enrollees under the age of 21.Managed care plans must ensure that members under the age of 21 haveaccess to services that are available in accordance with federal EPSDTrequirements. This would include medically necessary services covered byOhio Medicaid as well as any medically necessary screening, diagnosticand treatment services available to Medicaid consumers that exceedcoverage or benefit limits for members under age 21. Providers canrequest prior authorization to exceed coverage or benefit limits for membersunder age 21.PCPs are required to perform Healthchek medical check-ups in theirentirety and at the required intervals. All components of exams must bedocumented and included in the medical record of each Healthchek eligiblemember. Healthchek exams are to be completed within 90 days of theinitial effective date of membership for those children found to have apossible ongoing condition likely to require care management services.For additional information on the Healthchek program see OhioAdministrative Code Chapter 5160-14 or access the State of Ohio websiteat: hchek.aspx .12
Member Panel CapacityThe current maximum limit on the number of members a PCP can haveassigned to his/her practice is stated above the signature line on thesignature page of the provider’s Medicaid Addendum. All PCPs reserve theright to state the number of members they are willing to accept into theirpractice. Member assignment is based on the member’s choice and autoassignment, therefore, Buckeye DOES NOT guarantee that any providerwill receive a set number of members.If a PCP does declare a specific capacity for his/her practice and wants tomake a change to that capacity, the PCP must contact the BuckeyeProvider Services Department at 1-866-296-8731. A PCP shall not refuseto treat covered enrollees as long as the physician has not reached theirrequested panel size, and shall notify Buckeye at least 45 days in advanceof his or her inability to accept additional covered enrollees under Buckeyeagreements.Provider TerminationProviders should refer to their Buckeye contract for specific informationabout terminating from Buckeye.Other PCP Responsibilities Educate patients on how to maintain healthy lifestyles andprevent serious illness.Provide follow up on emergency care.Report all encounter data on CMS 1500 claim forms.Maintain confidentiality of medical information.Obtain authorizations for all inpatient and selected outpatientservices as listed on the current Prior Authorization List, exceptfor emergency services up to the point of stabilization.Buckeye providers should refer to his/her Buckeye contract for completeinformation regarding Buckeye PCP obligations and mode ofreimbursement.Specialist ResponsibilitiesSelected specialty services require a formal authorization from Buckeye.The specialist must abide by the prior authorization requirements when13
ordering diagnostic tests or rendering services. All non-emergency inpatientadmissions require prior authorization from Buckeye.The specialist must maintain contact with the PCP. This could includetelephone contact, written reports on consultations or verbal reports if anemergency situation exists.The specialist provider must: Obtain authorization from Buckeye Medical Management Departmentas needed before providing services. Coordinate the patient’s care with the PCP. Provide the PCP with consult reports and other appropriate recordswithin five (5) business days. Be available for or provide on-call coverage through another source24 hours a dayfor management of patient care. Maintain the confidentiality of medical information.Hospital ResponsibilitiesBuckeye utilizes a network of hospitals to provide services to Buckeyemembers. Hospitals must: Obtain authorizations for all inpatient and selected outpatientservices as listed on the current Prior Authorization List, except foremergency stabilization services. Notify Buckeye’s Medical Management Department within twobusiness days of an admission.Advance DirectivesBuckeye is committed to ensuring that its members know of, and are able toavail themselves of their rights to execute Advance Directives. Buckeye isequally committed to ensuring that its providers and staff are aware of, andcomply with their responsibilities under federal and state law regardingAdvance Directives.Any provider delivering care to Buckeye members must ensure adultmembers over the age of 18 years receive information on AdvanceDirectives and are informed of their right to execute Advance Directives.Providers must document such information in the permanent medicalrecord.Buckeye recommends to its providers that: The first point of contact in the PCP’s office should ask if the memberhas executed an Advance Directive. The member’s response shouldbe documented in the medical record.14
If the member has executed an Advance Directive, the first point ofcontact should ask the member to brin
Provider Manual . Guidelines For providers . Primary Care Provider (PCP) The primary care provider (PCP) is the cornerstone of Buckeye. The PCP serves as the “medical home” for the patient. The “medical home” concept assists in establishing a patient- provider
