Transcription
Provider and Billing 5-OH-C-00008 2015 Buckeye Health Plan. All rights reserved.
Table of ----------------------------------------------- 6HOW TO USE THIS PROVIDER MANUAL ---------------------------------------- 6KEY CONTACTS AND IMPORTANT PHONE NUMBERS -------------------- 6SECURE PROVIDER PORTAL ----- 7Functionality -------------- 7PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER ---------- 8Credentialing and Recredentialing ----------------------------------- 8Credentialing ------------------------ 9Recredentialing --------------------------- 9Practitioner Right to Review and Correct Information ---------------------------- 9Practitioner Right to Be Informed of Application Status ------------------------ 10Practitioner Right to Appeal or Reconsideration of Adverse Credentialing Decisions ----------------------------------- 10Provider Types That May Serve As PCPs ---------------------------------------- 10Member Panel ---------------------- 10Member Selection or Assignment of PCP ----------------------------------------- 11Withdrawing from Caring for a Member -------------------------------------------- 11PCP Coordination of Care to Specialists ------------------------------------------ 11Specialist Provider Responsibilities ------------------------------------------------- 12Appointment Availability and Wait Times ------------------------ 12Wait Time Standards for All Provider Types: ------------------------------------- 12Travel Distance and Access Standards -------------------------------------------- 13Covering Providers -------------------- 13Provider Phone Call Protocol ------- 1324-Hour Access to Providers ------- 14Hospital Responsibilities ---------------------------------------------- 15AMBETTER BENEFITS ------------- 15Overview ------------------- 15Additional Benefit Information --------------------------------------- 16HMO Benefit Plans -------------------- 16Preventive Services ------------------- 16Free Visits ------------------------------- 17Integrated Deductible Products ---- 17Maximum Out of Pocket -------- 17Adding a Newborn or an Adopted Child ------------------------------------------- 17VERIFYING MEMBER BENEFITS, ELIGIBILITY, AND COST SHARES 18Member Identification ------------------------------------------------ 18November 29, 20151
Preferred Method to Verify Benefits, Eligibility, and Cost Shares ------------------------------------------ 18Other Methods to Verify Benefits, Eligibility and Cost Shares ---------------------------------------------- 18Importance of Verifying Benefits, Eligibility, and Cost Shares ---------------------------------------------- 19Benefit Design -------------------------- 19Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) ---------------------------- 19MEDICAL MANAGEMENT --------- 19Utilization Management ------------------------------------------------- 19Medically Necessary ------------------ 19Timeframes for Prior Authorization Requests and Notifications ------------- 20Utilization Determination Timeframes ---------------------------------------------- 20Services Requiring Prior Authorization --------------------------------------------- 21Procedure for Requesting Prior Authorizations ---------------- 22Medical ----------------------------------- 22Behavioral ------------------------------- 22Medical and Behavioral -------------- 22Advanced Imaging --------------------- 23Cardiac Imaging ------------------------ 23National Imaging Associates Authorizations -------------------------------------- 23Behavioral Health Services --------- 23Pharmacy -------------------------------- 23Second Opinion ------------------------ 24Women’s Health Care ---------------- 24Abortion Services ---------------------- 24Retrospective ----------------------- 25Emergency Medical Condition and Emergency Services --------------------- 25Utilization Review Criteria ----------- 25Care Management and Concurrent Review ---------------------- 26Concurrent Review -------------------- 26Care Management --------------------- 26Care Management Process -------------------------------------------- 27Health Management ---- 27Nurtur ------------------------------------- 27Cenpatico -------------------------------- 28Ambetter’s Member Welcome Survey ----------------------------- 28Ambetter’s My Health Pays Member Incentive Program ----- 28Ambetter’s Gym Membership Program --------------------------- 28CLAIMS ---------------------------------- 29Verification Procedures ------------------------------------------------ 29Clean Claim Definition -------------------------------------------------- 30Non-Clean Claim ---- 30Upfront Rejections vs. Denials --------------------------------------- 31November 29, 20152
