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Provider and Billing -C-00024Ambetter from Home State Health is underwritten by CelticInsurance Company. 2020 Home State Health Plan, Inc.All rights reserved.
Table of ContentsHOW TO USE THIS PROVIDER MANUAL ---------------------------------------- 8NONDISCRIMINATION OF HEALTH CARE SERVICE DELIVERY--------- 9KEY CONTACTS AND IMPORTANT PHONE NUMBERS ------------------ 10SECURE PROVIDER PORTAL --- -------------------------------- 12Disclaimer -------------------- 12CREDENTIALING AND RECREDENTIALING ---------------------------------- 13Eligible Providers ---------- 14Non Registered CAQH Providers --------------------------------------- 14Credentialing Committee -------------------------------------------------- 14Recredentialing ------------- 14Practitioner Right to Review and Correct Information ----------- 15Practitioner Right to Be Informed of Application Status -------- 15Practitioner Right to Appeal or Reconsideration of Adverse Credentialing Decisions ----------------- 15PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER -------- 16Provider Types That May Serve As PCPs ---------------------------- 16Member Panel Capacity -- 16Member Selection or Assignment of PCP --------------------------- 16PCP Coordination of Care to ---------------------------------------- 17Appointment Availability and Wait --------------------------------- 18Travel Distance and Access Standards ------------------------------ 19Covering Providers -------- 19Provider Phone Call Protocol -------------------------------------------- 19Provider Data Updates and Validation -------------------------------- 20Hospital Responsibilities -------------------------------------------------- 20AMBETTER BENEFITS ------------- 21Overview ---------------------- 21Additional Benefit Information ------------------------------------------ 22Integrated Deductible Products ----------------------------------------- 22Non- Integrated Deductible Products --------------------------------- 23November 13, 20201
Maximum Out-of-pocket Expenses ------------------------------------ 23Free Visits -------------------- 23Covered Services ---------- 24Notification of Pregnancy ------------------------------------------------- 24Adding a Newborn or an Adopted ----------------------------------- 25Non-Covered Services --- 25Transplant Services ------- 25Tribal Provider (AIAN) American Indian Alaska Native ---------- 26MEMBER BENEFITS, MEMBER IDENTIFICATION CARD, ELIGIBILITY,AND COST SHARES ---------------- 27Member Benefits ----------- 27Member Identification Card ----------------------------------------------- 27Preferred Method to Verify Benefits, Eligibility, and Cost Shares --------------------------------------------- 27Other Methods to Verify Benefits, Eligibility and Cost Shares -------------------------------------------------- 28Importance of Verifying Benefits, Eligibility, and Cost Shares ------------------------------------------------- 29Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) ----------- 29MEDICAL MANAGEMENT --------- 30Utilization Management -- 30Medically Necessary ------ 30Timeframes for Prior Authorization Requests and Notifications ----------------------------------------------- 30Utilization Determination Timeframes -------------------------------- 31Services Requiring Prior Authorization ------------------------------ 31Procedure for Requesting Prior Authorizations ------------------- 32Advanced Imaging --------- 33Cardiac Imaging ------------ 33Physical Medicine Program ---------------------------------------------- 33Habilitation, Rehabilitation Services & Pain Management ----- 34National Imaging Associates Authorizations ----------------------- 34Pharmacy --------------------- 34Second Opinion ------------ 35Preventive Health Care --- 35Retrospective Review ---- 35Emergency Care ------------ 36November 13, 20202
Care Management and Concurrent Review ------------------------- 37CLAIMS ---------------------------------- 40Verification Procedures -- 40Clean Claim -------------- 41Non-Clean Claim Definition ----------------------------------------------- 41Upfront Rejections vs. Denials ------------------------------------------ 41Timely Filing ----------------- 42Refunds and -------- 42Who Can File Claims? ---- 43Electronic Claims Submission ------------------------------------------ 43Online Claim Submission ------------------------------------------------- 46Paper Claim Submission -------------------------------------------------- 46Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) ----------------------------- 48Corrected Claims, Requests for Reconsideration or Claim Disputes ---------------------------------------- 49Risk