Transcription
Provider ManualCommercial, Medicaid, Medicare June 2020PRV1 0620
Table of Contents1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.1 About This Manual . . . . . . . . . . . . . . . . . . 31.2 PacificSource Mission Statement . . . . . 32. Who to Contact . . . . . . . . . . . . . . . . . . . . . . . . . . 43. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104. Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . 224.14.24.34.44.54.64.74.8Credentialing . . . . . . . . . . . . . . . . . . . . .Locum Tenens . . . . . . . . . . . . . . . . . . .Taxpayer Identification Numbers . . . . .Physician and Provider ContractProvisions . . . . . . . . . . . . . . . . . . . . . . .Call Share Policy . . . . . . . . . . . . . . . . . .Accessibility . . . . . . . . . . . . . . . . . . . . .Providers . . . . . . . . . . . . . . . . . . . . . . . .Appeals Process . . . . . . . . . . . . . . . . . .22282829383941505. Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585.15.25.35.45.55.65.7Referral Policy . . . . . . . . . . . . . . . . . . . .Referral Procedure . . . . . . . . . . . . . . . .Referral Management Entities . . . . . . .Out-of-Network Referrals . . . . . . . . . . .Referral Not Required . . . . . . . . . . . . . .Referrals That Are Not Approved . . . . .Retroactive Referrals . . . . . . . . . . . . . .585960616162626. Medical Management . . . . . . . . . . . . . . . . . . 636.1 Medical Necessity and Coverage . . . .6.2 Care/Case Management . . . . . . . . . . .6.3 Quality Improvement and MedicalManagement . . . . . . . . . . . . . . . . . . . .6.4 Preapproval/Preauthorization . . . . . . . .6.5 Medicaid Retroactive ApprovalGuidelines . . . . . . . . . . . . . . . . . . . . . . .6.6 Medicare Retroactive AuthorizationGuidelines . . . . . . . . . . . . . . . . . . . . . . .6.7 Utilization Management . . . . . . . . . . . .6.8 Clinical Practice Guidelines . . . . . . . . .6.9 Commercial: NonreimbursedNursing Level Charges During anAcute Care Hospital Stay . . . . . . . . . . .6.10 Medicaid: Mental Health Services . . .6.11 Medicaid: Substance UseDisorder (SUD) . . . . . . . . . . . . . . . . . . .63646871777880828283857. Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867.1 Drug Lists/Formulary Coverage . . . . . . 868.1 Product Descriptions . . . . . . . . . . . . . . 908.2 Plan Features . . . . . . . . . . . . . . . . . . . . 919. Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1009.1 Enrollment . . . . . . . . . . . . . . . . . . . . . 10010. Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11110.1 Eligibility and Benefits . . . . . . . . . . . . 11110.2 HCPCS Coding . . . . . . . . . . . . . . . . . 11210.3 Claims and Payment Rules . . . . . . . . 11310.4 Claims Submission Requirements . . 11610.5 Corrected Claims Submission . . . . . . 12010.6 Medicare: Special Benefits . . . . . . . . 12010.7 Explanation of Payment (EOP) . . . . . . 12110.8 Prompt Pay Policy . . . . . . . . . . . . . . . . 12210.9 Accident Report Policy . . . . . . . . . . . . 12210.10 Coordination of Benefits . . . . . . . . . . 12311. Billing Requirements . . . . . . . . . . . . . . . . . . 12611.1 Incident to Billing . . . . . . . . . . . . . . . . 12611.2 Osteopathic Manipulation Treatment . 12711.3 Global Period . . . . . . . . . . . . . . . . . . . . 12811.4 Commercial: Obstetric andGynecology Care Billing Guidelines . . 12911.5 Emergency Services . . . . . . . . . . . . . 13311.6 Surgery . . . . . . . . . . . . . . . . . . . . . . . . 13511.7 Colonoscopy . . . . . . . . . . . . . . . . . . . . 14111.8 Evaluation and Management(E&M) Billing Guidelines . . . . . . . . . . 14111.9 Medicare: Annual WellnessVisit (AWV) . . . . . . . . . . . . . . . . . . . . . 14411.10 Ultrasound: Same-day Billing ofTransvaginal and Standard . . . . . . . . . 14611.11 Never Events Policy . . . . . . . . . . . . . . 14711.12 Routine Venipuncture and/orCollection of Specimens . . . . . . . . . . 14911.13 Inpatient Hospital Services . . . . . . . . 14911.14 Lab Handling Codes . . . . . . . . . . . . . . 15011.15 Clinical Lab Services . . . . . . . . . . . . . . 15011.16 Editing Software for Facility andProfessional Claims . . . . . . . . . . . . . . 15011.17 Vision—Routine vs. Medical . . . . . . . 15111.18 Telehealth or Telemedicine . . . . . . . . . 15112. Publications and Tools . . . . . . . . . . . . . . . . . 15412.1 Websites and Online Resources . . . . 15412.2 Email Newsletters and Bulletins . . . . 15612.3 Medicaid: LineFinder . . . . . . . . . . . . . 15612.4 Material in Alternate Format . . . . . . . 15612.5 Healthcare Interpreter (HCI) Services 15613. Health Plan Responsibility . . . . . . . . . . . . . 15814. Compliance & Program Integrity . . . . . . . . 162June, 20208. Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909.2 Member ID Card . . . . . . . . . . . . . . . . 1019.3 Rights and Responsibilities . . . . . . . . 1029.4 Member Grievance and AppealsProcess . . . . . . . . . . . . . . . . . . . . . . . . 1092
