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Provider and Billing -MS-C-00024 2020 Ambetter of Magnolia Inc. All rights reserved.
Table of ----------------------------------------------- 6HOW TO USE THIS PROVIDER MANUAL ---------------------------------------- 7NONDISCRIMINATION OF HEALTH CARE SERVICE DELIVERY--------- 8KEY CONTACTS AND IMPORTANT PHONE NUMBERS -------------------- 9SECURE PROVIDER PORTAL --- -------------------------------- 11Disclaimer -------------------- 11CREDENTIALING AND RECREDENTIALING---------------------------------- 12Eligible Providers ---------- 13Credentialing Committee -------------------------------------------------- 13Recredentialing ------------- 13Practitioner Right to Review and Correct Information ----------- 14Practitioner Right to Be Informed of Application Status -------- 14Practitioner Right to Appeal or Reconsideration of Adverse Credentialing Decisions ----------------- 14PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER -------- 15Provider Types That May Serve As PCPs ---------------------------- 15Withdrawing from Caring for a Member ------------------------------ 16PCP Coordination of Care to ---------------------------------------- 16Appointment Availability and Wait --------------------------------- 17Travel Distance and Access Standards ------------------------------ 17Covering Providers -------- 18Provider Phone Call Protocol -------------------------------------------- 18Provider Data Updates and Validation -------------------------------- 18Hospital Responsibilities -------------------------------------------------- 19AMBETTER BENEFITS ------------- 20Overview ---------------------- 20Additional Benefit Information ------------------------------------------ 21Integrated Deductible Products ----------------------------------------- 21Non- Integrated Deductible Products --------------------------------- 22November 13, 20201
Maximum Out-of-pocket Expenses ------------------------------------ 22Free Visits -------------------- 23Covered Services ---------- 23Notification of Pregnancy ------------------------------------------------- 24Adding a Newborn or an Adopted ----------------------------------- 24Non-Covered Services --- 24Transplant Services ------- 24Tribal Provider (AIAN) American Indian Alaska Native ---------- 25MEMBER 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 ------ 28Importance of Verifying Benefits, Eligibility, and Cost Shares ------------------------------------------------- 28MEDICAL 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 --------- 33Pharmacy --------------------- 34Second Opinion ------------ 35Preventive Health Care --- 35Retrospective Review ---- 36Emergency ---------------- 36Utilization Review ------- 36Care Management and Concurrent Review ------------------------- 37Health Management ------- 38Envolve PeopleCare ------ 38Ambetter’s Member Wellbeing Survey -------------------------------- 39November 13, 20202
Ambetter’s My Health Pays Member Rewards Program -------- 39CLAIMS ---------------------------------- 41Verification Procedures -- 41Clean Claim -------------- 42Non-Clean Claim Definition ----------------------------------------------- 43Upfront Rejections vs. Denials ------------------------------------------ 43Timely Filing ----------------- 43Refunds and -------- 44Who Can File Claims? ---- 44Electronic Claims Submission ------------------------------------------ 45Online Claim Submission ------------------------------------------------- 48Paper Claim Submission -------------------------------------------------- 48Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) ----------------------------- 49Corrected Claims, Requests for Reconsideration or Claim Appeals ----------------------------------------- 50Risk Adjustment and Correct Coding --------------------------------- 53Claim Reconsiderations Related To Code Editing And Editing ------------------------------------------------ 58CODE ------------------------------- 59CPT and HCPCS Coding - 59International Classification of Diseases (ICD-10) ----------------- 60Revenue Codes ------------- 60Edit Sources ----------------- 60Code Editing Principles -- 61Invalid Revenue to Procedure Code Editing ------------------------ 63Claim Reconsiderations Related To Code Editing ---------------- 67Viewing Claims Coding Edits -------------------------------------------- 68Clinical Payment Policy Appeals --------------------------------------- 69THIRD PARTY LIABILITY ---------- 70BILLING THE MEMBER ------------ 71Covered Services ---------- 71Non-Covered Services --- 71Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) ----------- 72Failure to Obtain Authorization ----------------------------------------- 72No Balance Billing --------- 72November 13, 20203
MEMBER RIGHTS AND RESPONSIBILITIES ---------------------------------- 73Member -------------------- 73Member Responsibilities -------------------------------------------------- 74PROVIDER RIGHTS AND RESPONSIBILITIES ------------------------------- 76Provider Rights ------------- 76Provider Responsibilities ------------------------------------------------- 76CULTURAL COMPETENCY ------- 79Language Services -------- 80Provider Accessibility Initiative ----------------------------------------- 81Americans with Disabilities Act (ADA) -------------------------------- 82COMPLAINT PROCESS ------------ 85Complaint/Grievance ----- 85Mailing Address ------------ 86QUALITY IMPROVEMENT PLAN -------------------------------------------------- 87Overview ---------------------- 87QAPI Program Structure - 87Quality Assessment and Performance Improvement Program Scope and Goals ----------------------- 88Performance Improvement Process ----------------------------------- 91Quality Rating System --- 92Provider Satisfaction - 93Qualified Health Plan (QHP) Enrollee Survey ----------------------- 93Provider Performance Monitoring and Incentive Programs --- 93REGULATORY MATTERS --------- 95Medical Records ----------- 95EMR Access ----------------- 97Medical Records Release ------------------------------------------------- 97Medical Records Transfer for New Members ----------------------- 97Federal And State Laws Governing The Release Of Information ---------------------------------------------- 97National Network ----------- 98Section 1557 of the Patient Protection and Affordable Care Act ----------------------------------------------- 99FRAUD, WASTE AND -------- 100FWA Program Compliance Authority and Responsibility ---- 101November 13, 20204