Adjustment and Correct Coding --------------------------------- 51Claim Reconsiderations Related To Code Editing and Editing ------------------------------------------------- 55CODE ------------------------------- 57CPT and HCPCS Coding - 57International Classification of Diseases (ICD-10) ----------------- 58Revenue Codes ------------- 58Edit Sources ----------------- 58Code Editing Principles -- 59Invalid Revenue to Procedure Code Editing ------------------------ 62Inpatient Facility Claim Editing ------------------------------------------ 62Administrative and Consistency Rules ------------------------------- 63Prepayment Clinical -- 63Claim Reconsiderations Related To Code Editing ---------------- 65Viewing Claims Coding Edits -------------------------------------------- 66Automated Clinical Payment Policy Edits --------------------------- 66Clinical Payment Policy Appeals --------------------------------------- 67THIRD PARTY LIABILITY ---------- 68BILLING THE MEMBER ------------ 69Covered Services ---------- 69November 13, 20203
Non-Covered Services --- 69Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) ----------- 70Failure to Obtain Authorization ----------------------------------------- 70No Balance Billing --------- 70MEMBER RIGHTS AND RESPONSIBILITIES ---------------------------------- 71Member -------------------- 71Member Responsibilities -------------------------------------------------- 72PROVIDER RIGHTS AND RESPONSIBILITIES ------------------------------- 74Provider Rights ------------- 74Provider Responsibilities ------------------------------------------------- 74CULTURAL COMPETENCY ------- 77Language Services -------- 78Provider Accessibility Initiative ----------------------------------------- 79Americans with Disabilities Act (ADA) -------------------------------- 79COMPLAINT PROCESS ------------ 83Complaint/Grievance ----- 83Provider Complaint/Grievance and Appeal Process ------------- 83Member Complaint/Grievance and Appeal Process -------------- 84Mailing Address ------------ 84QUALITY IMPROVEMENT PLAN -------------------------------------------------- 85Overview ---------------------- 85QAPI Program Structure - 85Quality Assessment and Performance Improvement Program Scope and Goals ----------------------- 86Performance Improvement Process ----------------------------------- 89Quality Rating System --- 89Provider Satisfaction - 91Qualified Health Plan (QHP) Enrollee Survey ----------------------- 91Provider Performance Monitoring and Incentive Programs --- 91REGULATORY MATTERS --------- 92Medical Records ----------- 92Access to Records and Audits by Ambetter from Home State Health --------------------------------------- 94EMR Access ----------------- 94November 13, 20204
Medical Records Release ------------------------------------------------- 94Medical Records Transfer for New Members ----------------------- 94Federal And State Laws Governing the Release of Information ------------------------------------------------ 94National Network ----------- 95Section 1557 of the Patient Protection and Affordable Care Act ----------------------------------------------- 96FRAUD, WASTE AND --------- 97FWA Program Compliance Authority and Responsibility ------ 98False Claims Act ----------- 98Physician Incentive Programs ------------------------------------------- 98APPENDIX ----------------------------- 100Appendix I: Common Causes for Upfront Rejections --------- 100Appendix II: Common Cause of Claims Processing Delays and Denials---------------------------------- 101Appendix III: Common EOP Denial Codes and Descriptions -------------------------------------------------- 101Appendix IV: Instructions for Supplemental Information ----- 102Appendix V: Common Business EDI Rejection Codes -------- 103Appendix VI: Claim Form Instructions ------------------------------ 105Appendix VII: Billing Tips and Reminders ------------------------- 105Appendix VIII: Reimbursement Policies ---------------------------- 136Appendix IX: EDI Companion Guide Overview ------------------- 139STATE MANDATED REGULATORY REQUIREMENTS -------------------- 158Arkansas -------------------- 158Arizona ---------------------- 158Florida ----------------------- 159Georgia ---------------------- 160Illinois ------------------------ 161Indiana ----------------------- -------------------------------- 166Missouri --------------------- 167Mississippi ----------------- 170North Carolina ------------ 170New Hampshire ----------- -------------------------------- 177Ohio -------------------------- 180November 13, 20205
Pennsylvania -------------- 183South Carolina ------------ 184Tennessee ------------------ 186Texas ------------------------- 186November 13, 20206
