PROV19614 APP_4/16/2014 Provider Manual January 2014 PP196 11/18/2013 Page 1 of 331 User Guide - Table of Contents Section 1.0 - Introduction 1.1 1.2 1.3 1.4 1.5 1.6 Provider Welcome Kentucky Medicaid Program Overview of Passport Health Plan Mission and Values Important Telephone Numbers Claim Submission Section 2.0 – Administrative Procedures 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 Eligibility Passport Health Plan Assignment Choosing a Primary Care Provider (PCP) Identification Cards Member Release for Ethical Reasons Health Education and Special Programs Credentialing/Re-Credentialing Process Provider Terminations/Changes in Provider Information Provider Grievances and Appeals Members’ Rights Member Grievances and Appeals Title VI Requirements: Translator and Interpreter Services Section 3.0 – Provider Roles and Responsibilities 3.1 3.2 3.3 3.4 Confidentiality The Role of the Primary Care Provider (PCP) The Role of Specialists and Consulting Practitioners Responsibilities of All Providers Page 2 of 331 Section 4.0 – Office Standards 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Appointment Scheduling Standards After-Hours Telephone Coverage Member to Practitioner Ratio Maximum Provider Office Standards Medical-Record-Keeping & Continuity &Coordination of Care Standards Hospital Care Kentucky Health Information Exchange – KHIE Communication Guidelines Section 5.0 – Utilization Management 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 Utilization Management Review Criteria/Standards for Review Authorization Requirements Online Authorization Inpatient Admissions and Observation Outpatient Services High-Cost Medications Prior Authorization for Members with Original Medicare Retrospective Authorization Denials - Appendix A: Radiology Codes - Appendix B: L codes - Appendix C: Ostomy Supplies Section 6.0 – Referrals 6.1 6.2 6.3 Member Self-Referral (Direct Access) Referral Requirements Distribution of Referrals Page 3 of 331 Section 7.0 – Benefit Summary and Exclusions 7.1 7.2 7.3 Benefit Summary Services Covered Outside Passport Health Plan Non-Covered Services Section 8.0 – Early and Periodic Screening, Diagnosis and Treatment (EPSDT) 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Overview of EPSDT EPSDT Eligibility Covered Services EPSDT Audits for Screening Elements EPSDT Tracking/Member Outreach EPSDT Reporting/Billing (Preventive Health Screens/Immunizations) EPSDT Expanded Services Section 9.0 – Quality Improvement 9.1 9.2 9.3 Quality Improvement Program Description Quality of Care Concerns Practitioner Sanctioning Policy Section 10.0 – Emergency Care / Urgent Care Services 10.1 10.2 10.3 10.4 Emergency Care Out-of-Service-Area Care Urgent Care Services Lock-In Program Section 11.0 – Special Programs 11.1 11.2 11.3 Case Management Health and Disease Management Programs Children Living in Out-Of-Home Placements Page 4 of 331 Section 12.0 – Outpatient Pharmacy Services 12.1 12.2 12.3 12.4 Prescribing Outpatient Medications for Passport Health Plan Members Covered Outpatient Pharmacy Benefits Drug Prior-Authorization Procedure Lock-In Program Section 13.0 – Obstetrical 13.1 13.2 13.3 13.4 Overview Member Access to Prenatal Care Obstetrical Practitioner’s Role General Procedure for Prior Authorization of Obstetrical Care and Delivery Section 14.0 – Family Planning 14.1 14.2 14.3 Services Network Claims Section 15.0 – Provider Billing Manual 15.1 15.2 15.3 15.4 15.5 15.6 15.7 Claim Submission Provider/Claim Specific Guidelines Understanding the Remittance Advice Denial Reasons and Prevention Practices Timely Filing Requirements Corrected Claims and Requests for Reconsideration and/or Refunds Contact Information for Claims Questions Page 5 of 331 Section 16.0 – Behavioral Health 16.1 16.2 16.3 16.4 16.5 16.6 16.7 Administrative Procedures Access to Care Behavioral Health Benefits Care Management and Utilization Management Authorization Procedures and Requirements Quality Improvement Behavioral Health Provider Billing Manual Section 17.0 – Forms and Documents 17.1 17.2 17.3 17.4 17.5 17.6 Preventive Health, Disease Management & Risk Assessment Forms Claim Forms Provider Contracting and Provider Network Management Forms MAP Forms Utilization Management Forms Mommy Steps Forms Section 18.0 – Important Contact Information 18.1 18.2 Passport Health Plan Important Contact Information Other Important Contact Information Section 19.0 – Dental Network 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 19.9 Important Contact Information Administrative Procedures Credentialing/Re-credentialing Provider Terminations/Changes in Provider Information Standards of Care for Dental Offices Dental Benefits Care Management and Utilization Management Authorization Procedures and Requirements Quality Improvement Page 6 of 331 19.10 Dental Provider Billing Manual 19.11 Fraud, Waste and Abuse 19.12 Cultural Competency Section 20.0 - Acronyms Page 7 of 331 Provider Manual Section 1.0 Introduction Table of Contents 1.1 Provider Welcome 1.2 Kentucky Medicaid Program 1.3 Overview of Passport Health Plan 1.4 Mission and Values 1.5 Important Telephone Numbers 1.6 Claim Submission Page 8 of 331 1.0 Introduction 1.1 Provider Welcome We are pleased you are part of the Passport Health Plan (Passport throughout this document) provider network. As a participant in Passport’s network, you have the opportunity to make Passport beneficial for both you and the members you serve. Passport knows providers are essential in delivering high-quality, cost-effective medical services to Medicaid recipients in the Commonwealth. We further recognize that achieving our mission “to improve the health and quality of life of our members” would not be possible without your participation. Passport is committed to earning your ongoing support and looks forward to working with you to provide the best service possible to Passport’s members. This Provider Manual explains the policies and administrative procedures of Passport. You may use it as a guide to answer questions about member benefits, claim submissions, and many other issues. This Provider Manual also outlines day-to-day operational details for you and your staff. It will describe and clarify the requirements identified in the Provider Agreement you hold with Passport. Updates to this Provider Manual will be provided on Passport’s website on a periodic basis. As your office receives communications from Passport, it is important that you and/or your office staff read the Provider Alerts, Medical Office Notes, Passport eNews, and other special mailings and retain them with this Provider Manual so you can integrate the changes into your practice. All Passport provider materials, including the Provider Manual and Provider Directory, are available online at www.passporthealthplan.com. Please note, the term “provider” as used throughout this Provider Manual is inclusive of all practitioners, individual and group affiliated, as well as facilities and ancillary service suppliers, as appropriate. 1.2 Kentucky Medicaid Program The Kentucky Department for Medicaid Services (DMS), under the Cabinet for Health and Family Services (CHFS), is responsible for administering the Kentucky Medicaid Program as explained in Section 1.3 below. DMS has contracted with Passport, and other managed care organizations (MCO), to administer Medicaid benefits. The Medicaid Program, identified as Title XIX of the Social Security Act, was enacted in 1965 and operates according to a state plan approved by the U.S. Department of Health and Human Services. Title XIX is a joint federal and state assistance program that provides payment for certain medical services provided to Kentucky recipients who lack sufficient income or other resources to meet the cost of their care. The basic objective of the Kentucky Medicaid Program is to aid the medically indigent of Kentucky in obtaining needed medical care. In May 2013, Gov. Steve Beshear announced the inclusion of 308,000 more Kentuckians in the Page 9 of 331 federal Medicaid health insurance program. “The expansion, together with the creation of the Health Benefit Exchange, will ensure that every Kentuckian will have access to affordable health insurance.” This expansion includes eligibility starting on January 1, 2014. As a provider of medical services, please be aware DMS, Passport, and the provider are bound by both federal and state statutes and regulations as well as revisions governing the administration of the state plan. The state cannot be reimbursed by the federal government for monies improperly paid to providers for non-covered, unallowable medical services. Therefore, Passport may request a return of any monies improperly paid to providers for non-covered services. The Kentucky Medicaid Program should not be confused with Medicare. Medicare is a federal program, identified as Title XVIII, primarily serving persons 65 years of age and older and some disabled persons under 65 years of age. The Kentucky Medicaid Program and Passport services eligible recipients of all ages. 1.2.1 Department for Medicaid Services The Kentucky Department for Medicaid Services (DMS), within the CHFS, bears the responsibility for developing, maintaining, and administering the policies and procedures, scope of benefits, and basis for reimbursement for the medical care aspects of the program. As a managed care organization (MCO) for DMS, Passport makes the actual reimbursement to providers for covered services provided to Passport members. It is important to note Passport does not determine eligibility for Medicaid. Determination of the eligibility status of individuals and families for Medicaid benefits is a responsibility of the local Department for Community Based Services (DCBS) offices located in each county of the Commonwealth (see Section 20.2, “Other Important Contact Information” for local offices). 1.2.2 Kentucky Medicaid Member Enrollment and Disenrollment Kentucky Medicaid members are given the option to participate in an annual open enrollment period, where they may choose to join one of the MCOs contracted by DMS to serve this region. New members are also given 90 days after the time of enrollment to change MCOs. DMS is responsible for this process, and maintains all member eligibility information in their KyHealth Net online system (see Section 2.4.1 for more information). Although Passport has policies in place for instances where we may request disenrollment of a member, DMS is responsible for disenrolling that member from Passport. 1.3 Overview of Passport Passport is the operating name for University Health Care, Inc. (UHC), a managed care organization that serves the Medicaid and the Kentucky Children’s Health Insurance Program (KCHIP) populations in the Commonwealth of Kentucky. UHC is a non-profit health maintenance organization (HMO) licensed in the Commonwealth of Kentucky. Page 10 of 331 Passport is sponsored by the University of Louisville Medical School Practice Association, University Medical Center, Inc., Jewish Heritage Fund for Excellence, Norton Healthcare, and the Louisville/Jefferson County Primary Care Association, which includes the Louisville Metro Department of Health and Welfare and Louisville's two Federally Qualified Health Centers: Family Health Centers and Park DuValle. The Partnership Council is a broad coalition of consumers and providers, including physicians, nurses, hospitals, health departments, and ancillary providers who help govern the operations of Passport. If you are interested in volunteering to participate on the Partnership Council or one of our committees, please contact your Provider Relations Specialist. 1.4 Mission and Values Passport’s vision is: To be the leading model for collaboration and innovation in health care Passport’s mission is: To improve the health and quality of life of our members The Organizational Values are: • • • • Integrity Community Collaboration Stewardship 1.5 Important Telephone Numbers 1.5.1 Case Management (877) 903-0082 The Case Management department is available 8:00 a.m. to 6:00 p.m. EST, (7:00 a.m. to 5:00 p.m. CST), Monday through Friday. The Case Management department assists members and providers in managing and coordinating services to meet the members’ medical and social needs. 1.5.2 Compliance Department Providers are also required to cooperate with the investigation of suspected Fraud and Abuse. If you suspect Fraud and Abuse by a Passport member or provider, it is your responsibility to report this immediately by calling one of the telephone numbers listed below: Passport Compliance Hotline: (855) 512-8500 Medicaid Fraud Hotline: (800) 372-2970 Passport Compliance Email Address: ComplianceHotline@passporthealthplan.com 1.5.3 Health & Disease Management (877) 903-0082 Page 11 of 331 The Health & Disease Management department is available 8:00 a.m. to 6:00 p.m. EST (7:00 a.m. to 5:00 p.m. CST), Monday through Friday. The Health & Disease Management department offers a number of programs to assist providers and members in the management of their care, including: • Chronic Respiratory Disease Management (including asthma and COPD) • Congestive Heart Failure (CHF) Disease Management • Diabetes Disease Management • Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) • Mommy Steps Perinatal Program • Obesity (SCORE Program) 1.5.4 Member Services (800) 578-0603 Member Services representatives are available 7:00 a.m. to 7:00 p.m. EST (6:00 a.m. to 6:00 p.m. CST), Monday through Friday. Member Services representatives assist members by answering questions regarding changes, benefits, and grievance issues, or by directing members to other Passport departments as needed, and by sending communication materials to members as needed. 1.5.5 NaviNet Customer Care (888) 482-8057 Passport has partnered with NaviNet to offer you a secure, real-time online connection between your office and Passport. NaviNet can assist your office processes so that you spend less time on the phone or processing paperwork. NaviNet registration and usage is offered free of charge. Services offered include eligibility verification, claim status inquiry, and referral submission and inquiry. 1.5.6 Other Services Service Behavioral Health Provider Beacon Health Strategies Telephone (855) 834-5651 Hours 24 hours/7 days/week Dental Avesis Incorporated (866) 909-1083 7 a.m. to 8 p.m. EST 6 a.m. to 7 p.m. CST Nurse Advice McKesson/Care For You (800) 606-9880 24 hours/7 days/week Radiology MedSolutions (888) 693-3211 (877) 791-4099 8 a.m. to 9 p.m. EST 7 a.m. to 8 p.m. CST Vision Block Vision (800) 243-1401 7 a.m. to 5 p.m. EST 8 a.m. to 6 p.m. CST 1.5.7 Pharmacy Prior Authorization (800) 578-0898 Passport’s Pharmacy Benefits Manager, PerformRx, prior authorization department is available 8:30 a.m. to 6:00 p.m. EST, (7:30 a.m. to 5:00 p.m. CST). The following fax numbers are available to request drug prior authorizations: Page 12 of 331 Standard Fax Requests: (877) 693-8280 Urgent Fax Requests: (877) 693-8476 Hospital Discharge: (877) 693-8476 Urgent requests should be reserved for those situations in which applying the standard procedure may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function. The use of urgent fax lines for non-urgent requests is not appropriate. Please refer to Section 12 for prior authorization procedural requirements. Note: effective April 1, 2014, Passport’s Pharmacy Benefits Manager will change to Magellan. Additional provider communication will be given prior to this change. 1.5.8 Provider Claims Service Unit (800) 578-0775 Option 2 The Provider Claims Service Unit (PCSU) receives providers’ calls regarding any issue specific to claims. The PCSU is available Monday through Friday from 8:00 a.m. to 6:00 p.m. EST (7:00 a.m. to 5:00 p.m. CST). 1.5.9 Provider Network Management (502) 585-7943 Provider Relations Specialists are available Monday through Friday, 8:00 a.m. to 5:00 p.m. EST, (7:00 a.m. to 4:00 p.m. CST), to offer orientations and in-service meetings for providers and their staff. These representatives also provide service calls and process any changes in your provider status, such as addresses and telephone numbers. 1.5.10 Provider Services (800) 578-0775 Option 3 Provider Services representatives are available Monday through Friday, 8:00 a.m. to 6:00 p.m. EST (7:00 a.m. to 5:00 p.m. CST), to assist providers with questions about policies, procedures, member eligibility, and benefits. Representatives are also available if providers need to request forms or literature, report member noncompliance, or assist members in obtaining ancillary direct access services or other specialty care. 1.5.11 Utilization Management (800) 578-0636 The Utilization Management department is available 8:00 a.m. to 6:00 p.m. EST (7:00 a.m. to 5:00 p.m. CST), Monday through Friday. The Utilization Management department assists providers with medical necessity determinations and requests for prior authorizations. Authorization requests for certain services may be submitted online. We highly recommend that providers utilize this functionality as available. Additional detail is available in Section 6 of this manual. Requests for authorization of services may be received during these hours of operation by: General: (800) 578-0636 Home Health: (502) 585-7320 DME: (502) 585-7310 Page 13 of 331 Radiology: (877) 791-4099 Requests may be faxed to: General fax: Home Health: DME: Retro fax: Therapy fax: (502) 585-7989 (502) 585-8204 (502) 585-7990 (502) 585-8207 (502) 585-8205 1.6 Claim Submission New and corrected paper claims are to be submitted to the following address: Passport Health Plan P.O. Box 7114 London, KY 40742 Please refer to Section 18 for additional claims filing instructions. Claims and correspondence for reconsideration or recovery are to be submitted to the following address: Passport Health Plan P.O. Box 7114 London, KY 40742 An active valid Kentucky Medicaid identification number, assigned by DMS, is required to receive any payment for services rendered. Page 14 of 331 Provider Manual Section 2.0 Administrative Procedures Table of Contents 2.1 Medicaid Eligibility 2.2 Passport Health Plan Assignment 2.3 Choosing a Primary Care Provider (PCP) 2.4 Identification Cards 2.5 Member Release for Ethical Reasons 2.6 Health Education and Special Programs 2.7 Credentialing/Re-Credentialing Process 2.8 Provider Terminations/Changes in Provider Information 2.9 Provider Appeals and Grievances 2.10 Members’ Rights 2.11 Member Appeals and Grievances 2.12 Title VI Requirements: Translator and Interpreter Services Page 15 of 331 2.0 Administrative Procedures 2.1 Medicaid Eligibility Most individuals who meet the Department for Medicaid Services (DMS) eligibility criteria for Medicaid are assigned to an MCO in the region, and include individuals in the following categories: A. Temporary Assistance to Needy Families (TANF); B. Child and family related; C. Aged, blind, and disabled Medicaid only; D. Pass through; E. Poverty level pregnant women and children, including presumptive eligibility; F. Aged, blind and disabled receiving State supplementation; G. Aged, blind, and disabled receiving Supplemental Security Income (SSI); or H. Under the age of twenty-one (21) years and in an inpatient psychiatric facility. I. Foster Care ages 0 – 18 and Former Foster Care ages 19 – 26 J. ACA Expanded Population ages 19-64 K. Presumptive Eligibility - Pregnant DMS does not allow certain categories of Medicaid beneficiaries to participate in managed care. Beneficiaries in the following categories are not eligible for assignment to an MCO: A. Individuals who shall spend down to meet eligibility income criteria; B. Individuals currently Medicaid eligible and have been in a nursing facility for more than thirty (30) days*; C. Individuals determined eligible for Medicaid due to a nursing facility admission including those individuals eligible for institutionalized hospice; D. Individuals served under the Supports for Community Living, Michele P, home and community-based, or other 1915(c) Medicaid waivers; E. Qualified Medicare Beneficiaries (QMBs), Specified Low Income Medicare Beneficiaries (SLMBs) or Qualified Disabled Working Individuals (QDWIs); F. Timed limited coverage for illegal aliens for emergency medical conditions; G. Working Disabled Program; H. Individuals in an intermediate care facility for mentally retarded (ICF-MR); and I. Individuals who are eligible for the Breast or Cervical Cancer Treatment Program. * If you have any questions regarding eligibility criteria, contact Provider Services at (800) 578-0775. 2.2 Passport Health Plan Assignment The Department for Medicaid Services assigns eligible beneficiaries to Passport when the beneficiary selects Passport on their enrollment application or as part of an automatic assignment process developed by DMS. Page 16 of 331 Once assigned to Passport, a member receives a welcome kit from Passport, which includes a welcome letter, member identification card, a Health Risk Assessment (HRA), and a Member Handbook. 2.3 Choosing a Primary Care Provider (PCP) Making sure our members have a medical home is at the heart of Passport’s approach to managed care. The PCPs, in their role as the Medical Home, provide our members with primary and preventive care and arrange other medically necessary services for members. Therefore, Passport acts quickly to make sure members are linked to a medical home. Passport has a multifaceted PCP assignment process that meets all DMS requirements. The process is based on our current Medicaid experience and computer generated assignment of an accessible PCP. Our plan and process to assign our members a PCP will occur as follows: • • If known, DMS will send member’s selected PCP via the daily/monthly 834 files. Passport will validate the transaction and assign the PCP if appropriate (i.e. PCP meets all Passport criteria for assignment) ensuring the member’s satisfaction and smooth transition to Passport. If the member requires assignment, our process will be as follows: o Identify members who require a PCP including SSI adult members (the process recognizes the need for longer timeframes for adult SSI members) o Review for historical claims data for PCPs o Review for prior PCP assignments for member o Review for PCPs for other family members Final step, if no assignment can be made, based on the above criteria, PCP assignment will be based on the member’s address. At the time of assignment, Passport members will be informed of their assigned PCP in the New Member Welcome Kit and their confirmation letter. The member will also be notified at this time of his/her right to change his/her PCP if he/she is not satisfied with our assignment. The member will also receive an ID card with the practice name and phone number printed on the ID card. If the member is not required to have a PCP, he/she will receive an ID card with “No PCP required” printed on the card. The above processes will be adapted as necessary to effectively assign PCPs to beneficiaries eligible for coverage (and assigned to Passport) through the Medicaid ACA Expansion population. 2.3.1 Changing PCPs Members can change PCPs twice in a 12 month period, and PCP changes are effective on the day the change is requested. To change a PCP, members must call our Member Services department. Upon receiving an existing member’s request to change a PCP, our Member Services Page 17 of 331 Representatives (MSRs) will: • • • Assist the member in finding a new provider (if requested), using methodologies outlined above, Perform the requested change in our system, and Advise the member of the effective date of the new PCP assignment. The member will then receive a new ID card with the PCP practice name and phone number printed on the ID card. Exceptions to the change of provider rule will apply in cases of provider termination, provider office closing, provider panel limitations and member re-location. In the case of voluntary provider termination, we will notify the member no less than thirty (30) days prior to the effective date of voluntary provider termination. The member will be sent a letter explaining that his/her provider is leaving Passport’s network and the member will need to contact Member Services to select a new PCP or to receive assistance selecting a new PCP. If the provider notifies Passport of voluntary termination with less than thirty (30) days from the effective date of voluntary termination, we will notify affected members as soon as Passport receives notification. Fortunately, due to our long history of superior provider satisfaction, most voluntary terminations are the result of providers retiring or moving out of the service area, not the result of provider dissatisfaction with Passport’s administration. In the case of involuntary provider termination, where Passport has decided to remove a provider from its network, Passport will notify affected members at least fifteen (15) days prior to the effective date of involuntary termination. Affected members will be sent a letter advising them to contact Member Services to select a new PCP or to receive assistance finding a new PCP. In either of these cases, if the member does not contact us to select a new PCP, Passport will use the auto-assignment process to assign the member to a new PCP. The goal of Member Services is to always provide satisfactory resolution, but if a request for a change in PCP is denied and the member is dissatisfied, the member will be advised of their appeal rights. The member will receive a written notice of the decision made by Passport. Passport also reviews member activity related to PCP transfers on an ongoing basis and works in conjunction with Health Management, Quality Improvement, and the Provider Realtions Specialists to provide education and assist if any areas of improvement are identified. Each PCP receives a monthly member panel list of those members who have selected or been assigned to his or her panel. The monthly member panel list is not to be used as a confirmation of eligibility. To confirm eligibility, call Provider Services at 1-800-578-0775 option 3. 2.4 Identification Cards Passport issues identification cards for each family member enrolled. Members are advised to keep the ID card Page 18 of 331 with them at all times. ID cards contain the following information: • • • • • Member’s name and date of birth. PCP group name and telephone number (if applicable). Passport identification number. Kentucky Medicaid identification number. Gender. In addition to the Passport ID card, each member is issued a Medicaid ID card by the Department for Medicaid Services (DMS). The Medicaid ID card is NOT the same as the Passport ID card: The Kentucky Medicaid ID card represents eligibility for the Medicaid Program and is also used to obtain Medicaid covered services that are not covered through Passport, such as transportation. Members are requested to keep and present their Kentucky Medicaid ID card along with their Passport ID card. 2.4.1 Member Identification and Eligibility Verification Passport member eligibility varies by month. Therefore, each participating provider is responsible for verifying member eligibility with Passport before providing services. Providers may verify eligibility using any of the following methods: • Online – check member eligibility by logging into NaviNet at https://navinet.navimedix.com Page 19 of 331 • KyHealth Net System - Use the State’s website to verify eligibility for all five (5) managed care organizations (MCOs) – including Passport – in one central location. Using your Medicaid ID (MAID) number, you may log directly onto this system at https://sso.kymmis.com, or find more information at www.chfs.ky.gov/dms/kyhealth.htm. • Telephone – you may also check member eligibility by calling our interactive voice response (IVR) system at (800) 578-0775. • Utilizing Passport’s real-time member eligibility service. Depending on your clearinghouse or practice management system, our real-time service supports batch access to eligibility verification and system-to-system eligibility verification, including point of service (POS) devices. • Asking to see the member’s Passport ID card and Kentucky Medicaid ID card. Please note that Passport cards are not returned to Passport when a member becomes ineligible. Therefore, the presentation of a Passport ID card is not sole proof that a person is currently enrolled in Passport. Providers should request a picture ID to verify that the person presenting is indeed the person named on the ID card. Services may be refused if the provider suspects the presenting person is not the card owner and no other ID can be provided. If you suspect a non-eligible person is using a member’s ID card, please report the occurrence to Passport’s Fraud and Abuse Hotline at (855)5128500 or the Medicaid Fraud Hotline at (800) 372-2970. 2.5 Member Release for Ethical Reasons A participating provider is not required to perform any treatment or procedure that may be contrary to the provider’s conscience, religious beliefs, or ethical principles. If such a situation arises, the provider should contact Provider Services at (800) 578-0775. A Provider Services representative will work with the provider to review the member’s needs and transfer or refer the member to another appropriately qualified provider for care. 2.6 Health Education and Special Programs Passport may refer members to health education classes provided by health agencies and providers or to Passport-provided programs. Providers who identify members who could benefit from education for a specific condition, such as pregnancy, asthma, congestive heart failure or diabetes, for example, may call (877) 903-0082 for class information and schedules. Members also have access to health topics through an audio health library. Pre-recorded messages on topics provide information on preventing illness, identifying warning signs and administering self-care. A member may call the 24Hour Nurse Advice Line to access the audio health library (see Section 2.6.3). 2.6.1 Language Assistance for Members Federal law requires providers to ensure that communications are effective. Providers who render health services, medical services, or social service programs to Passport members benefit from a program that receives federal financial assistance and are, therefore, subject Page 20 of 331 to the requirements of Title VI of the Civil Rights Act of 1964. This act prohibits recipients of benefits from a program receiving federal financial assistance, such as Medicaid, from being prohibited from or refused service on the grounds of race, color, or national origin. The term “on the grounds of national origin” has been interpreted to include persons with limited-English proficiency (LEP). Title VI requires every Medicaid provider, including Passport providers, to offer members equal access to benefits and services by ensuring that each LEP (limited English proficiency) person can communicate effectively in his or her language of choice. This law also requires providers to take necessary steps to provide language assistance at no cost to Medicaid members, including those enrolled with Passport. Providers may contact Passport’s Cultural & Linguistics Services Program at (502) 585-7303 for additional information and/or questions. 