False Claims Act --------- 101Physician Incentive Programs ----------------------------------------- 101APPENDIX ----------------------------- 103Appendix I: Common Causes for Upfront Rejections --------- 103Appendix II: Common Cause of Claims Processing Delays and Denials---------------------------------- 104Appendix III: Common EOP Denial Codes and Descriptions -------------------------------------------------- 104Appendix IV: Instructions for Supplemental Information ----- 105Appendix V: Common Business EDI Rejection Codes -------- 107Appendix VI: Claim Form Instructions ------------------------------ 109Appendix VII: Billing Tips and Reminders ------------------------- 109Appendix VIII: Reimbursement Policies ---------------------------- 131Appendix IX: EDI Companion Guide Overview ------------------- 134STATE MANDATED REGULATORY REQUIREMENTS -------------------- 153Arkansas -------------------- 153Arizona ---------------------- 153Florida ----------------------- 154Georgia ---------------------- 155Illinois ------------------------ 156Indiana ----------------------- -------------------------------- 161Missouri --------------------- 162Mississippi ----------------- 165North Carolina ------------ 166New Hampshire ----------- -------------------------------- 172Ohio -------------------------- 175Pennsylvania -------------- 178South Carolina ------------ 179Tennessee ------------------ 181Texas ------------------------- 181November 13, 20205
WELCOMEWelcome to Ambetter from Magnolia Health (“Ambetter”). Thank you for participating in our network of highquality 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, 20206
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 atwww.ambetter.magnoliahealthplan.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 1-877-687-1187 to request that a copy of this manual be mailed to you. Inaccordance with the Participating Provider Agreement, providers are required to comply with the provisionsof this manual. Ambetter routinely monitors compliance with the various requirements in this manual andmay initiate corrective action, including denial or reduction in payment, suspension, or termination if thereis a failure to comply with any requirements of this manual.Dental and Vision Provider ManualsEnvolve Dental and Vision provider manuals are available on the Secure Provider Portal. Providers mayvisit envolvedental.com or www.envolvevision.com and log on or contact us for these provider manuals.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, 20207
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, 20208
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 Magnolia HealthDepartmentAmbetter from Magnolia Health111 East Capitol Street Suite 500 Jackson, MS 39201Phone: 1-877-687-1187, Relay 711Fax: honeFax/Web AddressProvider ServicesNAMember ServicesNAMedical Management Inpatientand Outpatient PriorAuthorization1-855-300-2618Concurrent /Census Reports/Facesheets1-877-687-11871-855-300-2618Care Management1-855-300-2618Behavioral Health PriorAuthorizationN/A24/7 Nurse Advice LineNAPharmacy SolutionAdvanced Imaging, cardiac, andtherapy (MRI, CT, PET,Myocardial Perfusion Imaging,MUGA Scan, Echocardiology,stress echocardiology,Outpatient PT, OT, ST) (NIA)Cardiac Imaging (NIA)Envolve VisionNovember 13, AEnvolveVision.com
HEALTH PLAN INFORMATIONEnvolve DentalEnvolveDental.comInterpreter ServicesTo report suspected fraud,waste and abuseEDI Claims assistanceNovember 13, 2020NA1-866-685-8664NA1-800-225-2573 ext. 6075525e-mail: EDIBA@centene.com10
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 y 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, 202011
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 Magnolia Health in the Medicaid or aMedicare product, 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 information in a timely manner but in no eventlater than 10 days from the date of the change.Whether standardized credentialing form is utilized or a practitioner has registered their credentialinginformation on the Council for Affordable Quality Health (CAQH) website, the following information must beon file: Signed attestation as to correctness and completeness, history of license, clinical privileges,disciplinary actions, and felony convictions, lack of current illegal substance use and alcohol abuse,mental and physical competence, and ability to perform essential functions with or withoutaccommodation Completed ownership and control disclosure form Current malpractice insurance policy face sheet, which includes insured dates and the amounts ofcoverage Current controlled substance registration certificate, if applicable Current drug enforcement administration (DEA) registration certificate for each state in which thepractitioner will see Ambetter members Completed and signed W-9 form (initial credentialing only)
Provider Services department at 1-877-687-1187 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 the provisions of this manual. Ambetter routinely monitors compliance with the various requirements in this manual and
