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2017 Provider and Billing ManualA Medicare Advantage ProgramSuperiorHealthPlan.comPROV16-TX-C-00055
CONTENTSINTRODUCTION . 5OVERVIEW . 5KEY CONTACTS AND IMPORTANT PHONE NUMBERS. 6ENROLLMENT . 7Medicare Advantage (HMO) . 7Medicare Advantage (HMO SNP) . 7MEDICARE REGULATORY REQUIREMENTS . 7SECURE WEB PORTAL . 9Functionality . 9PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER . 10Credentialing and Re-credentialing . 10Credentialing Committee . 12Re-credentialing . 12Practitioner Right to Review and Correct Information . 12Practitioner Right to Be Informed of Application Status . 13Practitioner Right to Appeal Adverse Re-credentialing Determinations . 13ACCOUNT MANAGEMENT . 13Primary Care Providers . 13Specialist as the Primary Care Provider . 14Specialty Care Physicians . 14Hospitals . 15Ancillary Providers . 15APPOINTMENT AVAILABILITY . 16Telephone Arrangements . 16Provider Training . 17Training Requirements . 17SUPERIOR HEALTHPLAN MEDICARE ADVANTAGE BENEFITS . 17VERIFYING MEMBER BENEFITS, ELIGIBILITY and COST SHARES . 18Member Identification Card . 18Preferred Method to Verify Benefits, Eligibility and Cost Shares . 18Other Methods to Verify Benefits, Eligibility and Cost Shares . 191October 31, 2016
MEDICAL MANAGEMENT . 19Case Management . 19SNP Model of Care (MOC) and Case Management . 20Utilization Management . 23Utilization Determination Timeframes . 25Utilization Review Criteria . 27Behavioral Health Services . 27Pharmacy . 28Second Opinion . 30Women’s Health Care . 30Emergency Medical Condition . 31ENCOUNTERS AND CLAIMS . 31Encounter Reporting . 31CLAIMS. 31Verification Procedures . 32Upfront Rejections versus Denials . 33Timely Filing . 34Who Can File Claims? . 34Electronic Claims Submission . 34Online Claim Submission . 38Paper Claim Submission . 38Corrected Claims, Requests for Reconsideration or Claim Disputes . 39Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) . 41Risk Adjustment and Correct Coding . 42Coding Of Claims/ Billing Codes . 43CODE EDITING . 44CPT and HCPCS Coding Structure . 45International Classification of Diseases (ICD-10) . 46Revenue Codes. 46Edit Sources . 46Code Editing Principles . 48Invalid Revenue to Procedure Code Editing . 51Co-Surgeon/Team Surgeon Edits . 512October 31, 2016
Administrative and Consistency Rules . 51Prepayment Clinical Validation . 52Inpatient Facility Claim Editing . 54Payment and Clinical Policy Edits . 54Claim Reconsiderations Related To Code Editing and Editing . 54Viewing Claims Coding Edits . 54THIRD PARTY LIABILITY . 55BILLING THE MEMBER . 55Failure to Obtain Authorization . 55No Balance Billing . 55Non-Covered Services . 56MEMBER RIGHTS AND RESPONSIBILITIES . 56Member Rights . 56Member Responsibilities . 58PROVIDER RIGHTS AND RESPONSIBILITIES . 59Provider Rights . 59Provider Responsibilities . 59CULTURAL COMPETENCY . 61Interpreter Services . 63Americans with Disabilities Act . 63General Requirements . 63MEMBER GRIEVANCES AND APPEALS . 65Grievances . 65Appeals . 66Member Grievance and Appeals Address . 66PROVIDER COMPLAINT AND APPEALS PROCESS . 66Complaint . 66Authorization and Coverage APPEALS . 67Ombudsman Services . 67QUALITY IMPROVEMENT PLAN . 68Overview . 68Office Site Surveys . 73MEDICARE STAR RATINGS . 733October 31, 2016
How can providers help to improve Star Ratings? . 74Healthcare Effectiveness Data and Information Set (HEDIS) . 74Consumer Assessment of Healthcare Provider Systems (CAHPS) Survey . 75Medicare Health Outcomes Survey (HOS) . 76REGULATORY MATTERS . 76Medical Records. 76Federal and State Laws Governing the Release of Information . 78Health Insurance Portability and Accountability Act . 79Fraud, Waste and Abuse . 83False Claims Act . 85Physician Incentive Programs . 85First-Tier and Downstream Providers . 86APPENDIX . 86Appendix I: Common Causes for Upfront Rejections . 86Appendix II: Common Cause of Claims Processing Delays and Denials . 87Appendix III: Common EOP Denial Codes and Descriptions . 87Appendix IV: Instructions for Supplemental Information . 89Appendix V: Common HIPAA Compliant EDI Rejection Codes . 90Appendix VI: Claim Form Instructions . 92Appendix VII: Billing Tips and Reminders . 124Appendix VIII: Reimbursement Policies . 127Appendix IX: EDI Companion Guide . 1304October 31, 2016