2.6.2 Help for Those with Impaired Vision or Hearing The Member Handbook is available in alternative formats for members with visual impairments. Additionally, for members with hearing impairments who use a Telecommunications Device for the Deaf, Passport’s TDD/TTY number for Member Services is (800) 691-5566. 2.6.3 24-Hour Nurse Advice Line and Audio Health Library PCPs can encourage their patients to talk with a nurse 24 hours a day, 7 days a week by calling the 24-Hour Nurse Advice Line at (800) 606-9880. Passport wants to make certain that you are aware that through the same number, Passport members may access an audio health library of over 35 categories of health care topics, including: • • • • • • • • • • • • • • • • • Allergies and Immune System Blood and Cancer Bones, Muscles, and Joints Brain and Nervous System Cancer Heart and Blood Vessels Children Mouth and Teeth Diabetes Diet and Exercise Digestive System Ear, Nose, and Throat Eyes General Health Hormones Infectious Disease Injuries • • • • • • • • • • • • • • • • Medicines Mental and Behavioral Health Men’s’ Health Pain Management Physical and Sports Medicine Pregnancy Preventive Health Respiratory and Lung Problems. Sexual and Reproductive Health Skin Sleep Disorders Social and Family Surgery Tests and Diagnostic Procedures Urinary Problems Women’s Health Page 21 of 331 Members with limited English proficiency (LEP) can also access the 24-Hour Nurse Advice Line. Additionally, for members with hearing impairments who use a Telecommunications Device for the Deaf, the TDD/TTY number for the Nurse Advice Line is (800) 648-6056. NOTE: The 24-Hour Nurse Advice Line is not meant to take the place of the PCP and may not be used for after-hour coverage. However, it is an effective communication mechanism for dissemination of disease specific educational information as well as an alternative method for receiving information on self-care techniques in clinically appropriate circumstances. 2.7 Credentialing/Re-Credentialing 2.7.1 Initial Application Process To join the Passport network an application and credentialing process must be take place. This can be initiated by calling our Provider Services department at (800) 578-0775. We will send you a provider application packet and work with you to become credentialed and, if approved, contracted as a Passport network provider. Providers can also fill out a Provider Enrollment Request form online at http://www.passporthealthplan.com/providerEnrollment.aspx. Passport participates with the Council for Affordable Quality Healthcare (CAQH). Providers who are participating with this common credentialing application database should include their CAQH provider ID number with documents submitted to Passport. 2.7.1.1 Practitioners New practitioner applicants are required to complete their residency program and be eligible to obtain board certification prior to joining Passport. A practitioner is considered hospital based if they practice exclusively in a facility setting. These practitioners undergo a condensed review as it is the responsibility of the facility to verify their full credentials. New practitioners must include the following as applicable: • • A letter adding practitioner to each group. Completed Provider Application either a CAQH (Council for Affordable Quality Healthcare) universal credentialing application or the most current version of KAPER1 (Kentucky DMS application), including: o Additional copies of pages from the application (as needed); o Disclosure questions, as applicable, including but not limited to: Documentation of any malpractice suits or complaints. Documentation of any restrictions placed on practitioner by hospital, medical review board, licensing board, or other medical body or governing agency. Documentation of any conviction of a criminal offense within the last 10 years (excluding traffic violations); and, The attestation page (including the practitioner signature and current date). Page 22 of 331 • • • • • • • • • • • • • • Original, complete, and signed MAP Forms per the Kentucky DMS provider enrollment web page, http://chfs.ky.gov/dms/provEnr/Provider+Type+Summaries.htm. Copy of current State License Registration Certificate. Copy of current Federal Drug Enforcement Agency Registration. Copy of CLIA. Copy of collaborative agreement between an Advance Practice Registered Nurse and supervising practitioner. Copy of MAP 612 Statement of Authorization for Payment signed by both the physician assistant and supervising practitioner. Curriculum vitae or a summary specifying month and year, explaining any lapse in time exceeding six months. Copy of a W-9 with the legal and doing business name of the entity, Tax Identification Number, and mailing address for all 1099 tax information signed by an authorized agent for the entity. Copy of claim history form for each malpractice activity within the past five years. Copy of current professional liability insurance Certificate of Coverage, including the name and address of the agent and the minimum amount, in accordance with existing Kentucky laws at the time of the application submission. A copy of Medicare Certificate (a letter from the Centers for Medicare & Medicaid Services (CMS) with your unique Medicare provider identification number and practice location). Copy of social security card (If applicant has as social security card stating “valid for work only with DHS/INS Authorization,” please refer to additional requirements at http://www.chfs.ky.gov/dms/provEnr/). ECFMG (Education Council for Medical Graduates). FOX verification documentation for National Provider Identifier (NPI) and Taxonomy Code(s). 2.7.1.2 Organizational Provider New applicants must submit a completed application, which includes the following as applicable: • • • • • • • • Two signed Participating Provider Agreements. Completed facility/ancillary service application including the credentials verification release statement. Original, complete, and signed MAP Forms per the Kentucky Department for Medicaid Services provider enrollment web page, http://chfs.ky.gov/dms/provEnr/Provider+Type+Summaries.htm. Copy of current State License Registration Certificate. Hearing aid dealer current license for specializing in hearing instruments. Copy of CLIA, if applicable. Copy of a W-9 in the name of the facility/group, including the Tax Identification Number and mailing address for all tax information. Copy of current professional liability insurance Certificate of Coverage, including the name and address of the agent and the minimum amount, in accordance with existing Kentucky laws at the time of the application submission. Page 23 of 331 • • • • • • • • • • • A copy of Medicare Certificate (a letter from the Centers for Medicare & Medicaid Services (CMS) with your unique Medicare provider identification number and practice location), as applicable. Copy of current facility accreditation or certification. Model Attestation Letter for Psychiatric Residential Treatment Facilities (PRTF). DME Accreditation Certificate- exempt organizations need to submit a signed statement attesting to the exemption and documentation from CMS outlining the exemption. HME license issued by the KY Board of Pharmacy (per HB 282 and 201 KAR 2:350) (As of September 30, 2012) - exempt providers need to submit a signed statement attesting to the exemption. Medicare certification letter less than three years old with effective date of certification and physical location of where DME number is to be used. Medicare requires DME providers to re-enroll every 3 years. Independent labs must have a laboratory director, who must satisfy requirements set forth in 907 KAR 1:028 Section 1(8) and KRS 333.090 (1), (2), or (3) and supply documentation thereof. If not accredited or certified, a copy of the most recent CMS or state review. A copy of the mechanism that the organizational provider uses to monitor and improve patient safety. A copy of the transfer policy. FOX verification documentation for National Provider Identifier (NPI) and Taxonomy Code(s). Failure to submit a complete application may result in a delay in Passport’s ability to start the initial credentialing process. Practitioners may contact the Provider Enrollment department at (502) 588-8578 to check the status of their application. 2.7.2 Credentialing Process Passport assesses practitioner applicants through Passport’s credentialing process. With the receipt of all application materials, primary source verification is conducted by Passport's Provider Enrollment department. Following the verification of credentials, Passport’s Chief Medical Officer/designated Medical Director and/or Credentialing Committee reviews each application for participation. Passport will not initiate the credentialing review until a completed and signed application with attachments has been received. The normal processing time is between 60 to 90 days from date of submission of a completed application. 2.7.3 Reimbursement and the Credentialing Process Providers seeking participation in the Passport network and in the credentialing process will be reimbursed at the participating provider rate, starting from the date Passport receives a completed and signed application packet and confirmation that the provider has been issued a Kentucky MAID Page 24 of 331 number. If the Credentialing Committee denies participation, any claims paid during the interim will be recouped, and unpaid claims will be denied. Providers may begin submitting claims for services provided to Passport members once they have been notified of the receipt of their completed application and have been assigned a Provider ID number. Providers are required to submit all claims within 180 days of service, but no payment is made until Passport receives confirmation that the provider has been issued a Kentucky MAID number. Please note, claims submitted without a Kentucky Medicaid Identification (MAID) number will initially deny. Providers will receive notification from DMS when a MAID number is assigned. Providers are encouraged to notify Passport of receipt of a MAID number assignment. After Passport receives notification of a provider MAID number assignment, all claims received from the provider will be automatically reprocessed, starting from the date Passport received a completed and signed provider application. Providers will be considered participating Passport providers once they have met Passport’s credentialing requirements. Providers will be notified by Passport when they have been successfully credentialed by Passport. Providers applying for participation are excluded from the Provider Directory until the credentialing process has been completed in its entirety. 2.7.4 Providing Services Prior to Becoming a Credentialed Passport Provider If a provider determines a member must be seen prior to the assignment of a Provider ID number and notification of the receipt of a completed and signed application by Passport, the provider must obtain an authorization from Passport’s Utilization Management department in order to receive payment for services. Please note that an authorization for service does not guarantee payment. 2.7.5 Re-credentialing Process Passport re-credentials its providers, at a minimum, every three years. In addition, Passport conducts ongoing monitoring of Medicare and Medicaid sanctions as well as licensure sanctions or limitations. Practitioners who become participating and subsequently have restrictions placed upon their license will be reviewed by the Credentialing Committee and evaluated on a case-by-case basis, based upon their ability to continue serving Passport’s members. Member complaints and adverse member outcomes are also monitored and Passport will implement actions as necessary to improve trends or address individual incidents. If efforts to improve practitioner performance are not successful, the practitioner may be referred to the Credentialing Committee for review prior to his/her normally scheduled review date. 2.7.5.1 Practitioners Passport will generate a re-credentialing application on all practitioners with current CAQH applications on file. Practitioners without a CAQH on file will be notified by telephone or letter to Page 25 of 331 submit a re-credentialing application (most current version of the KAPER 1 or CAQH) with the following list of attachments: • Disclosure questions, as applicable, including but not limited to: o Documentation of any malpractice suits or complaints. o Documentation of any restrictions placed on practitioner by hospital, medical review board, licensing board, or other medical body or governing agency. o Documentation of any conviction of a criminal offense within the last 10 years (excluding traffic violations).; and, • The attestation page (including the practitioner signature and current date). • Copy of current State License Registration Certificate. • Copy of current Federal Drug Enforcement Agency Registration - if applicable. • Copy of current collaborative agreement between an Advance Practice Registered Nurse and supervising practitioner, as applicable. • Copy of MAP 612 Statement of Authorization for Payment signed by both the physician assistant and supervising practitioner, as applicable. • Copy of current professional liability insurance Certificate of Coverage, including the name and address of the agent and the minimum amount, in accordance with existing Kentucky laws at the time of the application submission. 2.7.5.2 Organizational Provider Passport sends a facility/ancillary service application to the organizational provider for completion. The re-credentialing application must include the following as applicable: • Completed facility/ancillary service application including the credentials verification release statement. • Copy of current State License Registration Certificate. • Copy of CLIA, if applicable. • Copy of a W-9 in the name of the facility/group, including the Tax Identification Number and mailing address for all tax information. • Copy of current professional liability insurance Certificate of Coverage, including the name and address of the agent and the minimum amount, in accordance with existing Kentucky laws at the time of the application submission. • Copy of claim history form for each malpractice activity within the past five years. • A copy of Medicare Certificate (a letter from the Centers for Medicare & Medicaid Services (CMS) with your unique Medicare provider identification number and practice location), as applicable. • Copy of current facility accreditation or certification. • If not accredited or certified a copy of the most recent CMS or state review. • A copy of the mechanism that the organizational provider uses to monitor and improve patient safety. • A copy of the transfer policy. Failure to return documents in a timely fashion may result in termination. If the termination period is longer than 30 days, the initial credentialing process would need to be completed in order to rePage 26 of 331 enroll as a participating provider. Practitioners or providers may contact the Provider Enrollment department at (502) 585-8578 to check the status of their re-credentialing application. Should Passport decide to deny or terminate a provider from participation with Passport, the provider will receive notification of the decision. The notification will include the reasons for the denial or termination, the provider’s rights to appeal and request a hearing within 30 days of the date of the denial notice, and a summary of the provider’s hearing rights. 2.8 Provider Terminations/Changes in Provider Information 2.8.1 Provider Terminations A provider desiring to terminate his/her participation with Passport must submit a written termination notice, to his/her assigned Provider Relations Specialist, at least ninety (90) days prior to the desired effective date of the termination. For terminations by primary care providers, the assigned Provider Relations Specialist will coordinate member notification and assignment to another PCP based on the PCP’s member panel. If a solo specialist or an entire specialty group decides to terminate the contract, a list of members receiving ongoing health care from the specialist and/or group must be sent to Passport within 60 days of the termination date for member notification to occur. The specialist’s Provider Relations Specialist will work with the specialist to ensure a smooth transition for the member’s continued care. 2.8.2 Changes in Provider and Demographic Information Providers are required to provide a 90-day prior written notice to both Passport’s Provider Network Management department and the Department for Medicaid Services of any changes in information regarding their practice. Such changes include: • Address changes, including changes for satellite offices. • Additions/deletions to a group. • Changes in billing locations, telephone numbers, tax ID numbers. Reimbursement may be affected if changes are not reported in accordance with Passport policy. Please note that providers are required by DMS to annually submit a copy of current license and annual disclosure of ownership. If these documents are not provided, the provider’s Kentucky Medicaid (MAID) number may be terminated. Your office will receive notice from the DMS when these documents are due for submission. Please respond timely to these requests. Page 27 of 331 2.8.3 Change in Location If a provider working in multiple offices discontinues working in one or more locations, written notification must be provided to Passport within 30 days detailing the locations where he/she will no longer see patients, as well as the specific offices where he/she will continue to see patients. 2.8.4 Panel Closings Passport recognizes that PCPs may occasionally need to limit the number of patients in their practices in order to deliver quality care. Passport will evaluate any requirements for minimal members per practitioner panel. (For additional information regarding member to practitioner ratios, see Section 4.3.) Once a PCP has accepted the number of Passport members agreed upon in the Primary Care Provider Agreement, a written request must be forwarded to Passport to impose panel restrictions. Please send your request to your Provider Relations Specialist at 5100 Commerce Crossings Drive, Louisville, KY 40229. Passport requests a 90-day advance written notice to change panel status. 2.8.5 Panel Limitations Panel limitations and/or removal of panel restrictions must be submitted in writing to the Provider Relations Specialist. Providers are notified by their Provider Relations Specialist of the approval or denial of the request. Approved panel limitations and/or removal of restrictions become effective the first of the following month after a request is approved by Passport. 2.8.6 Member Dismissals from PCP Practices Primary care providers (PCP) have the right to request a member's disenrollment from their practice and request the member be reassigned to a new PCP for the following circumstances: • Incompatibility of the PCP/patient relationship; • Inability to meet the medical needs of the member. PCPs do not have the right to request a member’s disenrollment from their practice in the following situations: • • • • A change in the member’s health status or need for treatment. The member’s utilization of medical services. A member’s diminished mental capacity. A member’s disruptive behavior that results from the member’s special health care needs unless the behavior impairs the PCP’s ability to provide services to the member or others. Disenrollment requests shall not be based on the grounds of race, color, national origin, handicap, age or gender. Page 28 of 331 Disenrollment requests must be submitted to Passport and sent via fax to Provider Enrollment at (215) 937-5304. Requests must include provider name, provider group ID number, member name, member ID number, reason for disenrollment request, and effective date. Members are not disenrolled from the PCP’s practice until all required information is received. Questions regarding this process may be directed to Provider Services at 1-800-578-0775 or contact your Provider Network Management Specialist. Disenrollment requests meeting Passport’s requirements as stated above are reviewed, determined to be appropriate, and processed within five business days of receipt by Provider Services. The disenrollment effective date must be at least 30 days from the request date to allow for the member’s transition to a new PCP unless extenuating circumstances necessitate an immediate effective date. The initial PCP must continue to serve the member until the new PCP assignment becomes effective, barring ethical or legal issues. The member has the right to appeal such a transfer via Passport’s formal appeal process. If a PCP's request does not meet the above stated requirements, the appropriate Provider Relations Specialist will contact the PCP directly to discuss. Please note this process does not apply to "age-out" disenrollment for pediatric practices. 2.8.7 Locum Tenens According to Passport policy, participating providers may utilize the services of a locum tenens provider, under temporary circumstances, for a maximum period of sixty (60) consecutive days. When locum tenens services are needed, participating providers must register the substitute provider. This process must be completed prior to the provision of any services by a locum tenens provider. To register a locum tenens provider, the participating Passport provider must complete a one-page Registration of Locum Tenens Physician form (available in Section 20 of this Provider Manual). Both the participating Passport provider and the locum tenens provider must sign the form. To complete the registration process, the signed form must be returned to Passport by mail or by fax to: Mail: Passport Health Plan Attn: Provider Enrollment 5100 Commerce Crossings Drive Louisville, Kentucky 40229 Fax: Attn: Provider Enrollment (502) 585-8280 Services rendered by a locum tenens provider must be billed utilizing the absent provider’s Passport Health Plan ID number and the Q6 modifier with the applicable procedure code(s). The Q6 modifier signifies that the service was provided by a locum tenens provider. According to the Passport Provider Agreement, the absent provider remains liable and all contractual terms remain effective throughout the employ of a locum tenens provider. Page 29 of 331 If services by a locum tenens provider remain necessary beyond the period of sixty (60) consecutive days, the locum tenens or substitute provider must apply for participation with Passport and complete the credentialing process and have or apply for a Kentucky Medicaid number. Upon becoming credentialed with Passport, the provider will be assigned a provider ID number for billing purposes. 2.9 Provider Appeals and Grievances 2.9.1 What is Appealable? Passport providers have the right to file an appeal regarding: • • A provider payment issue; or A contractual issue. 2.9.2 How do Provider’s File an Appeal? 2.9.2.1 Method of Appeal All provider appeals must be submitted in writing. Submit Provider Appeals to: Type of Appeal Timing of Appeal Address Behavioral Health Must be submitted within sixty (60) calendar days of the adverse action. Beacon Health Strategies Appeals Coordinator 500 Unicorn Park Drive Suite 401 Woburn, MA 01801 (855) 834-5651 TDD/TTY (866)834-9441 Claims Payment Issues Must be submitted within two (2) years of last process date of claim. Passport Health Plan Claim Appeals PO Box 7114 London, KY 40742 Contractual Issues Must be submitted within sixty (60) calendar days of the occurrence of the contractual issue being appealed. Passport Health Plan Legal Services / Contractual Appeals 5100 Commerce Crossings Drive Louisville, Kentucky 40299 Dental Must be submitted within thirty (30) calendar days of adverse action. Avesis Attn: Appeals Department PO Box 7777 Page 30 of 331 Type of Appeal Timing of Appeal Address Phoenix, AZ 85011-7777 (866) 909-1083 Medical, Administrative and Pharmacy Denials (An Administrative Denial is a denial issued for untimely notification of a request for a clinical service) Radiology Must be submitted within sixty (60) calendar days of the adverse action. Passport Health Plan Appeals Coordinator 5100 Commerce Crossings Drive Louisville, KY 40229 (502) 585-7307 Fax (502) 585-8461 Must be submitted within sixty (60) calendar days of the adverse action. MedSolutions Appeals Department 730 Cool Springs Blvd., Suite 800 Franklin, TN 37067 1-877-791-4099 Vision Must be submitted within thirty (30) calendar days of adverse action. Block Vision 939 Elkridge Landing Road, Suite 200 Linthicum, MD 21090 Attn: Provider Appeals 800-879-6901 2.9.2.2 Conduct of the Review A board-certified physician, who was not involved in the initial denial, will conduct the clinical review. The provider can also request that the reviewing physician have clinical expertise in treating the member’s condition or disease. Providers may submit documents in support of the appeal. 2.9.2.3 Resolution of the Appeal All provider appeals are resolved within thirty (30) calendar days of receipt of the appeal unless the time period is extended by fourteen (14) calendar days upon request of the provider or pursuant to our request. Providers will receive a written notice of the resolution of the appeal. 2.9.3 Provider Grievances A grievance is defined by federal and state law as an expression of dissatisfaction about any matter other than an adverse action. Passport providers have the right to file a grievance of any Passport decision that does not involve an adverse action. Page 31 of 331 2.9.3.1 How do Providers File a Grievance Timing: Providers have thirty (30) calendar days from the date of an event causing dissatisfaction to file a grievance. Method of Filing a Grievance: Provider grievances may be submitted orally or in writing. Submit Provider Grievances to: Type of Grievance Dental Address Avesis Attn: Appeals Department PO Box 7777 Phoenix, AZ 85011-7777 (866) 909-1083 Radiology MedSolutions Appeals Department 730 Cool Springs Blvd., Suite 800 Franklin, TN 37067 1-877-791-4099 Vision Block Vision 939 Elkridge Landing Road, Suite 200 Linthicum, MD 21090 800-879-6901 Pharmacy PerformRx Pharmacy Network Administration 200 Stevens Drive, 4th Floor Philadelphia, PA 19113 800-555-5690 All Other Provider Grievances Passport Health Plan 5100 Commerce Crossings Drive Louisville, KY 40229 (800) 578-0775 2.9.3.2 Resolution of the Grievance All provider grievances are resolved within thirty (30) calendar days of receipt of the grievance Page 32 of 331 unless the time period is extended by fourteen (14) calendar days upon request of the provider or pursuant to our request. For any extension not requested by the Provider, Passport will mail the Provider written notice of the reason for the extension within two (2) business days of the decision to extend the timeframe. Providers will receive a written notice of the resolution of the grievance. 2.10 Members’ Rights Members are informed of their rights and responsibilities through the Member Handbook. Passport providers are also expected to respect and honor members’ rights. The rights of our Members include, without limitation, the right to: A. Respect, dignity, privacy, confidentiality and nondiscrimination; B. A reasonable opportunity to choose a PCP and to change to another Provider in a reasonable manner; C. Consent for or refusal of treatment and active participation in decision choices; D. Ask questions and receive complete information relating to the Member's medical condition and treatment options, including specialty care; E. File a grievance or an appeal and to receive assistance in filing a grievance or appeal; F. Request a state fair hearing from the Department; G. Timely access to care that does not have any communication or physical access barriers; H. Prepare Advance Medical Directives pursuant to KRS 311.621 to KRS 311.643; I. Access to the Member’s Medical Records in accordance with applicable federal and state laws; J. Timely referral and access to medically indicated specialty care; and K. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The responsibilities of Passport Members include the responsibility to: A. B. C. D. E. F. Become informed about Member rights; Abide by the Contractor's and Department's policies and procedures; Become informed about service and treatment options; Actively participate in personal health and care decisions, practice healthy lifestyles; Report suspected Fraud and Abuse; and Keep appointments or call to cancel. 2.11 Member Appeals and Grievances 2.11.1 What is Appealable Members have the right to appeal any Passport decision involving an adverse action. An adverse action is defined by federal and state law. Page 33 of 331 An Adverse Action is: • • • • • • The denial or limited authorization of a requested service, including the type or level of service; The reduction, suspension, or termination of a previously authorized service; The denial, in whole or in part, of payment for a service; The failure to provide services in a timely manner; The failure to act within specified timeframes; or, The denial of a request to obtain services outside the network for specific reasons. No Retaliation for Filing an Appeal At no time will punitive or retaliatory action be taken against a Member for filing an appeal or a provider for supporting a Member appeal. 