WELCOMEWelcome to Ambetter from Home State Health (“Ambetter”). Thank you for participating in our network ofhigh quality physicians, hospitals, and other healthcare professionals.Ambetter’s Health Insurance Marketplace plans target a consumer population of lower income, previouslyuninsured individuals and families who, prior to having this health insurance, may have been Medicaideligible or unable to access care due to financial challenges.Partnering with Ambetter provides an opportunity for you to access a previously untapped consumerpopulation by providing coverage to those who qualify for generous premium and cost sharing subsidies.Ambetter has been very successful in attracting and retaining our target population, and continues to focuson engaging and acquiring these subsidy-eligible consumers through its unique plan designs, incentiveprograms, and effective communication.Ambetter is a Qualified Health Plan (QHP) as defined in the Affordable Care Act (ACA). Ambetter is offeredto consumers through the Health Insurance Marketplace, also known as the Exchange. The HealthInsurance 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 To offer consumers a choice of coverage leading to increased health care engagement andempowermentNovember 13, 20207
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 regarding Ambetter’soperations, policies, and procedures. Updates to this manual will be posted on our website atambetter.homestatehealth.com. Additionally, providers may be notified via bulletins and notices posted onthe website and potentially on Explanation of Payment notices. Providers may contact our Provider Servicesdepartment at 1-855-650-3789 to request that a copy of this manual be mailed to you. In accordance withthe Participating Provider Agreement, providers are required to comply with the provisions of this manual.Ambetter routinely monitors compliance with the various requirements in this manual and may initiatecorrective action, including denial or reduction in payment, suspension, or termination if there is a failure tocomply with any requirements of this manual.Dental and Vision Provider ManualsEnvolve Dental and Routine Vision provider manuals are available on the Secure Provider Portal. Providersmay visit envolvedental.com or www.envolvevision.com and log on or contact us for these providermanuals.Ancillary Provider ManualsAdditional provider manuals are available on the Secure Provider Portal. Providers may visit the followingand log on or contact us for these provider manuals: Envolve (RX)RX ADvancedTeledocBabylonNIAEvicoreAsh (AZ)Home Town HealthLogisticare Ambulance Emergency Non-Emergency and Non-Medical VendorUSMMMEDXMNovember 13, 20208
NONDISCRIMINATION OF HEALTH CARE SERVICEDELIVERYAmbetter complies with the guidance set forth in the final rule for Section 1557 of the Affordable Care Act,which includes notification of nondiscrimination and instructions for accessing language services in allsignificant member materials and physical locations that serve our members.All providers who join the Ambetter Provider Network must also comply with the provisions and guidanceset forth by the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR).Ambetter requires providers to deliver services to Ambetter members without regard to race, color, nationalorigin, age, disability or sex. Providers must not discriminate against members based on their paymentstatus and cannot refuse to serve based on varying policy and practices and other criteria for the collectingof member financial responsibility from Ambetter members.-Newborns’ and Mothers’ Health Protection ActThe Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act) provides protections for mothersand their newborn children relating to the length of their hospital stays following childbirth. Under theNewborns’ Act, group health plans may not restrict benefits for mothers or newborns for a hospital stay inconnection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a deliveryby cesarean section. The 48-hour (or 96- hour) period starts at the time of delivery, unless a woman deliversoutside of the hospital. In that case, the period begins at the time of the hospital admission. The attendingprovider may decide, after consulting with the mother, to discharge the mother and/or her newborn childearlier. The attending provider cannot receive incentives or disincentives to discharge the mother or herchild earlier than 48 hours (or 96 hours). Even if a plan offers benefits for hospital stays in connection withchildbirth, the Newborns’ Act only applies to certain coverage. Specifically, it depends on whether coverageis “insured” by an insurance company or HMO or “self-insured” by an employment-based plan. (Check theSummary