Upfront Rejection ---------------------- 31Denial ------------------------------------- 31Timely Filing -------------- 31Who Can File Claims? ---------------- 31Electronic Claims Submission --------------------------------------- 32Specific Data Record Requirements ------------------------------------------------ 32Electronic Claim Flow Description & Important General Information ------- 32Invalid Electronic Claim Record Upfront Rejections/Denials ----------------- 33Specific Ambetter Electronic Edit Requirements – 5010 Information ------- 33Corrected EDI ----------------------- 33Exclusions ------------------------------- 33Electronic Billing Inquiries ----------- 34Important Steps to a Successful Submission of EDI Claims: ----------------- 35Online Claim Submission ------------ 35Paper Claim Submission ------------- 35Acceptable Forms --------------------- 36Important Steps to Successful Submission of Paper Claims: ---------------- 36Corrected Claims, Requests for Reconsideration or Claim Disputes/Appeals --------------------------------------------- 36Corrected Claims ---------------------- 37Request for Reconsideration ------- 37Claim Dispute/Appeal ----------------- 38Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) --------------------------------------------- 38Risk Adjustment and Correct Coding ------------------------------ 39Coding of Claims/ Billing Codes --- 39Ambetter Code Auditing and Editing ------------------------------------------------ 40Same Date of Service ---------------- 43Claim Reconsiderations related to Code Auditing and Editing --------------- 46CPT Category II -------------------- 46Code Editing Assistant --------------- 46Clinical Lab Improvement Act (CLIA) Billing Instructions ---------------------- 46Paper ---------------------------------- ---------------------------------------------- 47Web --------------------------------------- 47Taxonomy Code Billing Requirement ----------------------------------------------- 48Scenario One: Rendering NPI is different than the Billing NPI -------------- 48Scenario Two: Rendering NPI and Billing NPI are the same ---------------- 49Third Party Liability -------------------- 50BILLING THE MEMBER ------------ 50Covered Services ------- 50Non-Covered Services -------------------------------------------------- 51Billing for ------------------------------- 51Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) ---------------------------- 51November 29, 20153
Premium Grace Period for Members NOT Receiving Advanced Premium Tax Credits (APTCs) --------------------- 51Failure to Obtain Authorization ----- 51No Balance Billing --------------------- 52MEMBER RIGHTS AND RESPONSIBILITIES ---------------------------------- 52Member Rights ---------- 52Member Responsibilities ----------------------------------------------- 53PROVIDER RIGHTS AND - 54Provider Rights ---------- 54Provider Responsibilities ---------------------------------------------- 55CULTURAL COMPETENCY ------- 56COMPLAINT PROCESS ------------ 57Provider Complaint/Grievance and Appeal Process ---------------------------- --------------------------------------- 57Authorization and Coverage Complaints ------------------------------------------ 58Member Complaint/Grievance and Appeal Process ----------- 58Mailing Address --------- 59Ombudsman ------------------------- 59QUALITY IMPROVEMENT PLAN -------------------------------------------------- 59Overview ------------------- 59QAPI Program Structure ----------------------------------------------- 60Practitioner Involvement ------------- 60Quality Assessment and Performance Improvement Program Scope and Goals --------------------- 60Practice Guidelines -------------------- 62Patient Safety and Quality of Care -------------------------------------------------- 63Performance Improvement Process ------------------------------------------------ 63Quality Rating System -------------------------------------------------- 63Healthcare Effectiveness Data and Information Set (HEDIS) ---------------- 64HEDIS Rate Calculations ------------ 64Who conducts Medical Record Reviews (MRR) for HEDIS ------------------- 64Provider Satisfaction Survey -------- 65Qualified Health Plan (QHP) Enrollee Survey ------------------------------------ 65Provider Performance Monitoring and Incentive Programs ------------------- 65REGULATORY MATTERS --------- 66Medical Records -------- 66Required ----------------------------- 66Medical Records Release ----------- 67Medical Records Transfer for New Members ------------------------------------- 67Medical Records Audits -------------- 67November 29, 20154
FEDERAL AND STATE LAWS GOVERNING THE RELEASE OFINFORMATION ------------------------ 68WASTE, ABUSE, AND FRAUD --- 68WAF Program Compliance Authority and Responsibility ---------------------- 69False Claims Act -------- 69Physician Incentive ------------------------------------------------ 70APPENDIX ------------------------------ 70Appendix I: Common Causes for Upfront Rejections -------- 71Appendix II: Common Cause of Claims Processing Delays and Denials ------------------------------- 71Appendix III: Common EOP Denial Codes and ----------- 72Appendix IV: Instructions for Supplemental --------------- 73Appendix V: Common Business EDI Rejection Codes ------- 74Appendix VI: Claim Form Instructions ----------------------------- 76Completing a CMC 1500 Claim Form ---------------------------------------------- 76Completing a UB-04 Claim Form -- 86UB-04 Hospital Outpatient Claims/Ambulatory Surgery ----------------------- 86UB-04 Claim Form Example -------- 87Appendix VII: Billing Tips and Reminders ------------------------ 98Appendix VIII: Reimbursement Policies ------------------------- 101Appendix IX: EDI Companion Guide ----------------------------- 103EDI Companion Guide Overview -------------------------------------------------- 103Rules of Exchange ------------------ 104Batch Matching ----------------------- 104TA1 Interchange Acknowledgement ---------------------------------------------- 104999 Functional Acknowledgement ------------------------------------------------ 104277CA Health Care Claim Acknowledgement ---------------------------------- 105Duplicate Batch Check ------------- 105New Trading Partners -------------- 106Claims Processing --- 106Acknowledgements -------------- 106Coordination of Benefits (COB) Processing ---------------------------------- 106Code Sets ---------------------------- 107Corrections and Reversals ------ 107Identification Codes and Numbers ------------------------------------------------ 108Connectivity Media for Batch Transactions ------------------------------------- ---------------------------------------- 109Direct Submission ----------------- 109Edits and Reports -------------------- 110Reporting ---------------------------- 110837: Data Element Table ---------- 110November 29, 20155