2.11.2 How do Members File an Appeal Timing Members have thirty (30) calendar days from the date of receiving a notice of adverse action, to file an appeal. Method of Appeal Member appeals can be either oral or in writing. An oral appeal must be followed by a written appeal, signed by the member and received by us within ten (10) calendar days of the member’s oral appeal. Authorized Representatives of Members May File an Appeal: An authorized representative may file an appeal on behalf of the member. An authorized representative is a legal guardian of the member for a minor or an incapacitated adult, or a representative of the member as designated in writing by the member to Passport. The personal representative of a deceased member may file an appeal on behalf of the member. A provider may be an authorized representative for a member only with the member’s written consent. The written consent must include a statement that the member is giving the provider the right to appeal and must also include a specific statement of the adverse action that is being appealed. A single written consent shall not qualify as a written consent for more than one: a. Hospital admission; b. Physician or other provider visit; or c. Treatment plan. Help for Members with filing an Appeal: Passport members may call Passport Member Services at (800) 578-0603 for help filing an appeal. Page 34 of 331 LEP persons will be given interpretation/translation assistance when necessary to navigate the appeals process. Submit Member Appeals to: Type of Appeal Address To Expedite a Member Appeal Behavioral Health Beacon Health Strategies Appeals Coordinator 500 Unicorn Park Drive Suite 401 Woburn, MA 01801 (855) 834-5651 TDD/TTY (866) 834-9441 Denial, in whole or in part, of payment for a service Passport Health Plan Claim Appeals PO Box 7114 London, KY 40742 Dental Avesis Attn: Appeals Department PO Box 7777 Phoenix, AZ 85011-7777 (866) 909-1083 Medical, Pharmacy, or Administrative Appeals (An Administrative Denial is a denial issued for untimely notification of a request for a clinical service) Passport Health Plan Appeals Coordinator 5100 Commerce Crossings Drive Louisville, KY 40229 (502) 585-7307, or 800-578-0603, option 0, Extension 7307 N/A (502) 585-7307 Fax (502) 585-8461 Radiology MedSolutions Appeals Department 730 Cool Springs Blvd., Suite 800 Franklin, TN 37067 1-877-791-4099 Appeals Department 1-877-791-4099 Vision Block Vision 939 Elkridge Landing Road, Suite 200 Linthicum, MD 21090 Attn: Member Appeals 800-879-6901 Page 35 of 331 800-879-6901 Acknowledgement of Receipt of the Appeal: Within five (5) working days of receiving an appeal, we will send the member a written notice that the appeal has been received and the expected date of resolution. Continuance of Services during an Appeal: A member’s services will continue during the appeal, if the member requested a continuation of benefits, until one (1) of the following occurs: 1. The member withdraws the appeal; 2. Fourteen (14) days have passed since the date of the resolution letter, if the resolution of the appeal was against the member and the member has not requested a state hearing or taken any further action; or, 3. A state hearing decision adverse to the member has been issued. Expedited Appeals An expedited review process is available for a member when the standard resolution time frame could seriously jeopardize the member’s life; health; or ability to attain, maintain, or regain maximum function. Expedited appeals are resolved within three (3) working days of receipt of the request. The three (3) working days timeframe will be extended for up to fourteen days if the Member requests the extension or we demonstrate to the Department that there is need for additional information and the extension is in the Member’s interest. If we request the extension, we will give the Member written notice of the reason for the extension. If we deny a request for a Member request for an expedited appeal, the appeal will be resolved within thirty (30) calendar days of receipt of the original request for appeal. We will give the Member prompt oral notice of the decision to deny expedition of the appeal. We will follow up with a written notice within two (2) calendar days of the denial. Conduct of the Review The review will be conducted by an individual who was not involved in the initial decision. Appeals involving denials for lack of medical necessity, the denial of expedited resolution of the appeal or clinical issues will be conducted by health care professionals who have the appropriate clinical expertise concerning the condition or disease under appeal. Members shall be given a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. Members will have the opportunity before and during the appeal to examine the Member’s file, including any medical records, and any other documents and records considered during the appeals process. Resolution of the Appeal All member appeals are resolved within thirty (30) calendar days of receipt of the appeal, unless the time period is extended by fourteen (14) calendar days upon request of the member or a request Page 36 of 331 made by us. If we request the extension, we will provide the Member with written notice of the extension and the reason for the extension within two (2) working days of the decision to extend. Members will receive a written notice of the resolution of the appeal. The notice will include the right to request a State Fair Hearing. Member Requests for a State Hearing If a member is not satisfied with the appeal resolution, the member has the right to request a State Fair Hearing. Requests for a State Fair Hearing must be made in writing postmarked or filed with the Kentucky Department for Medicaid Services, within forty-five (45) days of the notice of the appeal decision. Requests for a State Hearing should be forwarded to: Kentucky Department for Medicaid Services Division of Administration and Financial Management 275 East Main St., 6W-C Frankfort, KY 40601 (800) 635-2570 TDD/TTY (800) 775-0296 Kentucky Ombudsman Members may also contact the Kentucky Ombudsman at any time at the following address: Cabinet for Health and Human Services Office of Ombudsman 275 East Main St., 1E-B Frankfort, KY 40601 (800) 372-2973 TDD/TTY (800) 627-4702 What is a Grievance? A grievance is defined by federal and state law as an expression of dissatisfaction about any matter other than an adverse action. Passport members have the right to file a grievance concerning any Passport decision that does not involve an adverse action. No Retaliation for Filing a Grievance At no time will punitive or retaliatory action be taken against a Member for filing a grievance or a provider for supporting a Member grievance. How do Member’s file a Grievance? Page 37 of 331 Timing: Members have thirty (30) calendar days from the date of an event causing dissatisfaction to file a grievance. Method of Filing of Grievance: Grievances can be submitted either orally or in writing. Submit Member Grievances to: Passport Health Plan 5100 Commerce Crossing Drive Louisville, KY 40229 (800) 578-0603 Help for Members with filing a Grievance: Members may call Passport Member Services at (800) 578-0603 for help filing a grievance. LEP persons will be given interpretation/translation assistance when necessary to navigate the grievance process. Acknowledgement of Receipt of the Grievance: Within five (5) working days of receipt of a grievance, we will provide the member with a written notice that the grievance has been received and the expected date of resolution. Conduct of the Review The grievance review will be conducted by an individual who was not involved in the initial decision. Resolution of the Grievance All Member grievances are resolved within thirty (30) calendar days of the date the grievance was received. Members will receive a resolution letter that includes the information considered in investigating the grievance, findings and conclusions based on the investigation and the disposition of the grievance. Resolution may be extended by up to fourteen (14) calendar days if the Member requests the extension, or if we determine there is a need for additional information and the extension is in the Member’s interest. For any extension not requested by the Member, Passport will mail the Member written notice of the reason for the extension within two (2) business days of the decision to extend the timeframe. 2.12 Title VI Requirements: Translator and Interpreter Services Title VI of the Civil Rights Act of 1964 is a Federal law that requires any organization receiving direct or indirect Federal financial assistance to provide services to all beneficiaries without exclusion based Page 38 of 331 on race, color, or national origin. All Passport providers indirectly benefit from Federal financial assistance (via Medicaid). Therefore, under Title VI and the Culturally and Linguistically Appropriate Services (CLAS) Standards 4 - 7, as outlined by the Office of Minority Health, U.S. Department of Health and Human Services (DHHS), all Passport providers are required by law to: • Provide written and oral language assistance at no cost to any patient, including, but not limited to, Passport members with limited-English proficiency or other special communication needs, at all points of contact and during all hours of operation. Language access includes the provision of competent language interpreters. Note: The assistance of friends, family, and bilingual staff is not considered competent, quality interpretation. These persons should not be used for interpretation services except where a member has been made aware of his/her right to receive free interpretation in their preferred language and continues to insist on using a friend, family member, or bilingual staff for assistance in his/her preferred language. • Provide patients, including Passport members, verbal or written notice (in their preferred language or format) about their right to receive free language assistance services. • Post and offer easy-to-read member signage and materials in the languages of the common cultural groups in your service area. Vital documents, such as patient information forms and treatment consent forms, must be made available in the preferred language or format of patients, including Passport members. Additionally, under the CLAS Standards, Passport providers are strongly encouraged to: • Provide effective, understandable, and respectful care to all patients, including Passport members, in a manner compatible with his/her cultural health beliefs and practices of preferred language/format. • Implement strategies to recruit, retain, and promote a diverse office staff and organizational leadership representative of the demographics in your service area. • Educate and train staff at all levels, across all disciplines, in the delivery of culturally and linguistically appropriate services. • Establish written policies to provide interpretive services for patients, including Passport members. • Routinely document each patient’s preferred language or format, such as Braille, audio, or large type, in all medical records. Potential penalties of non-compliance with Title VI may include: Loss of federal and state funding, including future funding (i.e. providers may be prohibited from participating in Medicaid, Medicare, and/or incentive programs such as the Electronic Health Records incentive). • Legal action against providers from the DHHS, legal service organizations, and private individuals. • Page 39 of 331 • • "Informed consent" issues which may also lead to medical malpractice charges. Change in participation status with Passport. Providers may contact Passport’s Cultural and Linguistics Services Program Coordinator at (502) 585-8251 or e-mail cals@passporthealthplan.com for additional information or to schedule an on-site training. 2.12.1 Title VI Training/Resources Passport’s Cultural and Linguistics Services (CLSP) Program offers the following training materials and resources. Contact the CLSP Coordinator at (502) 585-8251-, e-mail cals@passporthealthplan.com, or visit our web site, www.passporthealthplan.com/provider/services/cals, for more details. • Onsite Trainings/Resources Our CLSP staff is a resource for Title VI/CLAS Standards, Cultural Diversity and assists providers in reaching and maintaining compliance. We offer free on-site trainings for office staff, an informative Provider Toolkit, and web-based information and resources. • Provider Office Materials In addition to the Provider Toolkit and other educational resources, Passport also offers provider office signage to assist office staff in complying with Title VI. These materials are available online or by calling the CLSP coordinator. • Translated Member Materials and TDD/TYY Lines Many member materials, including the Passport Member Handbook , are available in other languages and alternative formats such as Braille, audio, and large type. Members may call Member Services for copies. Additionally, for members with hearing impairments who use a Telecommunications Device for the Deaf (TDD), Passport’s TDD/TYY number for Member Services is: Passport - (800) 691-5566 • Discounts for Telephonic and Video Interpretation Passport also contracts with a telephonic and video interpretation vendor, InterpreTalk by Language Services Associates (LSA), to offer our providers a discounted rate. To set up an account and receive InterpreTalk services, please call (800) 305-9673 and ask for Client Services. It may take 48 to 72 hours to set up an InterpreTalk account to begin receiving interpretive services. Page 40 of 331 Provider Manual Section 3.0 Provider Roles and Responsibilities Table of Contents 3.1 Confidentiality 3.2 The Role of the Primary Care Provider (PCP) 3.3 The Role of Specialists and Consulting Practitioners 3.4 Responsibilities of All Providers Page 41 of 331 3.0 Provider Roles and Responsibilities 3.1 Confidentiality In accordance with federal and state laws, Passport Health Plan has established confidentiality policies and practices for its own operation and to outline expectations to our provider network. To obtain a copy of Passport Health Plan’s Notice of Privacy Practices (NPP), please visit www.passporthealthplan.com/membercenter. All providers must comply with state and federal laws and regulations and Passport Health Plan’s policies on the confidential treatment of member information in all settings. All providers are to treat members’ protected health information (PHI), including medical records, confidentially and in compliance with all federal and state laws and regulations, including laws regarding mental health, substance abuse, HIV and AIDS, as well as the Health Insurance Portability and Accountability Act (HIPAA). It is the provider’s responsibility to obtain the member’s written consent for the purpose of sharing member health information. Providers are authorized to share members’ protected health information with Passport Health Plan for the purposes of treatment, payment, and health care operations recognized as receiving a request to process claims and administer reimbursement for the same. Providers rendering services to Passport members are required to obtain special consent (authorization) from members for any uses or disclosures of protected health information beyond the uses of payment, treatment, and health care operations. Members have the right to specifically approve or deny the release of personal health information for uses other than payment, treatment, and health care operations. Examples of uses and disclosures that require special consent or authorization include data requested for workers’ compensation claims, release of information that could result in the member being contacted by another organization for marketing purposes, and data used in research studies. In cases where consent is required from members who are unable to give it or who lack the capacity to give it, Passport Health Plan and its providers/practitioners will accept special consent or authorization from persons designated by the member. Designated persons, such as parents or guardians, may authorize the release of personal health information and may obtain access to information about the member. Member information transferred from Passport Health Plan to another organization as permitted by routine or special consent will be protected and secured according to Passport Health Plan’s state and federal privacy policies and procedures. Passport Health Plan will use member information for quality studies, health outcomes measurements, and other aspects of health plan operations and will de-identify the information as dictated by federal privacy legislation. Page 42 of 331 Passport Health Plan members have the right to appeal any Passport decision that involves issues of information confidentiality and privacy. Passport Health Plan members are permitted to access, copy, and inspect their medical records upon request. One copy of a member’s complete medical record must be made available from the provider upon request at no charge and in accordance with state administrative regulations. 3.2 The Role of the Primary Care Provider (PCP) A primary care provider (PCP) is a licensed or certified health care practitioner, including a doctor of medicine, doctor of osteopathy, advanced practice registered nurse (including a nurse practitioner, nurse midwife and clinical specialist), physician assistant, or clinic (including a FQHC, primary care center and rural health clinic), that functions within the scope of licensure or certification, has admitting privileges at a hospital or a formal referral agreement with a provider possessing admitting privileges, and agrees to provide twenty-four (24) hours per day, seven (7) days a week primary health care services to individuals. Additionally, an Obstetrician/Gynecologist can serve as a PCP to a member with obstetrical or gynecologic health care needs, disability or chronic illness provided the specialist agrees to provide and arrange for all appropriate primary and preventive care. Passport Health Plan provides instructional materials that encourage members to seek their PCP’s advice before accessing medical care from any other source except for direct access services and emergency services. It is imperative the PCP’s staff fosters this idea and develops a relationship with the member that will be conducive to continuity of care. Primary care physician residents may function as PCPs. The PCP serves as the member's initial and most important point of contact with Passport Health Plan. This role requires a responsibility to both Passport Health Plan and the Member. Although PCPs are given this responsibility, Passport will retain the ultimate responsibility for monitoring PCP actions to ensure they comply with Passport and DMS policies. Specialty providers may serve as PCPs under certain circumstances, depending on the Member's needs. The decision to utilize a specialist as the PCP shall be based on agreement among the Member or family, the specialist, and Passport's medical director. The Member has the right to appeal such a decision in the formal appeals process. Passport will monitor the PCP's actions to ensure he/she complies with Passport and DMS policies including but not limited to the following: • • • • Maintaining continuity of the Member's health care; Exercising primary responsibility for arranging and coordinating the delivery of medicallynecessary health care services to members; Making referrals for specialty care and other Medically Necessary services, both in and out of network, if such services are not available within Passport's network; Maintaining a current medical record for the Member, including documentation of all PCP and Page 43 of 331 • • • • • • • • • • specialty care services, including periodic preventive and well-care services, and providing appropriate and timely reminders to members when services are due; Discussing Advance Medical Directives with all members as appropriate. See Section 3.4.4. Advanced Directives; Providing primary and preventative care, recommending or arranging for all necessary preventive health care, and adhering to the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) periodicity schedule and the Vaccines For Children (VFC) immunization schedule for each Passport Health Plan member younger than 21 years of age. Documenting all care rendered in a complete and accurate medical record that meets or exceeds the Department for Medicaid Services’ (DMS) specifications; Screening and evaluation procedures for the detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders; Arranging and referring members when clinically appropriate, to behavioral health providers; Providing periodic physical examinations as outlined in the Preventive Health Guidelines; Providing routine injections and immunizations; Providing or arranging 24-hours a day, seven days a week access to medical care. For additional information, see Section 4.2 – Office Standards; Arranging and/or providing necessary inpatient medical care at participating hospitals. Providing health education and information; and, Passport members have the right to a second opinion. If the member requests a second opinion, the PCP should complete a referral to a participating specialist. If there is not a specialist within the network, the PCP must call Passport’s Utilization Management department at (502) 578-0636 to request an authorization to a non-participating specialist. The PCP should perform routine health assessments as appropriate for a member’s age and gender and maintain a complete individual medical record of all services provided to the member by the PCP, as well as any specialty or referral services. PCPs are required, with the assistance of Passport Health Plan, to integrate into the member’s medical records any services provided by school-based health services or other external service providers. It is the responsibility of all PCPs to manage the care of their Passport Health Plan panel members and direct the members to specialty care services when necessary. It is the responsibility of the specialist practitioner to work closely with the PCP in this process. Dual eligible members, members who are presumptively eligible - pregnant, disabled children, and foster care children are not required to have a PCP but may request a PCP. All other members either make a selection or have Passport select a PCP for their medical home. The name and telephone number of the PCP or group selected appears on the member’s Passport Health Plan Identification Card. Please see Section 2.4.1 for more information about member eligibility and identification. Each PCP receives a monthly member panel list of those members who have selected or been assigned to him or her. It is advisable to verify eligibility at, or before, the time of service using one of the online eligibility tools, (NaviNet or KyHealth Net). Even with this verification, there are times when DMS retroactively terminates eligibility for certain members. In these circumstances, Passport may decide to recoup any amounts paid for these patients. Page 44 of 331 Coordination between Primary Care and Behavioral Health providers is a critical component of promoting health and wellness for Passport Health Plan members. We encourage primary care providers to review the behavioral health section of this provider manual for more information about the covered benefits, authorization requirements and other important behavioral health issues. Members never need a referral for behavioral health services. If you need assistance establishing behavioral health services for a Passport member, we encourage you to call our 24-hour Behavioral Health Services Hotline at 855-834-5651. To support our goal of integrated behavioral and physical health care, we offer a comprehensive prescription drug intervention program designed to alert our primary care providers of sub-optimal dosing, polypharmacy or other key issues for members who are prescribed psychotropic medications. The incorporation of comprehensive Behavioral and Mental Health Services brings about many changes. Working with the DMS and the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID), Passport will highlight the expectations for screening for behavioral health disorders by PCP’s in numerous settings. PCP’s may continue to provide any clinically appropriate Behavioral Health Services within the scope of their practice. The training sessions that are offered will review this in greater detail. New expectations extend to Behavioral Health specialists in that they are expected to communicate to the PCP the initial evaluation. Additionally, they are expected to provide, at minimum, quarterly reports of the member’s condition with the consent of the member or their legal guardian. 3.3 The Role of Specialists and Consulting Practitioners Specialty care practitioners provide care to members referred by their PCP. The specialty care practitioner must coordinate care through the PCP and must obtain necessary prior authorization for hospital admissions or specified diagnostic testing procedures. Refer to Section 5.3, “Authorization Requirements,” for a complete listing of procedures requiring prior authorization from Passport Health Plan’s Utilization Management department. Except for Direct Access Services and a few other services (see Section 6.1, “Member Self-Referral (Direct Access),” all members must obtain a valid referral from the PCP prior to receiving services from most specialty care providers/practitioners. Specialty practitioners must review the referral section of the PCP referral form to determine which services have been referred. The specialist must contact the PCP if he or she intends to provide services in excess of those initially requested. In these cases, the PCP must generate a second referral to cover the additional services. It is important that the specialty care provider communicates regularly with the PCP regarding any specialty treatment. Specialists are to report the results of their services to the member’s PCP just as they would for any of their patients. The specialist should copy all test results in a written report to the PCP. The PCP is to maintain referrals and specialist reports in the member’s central medical record and take steps to ensure that any required follow-up care or referrals are provided. Page 45 of 331 For electronic referral submission guidelines via NaviNet, please refer to Section 6.3. Page 46 of 331 3.4 Responsibilities of All Providers 3.4.1 Provider and Member Communications It is the provider’s responsibility to provide appropriate and adequate medical care to Passport Health Plan members, and no action of Passport Health Plan or any entity on the Plan’s behalf, in any way, absolves, relieves, or lessens the provider’s responsibility and duty to provide appropriate and adequate medical care to all patients under the provider’s care. Passport Health Plan agrees that regardless of the coverage limitations of the Plan, the provider may freely communicate with members regarding available treatment options and that nothing in this Provider Manual shall be construed to limit or prohibit open clinical dialogue between the provider and the member. 3.4.2 Medical Records Documentation in the medical record shall be timely, legible, current, detailed and organized to permit effective and confidential patient care and quality review. Complete medical records include, but are not limited to, medical charts, prescription files, hospital records, provider specialist reports, consultant and other health care professionals’ findings, appointment records, and other documentation sufficient to disclose the quantity, quality, appropriateness, and timeliness of services provided to the member. The member record shall be signed by the provider of service. Medical record confidentiality policies and procedures shall comply with state and federal guidelines, HIPAA and Passport Health Plan policy. HIPAA privacy and security audits will be performed to assure compliance as required by Passport Health Plan’s contract with the DMS. If a member were to change PCP’s, medical records should be forwarded to the new PCP within ten (10) days’ of receipt of a signed request. See Section 4.5 for additional detail regarding Medical Record Keeping 3.4.3 Treatment Consent Forms Treatment consent forms for specific procedures must be completed and signed by the member. A copy of the appropriate treatment consent form must be maintained in the member’s record. The following original treatment consent forms must be sent to the Plan, along with a copy of the claim, as required by state and federal laws. In accordance with Title VI, all vital documents (i.e. treatment and consent forms) must be translated into patient’s preferred language. These treatment consent forms are available from the Department for Medicaid Services (DMS) and in Section 19 of this Provider Manual: MAP-250 Consent for Sterilization MAP-251 Hysterectomy Consent Form MAP-235 Certification Form for Induced Abortion or Induced Miscarriage MAP-236 Certification Form for Induced Premature Birth Page 47 of 331 For additional information on completion of the above forms, please contact Passport Utilization Management at 800-578-0636 Additional information on family planning services is located in Section 17. 3.4.4 Advance Directives Living will, living will directive, advance directive, and directive are all terms used to describe a document that provides directions regarding health care to be provided to the person executing the document. In Kentucky, advance directives are governed by the Kentucky Living Will Directive Act codified in KRS 311.621 to 311.643, and as otherwise defined in 42CFR 489.100. Matters regarding application of advanced directives and related legal matters are defined in Kentucky Statutes, some of which are outlined in greater detail below; however, these should not be considered exhaustive lists. State and federal laws also provide guidance to these policies. Policies will be updated as soon as possible after guidance from these organizations is received. A member who is 18 years of age or older and who is of sound mind may make a written advance directive that does any or all of the following: • • • • Directs the withholding or withdrawal of life-prolonging treatment. Directs the withholding or withdrawal of artificially provided nutrition or hydration. Designates one or more adults as a surrogate or successor surrogate to make health care decisions on his or her behalf. Directs the giving of all or any part of his or her body upon death for any of the following reasons: medical or dental education, research, advancement of medical or dental science, therapy, or transplantation. A living will form is included in KRS 311.625. The form can be reviewed at http://www.lrc.ky.gov/krs/311%2D00/625.pdf. A copy of the living will may also be obtained through the Office of the Attorney General website at http://ag.ky.gov/civil/consumerprotection/livingwills.htm. Advance directives may be revoked in writing, by an oral statement, or by tearing up the written living will. The revocation is effective immediately. Health Care Surrogates. If a health care surrogate is appointed in the advance directive, the surrogate is required to consider the recommendations of the attending physician and to honor the requests made by the grantor in the advance directive. No Directive. What happens if an adult member does not have decisional capacity and has not executed an advance directive? Kentucky statutes authorize the following persons, in the order given, to make such decisions: • A judicially-appointed guardian of the member. • Spouse of the member. • Adult child of the member (or the majority of the children). Page 48 of 331 • Parents of the member. • Nearest living relative. Conscientious Objections. What happens if the practitioner or health care facility does not want to comply with a member’s advance directive because of matters of conscience? The provider/practitioner should notify the member and cooperate with the member in transferring the member, with all his or her medical records, to another provider/practitioner. The provider/practitioner must also clarify any differences between institutional conscientious objections and those that may be raised by individual practitioners. Also, the provider/practitioner must describe the range of medical conditions or procedures affected by the conscientious objection. Provider’s Responsibilities. In addition to reviewing the Kentucky Living Will Directives Act, providers should: • Discuss the member’s wishes regarding advance directives for care and treatment at the first visit, as well as during routine office visits when appropriate; • Document in the member’s medical record the discussion and whether the member has executed an advance directive; • Provide the member with information about advance directives, if asked; • File the advance directive in the member’s record upon receipt from the member; • Not discriminate against a member because he or she has or has not executed an advance directive; and, • Communicate to the member if the provider has any conscientious objections to the advance directive as indicated above. 