Plan Description, the document that outlines benefits and rights under the plan, or contact theplan administrator to find out if coverage in connection with childbirth is “insured” or “self-insured.”) TheNewborns’ Act provisions always apply to coverage that is self-insured. If the plan provides benefits forhospital stays in connection with childbirth and is insured, whether the plan is subject to the Newborns’ Actdepends on state law. Many states have enacted their own version of the Newborns’ Act for insuredcoverage. If your state has a law regulating coverage for newborns and mothers that meets specific criteriaand coverage is provided by an insurance company or HMO, state law will apply. All group health plansthat provide maternity or newborn infant coverage must include in their Summary Plan Descriptions astatement describing the Federal or state law requirements applicable to the plan (or any health insurancecoverage offered under the plan) relating to hospital length of stay in connection with childbirth for themother or newborn child.November 13, 20209
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 numberHEALTH PLAN INFORMATIONAmbetter from Home State HealthAmbetterfrom11720 Borman Dr.HomeStateSaint Louis, MO 63146Phone: 1-855-650-3789TTY/TDD: ntPhoneFax/Web AddressProvider ServicesNAMember ServicesNAMedical Management Inpatientand Outpatient Prior eetsReports/1-855-650-37891-855-690-3789Care 562Prior1-855-690-543324/7 Nurse Advice LineNAPharmacy SolutionAdvanced Imaging, cardiac, andtherapy(MRI,CT,PET,Myocardial Perfusion Imaging,MUGA Scan, Echocardiology,stress echocardiology, OutpatientPT, OT, ST) (NIA)1-866-399-09291-800-424-4794Cardiac Imaging (NIA)Envolve VisionEnvolve DentalNA1-855-650-3789Interpreter ServicesNovember 13, 2020NAEnvolveVision.comEnvolveDental.comNA10Health
HEALTH PLAN INFORMATIONTo report suspected fraud,waste and abuseEDI Claims assistanceNovember 13, 20201-866-685-8664NA1-800-225-2573 ext. 6075525e-mail: EDIBA@centene.com11
SECURE 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. The Portal can be accessed atambetter.homestatehealth.com.Functionality All users of the Secure Provider Portal must complete a registration process. Once registered, providers may:oCheck eligibility and view member rosteroView the specific benefits for a memberoView members remaining yearly deductible and amounts applied to plan maximumsoView status of all claims that have been received, regardless of how submittedoUpdate provider demographic information (address, office hours, etc.)oFor primary care providers, view and print patient lists. The patient list will indicate themember’s name, id number, date of birth, care gaps, disease management enrollment, andproduct in which they are enrolledoSubmit authorizations and view the status of authorizations that have been submitted formembersoView, submit, copy and correct claimsoSubmit batch claims via an 837 fileoView and download explanations of payment (EOP)oView a member’s health record, including visits (physician, outpatient hospital, therapy, etc.),medications, and immunizationsoView gaps in care specific to a member, including preventive care or services needed forchronic conditionsoSend and receive secure messages with Ambetter staffoAccess both patient and provider analytic toolsManage Account Access allows you to perform functions as an account manager such as adding portalaccounts needed in your office.DisclaimerProviders agree that all health information, including that related to patient conditions, medical utilizationand pharmacy utilization available through the portal or any other means, will be used exclusively for patientcare and other related purposes as permitted by the HIPAA Privacy Rule.November 13, 202012
CREDENTIALING AND RECREDENTIALINGThe credentialing and recredentialing process exists to verify that participating practitioners and providersmeet the criteria established by Ambetter, as well as applicable government regulations and standards ofaccrediting agencies.If a practitioner/provider already participates with Ambetter from Home State in the Medicaid or a Medicareproduct, the practitioner/provider will NOT be separately credentialed for the Ambetter product.Notice: In order to maintain a current practitioner/provider profile, practitioners/providers are required tonotify Ambetter of any relevant changes to their credentialing infor
HOW TO USE THIS PROVIDER MANUAL. Ambetter is committed to assisting its provider community by supporting their efforts to deliver well-coordinated and appropriate health care to our members. Ambetter is also committed to disseminating comprehensive and timely information to its providers through this provider manual regarding Ambetter's