1. Introduction1.1 About This ManualPacificSource has prepared this Provider Manual for our contracted providers. It is a reference tool to provideimportant information concerning the role of the provider and office staff in the delivery of healthcareto our members and your patients. This manual provides critical information regarding provider and planresponsibilities. This document should be used in conjunction with your contract with PacificSource. For thepurpose of brevity, we use the term “provider” throughout the manual to refer to physicians and/or providers.Take a moment to look over the sections that relate to your responsibilities. You will find the expandedglossary helpful in becoming familiar with common insurance terminology and, of course, yourcomments, questions and/or suggestions are always welcome.This manual does not address processes and procedures specific to the Legacy Health-PacificSource IntegratedDelivery System (IDS) within the Health Share of Oregon coordinated care organization (CCO). PacificSourcewill publish updates specific to the IDS as they become available. In the interim, if you have any questions aboutprocesses and procedures specific to serving members enrolled in the IDS within Health Share of Oregon, pleasecontact your Provider Service Representative or PacificSource Customer Service for additional information.Legacy Integrated Delivery Systems (IDS)In addition to using this Provider Manual, we suggest you visit our websites, .com, and Medicare.PacificSource.com. There you will find otheruseful tools, such as provider directories, formularies, and plan documents.We hope you will find the information in the Provider Manual and on the websites to be useful.PacificSource Provider Service Representatives are committed to providing tools that meet the needs ofour in-network physicians and providers. Please let us know if you have questions about any aspect ofthis manual or have suggestions regarding how we can improve this document in the future.Thank you for becoming a team member in the partnership between PacificSource, members, and ourin-network physicians and providers.Notice of ChangesFor any change in a PacificSource policy or process to this Provider Manual, we will provide writtennotice. Notice will be provided by email or by fax, and will be posted at these web pages:PacificSource.com/Providers, tions.PacificSource.com/ProvidersThis manual gives you the details about important information concerning the role of the providerand office staff in the delivery of healthcare to our members and your patients. It provides criticalinformation regarding provider and plan responsibilities. This document should be used inconjunction with your PacificSource contract.1.2 PacificSource Mission StatementThe Mission of PacificSourceProvider Network Department MissionTo create and maintain partnerships among internal and external customers resulting in adequate accessto quality service in a competitive market.June, 2020To provide better health, better care, and better cost to the people and communities we serve3
2. Who to ContactCommercial Customer ServiceOregon and Washington: (541) 684-5582, (888) 977-9299Idaho: (208) 333-1596, (800) 688-5008Montana: (406) 442-6589, (877) 590-1596Fax: (541) 684-5264Email: cs@pacificsource.comCall Customer Service Monday to Friday, from 7:00 a.m. to 5:00 p.m. PTMedicaid Customer ServiceToll-free, all areas: (800) 431-4135Central Oregon and Gorge: (541) 382-5920Marion, Polk, and Lane Counties: (503) 210-2515TTY: (800) 735-2900Fax: (541) 322-6423Email: CommunitySolutionsCS@pacificsource.comCall Medicaid Customer Service Monday to Friday, from 8:00 a.m. to 5:00 p.m. PTMedicare Customer ServiceBend, OR: (541) 385-5315Springfield, OR: (541) 225-3771Boise, ID: (208) 433-4612Toll-free: (888) 863-3637TTY: (800) 735-2900Fax: (541) 322-6423Email: MedicareCS@pacificsource.comCall Medicare Customer Service:October 1–March 318:00 a.m. to 8:00 p.m. local time zone, seven days a weekApril 1–September 308:00 a.m. to 8:00 p.m. local time zone, Monday–FridayContact for: Member benefits, eligibility information, or waivers Explanation of payments/vouchers In-network physicians and providers and changesJune, 2020 Deductible, coinsurance and/or copay information4
Claim questions/status PCP changes Referrals or prior authorization questions Appeal process Accident informationClaims BillingCommercial: See the back of the PacificSource member ID card.Mail Medicaid claims to:PacificSource Community SolutionsPO Box 7068Springfield, OR 97475-0068Mail Medicare claims to:PacificSource MedicarePO Box 7068Springfield, OR 97475-0068CredentialingPhone: (541) 684-5580Toll-free: (800) 624-6052, ext. 3747Fax: (541) 225-3644Email: ngPhone: (541) 684-5580Toll-free: (800) 624-6052, ext. 2580Fax: (541) 225-3643Commercial Email: Idaho: IDcontracting@pacificsource.com Montana: MTcontracting@pacificsource.com Oregon: ORcontracting@pacificsource.com Washington: WAcontracting@pacificsource.com All States: providercontracting@pacificsource.com Medicaid Email: providernet@pacificsource.com Medicare Email: providercontracting@pacificsource.comContact for: Direct credentialing application status Direct recredentialing inquiriesJune, 2020 Direct credentialing inquiries5