3.4.5 Suspected Child or Adult Abuse or Neglect Cases of suspected child or adult abuse or neglect might be uncovered during examinations. Child abuse is the infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that results in physical pain or injury, including mental injury. Abuse is an act of commission or neglect. If suspected cases are discovered, an oral report should be made immediately, by telephone or otherwise, to a representative of the local Department for Social Services office at (502) 595-4550. To facilitate the reporting of suspected child abuse and neglect cases, legislation affecting the reporting of child abuse (KRS 620.030) is printed on the reverse of the Child Abuse Reporting Form (DSS-115). These forms may be obtained from the local Department for Social Services office. Adult abuse is defined by KRS. 209.020 as, “the infliction of physical pain, mental injury, or injury of an adult.” The statute describes an adult as, “(a) a person 18 years of age who because of mental or physical dysfunctioning is unable to manage his [her] own resources or carry out the activity of daily living or protect himself [herself] from neglect or a hazardous or abusive situation without assistance from others and who may be in need of protective services; or (b) a person without regard to age who is the victim of abuse and neglect inflicted by a spouse.” Page 49 of 331 3.4.6 Fraud and Abuse The Federal False Claims Act and the Federal Administrative Remedies for False Claims and Statements Act are specifically incorporated into § 6032 of the Deficit Reduction Act. These Acts outline the civil penalties and damages against anyone who knowingly submits, causes the submission, or presents a false claim to any U.S. employee or agency for payment or approval. U. S. agency in this regard means any reimbursement made under Medicare or Medicaid and includes Passport Health Plan. The False Claims Acts prohibit anyone from knowingly making or using a false record or statement to obtain approval of a claim. Knowingly is defined in the statute as meaning not only actual awareness that the claim is false or fraudulent, but situations in which the person acts in deliberate ignorance of, or in reckless disregard of, the truth or falsity of the claim. The following are some examples of billing and coding issues that can constitute false claims and high-risk areas under this Act: • • • • • Billing for services not rendered; Billing for services that are not medically necessary; Billing for services that are not documented; Upcoding; and, Participation in kickbacks. Penalties (in addition to amount of damages) may range from $5,000 to $10,000 per false claim, plus three times the amount of money the government is defrauded. In addition to monetary penalties, the provider may be excluded from participation in the Medicaid and/or Medicare programs. Passport has developed a Program Integrity plan of internal controls and policies and procedures for preventing, identifying and investigating enrollee and provider fraud, waste and abuse. Our plan includes: • • • • • • • Enforcement of standards through disciplinary guidelines; Provisions for internal monitoring and auditing of the member and provider; Provisions for internal monitoring and auditing of subcontractors. Should issues be identified, the subcontractor shall be placed on a corrective action plan (CAP). The Department for Medicaid Services (DMS) will be notified of the CAP. Processes to collect outstanding debt from providers; Procedures for appeals; Compliance with the expectations of 42 CFR 455.20 by employing a method of verifying with the member whether the services billed by the provider were received by randomly selecting a minimum sample of 500 Claims on a monthly basis; and, Programs that run algorithms and edits on Claims data to identify outliers and patterns and trends. Passport’s Program Integrity Unit (PIU) conducts fraud, waste and abuse investigations for Passport. Page 50 of 331 The PIU is comprised of staff from a broad range of Passport departments. All Passport fraud, waste and abuse activity is reported to the DMS. PIU staff meeting regularly with the state Medicaid Fraud Control Unit (MFCU) which includes representatives from the DMS, the Office of the Inspector General (OIG) and the Office of the Attorney General (OAG). Providers are required to cooperate with the investigation of suspected Fraud and Abuse. If you suspect fraud, waste or abuse by a Passport member or provider, it is your responsibility to report this information immediately. Please contact: Passport Health Plan Compliance Hotline: Page 51 of 331 (855) 512-8500 Provider Manual Section 4.0 Office Standards Table of Contents 4.1 Appointment Scheduling Standards 4.2 After-Hours Telephone Coverage 4.3 Member to Practitioner Ratio Maximum 4.4 Provider Office Standards 4.5 Medical-Record-Keeping & Continuity & Coordination of Care Standards 4.6 Hospital Care 4.7 Kentucky Health Information Exchange – KHIE 4.8 Communication Guidelines Page 52 of 331 4.0 Office Standards PCPs are required to provide coverage for Passport Health Plan members 24 hours a day, seven days a week. When a PCP is unavailable to provide services, the PCP must ensure that he or she has coverage from another participating provider. Hospital emergency rooms or urgent care centers are not substitutes for coverage from another participating provider. Participating providers can consult their Passport Health Plan Provider Directory, or contact Provider Services at (800) 578-0775 with questions regarding which providers participate in the Passport Health Plan network. 4.1 Appointment Scheduling Standards Providers must adhere to the following appointment scheduling standards to assure timely access to medical care as required by the Department for Medicaid Services (DMS). Compliance with these standards will be audited by periodic on-site review of provider offices and chart sampling. Appointments with primary care providers (PCP) and specialists must be scheduled within 30 days for routine care and preventive care visits. • Appointment standards for other situations that might confront a PCP or specialist are as follows: Appointments for urgent care services must be scheduled within 48 hours. Non-urgent appointments requiring more immediate attention must be scheduled within 7 days. Appointments for emergency care must be immediately provided. Pregnant women in their first trimester are to be provided preventive care visits within 14 days of request. Pregnant women in their second trimester are to be provided preventive care visits within seven days of request. Pregnant women in their third trimester are to be provided preventive care visits within three days of request. Appointments for laboratory and radiology services must be scheduled within 30 days for routine care and 48 hours for urgent care. • 4.2 After-Hours Telephone Coverage A PCP’s office telephone must be answered in a way that the member can reach the PCP or another medical practitioner whom the practitioner has designated. Their telephone must be: • • • Answered by an answering service that can contact the PCP or another designated medical practitioner who can return the call within a maximum of 30 minutes; OR Answered by a recording directing the member to call another number to reach the PCP or another medical practitioner whom the practitioner has designated to return the call within a maximum of 30 minutes; OR Transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated medical practitioner who will return the call within a maximum of 30 minutes. Page 53 of 331 Unacceptable after-hours telephone coverage in a PCP’s office includes: • • • • No answer after office hours. Telephone answered after hours by a recording that tells members to leave a message. Telephone answered after hours by a recording that directs members to go to the emergency room for any services needed. Not returning calls within 30 minutes 4.3 Member to Practitioner Ratio Maximum Per DMS regulation 907 KAR 1:705, member to PCP ratios are not to exceed 1500 to 1. If any PCP is concerned about his or her panel size or prefers a ratio smaller than 1500 to 1, he or she should notify Provider Network Management in writing at the following address: Passport Health Plan 5100 Commerce Crossings Drive Louisville, KY 40229 Attention: Provider Network Management Passport Health Plan will set the maximum panel size at 1500 members per practitioner. However, the ratio may be adjusted for practices that employ physician extenders, such as physician assistants. Passport Health Plan will consider exceptions to the 1500 to 1 ratio upon PCP request. Exceptions will be allowed based on an analysis of the practice capacity and geographic availability of other PCP practices contracted with Passport Health Plan. For additional information regarding requests for panel closings and limitations, please see Section 2.8. 4.4 Provider Office Standards • • • • • • Providers must not differentiate or discriminate in the treatment of any member because of the member’s race, color, national origin, ancestry, religion, health status, sex, marital status, age, political beliefs, or source of payment. The office waiting times should not exceed 45 minutes. Members should be scheduled at the rate of six or less per hour. Health assessments/general physicals should be scheduled within 30 days. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screens for any new enrollee younger than 21 years of age should be scheduled within 30 days of enrollment, unless the child is already under the care of a PCP and the child is current with screens and immunizations. EPSDT screens for any new enrollee younger than two years of age should be scheduled within an appropriate time frame so that the child is not out of compliance with any required screenings. • PCPs should have a “no show” follow-up policy. For example, the PCP or specialist might send two notices of missed appointments to the member, followed up by a telephone call to Page 54 of 331 • • • • the member. Any actions for missed appointments should be documented in the member’s medical record. Provider Network Management must be notified of all PCP planned and unplanned absences of more than four days from the practice. Member medical records must be maintained in an area that is not accessible to persons not employed by the practice. When releasing a member’s medical record to another practice or provider, providers are required to first obtain written consent from the member. Any provider’s office administering care that may have an adverse effect must obtain the member’s signature on a form that describes the treatment and includes the medical indication and the possible adverse effects. Providers must complete specific treatment consent forms, such as hospice, sterilization, hysterectomy, or abortion as referenced in Section 3.4.3, “Treatment Consent Forms,” as required by state and federal regulations and laws. 4.5 Medical-Record-Keeping and Continuity and Coordination of Care Standards Passport Health Plan has adopted the following medical-record-keeping standards, which cover confidentiality, organization, documentation, access, and availability of records. These standards are determined by the National Committee for Quality Assurance (NCQA) and the Department for Medicaid Services (DMS) and may be revised as needed to conform to new NCQA or DMS recommendations. Compliance with these standards will be audited by periodic on-site review of practitioners' offices and chart samplings. Practitioners must achieve an average score of 80% or higher on the medical records review. Passport Health Plan will monitor practitioners’ scoring less than 80% through corrective action plans and re-evaluation. Confidentiality of Records Medical records are maintained in an area that is only accessible to practitioner office staff. Providers are also required to: Have policies addressing privacy and confidentiality of member information. • • • • • • • • Ensure that medical records are NOT accessible to those not employed by the practice. Post notice of privacy practices (NPP) in a prominent area of the office. Ensure that HIPAA policies and procedures are easily accessible for all staff members. Provide disclosures of PHI, patient’s right to request restriction of the use of PHI, and include a contact person within the practice. Locate copier and fax machines in an area that restricts unauthorized access or viewing. Password protect all computer screen savers. Protect all staff members’ computer access by requiring unique log-ins and time-limited passwords. Ensure that office staff shall send all emails containing PHI marked secured or encrypted. Organization of Records Page 55 of 331 • • • • • There is only one medical record per patient. The medical record is bound or pages fastened to prevent loss of medical information. Each and every page in the record contains the member’s name or ID number. The medical record is organized in chronological order with the most recent information appearing first. The record includes separate sections for progress notes, lab results, x-ray and other imaging studies, hospital records (ER report and discharge summaries), home health nursing reports, physical therapy reports, etc. All charts contain flow sheets for health maintenance. Documentation • • • • • • • • • • • • • • • • • The record is legible. Personal data includes date of birth, age, height, gender, home and work addresses, employer, home and work telephone numbers, marital status, emergency contact information, school name and telephone numbers (if no phone contact name and number), race, ethnicity, guardianship/custodial arrangements, and identifies preferred language. Entries are done in smudge-proof non-erasable ink. Medication allergies, adverse reactions, and no known allergies are prominently noted in the record. There is a completed immunization record in all pediatric records and/or appropriate history in all adult records. All charts contain a problem list, a medication list, and a treatment plan. Significant illnesses and medical conditions are indicated on the problem list, including working diagnoses. Medical history (for members seen three or more times) is easily identified and includes medical, surgical, obstetric histories, and serious accidents. For children and adolescents (18 years of age and younger), medical history includes prenatal care, birth, operations, and childhood illnesses. Documentation includes weight recorded at each regular visit. All entries in the medical record are signed or initialed and dated and all providers are identified by name. Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits. The specific time of return is noted in weeks, months, or PRN. Documentation will reflect assessment of and counseling for tobacco, alcohol, substance abuse, and risk of sexually transmitted diseases. If a consultation is requested, there is a note from the consultant in the record. Consultation, lab, and x-ray reports filed in the chart are initialed by the practitioner to indicate review. Consultation and abnormal lab and imaging study results have a specific notation in the record of follow-up plans. Emergency care provided is documented in the medical record, as well as follow-up visits provided secondary to reports of emergency room care. Evidence of reportable diseases and conditions are documented and reported appropriately to local or state health departments. There is evidence that preventive screenings and services are offered in accordance with Passport Health Plan’s Clinical Practice Guidelines. Use of risk assessments, disease maintenance, and preventive health sheets are encouraged (see Section 17, “Forms and Documents” for samples). Copies of consent forms, when applicable, are maintained in the record. Page 56 of 331 • • • The medical record also contains an indication of whether an adult (over 18 years old) member has executed an advance directive and a copy of the member’s advance directive, as applicable. Written denials for service and the reason for the denial are documented in the medical record. Hospital discharge summaries are included in the medical record. Access and Availability of Records • • • • Provider permits Passport Health Plan, on request, access to member medical records to inspect, review, and copy within five working days of receipt of request. Members have the right to all information contained in the medical record as required by law. Medical records must be made available to a member upon request. When a member changes PCPs, the medical records or copies of medical records shall be forwarded to the new PCP within ten (10) business days from receipt of request. When releasing records to an entity other than Passport, providers are first required to obtain written consent from the member. Continuity and Coordination of Care While there are some indicators of continuity and coordination of care included within the documentation standards, Passport will also assess medical records for evidence of continuity and coordination of care using the following criteria: • • • • • • • • • • The record is legible to someone other than the writer. Any record determined illegible by one reviewer shall be evaluated by a second reviewer. At each office visit, the history and the physical performed are documented and reflect appropriate subjective and objective information for presenting complaints, including any relevant psychological and social conditions affecting the patient’s medical/behavioral health. The working diagnosis is consistent with the clinical findings. The plan of action and treatment is consistent with the diagnosis and includes medication history, medications prescribed; including the strength, amount, and directions for use, as well as any therapies or other prescribed regimen. Lab and other studies are ordered as appropriate. Unresolved problems, referrals, and results from diagnostic tests, including results and/or status of preventive screening services (EPSDT) from previous office visits are addressed in subsequent visits. There is a review for the under-and over-utilization of consultations. Age or disease-appropriate direct access services or referrals must be documented in the medical record, for example: immunizations, diabetic retinal eye exams, family planning, and cancer screening services. There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic problem. Follow-up plans including consultations, referrals, directions, and time to return. 4.6 Hospital Care Practitioners must have admitting privileges to a Passport Health Plan network hospital or facility for Page 57 of 331 all patient groups for whom they are providing care. With prior written approval from Passport Health Plan’s Utilization Management department, a practitioner may arrange for another participating practitioner to provide inpatient coverage. 4.7 Kentucky Health Information Exchange – KHIE Passport Health Plan is dedicated to improving the health and quality of life of our members and actively supports the statewide implementation of the Kentucky Health Information Exchange (KHIE). The KHIE is the secure electronic information infrastructure created by the Commonwealth for sharing health information among health care organizations and offers health care providers the functionality to support meaningful use and a high level of patient-centered care. Passport Health Plan encourages participating PCP’s to connect to the KHIE through various communication channels such as annual workshops, routine onsite visits, and general provider relations interaction. KHIE is a secure, interoperable network which participating providers with certified electronic health record (EHR) technology can use to locate and share needed patient information with each other which results in improved coordination of care among physician practices, hospitals, labs, and across the various health systems. Some of the benefits include: • • • • • Real time access to patient health information including: Detailed patient summary Rx/medication history Laboratory results Radiology and other transcribed reports Clinical reminders/alerts Improved patient care quality and safety Reduced health care costs by reducing duplication of care Improved efforts to reduce health disparities Informed medical decisions at the time/place of care. We encourage you to visit ht t p: //K HI E. KY .G OV /c wk h ie/ Pa ges/ h ome .asp x to obtain more information on this program and guidance on how you can make the KHIE connection. 4.8 Communication Guidelines They Kentucky Department for Medicaid Services has developed guidance related to member materials and other communication for providers participating in Medicaid managed care organizations in the state. The guidance includes the following: • • • Providers are considered agents of all managed care organizations (MCOs). MCO’s must have a system of control over the content, form, and method of marketing and information materials published on its behalf or through its agents. Any listing of MCO’s in a provider office must include all Medicaid plans with which the provider does business. Page 58 of 331 4.8.1 Approval Process: • All communication materials referring to Passport Health Plan must be approved in writing by Passport and by the Kentucky Department for Medicaid Services (DMS). • Passport is responsible for submitting provider communication & information materials to the Kentucky Department for Medicaid Services (DMS) for approval. • DMS has the same approval authority over provider materials as it has over MCO materials. • Passport must correct any problems or errors on provider materials identified by DMS. 4.8.2 Distribution of Materials: • Passport may not distribute marketing materials through its provider network. • Branded health education materials may be distributed to providers by MCOs including Passport, but distribution must be limited to members of that specific plan. • Branded materials cannot be left in common areas, such as waiting rooms and lobbies. • Branded health education materials can not include enrollment or disenrollment information. Page 59 of 331 Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 Utilization Management Review Criteria/Standards for Review Authorization Requirements Online Authorization Inpatient Admissions and Observation Outpatient Services High Cost Medication Prior Authorization for Members with Original Medicare Retrospective Authorization Denials Available forms: Appendix A: Radiology Codes Appendix B: L codes Appendix C: Ostomy Supplies Page 60 of 331 5.0 Utilization Management 5.1 Utilization Management Utilization Management (UM) is the process of influencing the continuum of care by evaluating the necessity and efficiency of health care services and affecting patient care decisions through assessments of the appropriateness of care. The UM department helps to assure prompt delivery of medicallyappropriate health care services to Passport Health Plan members and subsequently monitors the quality of care. All Passport Health Plan participating providers are required to obtain prior authorization from the Plan’s UM department for inpatient services and specified outpatient services listed in Section 5.3, “Authorization Requirements.” Failure to submit an authorization or failure to submit an authorization in a timely manner may result in a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be verified for every request of service. The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except holidays. All requests for authorization of services may be received during these hours of operation by calling or faxing: Department Phone Number Fax Number General Number Concurrent Review Retrospective Review Home Health DME Therapies/Pain Management/Chiropractic (800) 578-0636 (502) 585-2023 (502) 585-7972 (502) 585-7320 (502) 585-7310 (502) 585-7989 (502) 585-7989 (502) 585-8207 (502) 585-8204 (502) 585-7990 (502) 585-6055 Cosmetics Appeals High Dollar Radiology Administered by MedSolutions (502) 585-7069 (502) 585- 7307 1-877-791-4099 (502) 585-8205 Request can be sent via confidential email to: PassportUMCosmetics @Passporthealthplan.com (502) 585-8461 1-888-693-3210 or on-line authorization at www.Medsolutionsonline.com After business hours or on holidays, a provider can leave a message and a representative will return the call the next business day. Passport Health Plan provides the opportunity for the provider to discuss a decision with the Medical Director, to ask questions about a utilization management issue, or to seek information from the nurse reviewer about the Utilization Management process and the authorization of care by calling Utilization Management at (800) 578-0636. Page 61 of 331 Because of frequent changes in member eligibility for Medicaid coverage, providers should verify continued eligibility via the Plan’s web site, www.passporthealthplan.com, or by calling the IVR or Provider Services at (800) 578-0775. 5.2 Review Criteria/Standards for Review Passport Health Plan’s Utilization Management (UM) department is charged with ensuring that the Plan’s members use their benefits appropriately. Passport’s UM Department uses InterQual® Criteria during the review process. In the event InterQual® Criteria is not available for a specific request, the reviewer may use internal medical policies which are reviewed and approved by actively practicing practitioners in the community. The Partnership Council approves both the use of InterQual Criteria® and Medical Polices. Criteria are only made available to participating and non-participating providers as allowed under copyright limitations and trademark considerations. At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will provide a copy of up to three (3) InterQual® Criteria guidelines. If the guidelines are not available for distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to request the guideline be read over the telephone, or review the guideline at Passport Health Plan. Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any time from the Passport UM Department or the Chief Medical Officer. Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines are shared with providers upon request. These requests may be made by contacting the UM Department or the Chief Medical Officer. Criteria are distributed to providers who have Medicare/Medicaid practitioner numbers issued by state and federal entities. 5.3 Authorization Requirements The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The general UM department phone number is: (800) 578-0636. The general UM department fax number is (502) 585-7989. The following table lists procedures and/or services that require authorization from Passport Health Plan’s Utilization Management (UM) department. Services Requiring Authorization All Inpatient Admissions / Hospitalizations Maternity Code Range: 644.XX through 665.XX --•If stay is less than or equal to 3 days with the above codes, no Page 62 of 331 authorization is required AUTHORIZATION IS REQUIRED FOR: All Cesarean Sections All Scheduled inductions All Non-par providers, regardless of delivery type Rehabilitation 23 Hour Observation Pain Management (i.e. Epidural Blocks – Trigger Point Injections) Home Hospice Stem Cell/Progenitor Cell Retrieval Investigational/Experimental Procedures Cosmetic Procedures Ocular Photodynamic Therapy/with Verteporfin (Visudyne) Neuropsychological Testing Diabetic Education Therapy Services Chiropractic Services No authorization for the first 12 visits in a calendar year Services beyond 12 visits require authorization Benefit limit = total of 26 chiropractic visits within a calendar period Specified Outpatient Surgical Procedures: PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging – Authorization administered by MSI Adenoidectomy - Cardiac Catheterization - EGD DME > $500 – rental or purchase All DME with E1399 Codes Enteral Products Select Orthotics / Prosthetics Ostomy Supplies Home Health / Skilled Nursing / Private Duty Nursing Home Infusion – IV Therapy (IVT) High Cost Medication > $400 Authorization for IVT will be administered by PBM (Perform RX) Synagis Injections – Authorizations administered by PBM (Perform RX) Nonparticipating Provider Services Select EPSDT Special Services Family Planning – Terminations Page 63 of 331 Policy for Newborns: An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If an infant born via NVD stays <= 3 days, authorization is not required. An infant born by C-Section does not require authorization until day six (6). If an infant born via CSection stays <= 5 days, authorization is not required. Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual cases. To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion, please contact the Passport Utilization Management (UM) department. The assigned authorization number must be submitted on the claim form. 5.4 Online Authorization Passport Health Plan’s Utilization Management Department utilizes an online authorization system via NaviNet. The online authorization system is a web-based auto-review system for providers to obtain authorization for services, including but not limited to: • • • • • • • • • • • Acute Therapies BiPAP Cesarean Section Cardiac Rehabilitation Hospital Bed Mediplanner Home Health Aid CPAP EGD Bili Lites Pulmonary Rehabilitation For questions regarding the online authorization, contact NaviNet or your Provider Network Account Manager. The online authorization system also allows you, the provider, to search for authorizations by member, authorization number, date of service and/or physician. View the following information online for each authorization: • • • • • • Member identification number, coverage dates, and PCP Authorization number Service requested Primary diagnosis Treatment dates Status of the authorization Page 64 of 331 The use of the online authorization system via NaviNet for select services is highly encouraged. 5.5 Inpatient Admissions and Observation Stays UM reviews all requests for inpatient admissions and observation stays utilizing InterQual® criteria and internal medical policies. For those requests meeting the established medical necessity criteria, an inpatient or observation stay will be authorized. Requests not meeting the established medical necessity criteria will be referred to Passport’s Medical Director for further review and evaluation. When requesting a review, at a minimum, documentation must include: • The member’s name and Passport Health Plan ID number. • The diagnosis for which the treatment or testing procedure is being sought. • Other treatment or testing methods that have been tried, their duration, and any outcomes. • Additional clinical information as applicable to the requested service. • Applicable sections of the medical record. Some authorization requests may require a physician’s letter of medical necessity or a copy of the medical records. These should be directed to the Utilization Management nurse who is coordinating the specific case. To receive authorization for an admission / observation stay, contact Passport Health Plan’s Utilization Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. 