INTRODUCTIONWelcome to Superior HealthPlan Medicare Advantage. Thank you for participating in our networkof physicians, hospitals and other health-care professionals.This Provider Manual is a reference guide for providers and their staff providing services tomembers who participate in Superior HealthPlan Medicare Advantage (HMO) and SuperiorHealthPlan Medicare Advantage (HMO SNP). In addition to the Provider Manual, SuperiorHealthPlan Medicare Advantage provides reference materials and policy updates on its websiteat SuperiorHealthPlan.com.OVERVIEWSuperior HealthPlan Medicare Advantage is a Medicare Advantage Organization (MAO)contracted with the Centers for Medicare and Medicaid Services (CMS) to provide two types ofMedicare Advantage Plans (HMO) and (HMO SNP). Superior's Medicare Advantage Plansprovide medical, behavioral and pharmacy services to its members.Superior HealthPlan Medicare Advantage is designed to achieve four main objectives: Full partnership between the member, their physician and their Superior HealthPlanMedicare Advantage Case Manager; Integrated Case Management (medical, social, behavioral health and pharmacy); Improved provider and member satisfaction; and Quality of life and healthy outcomes.All of our programs, policies and procedures are designed with these objectives in mind. ForMedicare Advantage (HMO SNP) these objectives mirror and support the objective of CMS andState guidelines to provide covered health-care services to low-income, elderly and physicallydisabled members.Superior HealthPlan Medicare Advantage takes the privacy and confidentiality of our members'health information seriously. We have processes, policies and procedures to comply with theHealth Insurance Portability and Accountability Act of 1996 (HIPAA) and CMS regulations. Theservices provided by the contracted Superior HealthPlan Medicare Advantage network providersare a critical component in meeting the objectives above. Our goal is to reinforce the relationshipbetween our members and their Primary Care Provider (PCP). We want our members to benefitfrom their PCP having the opportunity to deliver high quality care using contracted hospitals andspecialists. The PCP is responsible for coordinating our member’s health services, maintaining acomplete medical record for each member under their care and ensuring continuity of care. ThePCP advises the member about their health status, medical treatment options, which include thebenefits, consequences of treatment or non-treatment and the associated risks. Members areexpected to share their preferences about current and future treatment decisions with their PCP.Superior HealthPlan Medicare Advantage appreciates your partnership in achieving theseobjectives.5October 31, 2016
KEY CONTACTS AND IMPORTANT PHONE NUMBERSThe following table includes several important telephone and fax numbers available to providersand their office staff. When calling, it is helpful to have the following information available.1. The provider’s National Provider Identifier (NPI) number2. The practice Tax Identification (ID) Number3. The member’s ID numberHEALTH PLAN INFORMATIONWebsitewww.SuperiorHealthPlan.comForum II BuildingHealth Plan address7990 IH 10 West, Suite #300San Antonio, Texas 78230Phone NumbersPhoneTTY/TDDSuperior HealthPlanMedicare AdvantageHMO: 1-844-796-6811DepartmentHMO SNP: 1-877-935-8023PhoneProvider Services1-877-391-5921711FaxN/AMember ServicesN/AMedical ManagementInpatient and Outpatient PriorAuthorizationN/AConcurrent CensusReports/FacesheetsHMO: 1-844-796-6811HMO SNP: 1-877-935-80231-877-258-6960Case ManagementN/A24/7 Nurse Advice LineN/ABehavioral Health OutpatientPrior Authorization1-877-725-7751Interpreter ServicesN/APharmacy Services Claims1-877-935-8021N/AEnvolve Pharmacy National Imaging Associates1-800-642-7554N/AAECC Total Vision HealthPlan of Texas, Inc. (vision)1-888-756-8768N/ATo report suspected fraud,waste and abuse1-866-685-8664N/A6October 31, 2016
EDI Claims Assistance1-800-225-2573ext. 6075525E-mail: EDIBA@centene.comENROLLMENTMedicare Advantage (HMO)To qualify for Superior's Health Maintenance Organization (HMO) Plans, individuals need to beenrolled in Medicare only, Medicaid is not required for HMO Plans. HMO members will have costshares (copays, coinsurance, deductibles) depending upon the benefit. Please call the numberon the back of the member's Medicare Advantage card to determine what the member's copaywould be for the services your office is providing. Medicare Advantage (HMO) is available inBexar, Cameron, Collin, Dallas, Denton, El Paso, Hidalgo, Nueces and Smith Counties.Medicare Advantage (HMO SNP)Superior HealthPlan Medicare Advantage (HMO SNP) is a Dual-Eligible Special Needs Plans (DSNPs) which enroll individuals who are entitled to both Medicare and Medicaid and offer theopportunity of enhanced benefits by combining benefits available through Medicare and Medicaid.Health care for D-SNP members is coordinated through the delivery of covered Medicare andMedicaid health and long-term care services, using aligned Case Management and specialty carenetwork methods for high-risk individuals.Superior HealthPlan Medicare Advantage (HMO SNP) members are permitted to enroll ordisenroll on a monthly basis. Any changes will be effective the