DentalCommercial Dental Customer ServicePhone: (541) 225-1981Toll-free: (866) 373-7053Fax: (541) 684-5564Email: dental@pacificsource.com8:00 a.m. to 5:00 p.m. PTMedicaid Dental ProvidersPlease contact your dental care organization (DCO) for contracting information.Medicaid Dental ServicesAdvantage Dental Services: Toll-free (866) 268-9631, TTY: 711Capital Dental Care: Toll-free (800) 525-6800, TTY: 711ODS Community Health: Toll-free (800) 342-0526, TTY: 711Health ServicesMonday through Friday, 8:00 a.m. to 5:00 p.m.After normal business hours, calls to Health Services are forwarded to voice mail. A staff member willreturn the call the next business day. Any email communication received after hours will be answered thefollowing business day.Commercial:Phone:Oregon: (541) 684-5584, (888) 691-8209, ext. 2584Idaho: (208) 333-1563, (800) 688-5008Montana: (406) 442-6595, (877) 570-1563TTY: (800) 735-2900Fax:Oregon: (541) 225-3625Idaho: (208) 395-2697Montana: (406) caid:June, 2020Behavioral HealthPhone: (541) 382-5920, (800) 431-4135Fax: (541) 330-49106
Preapproval/ReferralsPhone: (541) 330-7301TTY: (800) 431-4135Intensive Care Management and Care CoordinationPhone: (541) 330-2507Toll-free: (888) 970-2507Utilization ReviewPhone: (541) 330-7301TTY: (800) 431-4135MedicarePhone:Oregon: (541) 330-7304Idaho: (208) 433-4624Toll-free: (888) 863-3637TTY: (800) 735-2900Fax:Oregon: (541) 382-2952Idaho Authorization and Referrals: (208) 395-2697Idaho Utilization Review: (208) 395-2696Contact for: Referrals Care/case management Utilization review Preauthorization/prior authorization Out-of-network referral information Specific medical necessity criteria/guidelinesPharmacy ServicesPhone: (541) 330-4999Toll-free (888) 437-7728TTY: (800) 735-2900Contact for: Exceptions to standard formulary rules Prior authorization for all medications (medically administered and pharmacy) Clinical consultation Care planning for patients with complex needsJune, 20207
Grievance and AppealsMedicare and Medicaid:Medicare Toll Free: (888) 863-3637Medicaid Toll Free: (800) 431-5920Phone: (541) 330-4992Fax: (541) 322-6424Commercial:Phone: (800) 624-6052Fax: (541)225-3632Email: lc@pacificsource.comProvider Network DepartmentPhysician/provider support and educationPhone: (541) 684-5580, (800) 624-6052, ext. 2580TTY: (800) 735-2900Fax: (541) 225-3643Email: providernet@pacificsource.comContact for: Physician/provider contract support Explanations of medical, administrative, or reimbursement policies General education on proper methods to use for billing and coding Questions about web connectivity to PacificSource Provider location changes Call share maintenance Physician/provider network information Limited practice designations Demographic updates, including tax identification numbers Physician/provider credentialingThe Provider Network department operates as a liaison between PacificSource and healthcareprofessionals. Recognizing the needs and perspectives of in-network physicians and providers,Provider Network is dedicated to giving our physicians and providers the highest quality service, with acommitment to working with practitioners in a fair, honest, and timely fashion.In our Provider Network Department, Provider Service Representatives have the following definedpurposes and responsibilities:June, 2020 Develop and provide support services to new and established contracted physicians and providersfor the purpose of contract education, compliance, and problem solving, and to ensure satisfactionwith PacificSource.8
Provide liaison support internally for physician and provider related issues, including questions orconcerns regarding contracts and operations. Develop educational materials for meetings and/or mailings as needed. Develop and maintain a Provider Manual outlining general information about PacificSource policiesand procedures applicable to healthcare professionals. Present contracted physicians and providers to members via current and accurateprovider directories. Identify and pursue opportunities for provider network expansion and enhanced memberaccess to healthcare.June, 20209