5.5.1 Inpatient Admissions and Observation Requirements All inpatient admissions and observation stays require an authorization. If a member is discharged from an inpatient level of care and subsequently re-admitted to the same hospital within 24 hours, the UM Department continues the member's inpatient stay under the same case reference number. Requests for prior authorization of elective inpatient or observation services should be received prior to the date the requested service will be performed. Passport Health Plan will accept the hospital’s or the attending physician’s request for prior authorization of elective hospital admissions; however, neither party should assume that the other has obtained prior authorization. For an urgent or emergent admission / observation, the facility must notify the plan within one business day of the admission. For weekend admissions or observation to a hospital or for services delivered on the weekend or after normal business hours, authorization must be obtained within one business day of the admission or service being provided. If the member’s condition or results of evaluation and testing meet inpatient criteria after the 23-hour Page 65 of 331 observation period, the stay will be converted to inpatient beginning with the observation stay admission date. All claims for this type of stay should be submitted with the entire length of stay as an inpatient. Failure to obtain authorization of an admission will result in an administrative denial of the admission. Denied authorization requests may be appealed (see Section 5.10.2 Administrative Denials). To receive authorization for an inpatient admission or observation, contact Passport Health Plan’s Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. Failure to obtain authorization of an admission will result in an administrative denial of the admission (see Section 2.11). Denied authorization requests may be appealed (see Section 2.11). Inpatient Only Codes: In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select surgical procedures must be performed in the inpatient setting. A detailed list of codes may be obtained at the following CMS website: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf If a provider performs one of the listed procedures in an outpatient setting and the claim is denied, they may submit supporting medical records documentation for review through the claims appeals process. 5.5.2 Inpatient Admissions to Non-Participating Facilities Requests for admission to non-participating facilities should be submitted to the Passport Health Plan UM department for review. To receive authorization for admission to a non-participating facility, contact Passport Health Plan’s Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. 5.5.3 Elective Participating-Hospital Transfer Policy Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient clinical information will be required to complete the authorization process, approve the transfer, and determine prospective length of stay. Page 66 of 331 Either the transferring or receiving facility may initiate the prior authorization; however, the transferring facility will be able to provide the most accurate required clinical information. If a hospital transfer request is made by another Passport Health Plan facility, the receiving facility may request that the transferring facility obtain the authorization before the case will be accepted at the receiving facility. The receiving facility should contact Passport Health Plan to confirm the authorization. In cases deemed emergent, notification of the admission is required within one business day after the transfer. To assist with transfers, contact Passport Health Plan’s Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. 5.5.4 Inpatient Rehabilitation Admissions If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan’s Utilization Management via phone (800) 578-0636 or fax (502) 585-7989. Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient Pulmonary Rehab. If the member is to be directly admitted from home or any other sub-acute facility, contact Passport Health Plan’s Case Management department at (800) 578-0636 ext. 2024. 5.5.5 Inpatient Skilled-Nursing Facility Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport Health Plan is responsible for costs of professional services, such as physician or therapist services that are not part of the routine facility service. After a member is in a nursing facility for 31 days, the disenrollment process begins for that member. Passport Health Plan’s responsibility for those nonfacility services continues for any of its members while they are still enrolled with the Plan. After the Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the DMS-contracted review entity. 5.6 Outpatient Services For authorization of select outpatient services listed in Section 5.3, “Authorization Requirements,” the PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for payment. Page 67 of 331 When requesting a review, at a minimum, documentation submitted must include: • The member’s name and Passport Health Plan ID number. • The diagnosis for which the treatment or testing procedure is being sought. • Other treatment or testing methods that have been tried, their duration, and any outcomes. • Additional clinical information as applicable to the requested service. • Applicable sections of the medical record. Some authorization requests may require a physician’s letter of medical necessity or a copy of the medical records. These should be directed to the Utilization Management nurse who is coordinating the specific case. Requests for prior authorization of elective services should be received prior to the date the requested service will be performed. Requests for authorization of urgent and emergent services must be submitted to UM within one business day of the procedure being performed. Passport Health Plan will accept the hospital’s or the attending physician’s request for prior authorization of elective hospital admissions; however, neither party should assume that the other has obtained prior authorization. Failure to obtain prior authorization for an elective procedure / service or failure to request authorization of an urgent or emergent procedure / service within one business day of the procedure/ service being performed or rendered will result in an administrative denial of the service (see Section 5.10.2). Denied requests may be appealed (see Section 2.11). The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm authorization, they may verify online via the online authorization system. 5.6.1 Outpatient Procedures / Diagnostics / Services Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from the Plan’s Utilization Management Department. See Table in section 5.3 for outpatient list. For authorization of select outpatient services listed in Section 5.3, “Authorization Requirements,” the provider notifies Passport Health Plan via the online authorization system, telephonically or by fax. The general UM department phone number is: (800) 578-0636. The general UM department fax number is (502) 585-7989. For Outpatient Imaging Services requiring authorization, see section 5.6.2. 5.6.2 Outpatient Radiology Services Providers are required to obtain authorization for select radiological services through the high dollar Page 68 of 331 radiology program for advanced diagnostic imaging services. This program is administered in partnership with MedSolutions (MSI). Authorizations are required for select diagnostic imaging services performed in an outpatient setting. Advanced diagnostic imaging includes: • • • • Computed Tomography (CT); Computed Tomographic Angiogram (CTA) Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA) Positron Emissions Tomography (PET) Nuclear Cardiac Imaging (NCM) Authorizations are performed at MSI using their own internal criteria and medical management system. MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is required for advanced diagnostic imaging services performed in any outpatient setting. Authorization is NOT required if the imaging service is performed in: • • • Emergency rooms Inpatient settings 23-hour observations – Service performed in observation do not require an authorization. However, the observation stay will still require a review by Passport. There are three (3) ways to request an authorization: 1. Internet: www.medsolutionsonline.com - Available 24/7 2. Phone: (877) 791-4099 Available 8 a.m. - 9 p.m. EST, Monday through Friday Toll free 3. Fax: 1-888-693-3210 Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer Service at (877) 791-4099 Only MedSolutions fax forms are accepted Available 24/7 See Appendix A for a list of codes that require an authorization. 5.6.3 Durable Medical Equipment The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan follows Medicare guidelines. DME PURCHASE DME items with billable charges greater than $500 require an authorization. Requests for authorization of purchase MUST be received PRIOR to the end of the rental period. DME RENTAL Page 69 of 331 Authorization requirements of rentals are determined by the billable price of the item being rented. Rental charges will be applied to purchase price. If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the rental is greater than $500, authorization is required. All items requiring customization or accessories require prior authorization. All mini-nebulizers will be a purchase only item and do not require prior authorization. Authorization requirements for DME purchases are based on total monthly cost or monthly quantity of items purchased. The following is a list of purchases with authorization requirements by quantity: Name Brand Diapers Item Generic Diapers Underpads (Chux) Ostomy Supplies Bedside Drainage Bags Syringes G-Tube Compression Stockings Quantity Limitations Regardless of quantity, all requests for name brand diapers require authorization 180 per month require authorization 180 per month require authorization 2 boxes per month require authorization 4 per month require authorization 100 per month require authorization 1 per month requires authorization 6 pair per year require authorization * Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM department.* Enteral Products • Enteral products with allowable amounts greater than $500 for a month’s supply require an authorization. These services should be billed according to the fee schedule in your Provider Contract (Allowable Charges). For authorization of DME, the provider notifies Passport Health Plan via the online authorization system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax number is: (502) 585-7990. For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A. For a list of Ostomy supplies that require an Authorization, see Appendix B. 5.6.4 Home Health Services When medically appropriate, home health, private duty nursing, or home hospice care, or home infusion may be a good alternative to hospitalization. Home health care, including both skilled and unskilled nursing, and hospice care and home infusion may be appropriate at other times as well. Page 70 of 331 Prior authorization of all home health / private duty nursing / hospice / home infusion services is required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse reviewer, the request may be given directly to the on-site review nurse. Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be obtained under EPSDT Special Services. A request for prior authorization must be received prior to the delivery of the service for a non-urgent request and within one business day of the service being performed for an urgent or emergent service. For authorization of Home Health Services, including home health care, private duty nursing and home hospice, the provider notifies Passport Health Plan through the online authorization system, telephonically or by fax. The Home Health phone number is: (502) 585-7320. The Home Health fax number is: (502) 585-8204. For authorization of home infusion, the provider should submit the infusion therapy authorization form to PerformRx via fax at 877-693-8280. The authorization form can be found at http://www.passporthealthplan.com/pharmacy/resources/priorauth/injectable-forms.aspx. 5.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services Providers are required to obtain prior authorization for physical, occupational, aquatic and speech therapy for acute and chronic conditions and chiropractic services. • Therapy Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the request may be given directly to the onsite review nurse. Review is required for the initial therapy visit and all subsequent visits. Requests for continuation of a service that is ongoing should be sent to the therapy department seven days prior to the end of the authorization period. Please fax request together with progress notes and current plan of care to (502) 585-8204. For authorization of therapy requests, providers must notify Passport Health Plan through the online authorization system, telephonically or by fax. The therapy phone number is: (502) 585-6055. The therapy fax number is (502) 585-8205. • Chiropractic Services Authorization requests for chiropractic services are required after the 12th visit. No authorization is required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic visits within a 12-month calendar period. • Outpatient Rehab Services Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the request may be given directly to the onsite review nurse. For authorization of Page 71 of 331 chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically at (502) 585-6055 or via fax at (502) 585-8205. 5.7 High-Cost Medications Providers are required to obtain prior authorization for High-Cost Medications greater than $400 billable amount per dose from the Utilization Management Department. This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy. Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See section 14 for prior authorizations related to pharmacy. For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or fax the request to (502) 585-7989. 5.8 Prior Authorization for Members with Medicare Prior authorization is not required for services listed on the prior authorization list when the member has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization requirements apply for both outpatient and inpatient services. For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior authorization of inpatient services must be obtained. If a member’s lifetime reserve days are exhausted during an inpatient hospitalization, notification to Passport Health Plan must be made within one business day of the notification to the facility of the exhaustion of benefits by Medicare. 5.9 Retrospective Authorization Retrospective review of inpatient services is performed when the patient was not a member of Passport Health Plan prior to or at the time of the service. Outpatient services do not require retrospective review by Utilization Management for members whose eligibility is determined retrospectively. Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit medical records for review and utilization management authorization request. If the practitioner does not provide documentation, the card issue date, segment date, and claims history are used. A decision and written notification is provided within ten (10) business days of receipt of the medical information for the retrospective review request. An administrative denial is issued for retrospective requests when the provider fails to request a utilization management review of the medical record within the timeframe specified. The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written Page 72 of 331 notification is provided. Requests received beyond 60 days from the card issue date or from the provider’s documentation of the date when they were aware of the member’s eligibility will be administratively denied. Send requests for retrospective review to: Utilization Management Retrospective Review 5100 Commerce Crossings Drive Louisville, KY 40229 The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart review, please send records via mail). 5.10 Denials An authorization request for a service may be denied for failure to meet guidelines, protocols, medical policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider Manual. Members may not be billed by participating providers for deductibles, copays, and coinsurance except those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members must be held harmless for denied services. To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact Utilization Management at (800) 578-0636. 5.10.1 Medical Necessity Denials Utilization Management utilizes InterQual® Guidelines, medical policies and protocols to render review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical Director for clinical review. A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a denial is issued, Utilization Management provides the name, telephone number, title, and office hours of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is available to discuss any decision rendered with the attending practitioner. 5.10.2 Administrative Denials An administrative denial is issued for those services for which the provider has not followed the requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may also be issued for failure to notify Utilization Management within one business day of an emergency service, procedure, or admission. A provider may appeal an administrative denial by submitting the appeal request in writing to: Page 73 of 331 Clinical Appeals Department 5100 Commerce Crossings Drive Louisville, KY 40229 Appendix A: Radiology Codes The codes on the list below require authorization through MedSolutions CPT ® MRI TMJ CT CT CT CT CT CT CT CT CT CT CT CT CT Angiography (CTA) CPT® Code 70336 70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70496 CT Angiography (CTA) 70498 MRI MRI MRI MRA MRA MRA 70540 70542 70543 70544 70545 70546 MRA MRA MRA 70547 70548 70549 MRI MRI MRI Functional MRI (fMRI) 70551 70552 70553 70554 Functional MRI (fMRI) 70555 CT CT CT 71250 71260 71270 CPT® Description MRI Temporomandibular Joint (s) CT Head without contrast CT Head with contrast CT Head with & without contrast CT Orbit, et al without contrast CT Orbit, et al with contrast CT Orbit, et al W & W/O CT Maxillofacial area, (sinus) without contrast CT Maxillofacial area, (sinus) with contrast CT Maxillofacial area, (sinus) W & W/O CT Soft-tissue Neck without contrast CT Soft-tissue Neck with contrast CT Soft-tissue Neck with & without contrast W & W/O CTA HEAD, with contrast, including noncontrast images, if performed, & image post-processing CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing MRI Orbit, Face and/or Neck without contrast MRI Orbit, Face and/or Neck with contrast MRI Orbit, Face and/or Neck W & W/O MR Angiography (MRA) Head without contrast MR Angiography (MRA) Head with contrast MR Angiography (MRA) Head with and without contrast W & W/O MR Angiography (MRA) Neck without contrast MR Angiography (MRA) Neck with contrast MR Angiography (MRA) Neck with and without contrast W & W/O MRI Brain (Head) without contrast MRI Brain (Head) with contrast MRI Brain (Head) with and without contrast W & W/O MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing CT Chest without contrast CT Chest with contrast CT Chest with and without contrast W & W/O Page 74 of 331 CPT ® CT Angiography (CTA) CPT® Code 71275 MRI MRI MRI MRA 71550 71551 71552 71555 CT CT CT CT CT CT CT CT CT MRI MRI MRI MRI MRI MRI MRI MRI MRI MRA 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149 72156 72157 72158 72159 CT Angiography (CTA) 72191 CT CT CT MRI MRI MRI MRA CT CT CT CT Angiography (CTA) 72192 72193 72194 72195 72196 72197 72198 73200 73201 73202 73206 MRI MRI MRI MRI MRI MRI 73218 73219 73220 73221 73222 73223 CPT® Description CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing MRI Chest without contrast MRI Chest with contrast MRI Chest with and without contrast W & W/O MR Angiography (MRA) Chest (excluding myocardium)- W or W/O CT Cervical Spine without contrast CT Cervical Spine with contrast CT Cervical Spine with and without contrast W & W/O CT Thoracic Spine without contrast CT Thoracic Spine with contrast CT Thoracic Spine with and without contrast W & W/O CT Lumbar Spine without contrast CT Lumbar Spine with contrast CT Lumbar Spine with and without out contrast W & W/O MRI Cervical Spine without contrast MRI Cervical Spine with contrast MRI Thoracic Spine without contrast MRI Thoracic Spine with contrast MRI Lumbar Spine without contrast MRI Lumbar Spine with contrast MRI Cervical Spine with and without contrast W & W/O MRI Thoracic Spine with and without contrast W & W/O MRI Lumbar Spine with and without contrast W & W/O MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing CT Pelvis without contrast CT Pelvis with contrast CT Pelvis with and without contrast W & W/O MRI Pelvis without contrast MRI Pelvis with contrast MRI Pelvis with and without contrast W & W/O MR Angiography (MRA) Pelvis -with or without contrast CT Upper Extremity without contrast CT Upper Extremity with contrast CT Upper Extremity with and without contrast W & W/O CTA Upper Extremity, with contrast, including noncontrast images, if performed, & image postprocessing MRI Upper Extremity-other than joint-without contrast MRI Upper Extremity-other than joint-with contrast MRI Upper Extremity-other than joint-W & W/O MRI Any Joint of Upper Extremity--without contrast MRI Any Joint of Upper Extremity--with contrast MRI Any Joint of Upper Extremity—W & W/O Page 75 of 331 MRA CPT ® CPT® Code 73225 CT CT CT CT Angiography (CTA) 73700 73701 73702 73706 MRI MRI MRI MRI MRI MRI MRA 73718 73719 73720 73721 73722 73723 73725 CT CT CT CT Angiography (CTA) 74150 74160 74170 74174 CT Angiography (CTA) 74175 CT CT CT MRI MRI MRI MRA Diagnostic CT Colonography (CTC) Diagnostic CT Colonography (CTC) 74176 74177 74178 74181 74182 74183 74185 74261 CT Colonography (CTC) for Screening Cardiac MRI Cardiac MRI 74263 Cardiac MRI 75561 Cardiac MRI 75563 Cardiac MRI 75565 74262 75557 75559 CPT® Description MR Angiography (MRA) Upper Extremity -with or without contrast CT Lower Extremity without contrast CT Lower Extremity with contrast CT Lower Extremity with and without contrast W & W/O CTA Lower Extremity, with contrast, including noncontrast images, if performed, & image postprocessing MRI Lower Extremity-other than joint-without contrast MRI Lower Extremity-other than joint-with contrast MRI Lower Extremity-other than joint- W & W/O MRI Any Joint of Lower Extremity--without contrast MRI Any Joint of Lower Extremity--with contrast MRI Any Joint of Lower Extremity—W & W/O MR Angiography (MRA) Lower Extremity-with or without contrast CT Abdomen without contrast CT Abdomen with contrast CT Abdomen with and without contrast W & W/O Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing CT Abdomen & Pelvis, without contrast CT Abdomen & Pelvis, with contrast CT Abdomen & Pelvis, with and without contrast MRI Abdomen without contrast MRI Abdomen with contrast MRI Abdomen with and without contrast W & W/O MR Angiography (MRA) Abdomen-with or without contrast Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including noncontrast images, if performed Computed tomographic (CT) colonography, screening, including image postprocessing Cardiac MRI for morphology and function without contrast Cardiac MRI for morphology and function without contrast material; with stress imaging Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Page 76 of 331 CPT ® Cardiac CT Calcium Scoring Cardiac CT CPT® Code 75571 CPT® Description CT, heart, without contrast with quantitative 75572 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed) Cardiac CT 75573 CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed) CT Coronary Angiography (CTCA) 75574 CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT Angiography (CTA) 75635 3D Rendering 3D Rendering CT MR Spectroscopy (MRS) Unlisted CT Unlisted MR CT guidance CT guidance 76376 76377 76380 76390 76497 76498 77011 77012 CT guidance MR Guidance MR Guidance Breast MRI Breast MRI CT Bone Density MRI Bone Marrow Nuclear Cardiac Imaging 77013 77021 77022 77058 77059 77078 77084 78451 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing 3D Rendering with interpretation and reporting of CT, 3D Rendering with interpretation and reporting of CT, CT Limited or Localized follow-up MR Spectroscopy (MRS) Unlisted CT procedure (eg, diagnostic, interventional) Unlisted MR procedure (eg, diagnostic, interventional) CT guidance stereotactic localization CT guidance needle placement (eg, biopsy, aspiration, injection, localization device) CT Guidance for, and monitoring of, parenchymal tissue MR guidance for needle placement (eg, for biopsy, MR guidance for, and monitoring of, parenchymal tissue MRI BREAST, without and/or with contrast UNILATERAL MRI BREAST, without and/or with contrast BILATERAL CT BONE MINERAL DENSITY study, 1 or more sites, axial MRI Bone Marrow blood supply Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Nuclear Cardiac Imaging 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Page 77 of 331 CPT ® Nuclear Cardiac Imaging CPT® Code 78453 CPT® Description Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Nuclear Cardiac Imaging 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Cardiac PET Nuclear Cardiac Imaging 78459 78466 Nuclear Cardiac Imaging 78468 Nuclear Cardiac Imaging Nuclear Cardiac Imaging 78469 78472 Nuclear Cardiac Imaging 78473 Nuclear Cardiac Imaging 78481 PET Cardiac (myocardial imaging) – metabolic evaluation Myocardial Imaging, infarct avid, planar; qualitative or quantitative Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique Myocardial Imaging, infarct avid, planar; tomographic SPECT Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Nuclear Cardiac Imaging 78483 Cardiac PET 78491 Cardiac PET 78492 Nuclear Cardiac Imaging Nuclear Cardiac Imaging 78494 78496 Unlisted Nuclear Cardiology Non-Cardiac PET Non-Cardiac PET Non-Cardiac PET Non-Cardiac PET Non-Cardiac PET Non-Cardiac PET 78499 78608 78609 78811 78812 78813 78814 PET Brain – metabolic evaluation PET Brain – perfusion evaluation PET imaging; limited area (eg, chest, head/neck) PET imaging; skull base to mid-thigh PET imaging; whole body PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck) Non-Cardiac PET 78815 Non-Cardiac PET 78816 Ceberal Perfusion 0042T PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body Ceberal Perfusion Analysis using CT with contrast Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction PET Cardiac (myocardial imaging), perfusion single study at rest or stress PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress Cardiac Blood Pool imaging, gated equilibrium, SPECT Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass Unlisted Nuclear Cardiology diagnostic nuclear Page 78 of 331 CPT ® Analysis CAD for Breast MRI Magnetic Source Imaging MRCP MRI Low field Cardiac CT Calcium Scoring CPT® Code CPT® Description 0159T S8035 CAD, including computer algorithm analysis, BREAST Magnetic Source Imaging S8037 S8042 S8092 MRCP (Magnetic ResonancE) MRI Low field CT ELECTRON BEAM (Ultrafast CT) for calcium scoring Page 79 of 331 Appendix B – Orthotics and Prosthetics (L codes) AUTHORIZATION REQUIRED HCPCS Description L0113 Cranial cervical orthosis, torticollis type, w/wo joint, w/o soft interface, prefab. Incl. fitting & adj. L0130 Flex thermoplastic collar molded to patient L0170 Cervical collar molded to pt L0220 Thor rib belt custom fabrica L0430 Spinal orthosis, Dewall posture protector HCPC Description L5460 Postop app non-wgt bear dsg L0452 L0456 L0460 L0462 L0464 L0480 L0482 L0484 L0486 L0488 L0491 L0622 L0623 L0624 L0629 L0631 L0632 L0634 L5500 Init bk ptb plaster direct L5505 L5510 L5520 Init ak ischal plstr direct Prep BK ptb plaster molded Perp BK ptb thermopls direct TLSO flexible, provides trunk support, upper thoracic region, customized TLSO, flexible thoracic region, prefab L5530 Prep BK ptb thermopls molded L5535 Prep BK ptb open end socket TLSO, triplanar control prefab TLSO, triplanar control, prefab TLSO, triplanar control 4 piece rigid plastic with interface, prefab TLSO, triplanar control, one piece rigid plastic shell TLSO, triplanor, custom fabricated, one piece rigid plastic shell, each TLSO, triplanor control, two piece L5540 L5560 L5570 Prep BK ptb laminated socket Prep AK ischial plast molded Prep AK ischial direct form L5580 Prep AK ischial thermo mold L5585 Prep AK ischial open end L5590 Prep AK ischial laminated TLSO, triplanor control 2 piece rigid plastic with interface, custom TLSO triplanor, one piece, prefab TLSO 2 rigid plastic shells, pre fab Sacroiliac orthosis, flexible, custom Sacroiliac orthosis, rigid or semi-rigid, pre fab Sacroiliac orthosis, rigid or semi-rigid, custom Lumbar-sacral orthosis, flexible, custom Lumbar-sacral orthosis, sagittal control, pre fab Lumbar-sacral orthosis, sag. Control, rigid ant./post. Custom Lumbar-sacral orthosis, sag. Control, rigid post., custom L5595 Hip disartic sach thermopls L5600 L5610 L5611 L5613 Hip disart sach laminat mold Above knee hydracadence Ak 4 bar link w/fric swing Ak 4 bar ling w/hydraul swig L5614 4-bar link above knee w/swng L5616 L5639 Ak univ multiplex sys frict Below knee wood socket L5643 Hip flex inner socket ext fr L5645 Ak flexibl inner socket ext Page 80 of 331 L0635 Lumbar-sacral orthosis, sag-coronal control, prefab Lumbar-sacral orthosis, sag-coronal control, custom Lumbar-sacral orthosis, sag-coronal control, rigid ant/post., prefab Lumbar-sacral orth, sag-coronal control, rigid ant./post., custom Lumbar-sacral orthosis, sag.