first (1st) day of the month followingthe request for change. Medicare Advantage (HMO SNP) is available in Bexar, Collin, Dallas,Nueces and Rockwall Counties.MEDICARE REGULATORY REQUIREMENTSAs a Medicare contracted provider, you are required to follow a number of Medicare regulationsand CMS requirements. Some of these requirements are found in your Provider Agreement whileothers have been described throughout this manual. A general list of the requirements can bereviewed below: Providers may not discriminate against Medicare members in any way based on the healthstatus of the member.Providers must ensure that members have adequate access to covered health services.Providers may not impose cost sharing on members for influenza vaccinations orpneumococcal vaccinations.Providers must allow members to directly access mammography screening and influenzavaccinations.Providers must provide female members with direct access to women’s health specialistsfor routine and preventive health care.Providers must comply with Plan processes to identify, access and establish treatment forcomplex and serious medical conditions.7October 31, 2016
Superior HealthPlan Medicare Advantage will provide you with at least 60 days writtennotice of termination if electing to terminate our agreement without cause, or as describedin you Participation Agreement if greater than 60 days. Providers agree to notify SuperiorHealthPlan Medicare Advantage according to the terms outlined in the ParticipationAgreement.Providers will ensure that their hours of operation are convenient to the member and donot discriminate against the member for any reason. Providers will ensure necessaryservices are available to members 24 hours a day, seven (7) days a week and providebackup coverage during their absence.Marketing materials must adhere to CMS guidelines and regulations and cannot bedistributed to Superior HealthPlan Medicare Advantage members without CMS approvalsof the materials and forms.Services must be provided to members in a culturally competent manner, includingmembers with limited reading skills, limited English proficiency, hearing or visionimpairments and diverse cultural and ethnic backgrounds.Providers will work with Superior HealthPlan Medicare Advantage procedures to informour members of health-care needs that require follow-up and provide necessary trainingin self-care management.Providers will document in a prominent part of the member’s medical record whether themember has executed an Advance Directive.Providers must provide services in a manner consistent with professionally recognizedstandards of care.Providers must cooperate with Superior HealthPlan Medicare Advantage to disclose toCMS all information necessary to evaluate and administer the program and all informationCMS may need to permit members to make an informed choice about their Medicarehealth insurance coverage.Providers must cooperate with Superior HealthPlan Medicare Advantage in notifyingmembers of provider contract terminations.Providers must cooperate with the activities of any CMS approved independent qualityreview or improvement organization.Providers must comply with any Superior HealthPlan Medicare Advantage medicalpolicies, Quality Improvement (QI) Programs and medical management procedures.Providers will cooperate with Superior HealthPlan Medicare Advantage in disclosingquality and performance indicators to CMS.Providers must cooperate with Superior HealthPlan Medicare Advantage procedures forhandling grievances, appeals and expedited appeals.Before providing a service, providers must fully disclose to all members services notcovered by Superior HealthPlan Medicare Advantage. The member must sign anagreement of this understanding. If the member does not, the claim may be denied andthe provider will be liable for the cost of the service.Providers must allow CMS or its designee access to records related to SuperiorHealthPlan Medicare Advantage services for a period of 10 years following termination ofthis agreement.8October 31, 2016
Provider must comply with all CMS requirements regarding the accuracy andconfidentiality of medical records.Provider shall provide services in accordance with Superior HealthPlan MedicareAdvantage policy: (a) to all members, for the duration of the Superior HealthPlan MedicareAdvantage contract period with CMS, and (b) to members who are hospitalized on thedate the CMS contract with Superior HealthPlan Medicare Advantage terminates or in theevent of an insolvency through discharge.Provider shall disclose to Superior HealthPlan Medicare Advantage all offshore contractorinformation with an attestation for each such offshore contractor in a format required orpermitted by CMS.SECURE WEB PORTALSuperior HealthPlan Medicare Advantage offers a robust Secure