WELCOMEWelcome to Ambetter from Buckeye Health Plan (“Ambetter”). Thank you for participating in our networkof participating physicians, hospitals and other healthcare professionals.Ambetter is a Qualified Health Plan (QHP) as defined in the Affordable Care Act (ACA). Ambetter will beoffered to consumers through the Health Insurance Marketplace also known as the Exchange in Ohio.The Health Insurance Marketplace makes buying health insurance easier.The Affordable Care Act is the law that has changed healthcare. The goals of the ACA are: to help more Americans get health insurance and stay healthy; and to offer consumers a choice of coverage leading to increased health care engagement andempowerment.HOW TO USE THIS PROVIDER MANUALAmbetter is committed to assisting its provider community by supporting their efforts to deliver wellcoordinated and appropriate health care to our members. Ambetter is also committed to disseminatingcomprehensive and timely information to its providers through this Provider Manual (“Manual”) regardingAmbetter’s operations, policies and procedures. Updates to this Manual will be posted on our website atAmbetter.BuckeyeHealthPlan.com. Additionally, providers may be notified via bulletins and noticesposted on the website and potentially on Explanation of Payment notices. Providers may contact ourProvider Services Department at 1-877-687-1189 to request that a copy of this Manual be mailed to you.In accordance with the Participating Provider Agreement, providers are required to comply with theprovisions of this Manual. Ambetter routinely monitors compliance with the various requirements in thisManual and may initiate corrective action, including denial or reduction in payment, suspension ortermination, if there is a failure to comply with any requirements of this Manual.KEY CONTACTS AND IMPORTANT PHONE NUMBERSThe following table includes several important telephone and fax numbers available to providers and theiroffice staff. When calling, it is helpful to have the following information available.1. The provider’s NPI number2. The practice Tax ID Number3. The member’s ID numberWebsiteHEALTH PLAN INFORMATIONAmbetter.BuckeyeHealthPlan.comHealth Plan addressPhone NumbersBuckeyeDepartmentProvider ServicesMember ServicesMedical Management Inpatientand Outpatient PriorAuthorizationConcurrent Review/ClinicalNovember 29, 2015Buckeye Health Plan4349 Easton Way, Suite 200Columbus, OH -687-11891-866-912-629261-888-241-0664
HEALTH PLAN esheetsCare ManagementBehavioral Health PriorAuthorization24/7 Nurse Advice LineU.S. ScriptAdvanced Imaging (MRI, CT,PET) (NIA)Cardiac Imaging (NIA)OptiCare (Vision)DentaQuest (Dental)Interpreter Services – VoianceTo report suspected fraud,waste and abuseEDI Claims 7-11891-866-685-86641-800-225-2573 ext. 6075525e-mail:EDIBA@centene.comSECURE PROVIDER PORTALAmbetter offers a robust secure provider portal with functionality that is critical to serving members and toease administration for the Ambetter product for providers. Each participating provider’s dedicatedProvider Relations Specialist will be able to assist and provide education regarding this functionality. ThePortal can be accessed at Ambetter.BuckeyeHealthPlan.com.FunctionalityAll users of the secure provider portal must complete a registration process. If you are already aregistered user of the Buckeye Portal, you do not have to complete a separate registration.Once registered, providers may: All users of the secure provider portal must complete a registration process. Once registered, providers may:-check eligibility and view member roster-view the specific benefits for a member;-view members remaining yearly deductible and amounts applied to plan maximums.-view the status of all claims that have been submitted regardless of how submitted;-update provider demographic information (address, office hours, etc.);-for primary care providers, view and print patient lists. This patient list will indicate themember’s name, member ID number, date of birth, care gaps, Disease Managementenrollment and the product in which they are enrolled;-submit authorizations and view the status of authorizations that have been submitted formembers;-view, submit, copy and correct claims-submit batch claims via an 837 file;-view and download Explanations of Payment (EOP);November 29, 20157
-view a member’s health record including visits (physician, outpatient hospital, therapy, etc.);medications, and immunizations;-view gaps in care specific to a member including preventive
The provider's NPI number 2. The practice Tax ID Number 3. The member's ID number. HEALTH PLAN INFORMATION . Website . Ambetter.BuckeyeHealthPlan.com . DentaQuest (Dental) 1-877-687-1189 : Interpreter Services - Voiance . 1-877-687-1189 : To report suspected fraud, waste and abuse . 1-866-685-8664 :