-coronal control, rigid post. Prefab Lumbar-sacral orthosis, sag-coronal control, rigid post., custom L5647 Below knee suction socket L5648 Above knee air cushion socket L5649 Isch containmt/narrow m-l so L5651 Ak flex inner socket ext fra L5670 Bk molded supracondylar susp L5673 L0700 Ctlso a-p-l control molded L5679 L0710 Ctlso a-p-l control w/ inter L5681 L0810 L0820 Halo cervical into jckt vest Halo cervical into body jack L5682 L5683 L0830 L0999 L1000 L1001 L1200 L1300 L1310 L1499 L1500 L1510 L1520 L1680 L1685 L1686 L1690 Halo cerv into milwaukee typ Addition to spinal orthosis, NOS Ctlso milwauke initial model Cervical TLSO, infant, prefab Furnsh initial orthosis only Body jacket mold to patient Post-operative body jacket Spinal orthosis NOS Thkao mobility frame Thkao standing frame Thkao swivel walker Pelvic & hip control thigh c Post-op hip abduct custom fa HO post-op hip abduction Combination bilateral LS/hip/femur L5700 L5701 L5702 L5704 L5705 L5706 L5707 L5716 L5718 L5722 L5724 L5726 L5728 L5780 L5781 below knee/above knee socket insert, silicone gel or elastomeric w/locking mech, custom below knee/above knee socket insert, silicone gel or elastomeric no locking mech, custom below knee/above knee, custom fab. Socket inset initial only for cong. Or atypical Bk thigh lacer glut/ischia molded below knee/above knee, custom fab, socket inset, initial only not cong.or atypical Replace socket below knee Replace socket above knee Replace socket hip Custom shape covr below knee Custom shape cover above knee Custom shape cvr knee disart Custom shape cover hip disart Knee-shin exo mech stance ph Knee-shin exo frct swg & sta Knee-shin pneum swg frct exo Knee-shin exo fluid swing ph Knee-shin ext jnts fld swg e Knee-shin fluid swg & stance Knee-shin pneum/hydra pneum Addt. to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system L1700 L1710 L1720 Legg perthes orth toronto typ Legg perthes orth newington Legg perthes orthosis trilat L5782 L5790 L5795 L0636 L0637 L0638 L0639 L0640 Page 81 of 331 Addt. To lower leg prosth. Vacuum Exoskeletal ak ultra-light m Exoskel hip ultra-light mate L1730 L1755 L1832 L1834 L1840 L1843 Legg perthes orth scottish Legg perthes patten bottom KO adj jnt pos rigid support KO w/0 joint rigid molded to KO derot ant cruciate custom KO single upright thigh & calfprefabricated, each KO w/adj jt rot cntrl molded KO w/ adj flex/ext rotat cus KO w adj flex/ext rotat mold KO supracondylar socket mold AFO molded ankle gauntlet supramalleolar w/straps w/wo interface/pads, custom fabricated AFO, rigid anterior tibial section,pre fab, incl. Fitting & adj. L5811 L5814 L5816 L5818 L5822 L5824 Endo knee-shin mnl lck ultra Endo knee-shin hydral swg ph Endo knee-shin polyc mch sta Endo knee-shin frct swg & st Endo knee-shin pneum swg frc Endo knee-shin fluid swing p L5826 L5828 L5830 L5840 L5845 L5848 Miniature knee joint Endo knee-shin fluid swg/sta Endo knee-shin pneum/swg pha Multi-axial knee/shin system Knee-shin sys stance flexion Knee-shin system dampening feature L5856 L1940 AFO, plastic or other material custom L5857 L1945 AFO molded plas rig ant tib L5858 L1950 L1951 L5930 L5950 L1960 L1970 AFO spiral molded to pt plas spiral, IRM type, plastic or other material prefab, incl. Fitting and adj. AFO pos solid ank plastic mo; custom AFO plastic molded w/ankle j Addt. To lower ext. prosthesis, knee shin sys.,microprocessor, incl. Sensor, any type Addt. To lower ext. prosth., swing phase only knee shin sys.,micro, incl. Sensor , any type Addt. To lower ext. prosth, knee shin sys.,micro, incl. Sens , stance phase High activity knee frame Endo ak ultra-light material L1980 L1990 L2000 AFO sing solid stirrup calf custom AFO doub solid stirrup calf; custom KAFO using fre stirr thi/calf; custom L5966 L5968 L5973 L2005 KAFO any material, single or dbl. Upright includes ankle joint custom fabricated KAFO single upright, free ankle, solid stirrup KAFO dbl solid stirrup band/ KAFO dbl solid stirrup w/o j KAFO full plastic, single upright, w/wo free motion knee,custom fabricated KAFO plas doub free knee mol KAFO plas sing free knee mol KAFO w/o joint multi-axis an Hkafo torsion cable hip pelv; custom L5976 Endo hip ultra-light materia addt. Endoskeleton above knee, flexible protective outer surface Hip flexible cover system Multiaxial ankle w dorsiflex Endoskeletal ankle foot system, microprocessor, incl. power source Energy storing foot L5979 Multi-axial ankle/ft prosth L5980 L5981 L5987 Flex foot system Flex-walk sys low ext prosth Shank ft w vert load pylon L5988 L5990 L5999 L6000 Vertical shock reducing pylo addt. To lower ext. user adj. ht Lower extremity prosthesis, NOC Par hand robin-aids thum rem L1844 L1845 L1846 L1860 L1904 L1907 L1932 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2050 L5960 L5964 Page 82 of 331 L2060 L2070 L2080 L2090 L2106 L2108 L2116 L2126 L2128 L2132 L2134 L2136 L2232 L6010 L6020 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 Hand robin-aids little/ring Part hand robin-aids no fing Wrst MLd sck flx hng tri pad Wrst mold sock w/exp interfa Elb mold sock flex hinge pad Elbow mold sock suspension t Elbow mold doub splt soc ste Elbow stump activated lock h Elbow mold outsid lock hinge Elbow molded w/ expand inter Elbow inter loc elbow forarm Shlder disart int lock elbow Shoulder passive restor comp L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6400 L6450 L6500 L6550 L6570 Shoulder passive restor cap Thoracic intern lock elbow Thoracic passive restor comp Thoracic passive restor cap Postop dsg cast chg wrst/elb Postop dsg cast chg elb dis/ Postop dsg cast chg shlder/t Below elbow prosth tiss shap Elb disart prosth tiss shap Above elbow prosth tiss shap Shldr disar prosth tiss shap Scap thorac prosth tiss shap L6580 Wrist/elbow bowden cable mol L6582 L6584 Wrist/elbow bowden cbl dir f Elbow fair lead cable molded L3201 L3202 L3203 L3204 Hkafo torsion ball bearing j; custom Hkafo torsion unilat rot str; custom Hkafo unilat torsion cable, custom Hkafo unilat torsion ball br, custom AFO tib fx cast plaster mold, custom AFO tib fx cast molded to pt Afo tibial fracture rigid Kafo fem fx cast thermoplas Kafo fem fx cast molded to p Kafo femoral fx cast soft Kafo fem fx cast semi-rigid Kafo femoral fx cast rigid Addt. To lower extremity orthosis, rocker bottom, custom fabricated only Molded inner boot Lacer molded to patient, custom Pre-tibial shell molded to p Prosthetic type socket molded Th/wght bear quad-lat brim m Th/wght bear quad-lat brim custom Th/wght bear m-l brim mo Th/wght bear m-l brim cu Thigh/wght bear lacer molded Plastic mold recipro hip & c Metal frame recipro hip & ca Orthotic side bar, Disconnect device, each addt. to lower ext-joint, knee or ankle, custom only, each Lower extremity orthosis NOS Foot arch support, removable, premolded, longitudinal & horizontal, each Oxford w supinator/pronator inf each Oxford w supinator/pronator child each Oxford w supinator/pronator jun each Hightop w supp/pronator infant each L6586 L6588 L6590 L6611 L3206 L3207 L3208 Hightop w supp/pronator child each Hightop w supp/pronator junior each Surgical boot, each infant L6623 L6624 L6638 Elbow fair lead cable dir fo Shdr fair lead cable molded Shdr fair lead cable direct Addt. To upper ext. prosthesis, ext. pwr switch addt. Spring-asst. rot wrst w/ latch Upper ext. addt. Flex. Ext rotation wrist upper ext addt. To prosth. Electric locking only for use with manually powered elbow L2280 L2330 L2340 L2350 L2510 L2520 L2525 L2526 L2540 L2627 L2628 L2768 L2861 L2999 L3060 Page 83 of 331 L3209 L3211 L3212 L3213 L3214 Surgical boot, each child Surgical boot, each junior Benesch boot pair infant Benesch boot pair child Benesch boot pair junior L6686 L6689 L6690 L6693 L6694 L3215 Orthopedic ftwear ladies oxf each L6695 L3216 Orthopedic ftwear ladies depth each L6696 L3217 Ladies shoes hightop depth each L6697 L3219 Orthopedic mens shoes oxford each L6707 L3221 Orthopedic mens shoes dpth each L6708 L3222 Mens shoes hightop depth inl each L6709 L3224 Woman's shoe oxford brace each L6712 L3225 Man's shoe oxford brace each L6713 L3230 Custom shoes depth inlay each L6714 L3250 Custom mold shoe remov prost each L6721 L3251 Shoe molded to pt silicone s each L6722 Terminal device, hook or hand, heavy duty, mechanical, vol. closing, any material, any size, lined or unlined, each L3252 Shoe molded plastazote cust each L6881 L3253 Shoe molded plastazote cust each L6882 L3254 L3255 L3257 L3330 Orth foot non-std size/w Orth foot non-std size/w Orth foot add charge split Lift elevation, metal extension, (skate) each L6895 L6900 L6905 L6910 Automatic grasp, addt. To upper limb elect. Prosth. Terminal device Microprocessor control feature, addt. To upper limb prosth. Terminal device Custom glove Hand restorat thumb/1 finger Hand restoration multiple fi Hand restoration no fingers Page 84 of 331 Suction socket Frame typ socket shoulder di Frame typ sock interscap-tho Locking elbow forearm cntrbal Add. To upper ext. pros.,for use with locking mechanism Add. To upper ext. pros., not for use with locking mechanism, custom Add. To upper ext. pros., congenital or atypical traumatic amputees, initial only Add. To upper ext. pros., other than congenital or traumatic amputees, initial only term dev hook, mech vol closing, any material, any size, lined or unlined term dev, hand, mech vol opening, any material, any size term dev hand, mech vol. closing, any material, any size Terminal device, hook,mechanical vol. closing, any material, any size, lined or unlined, Pediatric, each Terminal device, hand, mechanical, vol. opening, any material, any size,lined or unlined, Pediatric, each Terminal device, mechanical, vol. closing, any material, any size, Pediatric, each terminal device, hook or hand, hvy, dty., mechanical, vol.opening, any material, any size, lined or unlined, each L3649 L3671 L3702 orthopedic shoe modification NOS Shoulder othosis, cap design w/o joints elbow orthosis w/o joints, may include soft interface, straps, custom fabricated incl. fitting & adj. L6915 L6920 L6925 Hand restoration replacmnt g Wrist disarticul switch ctrl Wrist disart myoelectronic c L3720 L3730 L3740 L3763 Forearm/arm cuffs free motio Forearm/arm cuffs ext/flex a Cuffs adj lock w/ active con elbow wrist hand orthosis rigid w/o joints custom fab incl. fitting & adj. WHFO, incl. 1 or more nontorsion joints. Custom WHFO, rigid w/o joints, custom, Addt. to upper ext. joint, wrist, or elbow, custom fabricated only, each Hinge extension/flex wrist/f Hinge ext/flex wrist finger Whfo electric custom fitted wrist/hand orthosis custom L6930 L6935 L6940 L6945 Below elbow switch control Below elbow myoelectronic ct Elbow disarticulation switch Elbow disart myoelectronic c L6950 Above elbow switch control L6955 L6960 Above elbow myoelectronic ct Shldr disartic switch contro L6965 L6970 L6975 L7007 L3906 L3907 L3913 Wrist hand orthosis, w/o joints, custom Whfo wrist gauntlt thmb spica Hand finger orthosis, w/o joints, may include soft interface, straps, custom fabricated, incl fitting & adjustment, each L7008 L7009 L7040 Shldr disartic myoelectronic Interscapular-thor switch ct Interscap-thor myoelectronic elect. Hand, myoelectric or switch, adult elect. Hand, myoelectric or switch, ped elect hook, switch or myoelect, adult Prehensile actuator switch controlled L3927 L7045 Electric hook, switch or myoelectric controlled, pediatric L7170 Electronic elbow hosmer swit L7180 Electronic elbow utah myoele L3960 Finger orthosis, PIP/DIP, non-torsion w/o joint/spring, ext./flex., pre-fab, incl fitting & adj., each Finger orthosis, w/o joints, may include soft interface, custom fabricated, incl. fitting & adjustment, each addt. Of joint to upper ext orth. any material, per joint Sewho airplan desig abdu pos L7181 L3962 Sewho erbs palsey design abd L7185 L3964 L3965 L3966 L3968 L3969 L3971 Seo mobile arm sup att to wc Arm supp att to wc rancho ty Mobile arm supports reclinin Friction dampening arm supp Monosuspension arm/hand supp SEHWO, shoulder cap design, custom fabricated L7186 L7190 L7191 L7260 L7261 L7266 electronic elbow, sim. Control of elbow and terminal device electronic elbow, sim. Variety Village or equal switch control Electron elbow child switch Elbow adolescent myoelectron Elbow child myoelectronic ct Electron wrist rotator otto Electron wrist rotator utah Servo control steeper or equ L3806 L3808 L3891 L3900 L3901 L3904 L3905 L3933 L3956 Page 85 of 331 L3999 L7272 Analogue control unb or equa L7274 L7499 Proportional ctl 12 volt uta Upper extremity prosthesis NOS L4010 L4020 L4030 Upper limb orthosis, not otherwise specified Repl girdle milwaukee orth Replacement strap, any orthosis, includes all components, any lgth., any type Replace trilateral socket brim Replace quadlat socket brim Replace socket brim cust fit L7500 L7510 L7520 L4040 L4050 L4205 L4210 Replace molded thigh lacer Replace molded calf lacer Repair orthotic device per 15 min labor repair or replace minor parts L7600 L7900 L8000 L8001 L5000 Sho insert w arch toe filler L8002 L5010 L5020 L5050 Mold socket ank hgt w/ toe f Tibial tubercle hgt w/ toe f Ank symes mold sckt sach ft L8020 L8030 L8031 L5060 L5100 L5105 Symes met fr leath socket ar Molded socket shin sach foot Plast socket jts/thgh lacer L8035 L8039 L8040 L5150 Mold sckt ext knee shin sach L8041 L5160 Mold socket bent knee shin s L8042 L5200 Knee sing axis fric shin sach L8043 L5210 No knee/ankle joints w/ ft b L8044 L5220 No knee joint with artic ali L8045 L5230 Fem focal defic constant fri L8046 L5250 Hip canadian sing axi cons fric L8047 L5270 Tilt table locking hip sing L8048 L5280 Hemipelvect canadian sing axis L8049 Prosthetic dvc repair hourly Repair of prosthetic device, minor parts Repair prosthetic device, labor component, per 15 min Prosthetic donning sleeve, any material Vacuum erection system Mastectomy bra - 5 per year Breast prosthesis , masectomy bra with integrated breast prothesis form, unilateral - 5 per year Breast prosthesis, masectomy bra with integrated breast prothesis form, bilateral - 5 per year Mastectomy form - 2 per year Breast prosthesis silicone/e - 2 per year Breast prosthesis, silicone or equal, with intergral adhesive, each Custom breast prosthesis Breast prosthesis, NOS Nasal prothesis, provided by a nonphysician Midfacial prothesis, provided by a nonphysician Orbital prothesis, provided by a nonphysician Upper facial prosthesis, provided by a non-physician Hemi-facial prosthesis, provided by a non-physician Prosthetic External Ear provided by a non-physician Partial facial prosthesis, provided by a non-physician Nasal septal prosthesis, provided by a non-physician Unspecified Maxillofacial Prosthesis, by a non-physician Repair or modification of maxillofacial prosthesis, by a non-physician L4000 L4002 Page 86 of 331 L5301 L8499 Unlisted Misc prosthetic service L8500 artifical larynx L8501 Tracheostomy speaking valve L8505 Artificial larynx replacement battery/accessory, any type, each L8619 cochlear implant external speech processor replacement L5400 Below Knee molded socket, shin each foot, endosketal system Knee disarticulation , molded socket, external knee joints, shin,sach foot endo Above Knee, molded socket, open end, sach foot, endoskelttal system, single axis knee Hip disarticulation, Canadian type, molded socket endoskeletal system, hip joint, single Hemipelvectomy, Canadian type, molded socket, endoskeletal hip joint single axis knee Postop dress & 1 cast chg bk L8627 L5410 Postop dsg bk ea add cast ch L8628 L5420 Postop dsg & 1 cast chg ak/d L8629 Cochlear implant, external speech processor, component, replacement Cochlear implant, external controller component, replacement Transmitting coil and cable, integrated for use with cochlear implant device, replacement L5430 Postop dsg ak ea add cast ch L8691 L5450 Postop app non-wgt bear dsg L5311 L5321 L5331 L5341 auditory osseointegrated dev, ext. sound replacer, repl only AUTHORIZATION NOT REQUIRED HCPCS L0120 L0140 L0150 L0160 Description Cerv flexible non-adjustable Cervical semi-rigid adjustab Cerv semi-rig adj molded chn Cerv semi-rig wire occ/mand HCPC L3670 L3675 L3710 L3760 L0172 Cerv col thermplas foam 2 piece L3762 L0174 Cerv col foam 2 piece w thor L3807 L0180 L0190 Cer post col occ/man sup adj Cerv collar supp adj cerv ba - 1 Per Year * Cerv col supp adj bar & thor - 1 per L3908 L3912 Description Acromio/clavicular canvas&we Canvas vest SO Elbow elastic with metal joi Elbow orthosis, adj position locking joints, prefab, inc fitting and adj Elbow orthosis rigid, w/o joints, prefab, soft interface, incl. Fitting/adj. WHFO w/o joints, prefab includes fitting and adjustments any type Wrist cock-up non-molded Flex glove w/elastic finger L3915 WHFO, rigid with 1 or more joints, L0200 Page 87 of 331 L0450 L0454 L0466 year * TLSO flexible, provides trunk support, uper thoracic region, prefab TLSO, Flexible, provides trunk support, sacrococcygeal juntion to T-9, prefab TLSO Sagittal control, prefab L3917 L3923 L3925 prefab, hand orthosis, metacarpal fracture orthosis, prefab, incl fitting and adj. Hand finger orthosis, without joint, prefab, inc fitting and adj Finger orthosis, PIP/DIP, non-torsion joint/spring, ext./flex., pre-fab, incl fitting & adj., each Hand finger orthosis, incl. 1 or more nontorsion joints, turnbuckles, elastic bands/spring, straps, pre-fab, incl. fitting & adj., each L0468 TLSO sagittal-coronol control, rigid posterior frame - 1 per year * L3929 L0470 TLSO triplanar control - 1 per year * L3931 Wrist, hand, finger orthosis, incl. 1 or more nontorsion joints,turnbuckles, elastic bands/springs, straps, pre-fab, incl. fitting & adj., each L0472 TLSO, triplanar control, hyperextension prefab - 1 per year * TLSO sagittal coronal control one piece prefab TLSO 3 rigid plastic shells, pre fab - 1 per year * Sacroiliac orthosis, flexible, pre fab Lumbar orthosis, flexible, pre fab Lumbar orthosis, sagittal control, pre fab Lumbar orthosis, sagittal control with rigid ant./post. Panels, pre fab Lumbar-sacral orthosis, flexible, pre fab Lumbar-sacral orthosis, sag. Control, pre fab Lumbar-sacral orthosis, sag. Control, rigid post., pre fab Tlso corset front Lso corset front Tlso full corset Lso full corset Axillary crutch extension Peroneal straps pair Stocking supp grips set of 4 Protective body sock each Ctlso axilla sling Kyphosis pad Kyphosis pad floating Lumbar bolster pad L3970 Elevat proximal arm support L3972 Offset/lat rocker arm w/ ela L3974 Mobile arm support supinator L3980 L3982 L3984 Upp ext fx orthosis humeral Upper ext fx orthosis rad/ul Upper ext fx orthosis wrist L3995 L4045 L4055 Add. To upper ext. sock, fracture, or equal, each Replace non-molded thigh lac Replace non-molded calf lace L4060 Replace high roll cuff L4070 L4080 L4090 L4100 L4110 L4130 L4350 L4360 L4370 L4380 L4386 L4394 Replace prox & dist upright Repl met band kafo-afo prox Repl met band kafo-afo calf/ Repl leath cuff kafo prox th Repl leath cuff kafo-afo cal Replace pretibial shell Pneumatic ankle cntrl splint Pneumatic walking splint Pneumatic full leg splint Pneumatic knee splint Non-pneumatic walking boot Replacement Foot Drop Splint L0490 L0492 L0621 L0625 L0626 L0627 L0628 L0630 L0633 L0970 L0972 L0974 L0976 L0978 L0980 L0982 L0984 L1010 L1020 L1025 L1030 Page 88 of 331 L1040 L1050 L1060 L1070 L1080 L1085 L1090 L1100 L1110 L4396 L4398 L5617 L5618 L5620 L5622 L5624 L5626 L5628 Static AFO Foot drop splint recumbent AK/BK self-aligning unit ea Test socket symes Test socket below knee Test socket knee disarticula Test socket above knee Test socket hip disarticulat Test socket hemipelvectomy L5629 L5630 L5631 L5632 L5634 L5636 L5637 L5638 L5640 L5642 L5644 L5646 L5650 L5652 L5653 L5654 L5655 L5656 L5658 L5661 L5665 Below knee acrylic socket Syme typ expandabl wall sckt Ak/knee disartic acrylic soc Symes type ptb brim design s Symes type poster opening so Symes type medial opening so Below knee total contact Below knee leather socket Knee disarticulat leather so Above knee leather socket Above knee wood socket Below knee air cushion socket Tot contact ak/knee disart s Suction susp ak/knee disart Knee disart expand wall sock Socket insert symes Socket insert below knee Socket insert knee articulat Socket insert above knee Multi-durometer symes Multi-durometer below knee L1847 L1850 L1900 Lumbar or lumbar rib pad Sternal pad Thoracic pad Trapezius sling Outrigger Outrigger bil w/ vert extens Lumbar sling Ring flange plastic/leather Ring flange plas/leather molded to patient Covers for upright each Lateral thoracic extension Anterior thoracic extension Milwaukee type superstructur Lumbar derotation pad Anterior asis pad Anterior thoracic derotation pad Abdominal pad Rib gusset (elastic) each Lateral trochanteric pad Abduct hip flex frejka w cvr Abduct hip flex frejka covr Abduct hip flex pavlik harne Abduct control hip semi-flex Pelv band/spread bar thigh c HO abduction hip adjustable HO abduction static plastic KO elastic with joints KO elas w/ condyle pads & jo KO immobilizer canvas longit KO locking knee joint pre fab incl. Fitting and adj. KO adjustable w air chambers KO swedish type AFO sprng wir drsflx calf bd L5666 L5668 L5671 L1902 L1906 L1910 L1920 L1930 AFO ankle gauntlet AFO multiligamentus ankle su AFO sing bar clasp attach sh AFO sing upright w/ adjust s AFO plastic or other material, includes L5672 L5676 L5677 L5678 L5680 Below knee cuff suspension Socket insert w/o lock lower Addition to lower extremity, below knee/above knee suspension locking mechanism Bk removable medial brim sus Bk knee joints single axis pair Bk knee joints polycentric pair Bk joint covers pair Bk thigh lacer non-molded L1120 L1210 L1220 L1230 L1240 L1250 L1260 L1270 L1280 L1290 L1600 L1610 L1620 L1630 L1640 L1650 L1660 L1810 L1820 L1830 L1831 Page 89 of 331 L2035 fitting & adjustment plastic or other material w/ankle joint, prefab, incl. Fitting and adj. KAFO plastic pediatric size L2040 Hkafo torsion bil rot straps L5686 L2112 L2114 L2180 L2182 L2184 L2186 L2188 L2190 L2192 L2200 L2210 L2220 L2230 L2240 L5688 L5690 L5692 L5694 L5695 L5696 L5697 L5698 L5699 L5710 L5711 L5712 L5714 L5785 L2250 L2260 L2265 L2270 L2275 AFO tibial fracture soft, pre-fab AFO tib fx semi-rigid, pre-fab Plas shoe insert w ank joint Drop lock knee Limited motion knee joint Adj motion knee jnt lerman t Quadrilateral brim Waist belt Pelvic band & belt thigh fla Limited ankle motion ea jnt Dorsiflexion assist each joi Dorsi & plantar flex ass/res Split flat caliper stirr & p Addt. To lower extremity orthosis, round caliper & plate attachment Foot plate molded stirrup at Reinforced solid stirrup Long tongue stirrup Varus/valgus strap padded/li Plastic mod low ext pad/line L2300 L2310 L2320 L2335 L2360 L2370 Abduction bar jointed adjust Abduction bar-straight Non-molded lacer Anterior swing band Extended steel shank Patten bottom L5920 L5925 L5940 L5962 L5970 L5971 L2375 L2380 L2385 L2387 Torsion ank & half solid sti Torsion straight knee joint; Straight knee joint heavy du Addt. to lower extremity, polycentric knee joint, for custom fabricated KAFO, each joint Offset knee joint each L5972 L5974 L5975 L5978 Endoskel knee-shin mnl lock Endo knee-shin frct swg & st Endo ak/hip knee extens assi Mech hip extension assist Addt. Endoskeleton, below knee, alignable system Endo ak/hip alignable system Above knee manual lock Endo bk ultra-light material Below knee flex cover system Foot external keel sach foot All lower extremity prosthesis, SACH foot, replacement only Flexible keel foot Foot single axis ankle/foot Combo ankle/foot prosthesis Ft prosth multiaxial ankl/ft L5982 Exoskeletal axial rotation L1971 L2390 L5684 Bk fork strap L5685 Addt. To lower ext. orthosis, below knee, susp./sealing sleeve, any mat. Each below knee back check extension control Bk waist belt webbing Bk waist belt padded and lin Ak pelvic control belt light Ak pelvic control belt pad/l Ak sleeve susp neoprene/equa Ak/knee disartic pelvic join Ak/knee disartic pelvic band Ak/knee disartic silesian ba Shoulder harness Kne-shin exo sng axi mnl loc Knee-shin exo mnl lock ultra Knee-shin exo frict swg & st Knee-shin exo variable frict Exoskeletal bk ultralt mater L5810 L5812 L5850 L5855 L5910 Page 90 of 331 L2395 Offset knee joint heavy duty L5984 L2397 L2405 L2415 L2425 L2430 L2492 L2500 L2530 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2630 L2640 L2650 L2660 L2670 L2680 L2750 L2755 L5985 L5986 L6386 L6388 L6600 L6605 L6610 L6615 L6616 L6620 L6625 L6628 L6629 L6630 L6632 L6635 L6637 L6640 L6641 L6642 L6645 L6650 L6655 L6660 L2760 L2780 L2785 L2795 L2800 L2810 L2820 L2830 L2840 L2850 Suspension sleeve lower ext Knee joint drop lock ea jnt Knee joint cam lock each joi Knee disc/dial lock/adj flex Knee jnt ratchet lock ea jnt Knee lift loop drop lock rin Thi/glut/ischia wgt bearing Thigh/wght bear lacer non-mo Thigh/wght bear high roll cu Hip clevis type 2 posit jnt Pelvic control pelvic sling Hip clevis/thrust bearing fr Hip clevis/thrust bearing lo Pelvic control hip heavy dut Hip joint adjustable flexion Hip adj flex ext abduct cont Pelvic control band & belt u Pelvic control band & belt b Pelv & thor control gluteal Thoracic control thoracic ba Thorac cont paraspinal uprig Thorac cont lat support upri Plating chrome/nickel pr bar Addt. Lower ext.,high strength, custom fab. Only Extension per extension per Non-corrosive finish per bar Drop lock retainer each Knee control full kneecap Knee cap medial or lateral p Knee control condylar pad Soft interface below knee se Soft interface above knee se Tibial length sock fx or equ Femoral lgth sock fx or equa L3000 L3001 L3002 foot insert Berkeley shell, each foot insert Spenco, each foot insert, Plastazote , each L6691 L6692 L6698 L6665 L6670 L6672 L6675 L6676 L6680 L6682 L6684 L6687 L6688 Page 91 of 331 Endoskeletal axial rotation, w/wo adjustability Lwr ext dynamic prosth pylon Multi-axial rotation unit Postop ea cast chg & realign Postop applicat rigid dsg on Polycentric hinge pair Single pivot hinge pair Flexible metal hinge pair Disconnect locking wrist uni Disconnect insert locking wr Flexion-friction wrist unit Rotation wrst w/ cable lock Quick disconn hook adapter o Lamination collar w/ couplin Stainless steel any wrist Latex suspension sleeve each Lift assist for elbow Nudge control elbow lock Shoulder abduction joint pai Excursion amplifier pulley t Excursion amplifier lever ty Shoulder flexion-abduction joint, each Shoulder universal joint, each Standard control cable extra Heavy duty control cable Teflon or equal cable lining Hook to hand cable adapter Harness chest/shlder saddle Harness figure of 8 sing con Harness figure of 8 dual con Test sock wrist disart/bel e Test sock elbw disart/above Test socket shldr disart/tho Frame typ socket bel ow elbow or wrist Frame typ sock above elbow or elbow disarticulation Removable insert each Silicone gel insert or equal Add. To upper ext. pros., lock mechanism, excludes socket insert L3003 foot insert, Silicone gel , each L6703 L3010 Longitudinal Arch support each L6704 L3020 Foot longitud/metatarsal supp L6706 L3030 Foot arch support remov prem L6711 L3040 L6805 L3100 Foot arch support remov premolded longitudinal, each Hallus-valgus night dynamic splint L3140 L3150 L3160 L3170 Abduction rotation bar shoe Abduction rotation bar w/o shoe Shoe styled postioning device Foot plastic heel stablizer L6890 L7360 L7362 L7364 L3260 Ambulatory surgical boot each L7366 L3265 L3300 Plastazole sandal each Lift, Elevation Heel, Tapered to Metata L7367 L7368 L3310 Shoe lift elev heel/sole neo L7400 L3320 shoe lift elev heel/sole cor L7401 L3332 Shoe lift inside tapered up to 1/2 inch L7403 L3334 Shoe, lift elevation, heel, per inch, each L7404 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 shoe wedge sach shoe sole wedge shoe sole wedge outside sole shoe sole wedge between sole shoe clubfoot wedge shoe outflare wedge shoe metarsal bar wedge shoe metarsal bar between full sole/heel wedge btween shoe heel count plast reinforc L8010 L8015 L8300 L8310 L8320 L8330 L8400 L8410 L8415 L8417 L3440 L3450 heel leather reinforced shoe heel sach cushion type L8420 L8430 L6810 Page 92 of 331 term. Device, passive hand mitt, any material, any size term. Device, sport/rec/work, any material, any size term dev hook, mech vol opening, any material, any size Terminal device, hook, mechanical, vol. opening, any material, any size, lined or unlined, Pediatric, each Modifier wrist flexion unit addt to terminal device Addt to terminal device, precision pinch device Production glove Six volt battery, each Battery charger, six volt, each Twelve volt battery , each - 2 per year * Battery charger 12 volt each - 1 per 4 years * lithium ion battery replacement Lithium battery charger - 1 per 4 years * Addt. To upper ext. prosth. Ultralight material Addt. To upper ext. prosthesis above elbow disart. Ultralight material Addt. To upper ext. prosth. acrylic material addt. To upper ext prosth. Above elbow disart. Acrylic Mastectomy sleeve Ext breast prosthesis garment Truss single w/ standard pad Truss double w/ standard pad Truss addition to std pad wa Truss add to std pad scrotal Sheath below knee Sheath above knee Sheath upper limb Prosthetic sheath/sock, incl. gel cushion layer, below knee or above knee, each Prosthetic sock multi ply BK Prosthetic sock multi ply AK L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 shoe heel new leather standard shoe heel new rubber standard shoe heel thomas with wedge shoe heel thomas extend to B shoe heel pad &depress for shoe heel pad removeable for ortho shoe add leather insol orthopedic shoe add rub insl L8435 L8440 L8460 L8465 L8470 L8480 L8485 L8507 L3520 ortho shoe add felt w leather insol L8509 L3530 L3540 ortho shoe add half sole ortho shoe add full sole L8510 L8511 L3550 ortho shoe add standard toe tap L8512 L3560 ortho shoe add horseshoe toe tap L8513 L3570 ortho shoe add instep extension L8514 L3580 ortho shoe add instep velcro clos L8515 L3590 ortho shoe convert firm to soft count L8615 L3595 ortho shoe add march bar L8616 L3600 Trans shoe calip plate exist L8617 L3610 Trans shoe caliper plate new L8618 L3620 Trans shoe solid stirrup existing L8621 L3630 Trans shoe solid stirrup new L8622 L3640 Shoe Dennis Browne splint both L8623 L3650 Shlder fig 8 abduct restrain L8624 L3660 Abduct restrainer canvas&web L8695 Page 93 of 331 Pros sock multi ply upper lm Shrinker below knee Shrinker above knee Shrinker upper limb Pros sock single ply BK Pros sock single ply AK Pros sock single ply upper l Tracheo-esophageal voice prosthesis, patient inserted, any type Tracheo-esophageal voice prosthesis, inst. by lic. Health care provider, any type Voice Amplifier Insert for Indwelling T/E prosthesis with or W/O valve replacement each Gelatin capsules or equ. use with T/E prosthesis replacement only per 10 Cleaning device used with T/E prosthesis replacement only each T/E puncture dilator replacement only each gelatin capsule application device for use with TE voice prosthesis, each Headset/Headpiece for use with cochlear implant device, replacement microphone for use with cochlear implant device, replacement transmitting coil for use with cochlear implant device, replacement transmitter cable for use with cochlear implant device, replacement Zinc air battery for use with cochlear implant device, each Alkaline batt. For use with coch. Imp. Device, any size,each Lithium ion battery coch. imp. Device speech proc.other than Ear level, ea Lithium ion battery for coch. imp. Device speech proc. Ear level, each ext recharging sys for battery(ext) for use with implantable neurostimulator Appendix C – Ostomy Supplies Any request that exceeded $500.00 will require prior authorization. A4421 A4465 A4466 A4483 A4600 A4601 A4649 A4366 AUTHORIZATION REQUIRED Ostomy supply, miscellaneous Non elastic binder for extremity Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each Moisture exchanger, disposable, for use with invasive mechanical ventilation, each sleeve for intmt. Limb compression device, replac. only Lithium ion battery for non-prosthetic use, repl. Only Surgical Supply, Miscellaneous Authorization is required Authorization is required Authorization is required Ostomy vent, any type, each Authorization required > 1 per calendar month Authorization required > 1 per calendar month Authorization required > 1 per calendar month Authorization required > 10 per calendar month Authorization required > 20 per calander month Authorization required > 4 per year Authorization required > 4 per year Authorization required > 4 oz per calendar month Authorization required > 4 per calendar month Authorization required > 6 per year Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Ostomy belt A4400 Ostomy irrigation set A4404 Ostomy ring each A4362 Solid skin barrier A4398 Ostomy irrigation bag A4399 Ostomy irrig cone/cath w brs A4402 Lubricant price is per oz. 1 oz.