Provider Portal with functionalitythat is critical to serving members and facilitating administration for the Superior HealthPlanMedicare Advantage product for providers. Each participating provider’s dedicated AccountManager will be able to assist and provide education regarding this functionality. The Portal canbe accessed at www.SuperiorHealthPlan.com.FunctionalityAll users of the Secure Provider Portal must complete a registration process. If you are already aregistered user on the Secure Provider Portal, a separate registration is not needed.Once registered, providers may: Verify eligibility. View the specific benefits for a member. View benefit details including member cost share amounts for medical, pharmacy, dentaland vision services. View demographic information for the providers associated with the registered TIN suchas: office location, office hours and associated providers. Update demographic information such as address, office hours, etc. View and print patient lists. This patient list will indicate the member’s name, member IDnumber, date of birth and the product in which they are enrolled. Submit authorizations and view the status of authorizations that have been submitted formembers. View claims and the claim status. Submit individual claims, batch claims or batch claims via an 837 file. View and download Explanations of Payment (EOP). View a member’s health record including physician, outpatient hospital and therapy visits,medications and immunizations. View gaps in care specific to a member including preventive care or services needed forchronic conditions. Send secure messages to Superior HealthPlan Medicare Advantage staff.9October 31, 2016
PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDERCredentialing and Re-credentialingThe credentialing and re-credentialing process exists to verify that participating providers meetthe criteria established by Superior HealthPlan Medicare Advantage as well as applicablegovernment regulations and standards of accrediting agencies.If a provider already participates with Superior HealthPlan in the Medicaid product, the providerwill not be separately credentialed for the Advantage product.Note: In order to maintain a current provider profile, practitioners/providers are required to notifySuperior HealthPlan Medicare Advantage of any relevant changes to their credentialinginformation in a timely manner but no later than 10 days from the date of the change.Whether a State utilizes a standardized credentialing form or a provider has registered theircredentialing information on the Council for Affordable Quality Health (CAQH) website, thefollowing information must be on file: A valid NPI.Complete, correct, signed and dated application.Attestation of historical loss of license and/or clinical privileges, disciplinary actions and/orfelony convictions.Attestation to lack of current substance and/or alcohol abuse.Attestation to mental and physical competence to perform the essential duties of theprofession.Attestation to the correctness/completeness of the application.Signed and dated Release of Information form.Current unrestricted license in the state where the practice is located.Current valid and applicable Federal Drug Enforcement Administration (DEA) certificateand State Department of Public Safety (DPS) certificate.Current liability insurance in compliance with minimum limits set by Superior HealthPlan’sProvider Agreement.Proof of highest level of education. For physicians, proof of graduation from an accreditedmedical school or school of osteopathy, proof of completion of an accredited residencyprogram, or proof of Board Certification. Note: Verification of completion of a fellowshipdoes not meet this requirement.Current admitting privileges in good standing at an in-network/inpatient facility or writtendocumentation from a physician/group of physicians, who participate with SuperiorHealthPlan Medicare Advantage, stating that they will assume the inpatient care of all ofthe provider’s plan members who require admission and that they will do so at aparticipating facility.Mid-level practitioners must submit proof of supervising, collaborative agreement,protocols, or other written authorization (as required by state law or health plan10October 31, 2016
requirements) with a licensed physician who is participating with the health plan, that setsforth the manner in which the mid-level practitioner and licensed physician cooperate,coordinate and consult with each other in the provision of
October 31, 2016 . CONTENTS . . Superior's Medicare Advantage Plans provide medical, behavioral and pharmacy services to its members. . San Antonio, Texas 78230 . Phone Numbers Phone . TTY/TDD Superior HealthPlan ; Medicare Advantage : HMO: 1-844-796-6811 : HMO SNP: 1-877-935-8023;