3. GlossaryAccess: Ability to obtain medical services.Accreditation: Accreditation programs give an official authorization or approval to an organization againsta set of industry-derived standards.Actuary: A person in the insurance field who determines insurance policy rates and conducts variousother statistical studies.Adjudication: Processing a claim through a series of edits to determine proper payment.Administrative Services Only (ASO) Contract: A contract between an insurance company and a selfinsured plan where PacificSource performs administrative services only; for example, claims processing.Allied Health Professional (AHP): All healthcare providers who are not licensed as doctors of medicineor osteopathy; for example, nurse practitioners, physician assistants, and chiropractors.Alternative Care: Medical care received in lieu of inpatient hospitalization. Examples include outpatientsurgery, home healthcare, and skilled nursing facility care. It also may refer to nontraditional caredelivered by providers, such as acupuncturists.Ambulatory Care: Healthcare services rendered in a hospital’s outpatient facility, physician’s office, orhome healthcare; often used synonymously with the term “outpatient care.”Ancillary Medical Service: Covered service necessary for diagnosis and treatment of members.Includes, but is not limited to, ambulance, ambulatory or day surgery, durable medical equipment,imaging service, laboratory, pharmacy, physical or occupational therapy, urgent or emergency care, andother covered service customarily deemed ancillary to the care furnished by primary care or specialistphysicians or providers.Annual Enrollment Period (AEP): A set time each fall when Medicare members can change theirhealth or drugs plans or switch to Original Medicare. The Annual Enrollment Period is from October 15until December 7.Appeal Process for Terminated Providers: The system for the receipt, handling, and disposition ofprovider complaints and grievances in regards to contract termination, as described in the PacificSourcePolicies and Procedures.Balance Billing: Sometimes referred to as extra billing, is the practice of a healthcare provider billing apatient for the difference between what the patient’s health insurance chooses to reimburse and whatthe provider chooses to charge.Behavioral Healthcare: Treatment of mental health and/or substance use disorders.Benefit Package/Plan: Specific services provided by the insurance carrier. Covered services,copayments or deductible requirements, limitations, and exclusions contained in the contract betweenPacificSource and a member or subscriber group.Board Certified: A physician who has passed an examination given by a medical specialty board.Call Share: The physicians or providers on whom a practitioner relies for backup coverage during timesthey are unavailable.June, 2020Board Eligible: A physician who has graduated from an approved medical school and is eligible to take aspecialty board examination.10
Call Share Group: A group of providers with similar specialties who have joined together to provide callshare services.Capitation: A method of paying for medical services on a per-person rather than a per-procedure basis.Carrier: Insurer, underwriter of risk.Carve Out: Medical services that are specifically identified in a contract and paid under adifferent arrangement.Care/Case Management: The process whereby a healthcare professional supervises the administrationof medical or ancillary services to a patient, typically one who has a catastrophic disorder or who isreceiving mental health services. Care/case managers reduce the costs associated with the care of suchpatients, while providing high-quality medical services.Case Rate: A “package price” for a specific procedure or diagnosis-related group.Centers for Medicare and Medicaid Services (CMS): The agency within the Department of Health andHuman Services that administers the Medicare program.Certified Interpreter: A person who is certified as competent interpreter by a professional organizationor government entity through rigorous testing based on appropriate and consistent criteria. This includespassing a standardized national test.Clean Claim: (1) A claim that has no defect, impropriety, lack of any required substantiating documentation(consistent with § 422.310(d)) or particular circumstance requiring special treatment that prevents timelypayment; and (2) A claim that otherwise conforms to the clean claim requirements for equivalent claimsunder original Medicare.Clinic: A healthcare facility for providing preventive, diagnostic, and treatment services to patients in anoutpatient setting.Clinical Quality Utilization Management (CQUM) Committee and Pharmacy & TherapeuticsCommittee: The CQUM Committee promotes quality and oversees performance improvement projects,identifies topics for quality and performance improvement efforts, and oversees and evaluates qualityand performance improvement plans. The Pharmacy & Therapeutics Committee (P&T) maintains drugformular
Medicaid Dental Providers Please contact your dental care organization (DCO) for contracting information. Medicaid Dental Services Advantage Dental Services: Toll-free (866) 268-9631, TTY: 711 Capital Dental Care: Toll-free (800) 525-6800, TTY: 711 ODS Community H