=1 unit A4397 Irrigation supply sleeve A4361 Ostomy face plate A4416 Ostomy pouch, closed, w/barrier att. W/filter 1 pc. Each A4417 Ostomy pouch,closed, w/barrier att.,w/built-in convexity, w/filter 1 pc, each Ostomy pouch,closed, w/o barrier att. W/filter 1 pc. Each A4419 A4420 Authorization is required Authorization is required Authorization is required AUTHORIZATION REQUIRED IF QUANTITY LIMIT IS A4367 A4418 Authorization is required Ostomy pouch, closed, use on barrier w/non-lock flange,w/filter 2pc, each Ostomy pouch, closed, use on barrier with lock flange 2 pc, each Page 94 of 331 A4423 Ostomy pouch closed, 2 pc. Locking flange, each A4424 Ostomy pouch, drainable,w/barrier 1 pc, each A4425 Ostomy pouch drainable, non-locking flange 2 pc each A4426 Ostomy pouch, drainable, with locking flange, 2 pc. Each A4427 A4428 Ostomy pouch, drainable , use on barrier w/locking flange, w/filter 2 pc, each Electrodes, apnea monitor, per pair A4429 Ostomy pouch, urinary w/convexity, faucet type tap, each A4430 ostomy pouch urinary, ext. wear, convexity, faucet tap, each A4431 ostomy pouch, urinary, w/barrier, faucet type tap, w/valve ea. A4432 ostomy pouch, urinary, non-locking flange, faucet type, ea. A4433 ostomy pouch, urinary, w/locking flange, ea. A4434 ostomy pouch, urinary, w/locking flange, w/faucet type tap ea. A4624 Tracheal suction tube A4625 Trach care kit for new trach A5082 Continent stoma catheter A5093 Ostomy accessory convex inse A4626 Tracheostomy cleaning brush A5061 Pouch drainable w barrier at A5062 Drnble ostomy pouch w/o barr A5063 Drain ostomy pouch w/flange A5071 Urinary pouch w/barrier A5072 Urinary pouch w/o barrier A5073 Urinary pouch on barr w/flng Page 95 of 331 Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 60 per calendar month Authorization required > 91 per calendar month Authorization required if > 1 per calendar month Authorization required if > 1 per calendar month Authorization required if > 10 per calendar month Authorization required if > 2 per calendar month Authorization required if > 20 per calendar month Authorization required if > 20 per calendar month Authorization required if > 20 per calendar month Authorization required if > 20 per calendar month Authorization required if > 20 per calendar month Authorization required if > 20 per calendar month A4623 Tracheostomy inner cannula A5055 Stoma cap A5081 Continent stoma plug A4455 Adhesive remover per ounce A5051 Pouch clsd w barr attached A5052 Clsd ostomy pouch w/o barr A5053 Clsd ostomy pouch faceplate A5054 Clsd ostomy pouch w/flange A4392 A4363 A4364 A4365 A4368 A4369 A4371 A4372 A4373 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4384 A4385 A4387 A4388 A4389 A4390 A4391 A4393 A4394 A4395 A4396 Authorization required if > 31 per calendar month Authorization required if > 31 per calendar month Authorization required if > 31 per calendar month Authorization required if > 32 ounces Authorization required if > 60 per calendar month Authorization required if > 60 per calendar month Authorization required if > 60 per calendar month Authorization required if > 60 per calendar month AUTHORIZATION NOT REQUIRED Urinary pouch w st wear barr Ostomy clamp, any type , each Adhesive, liquid or equal, any type, per ounce Ostomy adhesive remover wipe Ostomy filter Skin barrier liquid per oz Skin barrier powder per oz Ostomy Skin barrier solid 4x4 equiv Skin barrier with flange Drainable plastic pch w fcpl Drainable rubber pch w fcplt Drainable plstic pch w/o fp Drainable rubber pch w/o fp Urinary plastic pouch w fcpl Urinary plastic pouch w/o fp Ostomy pouch, urinary, for use on faceplate, plastic, each Urinary hvy plstc pch w/o fp Urinary rubber pouch w/o fp Ostomy faceplt/silicone ring Ost skn barrier sld ext wear Ost clsd pouch w att st barr Drainable pch w ex wear barr Drainable pch w st wear barr Drainable pch ex wear convex Urinary pouch w ex wear barr Urine pch w ex wear bar conv Ostomy pouch liq deodorant w/wo lubricant Ostomy pouch solid deodorant Ostomy belt with peristomal hernia support Page 96 of 331 No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required A4405 A4406 A4407 A4408 A4409 A4410 A4411 A4412 A4413 A4414 A4415 A4450 A4452 A4456 A4481 A4556 A4557 A4558 A4561 A4562 A4565 A4566 A4595 A4604 A4605 A4606 A4608 A4611 A4612 A4613 A4614 A4618 A4619 A4627 A4628 A4629 A4630 A4635 A4636 A4637 Ostomy skin barrier, non-pectin based, paste, per oz Ostomy skin barrier, pectin based, per oz Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 or < Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 or > Ostomy skin barrier with flange Ostomy skin barrier, with fl, ex wear, without built in convexity, >4x4 ea Ostomy skin barrier, solid 4x4 or eq. ext. wear, built in convexity, each Ostomy pouch, drainable, high otpt, use on barrier w/ o filter each Ostomy pouch, drainable, high otpt, use on barrier w/ fl with filter ea Ostomy skin barrier, with fl, w/o built in convexity 4x4 or < Ostomy skin barrier, with fl, w/o built in convexity 4x4 or > Tape, non-water proof, 18 sq inches Tape, water proof , 18 sq inches Adhesive remover, wipes, any type, each Tracheostoma filter Electrodes, apnea monitor, per pair Lead wires, apnea monitor per pair Conductive paste or gel for use with electrical device E.G. tens Pessary, rubber, any type Pessary, nonrubber, any type Slings Canvas vest SO TENS suppl 2 lead per month tubing with integrated heat use with pos. airway pressure device Tracheal suction catheter, closed system, each Oximeter probe replacement Transtracheal oxygen catheter, each Heavy duty battery, Ventilator, replacement for patient owned Battery cables Battery charger Hand-held PEFR meter Breathing circuits Face tent Spacer, bag or reservoir for inhaler Oropharyngeal suction cath Tracheostomy care kit Repl bat t.e.n.s. own by pt Underarm crutch pad Handgrip for cane etc Repl tip cane/crutch/walker Page 97 of 331 No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required No authorization required A4640 A5083 Alternating pressure pad Continent device, stoma absorptive cover for continent device, each Page 98 of 331 No authorization required No authorization required Provider Manual Section 6.0 Referrals Table of Contents 6.1 Member Self-Referral (Direct Access) 6.2 Referral Requirements 6.3 Distribution of Referrals Page 99 of 331 6.0 Referrals 6.1 Member Self-Referral (Direct Access) There are a number of services covered by Passport Health Plan for which members can make appointments with participating Passport Health Plan providers without referrals from their PCP. These include: • • • • • • • • • • • • Routine vision care services, including diabetic retinal exams and the fitting of eyeglasses provided by ophthalmologists, optometrist, and opticians. Routine dental services and oral surgery services and evaluations by orthodontists and prosthodontists (orthodontic and prosthodontic services require prior authorization). Maternity care (authorization is required after the first prenatal visit). Immunizations for members younger than 21 years of age. Screening, evaluation, and treatment for sexually transmitted diseases. Screening, evaluation, and treatment for tuberculosis. Chiropractic services up to 12 visits. Testing for HIV, HIV-related conditions, and other communicable diseases. Pap smears and mammograms. GYN services, including Pap smears and mammograms. Voluntary Family Planning in accordance with federal and state laws and judicial opinion Routine outpatient behavioral health services do not require a PCP referral. Please see section 16.5 (Authorization Procedures and Requirements) for those requiring prior authorization. NOTE: For family planning services, members may self-refer to any participating Medicaid provider. For more information, please refer to Section 17, “Family Planning.” 6.1.1 Additional Referral Exceptions In addition to the direct access services outlined above, members do not need referrals for the following: • • Services provided by the Commission for Children with Special Health Care Needs or the WINGS Clinic. The following list of diagnoses (when billed as the primary diagnosis): CODE ESRD 585 586 HIV/AIDS 042 79.51 79.52 79.53 CANCER 140-208 DESCRIPTION Chronic Kidney Disease (CKD) Renal failure, unspecified Human immunodeficiency (HIV) disease Human T-cell lymphotrophic virus, type I (HTLV-I) Human T-cell lymphotrophic virus, type II (HTLV-II) Human immunodeficiency virus, type 2 (HIV-2) Malignant Page 100 of 331 230-234.0 235-238 239 – 239.9 • • • Carcinoma in situ Neoplasm of uncertain behavior Neoplasm of unspecified behavior Diabetic retinal exams. OB/GYN services (Authorization is required after the first prenatal visit). Perinatologists/geneticists. The following referral exceptions also apply: • • • • One lifetime referral is required for each transplant. Referrals to specialists are not required for children in foster care or living in out-of-home placements. Referrals are not required for participating orthopedists. Referrals are not required for members with Medicare or Tricare as the primary payer. 6.2 Referral Requirements Passport’s referral requirements are based on the premise that our members are best served with a primary home for care and oversight, thus the PCP is responsible for coordinating the member’s health care. Except as outlined in Sections 7.1 and 7.1.1, if the member needs to see a specialist, the PCP will complete and issue a referral to the specialist.* • • • • • • • • PCP referrals can only be made to participating specialists, unless the necessary service is not available from participating Passport Health Plan practitioners. Prior approval by Utilization Management is not required for referrals to participating providers, but a referral must be completed. For referrals to a nonparticipating specialist, the PCP must request prior authorization from Passport Health Plan’s Utilization Management department. The PCP should verify that the specialist accepts Kentucky Medicaid. Requests for retrospective review of inpatient services provided by nonparticipating providers require review and authorization by Utilization Management. Cases requiring follow-up visits or treatment by nonparticipating providers that were not prior authorized must be reviewed by Utilization Management. Referrals for consultation, diagnostic studies and treatment are valid for a time span indicated by the referring provider (three, six, nine, or 12 months) with unlimited visits. The PCP may also designate a visit limit if preferred. If a referral is designated as consultation, diagnostic studies, and treatment, it is also valid for any outpatient testing or procedures that are ordered by the specialist unless those services are listed on the Passport Health Plan prior-authorization list. Passport Health Plan members have the right to a second opinion. If the member requests a second opinion, the PCP should complete a referral to a participating specialist. If there is not a specialist within the network, the PCP can request an authorization to a nonparticipating specialist by calling Passport Health Plan’s Utilization Management department at (800) 578-0636. *An exception occurs when a member is new to Passport (in the first 30 days after enrollment) and has not yet selected or been assigned to a PCP. Under these circumstances, if a member requires Page 101 of 331 specialist care, a participating specialist provider may contact the UM department to request authorization of a one-time visit without a referral. NOTE: Please refer to the Passport Health Plan Real-Time Provider Directory on www.passporthealthplan.com to verify participating providers. Occasionally, a referral will be made following a telephone conversation between the member and the PCP who determines the need for specialty care. When a verbal referral is made, it is the PCP’s responsibility to follow up with either an electronic or paper referral. Members may not obtain a referral to a specialist when the PCP can perform the services. 6.2.1 Referral for Urgent Care A referral is required for all urgent care visits except as indicated below: • If it is Saturday, Sunday, a national holiday, or a weekday after 4 p.m., Passport Health Plan members may go to specified urgent care centers. For the latest listing of participating centers, please reference Passport’s website (in process). 6.2.2 Original Medicare Primary Member Referrals Passport Health Plan members who are covered by Medicare or TriCare as their primary insurance are not required to have referrals for specialist care and may go to any participating or nonparticipating practitioner, as set forth in this Provider Manual. These members have a Passport Health Plan identification card with “Medicare Primary” as the PCP. Providers will be paid on a feefor-service basis for all covered services provided to Passport Health Plan members who are also covered by Medicare or Tricare. Providers are required to bill Medicare or Tricare first and only submit to Passport Health Plan the coinsurance and deductible amounts or those amounts not covered by their primary insurance as shown on the EOB. 6.3 Distribution of Referrals Passport Health Plan currently offers two options for the initiation and submission of referrals. While paper referral forms remain an option at this time, providers are strongly encouraged to use the electronic submission process available at www.passporthealthplan.com or by logging onto NaviNet at https://navinet.navimedix.com. Distribution of forms is based on the selected method and detailed below: • Electronic Referrals initiated via the web-based program are automatically transmitted to Passport. PCPs should print three copies of the referral to be distributed as follows: Specialist copy (to be sent with member or mailed to a specialist). Member’s copy. PCP’s copy (to be placed in member’s chart). • Paper (See Section 19 for a sample form.) Page 102 of 331 Completed referral forms should be distributed as follows: Copy 1 - Send to Passport Health Plan immediately at: Passport Health Plan P.O. Box 7114 London, KY 40742 Copy 2 - Specialist copy (to be sent with member or mailed to specialist). Copy 3 - Patient’s copy. Copy 4 - PCP’s copy (to be placed in member’s chart). Responsibilities of the specialist or consulting practitioner: • Retain copy of referral form for the member’s file. • Send a copy of the consult report to the PCP. Page 103 of 331 Provider Manual Section 7.0 Benefit Summary and Exclusions Table of Contents 7.1 Benefit Summary 7.2 Services Covered Outside Passport Health Plan 7.3 Non-Covered Services Page 104 of 331 7.0 Benefit Summary and Exclusions 7.1 Benefit Summary Basic services covered under Passport Health Plan include, but are not limited to: • Alternative birthing center services. • Ambulatory surgical center services. • Behavioral Health Services, including: • Community Mental Health Services. • Impact Plus Services. • Inpatient behavioral health services. • Outpatient Mental Health Services. • Psychiatric Residential Treatment Facilities (Level I and Level II.) • Chiropractic services. • Dental services, including oral surgery, orthodontics, and prosthodontics. • Durable medical equipment (DME), including prosthetic and orthotic devices and disposal medical supplies. • Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening and special services. • End stage renal dialysis services. • Family planning clinic services in accordance with federal and state law and judicial opinion. • Hearing services, including hearing aids for members younger than age 21. • Home health services. Private Duty Nursing (2,000 hours per year) • Hospice services. • Independent laboratory services. • Inpatient hospital services. • Intensive Case Management. • Meals and lodging for appropriate escort of members. • Medical detoxification. • Medical services, including those provided by physicians, advanced practice registered nurses, physicians assistants and FQHCs/ primary care centers and rural health clinics. • Organ transplant services not considered investigational by the FDA. • Other laboratory and x-ray services. • Outpatient hospital services. • Pharmacy and limited over-the-counter drugs including mental/behavioral health drugs. • Podiatry services. • Preventive health services, including those currently provided in public health departments, FQHCs/primary care centers, and rural health clinics. • Specialized Case Management Services for Members with Complex, Chronic Illnesses (includes adult and child targeted case management). Page 105 of 331 • Targeted Case Management. • Therapeutic evaluation and treatment, including physical therapy, speech therapy, occupational therapy. Transportation to covered services, including emergency and nonemergency ambulance and other stretcher services. Urgent and emergency care services. Vision care, including vision examinations, services of opticians, optometrists and ophthalmologists, including eyeglasses for members younger than age 21. Specialized Children's Services Clinics. • • • • NOTE: Please remember some services/benefits require a prior authorization. Please see Section 6.0 for more information. Meals, lodgings and transportation necessary to maintain a member and one designated attendant are covered, if necessary, when the member is accessing approved and necessary medical care at a site, in or outside of Kentucky, which is at a sufficient distance to preclude daily travel to and from the recipient’s home. This service requires prior approval with specific maximum rates applicable to standard and high-rate areas. 7.1.1 Allergy Testing and Treatment Consultation and testing by an allergist is covered for any member with a referral from the member’s PCP. Allergy injections may be administered by either an allergist or by the member’s PCP. 7.1.2 Behavioral Health Service Passport Health Plan has contracted with Beacon Health Strategies, LLC to administer comprehensive behavioral health benefits for Passport members beginning January 2013. Section 19 of this provider manual provides comprehensive detail of this service. 7.1.3 Dental Care Passport Health Plan has contracted with a dental benefits manager to administer and provide all primary care dental services for all members. A PCP referral is not required for routine dental services. Members may obtain assistance with locating a dental practitioner by calling Member Services at (800) 578-0603. Members may also visit the Plan’s web site at www.passporthealthplan.com. Specialty dental services do not require a referral, for example, orthodontic evaluation (see Section 6.1, “Member Self-Referral (Direct Access)”) and are only covered for children younger than age 21. For more information, please see Section 1, “Important Telephone Numbers,” for our Page 106 of 331 dental benefits manager’s contact information. 7.1.4 Durable Medical Equipment (DME) Passport Health Plan covers medically-necessary durable medical equipment (DME) and supplies that are covered under the fee-for-service Medicaid program. Members are required to have a practitioner’s order to receive the covered DME or supplies (see Section 5.6.3). The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the supplier for a period of five years. The only exception is oxygen for which Passport Health Plan follows Medicare guidelines. 7.1.5 Family Planning Services Family planning services are meant to prevent or delay pregnancy for individuals of childbearing age. These services include: • • • • • • • • • • Health education and counseling. Limited history and physical exam. Laboratory tests as medically necessary. Diagnosis and treatment of STDs. Screening, testing, and counseling of at-risk individuals for HIV and referral for treatment. Follow-up care for complications associated with contraceptive methods issued by a family planning provider. Contraceptive prescriptions, devices, supplies. Tubal ligation with required consent form completed. Vasectomies with required consent form completed. Pregnancy testing and counseling. Passport Health Plan members may obtain family planning services from any state-approved Medicaid provider. No referral from the PCP is required for routine family planning services. Some family planning services require authorization. For more information on benefits and/or a list of providers, refer to Section 17, “Family Planning” in this Provider Manual. Please direct members to call our Member Services department at (800) 578-0603. 7.1.6 Home Health Care When medically appropriate, home health care may be a good alternative to hospitalization. Home health care, including skilled and unskilled nursing, may be medically appropriate at other times as well. Passport Health Plan’s Utilization Management department must prior authorize all home health services (see Section 6.4.2). Page 107 of 331 7.1.7 Hospice Care If a member needs hospice care, the hospice provider must contact Passport Health Plan’s Utilization Management department for prior authorization. 7.1.8 Laboratory Services All laboratory work should be sent to participating laboratories. For assistance locating a participating laboratory, providers may go to our online directory at http://passport.prismisp.com/. Choose “Other Services” > Laboratory Services. Both PCPs and specialists may order lab services. Participating practitioners who cannot perform venipuncture in their office should send members to the nearest participating laboratory. 7.1.9 Prenatal Care A referral is not necessary to an obstetrical provider, and a member may self-refer to any participating obstetrical provider. The OB provider should confirm eligibility. Providers are no longer required to obtain global authorization for antepartum cases. However, you must submit the initial ACOG or ACOG-like assessment which includes the member’s medical and obstetric history within two business days of a member’s initial prenatal visit. You can email the completed form to Passport.GlobalAuths@passporthealthplan.com or fax it to (502) 585-7970. 7.1.10 Prescriptions Prescription benefits are administered for Passport Health Plan members through a pharmacy benefits manager (PBM). Members must have prescriptions filled at participating pharmacies. For assistance locating a participating pharmacy, members should call Member Services (800) 578-0603 or search the on-line pharmacy directory. For additional information on the outpatient pharmacy benefits, please refer to Section 14 of this Provider Manual or visit www.passporthealthplan.com. 7.1.11 Presumptive Eligibility Presumptive Eligibility (PE) was implemented on November 1, 2001 by the Kentucky Department for Medicaid Services (DMS). PE enables qualified pregnant women to receive prenatal care (for up to 90 days) while their eligibility for full Medicaid benefits is determined. For additional information regarding PE (including the complete list of covered services), please see Section 16.13. Page 108 of 331 7.1.12 Radiology PCPs and specialists may order routine radiology services for members. Specialty Radiology: Prior Authorization is required for select CT/CTA, MRI/MRA, PET, and NCM/MPI through MedSolutions. Refer to Section 5.3 – Prior Authorization Requirements. 7.1.13 Skilled-Nursing Facility Should a member need authorization for admission to a skilled-nursing facility, the PCP should contact the Department for Medicaid Services (DMS). They will coordinate necessary arrangements between the PCP and the skilled-nursing facility in order to provide continuity of the member’s care. Passport Health Plan covers the costs of health care services that are not part of nursing facility costs for up to 31 days or until the member is disenrolled from Passport Health Plan by DMS. After the member has been in a skilled nursing facility for 31 days, the disenrollment process begins. After disenrollment, the member is re-enrolled with the feefor-service Medicaid program except when a member is under the care of Hospice and in a skilled-nursing facility. In this case, Passport Health Plan will continue to cover services under the hospice benefit even after 31 days. 7.1.14 Transportation Emergency transportation and stretcher services are covered by Passport Health Plan. Members may be eligible for non-emergency transportation services to and from medical appointments. This is a covered benefit by DMS. Members should call the appropriate transportation broker at least three days ahead of time when scheduling transportation. The telephone numbers for transportation brokers for each county can be found in Section 20.2, “Other Important Contact Information.” Members may also access this information by calling Passport Health Plan Member Services at (800) 578-0603. 7.1.15 Vision Care Passport Health Plan has contracted with a vision benefits manager to administer and provide routine vision care benefits to members. A PCP referral is not required for vision services. An annual routine eye refraction exam is covered for adult and child members. Eyeglasses are a benefit for children under age 21. Some exceptions apply to KCHIP members. Members may obtain a list of vision practitioners by calling Member Services at Page 109 of 331 (800) 578-0603 or by checking the provider directory on the Plan’s website at www.passporthealthplan.com. Members requiring vision care because of a medical condition must be referred by their PCP to a participating Passport Health Plan ophthalmologist. For more information, call Provider Services at (800) 578-0775 or refer to Section 1, “Important Telephone Numbers,” for our vision benefits manager’s contact information. 7.2 Services Covered Outside Passport Health Plan Members may continue to receive certain health services not covered by Passport Health Plan but covered by DMS. Members may obtain these services from any Medicaid provider by using their Medicaid ID. Members choosing to obtain these services are encouraged to notify their PCP to update their medical records. The following services are covered outside Passport Health Plan: • • • • • Nursing facility services. Early-intervention services for children. School-based services for any child member younger than the age of 21 with an individualized education plan. Waiver services. Nonemergency transportation. Additional information about these services can be obtained from DMS. 7.3 Non-Covered Services Services that are not covered by Passport Health Plan or the Kentucky Medicaid Program include: • • • • • • • • • • • • Non-medically-necessary services. Cosmetic services. Custodial, convalescent, or domiciliary care. Experimental procedures not approved by Kentucky’s Medicaid Program. Hysterectomy procedures, if performed for hygienic reasons or sterilization only. Infertility treatment (medical or surgical). Paternity testing. Personal items or services, such as a television or telephone, while the patient is in the hospital. Postmortem services. Reversal of sterilization services. Sex-change procedures. Sterilization of a mentally incompetent or institutionalized individual. Page 110 of 331 The following are services currently not covered by the Kentucky Medicaid Program: • • • • • • • • • • • • • • Any laboratory service performed by a provider without current certification in accordance with the Clinical Laboratory Improvement Amendment (CLIA). This requirement applies to all facilities and individual providers of any laboratory service; Cosmetic procedures or services performed solely to improve appearance; Hysterectomy procedures, if performed for hygienic reasons or for sterilization only; Medical or surgical treatment of infertility (e.g., the reversal of sterilization, invitro fertilization, etc.); Induced abortion and miscarriage performed out-of-compliance with federal and Kentucky laws and judicial opinions; Paternity testing; Personal service or comfort items; Post mortem services; Services including, but not limited to, drugs that are investigational, mainly for research purposes or experimental in nature; Sex transformation services; Sterilization of a mentally incompetent or institutionalized member; Services provided in countries other than the United States, unless approved by the Secretary of the Kentucky Cabinet for Health and Family Services; Services or supplies in excess of limitations or maximums set forth in federal or state laws, judicial opinions and Kentucky Medicaid program regulations referenced herein; and, Services for which the Member has no obligation to pay and for which no other person has a legal obligation to pay are excluded from coverage. NOTE: Under EPSDT, some exceptions may be made if a service is medically-necessary. Page 111 of 331 Provider Manual Section 8.0 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Table of Contents 8.1 Overview of EPSDT 8.2 EPSDT Eligibility 8.3 Covered Services 8.4 EPSDT Audits for Screening Elements 8.5 EPSDT Tracking/Member Outreach 8.6 EPSDT Reporting/Billing (Preventive Health Screens/Immunizations) 8.7 EPSDT Expanded Services Page 112 of 331 8.0 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) 8.1 Overview of EPSDT Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a federally mandated Medicaid program developed to ensure that the Medicaid population younger than the age of 21 is monitored for preventable and treatable conditions which, if undetected, could result in serious medical conditions and/or costly medical care. Passport must track the progress of all members younger than the age of 21 and perform outreach as needed to encourage members to obtain EPSDT health screens according to the Bright Futures/American Academy of Pediatrics (AAP) Guidelines for screening intervals. Once a condition is detected, treatment may be considered under EPSDT Special/Expanded Services if it is not a current covered benefit under Medicaid, if medical necessity is proven. EPSDT preventive health screens that result in any treatment recommendations must be monitored to ensure follow-up has occurred. 8.2 EPSDT Eligibility 8.2.1 Member Eligibility Passport members from birth to age 21 are entitled to receive EPSDT services. 8.2.2 Practitioner Eligibility All Passport PCPs who see children younger than the age of 21 are required to conduct EPSDT screenings and complete all EPSDT billing requirements. 8.3 Covered Services The following services are covered under the EPSDT preventive care program: • Comprehensive screening exams according to the Bright Futures/American Academy of Pediatrics (AAP) periodicity schedule see http://www.passporthealthplan.com/pdf/provider/resources/epsdt/aap-periodicityschedule.pdf : • All Passport eligible members under the age of 21 are entitled to EPSDT services 8.4 EPSDT Audits for Screening Elements As part of Passport’s Quality Improvement Program, the EPSDT/Quality Improvement (QI) department will conduct an annual audit of submitted EPSDT claims by providers to review for completion of the age appropriate elements based on the approved Periodicity schedule. A benchmark has been established that each provider score at least 80% on the completion of all Page 113 of 331 elements of an age appropriate screen. If a provider scores less than 80%, the EPSDT/QI staff will provide a detailed report of missing elements and education regarding the age appropriate standards. The provider will be reviewed again in six months after the education has been completed. If a provider does not meet the 80% score at that time, the provider must submit a corrective action plan that is to be reviewed and approved by the Chief Medical Officer (CMO) and Child and Adolescent/Quality Medical Management Committees (C&A/QMMC). Additional sanctions are to be determined and approved by the CMO and C&A/QMMC. 8.5 EPSDT Tracking/Member Outreach Tracking begins at enrollment for both newborns and other members and continues periodically thereafter: • • • The EPSDT program and the importance of preventive care are outlined in the Member Handbook. EPSDT articles are included in all member newsletters, on Passport’s web site, and in Passport’s telephone on-hold messages. Reports are generated to check for members who are due/overdue for preventive screens. If no documentation from the PCP has been processed, follow-up calls are made or notices are mailed to members. Reports are generated for members who cannot be reached through written notification or by telephone. These members are referred for home visit outreach. 8.6 EPSDT Protocols To complete an EPSDT preventive health screen: Verify member’s eligibility via KyHealth Net, referencing the PCP monthly panel list, utilizing the EPSDT Eligibility Confirmation Form, or contacting the EPSDT team at (877) 903-0082, ext. 8210. • For more information about KyHealth Net, or to create an account, visit www.chfs.ky.gov/dms/kyhealth.htm. • Once eligibility is verified, inform the parent/guardian that the visit will be an EPSDT screening. • Have the parent or legal guardian sign a consent form authorizing the practitioner to perform screening tests or other assessment procedures pertaining to EPSDT preventive health screens. • To receive reimbursement, all EPSDT services must be submitted as part of the standard electronic (837) or paper (CMS-1500) claims submission process. To submit EPSDT services via claims: • Continue to bill using the codes for comprehensive history and physical exam as used today. These codes must correspond with the member's age. CPT Code Modifier Code Description Billing Format 99381EP New Patient 837/CMS-1500 99385 Page 114 of 331 9939199395 • • • • • EP Established Patient 837/CMS-1500 Add an "EP" modifier to the physical exam code only when all components of the appropriate EPSDT screening interval have been completed and documented in the member's medical record. Do not add the EP modifier to other services being billed (i.e. immunizations). Acknowledge the following health evaluation services have been completed by submitting the appropriate CPT Category II codes, according to the member's age, as outlined below. CPT II codes must include a nominal charge (i.e. $.01 or $1.00 not blank or zero) in order to adjudicate correctly. Two years of age and above: 3008F to confirm the BMI has been performed and documented in the member's medical record. Nine years of age and above: 2014F to confirm the member's mental status has been assessed and documented in the member's medical record. Note in the appropriate box on the Referral Form that a referral has been made for additional services, related to an EPSDT screening. Mail Paper Claims to: Passport Health Plan P.O. Box 7114 London, KY 40742 8.8 EPSDT Reporting/Billing (Preventive Health Screens/ Immunizations) Practitioners who perform complete EPSDT health screens according to the recommendations in the Preventive Health Guidelines will be reimbursed a fee-for-service rate. EPSDT health screens must be billed on the standard electronic (837) or paper (CMS-1500) claim form. Practitioners will be reimbursed an additional administration fee for recommended childhood and adolescent immunizations. Page 115 of 331 Provider Manual Section 9.0 Quality Improvement Table of Contents 9.1 Quality Improvement Program Description 9.2 Quality of Care Concerns 9.3 Practitioner Sanctioning Policy Page 116 of 331 9.0 Quality Improvement 9.1 Quality Improvement Program Description The purpose of the Quality Improvement (QI) Program is to provide the infrastructure for the continuous monitoring, evaluation and improvement in care, safety, and service. Providers may obtain a copy of Passport Health Plan’s complete “Quality Improvement Program Description,” “Quality Improvement Program Evaluation,” or “Quality Program Committee Structure” and/or a copy of a summary of its annual evaluation by visiting the Passport website at www.passporthealthplan.com/member/eng/qi-program/index.aspx or by contacting their Provider Relations Specialist. 9.2 Quality of Care Concerns Quality of Care Concerns may be reported by both internal and external customers such as members, providers, and advocates. All reported concerns are investigated and monitored for trends. In the event a quality of care concern is reported, Passport requires full cooperation with the investigation of the concern. This includes the timely submission of requested medical records and the implementation of corrective action plans. Providers have the right to respond to reported concerns. For more information regarding quality of care concerns, please contact the Quality Improvement department at (800) 578-0636, ext. 8571. 9.3 Practitioner Sanctioning Policy In the event Passport Health Plan identifies health care services rendered to a Passport Health Plan member by a participating practitioner that are outside the recognized treatment patterns of the organized medical community and quality management and/or credentialing standards, the practitioner may be subject to sanctions. The National Practitioner Data Bank (NPDB) may be notified of all negative outcomes if formal sanctioning proceedings are implemented and if the outcome is to last 30 days or more. In addition to the above, Passport Health Plan will exclude and/or penalize a provider under any of the following conditions: • • • The Plan has received recommendations to take such actions as a result of an investigation conducted by the Office of the Inspector General or other appropriate state and/or federal agency. The provider fails to cooperate with an investigation of alleged fraud and abuse. The provider has been listed on the Medicare/Medicaid Sanctions Report. Page 117 of 331 Possible sanctions for deviation from accepted quality management and/or credentialing standards and program integrity violations include: • • • • Limiting a PCP’s panel, not necessarily limited to freezing new member assignment. Termination of participating provider status. Withholds from future claims payments of amounts that are improperly paid or reasonable estimates of such amounts. Suspension of claims activity. Page 118 of 331 Provider Manual Section 10.0 Emergency Care/Urgent Care Services Table of Contents 10.1 Emergency Care 10.2 Out-of-Service-Area Care 10.3 Urgent Care Services 10.4 Lock-In Program Page 119 of 331 10.0 Emergency Care/Urgent Care Services 10.1 Emergency Care 10.1.1 Definition Services for medical emergencies are covered when provided in a hospital, physician’s office or other ambulatory setting. As defined in 42 USC 139dd(e) and 42 CFR 438.114, Emergency Medical Condition means: (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention to result in (i) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part; or (B) with respect to a pregnant woman who is having contractions (i) that there is an inadequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child. 10.1.2 PCP Responsibilities If the member calls the primary care practitioner’s (PCP) office prior to going to the ER and if the situation can be handled in the PCP’s office, it is the PCP’s responsibility to comply with Passport’s access standards. A referral or authorization is not required for a member to be seen in the emergency room (ER). It is also the responsibility of the PCP, per his or her contract with Passport, to have after-hours call service 7 days a week, 24 hours a day. Use of Passport’s 24-Hour Nurse Advice Line is not an acceptable alternative to after-hours call service. Giving members easily understood instructions during regular office visits may help avoid afteroffice-hours calls or ER visits. Reviewing home treatment for common conditions, such as fever, vomiting, diarrhea, and earaches may give members or their caregivers more confidence in handling these conditions when they arise. Providing written instructions to be used as a reference may also be helpful. 10.2 Out-of-Service-Area Care 10.2.1 Definition Emergency care as described in Section 10.1.1 is also a covered benefit for Passport members when they are out of the service area. A referral or prior authorization is not required for out-of-servicearea emergency care in the ER. For an out-of-network provider to receive reimbursement a Kentucky Medicaid ID number and Passport Provider ID number is needed. Page 120 of 331 10.3 Urgent Care Services 10.3.1 Definition Urgent care may be a covered service in an urgent care center, PCP office, or other ambulatory setting. Urgent care means care for a condition not likely to cause death or lasting harm but for which treatment should not wait for a normally scheduled appointment. Members are advised via Passports educational materials to contact their PCP before seeking medical treatment elsewhere. 10.3.2 PCP Responsibilities If the member calls prior to going to a licensed, credentialed urgent care center and the situation can be handled in the PCP’s office, it is the PCP’s responsibility to see the member within Passport’s access guidelines. For the current listing of urgent care centers, please visit the Provider Directories section of our web site, www.passporthealthplan.com/provider/resources/directories. To request a hard copy of this listing, please contact your Provider Relations Specialist or Provider Services at (800) 578-0775. 10.4 Lock-In program The Passport Health Plan Lock-In Program is designed to ensure medical and pharmacy benefits are received at an appropriate frequency and are medically necessary. The Lock-In Program is a requirement of the Kentucky Department for Medicaid Services (DMS). Inappropriate use or abuse of Medicaid benefits may include: • • • Excessive emergency room or practitioner office visits; Multiple prescriptions from different prescribers and/or pharmacies; and/or, Reports of fraud, abuse, or misuse from law enforcement agencies, practitioners, Office of the Inspector General, pharmacies, and Passport staff. Under the Lock-In Program, a member’s medical and pharmacy claims history and diagnoses are reviewed for possible overutilization. Members who meet the criteria will either be locked-in to a designated hospital for non-emergency services; and/or one prescriber, who may not necessarily be the member’s PCP, and one pharmacy for controlled substances. • • • Members who receive services from a non-designated or non-referred provider (i.e. via PCP) and are informed of the financial responsibility before the service is provided will be responsible for payment. Members who receive services provided in the emergency department of a hospital for a condition that is not determined to be an emergency will also be responsible for payment. Lock-in members must be provided the Acknowledgement of Responsibility for Payment form located at : http://www.chfs.ky.gov/dms/provider.htm Page 121 of 331 All designated providers (i.e. PCPs, controlled substance prescribers, hospitals and pharmacies) will receive written notice of the member’s Lock-In status. All members have the right to appeal within the first 30-days of the Lock-In effective date. Initially, a member will be locked-in for a minimum of 24 months. At least annually, members will be reviewed to determine whether to maintain their lock-in status for another 12-month period. The Lock-In Program is not intended to penalize or punish the member. The program is intended to: • • • • Connect members with case managers who can identify reasons for over use of medical services and provide education on their health care needs; Reduce inappropriate use of health care services; Facilitate effective utilization of health care services; and, Enhance quality of care by developing a stable patient-physician and patient-pharmacist relationship. Page 122 of 331 Provider Manual Section 11.0 Special Programs Table of Contents 11.1 Case Management 11.2 Health and Disease Management Programs 11.3 Children Living in Out-Of-Home Placements Page 123 of 331 11.0 Special Programs 11.1 Case Management 11.1.1 Definition Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. 11.1.2 Target Populations Members who may benefit from case management are those with ongoing complex medical needs. The following may warrant case management; however, these are certainly not all-inclusive: • • • • • • Children in/or receiving foster care or adoption assistance; Blind/Disabled children under the age of 19 and related populations eligible for SSI; Adults over the age of 65; Homeless; Individual with chronic physical health illnesses; and, Individuals with chronic behavioral health illnesses. 11.1.2.1 How are Referrals Generated? Referrals to Case Management are received through many sources: • • • • • • • Member Services line; Passport member and provider inquiries; Completed Health Risk Assessments (HRAs); Recently discharged members from hospitals or who have required Emergency Room care; Outreach calls by RROT case managers to members who have called the 24-hour Nurse Line and require further assistance from our Case Management staff; Internal department referrals; and, Providers seeking case management referrals for their patients. 11.1.3 How to Request Case Management Services Practitioners, as well as members and other interested parties, may request case management services. Practitioners may contact the Rapid Response department at (877) 903-0082 from 8:00 a.m. to 6:00 p.m. EST to make a case management referral or by completing the Care Coordination Referral Form available online at http://www.passporthealthplan.com/provider/resources/tutorials/index.aspx. If you would like to speak with the case manager once he or she is assigned, notify the Rapid Response coordinator when you make a case management request. Participation in Case Management is voluntary and the Page 124 of 331 member has the right to decline any or all parts of the program. 11.1.4 Rapid Response Outreach Team The Rapid Response Outreach (RROT) team was developed at Passport to address members’ health questions, to identify members in need of care coordination services, and to address the urgent needs of our members. Our goal is to reduce both unnecessary emergency room visits and in-patient stays, as well as assist in removing barriers to needed healthcare services. The team consists of Registered Nurses, and Case Management Technicians (under the direction of the clinical staff), with Social Workers, Pharmacists, Pharmacy Technicians and Durable Medical Equipment support staff. 11.1.4.1 What we do The members of the Passport Rapid Response Outreach Team are trained to assist in the rapid triage of members' needs. The team assists members in investigating and overcoming the barriers to achieving their health care goals. The RROT can assist with: • • • • • • • • • • Questions concerning how to obtain supplies or services from Durable Medical providers; Transportation scheduling; Assisting with pharmacy and barriers to receiving medications; Collaborating with specialists; Coordination of physician appointments; Scheduling preventive health screens; Facilitating medication access; Informing members of the available community resources, assist them in completing the application process and follow through of services; Outreaching to members for HEDIS® measures; and, Resources for resolution of legal questions such as the creation of advanced directives, living trusts, or other types of legal assistance. 11.1.4.2 Contact the Rapid Response Outreach Team The Rapid Response Outreach Team can be reached at 877-903-0082 from 8:00 a.m. until 6:00 p.m. EST, Monday through Friday. After hours, there is a 24-hour Nurse Call Line available to all members at 800-606-9880. 11.2 Health and Disease Management Programs 11.2.1 Introduction Passport is committed to working with providers to help keep members healthy by supporting preventative care. One way to do this is through Health and Disease Management programs that ideally prevent or decrease exacerbation of an illness by a comprehensive, integrated approach to care. Passport’s Health and Disease Management programs include the Diabetes Disease Page 125 of 331 Management Program, the Chronic Respiratory Disease Management Program, the Congestive Heart Failure (CHF) Program, the Mommy Steps Perinatal Program, and the Obesity Program. Practitioners are informed about the programs through various methods, including Passport’s Provider Manual, web site, provider communications, New Provider Orientation Kit, office sitevisits by the Provider Relations Specialists, and face-to-face education visits by the disease specific provider. 11.2.2 Purpose of Programs Each program emphasizes education for targeted members and providers to improve the overall health, wellness, and quality of the member’s life. The goal of the programs is to provide tools to educate the member on promoting improved health through better prevention, detection, treatment, and education. These programs aim to facilitate member understanding and responsibility of the disease process as well as coordination of care between the member and/or caregiver and the provider. Programs focus on increasing both member and provider adherence with well-established and professionally recognized guidelines. 11.2.3 Evaluation of Programs The objectives, activities, and outcomes of each Health and Disease Management Program are continually evaluated and measured against national standards. Updates and revisions are made as needed, with the programs being reviewed at least annually. Reviews consist of: • • • • • Measuring participation rates; Determining whether the programs have demonstrated improvement in outcomes and quality of care provided to members; Evaluating the overall effectiveness of the programs; Exploring he barriers and limitations of the programs; and, Revising areas as needed to improve effectiveness of the programs. 11.2.4 Type of Disease Management Program Passport offers the following Disease Management Programs: • • • • • Diabetes Disease Management Program Chronic Respiratory Disease Management Program Congestive Heart Failure (CHF) Disease Management Program Obesity Disease Management Program Mommy Steps Program (for Pregnant Members) Please reference Passport’s website at www.passporthealthplan.com for additional program information. 11.3 Children Living in Out-Of-Home Placements Page 126 of 331 This term refers to children living in one of the following: • Foster care. • Guardianship. • Department of Juvenile Justice. • Psychiatric residential treatment facilities. • Group home. • Adoption assistance. Due to the nature of children requiring an out-of-home placement, the Department for Medicaid Services (DMS) sometimes moves children outside of the Passport service area where Passport may not have participating providers. Children living in out-of-home placements do not choose a PCP. Participating or nonparticipating practitioners with a valid Kentucky Medicaid Identification (MAID) number may provide medical treatment for these children. Children living in out-of-home placements can be treated by specialists without a referral. They require prior authorization for the following services only: inpatient hospital admissions, private duty nursing, skilled services provided at a special needs daycare, and home health services. To pre-certify these services, contact Utilization Management at (800) 578-0636. In addition, non-participating OB providers are required to obtain authorization for OB services. Children living in out-of-home placements will have “No PCP Required” located on their Passport card where the name of the PCP usually appears. These children may relocate often and may present for treatment without a card or with a card that is not current. Providers may contact Provider Services at (800) 578-0775 to verify eligibility and out-of-home placement status. Eligibility may also be checked via NaviNet at www.navinet.navimedix.com. Foster Parents/Guardians can direct questions to Member Services at (800) 578-0603. 11.3.1 Foster Care/Adoption/Guardianship Liaison The Foster Care/Adoption/Guardianship Liaison works in collaboration with the Department for Community Based Services to identify DCBS clients for Care Coordination Services. The Foster Care/Adoption/Guardianship Liaison is responsible for identifying and correcting problems with special populations including Foster Care, Guardianship, Department of Juvenile Justice, Kinship, Adoptive Assistance, Residents of Psychiatric Treatment Facilities, and Group Homes. The Foster Care/Adoption/Guardianship Liaison serves as a primary contact for foster and adoptive parents, guardians and DCBS supervisor for issues and concerns. Foster Parents/Guardians can direct questions to Member Services at (800) 578-0603. 11.3.2 Homeless Services Passport provides ongoing face-to-face member/benefits education sessions throughout the year. These sessions are conducted at the various transitional and homeless shelters throughout the state. Special attention is given to those victims of domestic violence residing in emergency shelters. Page 127 of 331 Provider Manual Section 12.0 Outpatient Pharmacy Services Table of Contents 12.1 Prescribing Outpatient Medications for Passport Health Plan Members 12.2 Covered Outpatient Pharmacy Benefits 12.3 Drug Prior-Authorization Procedure 12.4 Lock-In Program Page 128 of 331 12.0 Outpatient Pharmacy Services 12.1 Prescribing Outpatient Medications for Passport Health Plan Members Any health care provider licensed to prescribe medications in the Commonwealth of Kentucky may write a prescription for a Passport Health Plan member provided it is within the scope of the provider’s medical licensure and the prescriber has a valid, current Kentucky Medicaid license number. The provider’s National Provider Identifier (NPI) and Medicaid number must appear on the prescription presented to the member for the prescription to be filled. Pharmacies must include the prescriber’s NPI when submitting all prescriptions for coverage. 12.2 Covered Outpatient Pharmacy Benefits Passport Health Plan must have available to its members all medications appearing on the Department for Medicaid Services (DMS) Drug List; however, Passport may impose additional requirements for medical necessity through the use of prior authorizations. In addition, Passport covers certain diabetic supplies. Passport may also impose quantity limits or day supply limits, and other appropriate edits to promote both safety and evidence-based therapy. The Pharmacy and Therapeutics Committee, comprised of practitioners, pharmacists, and consumer representatives, meets regularly to update the preferred drug list. Working with Passport Health Plan’s pharmacy benefits manager (PBM), the Pharmacy and Therapeutics Committee annually reviews each category of drugs to identify preferred drugs based upon clinical and pharmacoeconomic data to promote cost-effective, evidence-based practices. Providers are encouraged to use Passport’s Preferred Drug List. Providers may view the preferred drug list via Passport’s online searchable formulary. Updates to the Preferred Drug List are also distributed via Passport’s Pharmacy News Bulletin which is also available through your Provider Network Account Manager or Passport’s website www.passporthealthplan.com/pharmacy/communication/news/index.aspx 12.2.1 Categories of Covered Drugs Three categories of drugs (available on Passport Health Plan’s web site, http://www.passporthealthplan.com/pharmacy/formulary/index.aspx) are covered for Passport Health Plan members: • Preferred medications: Drugs that have been evaluated by Passport Health Plan’s Pharmacy and Therapeutics Committee and found to provide pharmacoeconomic value, therapeutic benefits, and a history of safe use. Some preferred drugs may have age edits and require step therapy. • Prior authorized drugs (PA): These drugs may require the use of a non-prior authorized drug (step therapy) and/or meet additional medical necessity criteria for approval. Medical necessity criteria may include peer-reviewed criteria, relevant and statistically-appropriate Page 129 of 331 studies, and FDA approvals for drug use. • Selected categories of over-the-counter (OTC) drugs: Covered OTC drugs should be used in the course of current or ongoing therapy. A valid prescription for these medications is required for dispensing. Drugs in all three of the above categories may have limits for quantity dispensed, days’ supply, and requirements for use to ensure medical necessity. 12.2.2 Categories of Covered Diabetic Supplies The following diabetic supplies are only covered through the pharmacy with a valid prescription: • • • • • • • • • Blood glucose meter Blood glucose test strips Calibrator solutions Insulin syringes Blood ketone test or reagent strips Urine test or reagent strips Lancets Lancing devices Pen needles Quantity limits may apply. 12.3 Drug Prior-Authorization Procedure 12.3.1 Prescription Medications and Prior Authorization 12.3.1.1 When is a Prior Authorization (PA) Required? PA is necessary for some medications to establish medical necessity and to ensure eligibility for coverage per State and/or Federal regulations. This may be due to specific Food and Drug Administration (FDA) indications, the potential for misuse or overuse, safety limitations, or costbenefit justifications. PA is required for medications that are: • • • • • • • Outside the recommended age, dose or gender limits; Non-preferred (potential for “step therapy1” before approval); Non-formulary; Duplication in therapy (i.e. another drug currently used within the same class); New to the market and not yet reviewed by Passport’s Pharmacy & Therapeutics (P&T) Committee; Prescribed for off-label use or outside of certain diseases or specialties; or, An incorrect ICD-9 code when required. Page 130 of 331 12.3.1.2 How to Submit and Receive Notification on a PA STEP 1: Determine if the drug requires PA.* • For the PA status of specific covered medications, please refer to our online searchable formulary by visiting www.passporthealthplan.com/pharmacy. STEP 2: Complete the PA form in its entirety. • The Passport Prior Authorization Form is available on www.passporthealthplan.com/pharmacy. • A physician, nurse practitioner, or pharmacist may complete this form. STEP 3: Submit the completed form for review to (877) 693-8280 or complete the online submission form at www.passporthealthplan.com/pharmacy and click on “Online Prior Authorization.” If the request is for a hospital discharge, check that box on the form. STEP 4: Receive the response. You may expect a response within 24 hours after submission. Your office must have the area code programmed into your fax machine with a Called Subscriber Identification (CSID) number in order to receive fax confirmation of PA receipt. Step therapy is defined as a trial of the safest and most cost effective therapy prior to progressing to other, more costly or recently-approved therapies (i.e. “step protocol”). 1 *Timeframes are developed in accordance with requirements established by the Kentucky Department for Medicaid Services (DMS) and are subject to change. Incomplete or unclear information on the form may delay processing of a PA. 12.3.1.3 What Happens During the PA Review Process: 1st review: A pharmacy technician compares all information on the request to Passport’s clinical authorization criteria. Passport utilizes medical criteria developed in collaboration with our Pharmacy Benefits Manager (PBM) and the P&T Committee. Criteria are derived from one or more of the following: • • • • • Published American Federal Food and Drug approval indications for Therapy; Federal and/or State regulatory requirements; Drug compendia such as the American Hospital Formulary Service-Drug Information (AHFS-DI), the Gold Standard Clinical Pharmacology, the DrugDex or “Facts and Comparisons;” Evidence-based guidelines provided by non-biased resources from government agencies, such as the Agency for Healthcare Review and Quality(AHRQ), the American Society of Clinical Oncologists (ASCO), or the American Academy of Pediatrics (AAP); and/or, Current medical literature and peer-reviewed, non-biased publications based on appropriate scientifically designed study protocol with validated outcome endpoints. Page 131 of 331 2nd review: If the request does not meet Passport’s clinical authorization criteria, it is forwarded to a registered pharmacist. Additional information may be requested via fax or telephone from the prescribing provider. 3rd review: If the pharmacist cannot approve the request, the request is forwarded electronically to a Passport Medical Director for a decision. 12.3.1.4 How Providers Are Notified of PA Decisions A fax will be sent to the requesting provider’s submitted fax number with one of the following PA decisions. Approved The PA request has been approved for pharmacy reimbursement. Based on the medication and if requested by the prescriber, approvals may be granted for up to twelve (12) months. Partial Denial Reimbursement has been approved for a therapeutic alternative or for a different dose than requested. Deferral The final PA action was not decided due to the need for additional information. Providers must fax the requested information back to the PBM in order to obtain a final PA decision. Denial The PA request was denied. All PA denials are issued by a licensed physician. These decisions may be appealed. Denial rationale is included on every PA denial fax, and whenever possible, with a recommendation for an alternate preferred medication. However, denials for medications not indicated for clinical use may not include medication alternatives. 12.3.1.5 Emergency Supply Pharmacies may dispense a 72-hour emergency supply of medication if they are unable to contact the prescriber for prior authorization. This does not apply to drugs excluded from coverage by state and federal regulations. 12.3.1.6 Prescription Cost Sharing Beginning January 1, 2014, some Passport Health Plan members will have a copay for prescriptions. Copay requirements are as follows: 2014 Cost Sharing Requirements $0 Generic Drugs $2 Preferred Drugs $4 Non-preferred Drugs Page 132 of 331 Total cost sharing cannot exceed an aggregate of 5% of a family’s income per calendar quarter. The pharmacy will be made aware of any copayment responsibility and will collect it from the member when the claim is adjudicated. A pharmacist may refuse to dispense a prescription to a member who does not pay the cost sharing amount at the time of picking up the prescription; however, the pharmacist must dispense a 72hour supply of the prescribed drug if the member has an emergency condition which requires an emergency supply of the drug. The following members do not have a copayment requirement unless they receive a non-preferred medication. • • • • • • • Members 18 years of age and under; Pregnant members; Institutionalized members; Members receiving family planning services and supplies; American Indians receiving services directly by an American Indian health care provider or through referral under contract health services; Members in hospice care; and, Members receiving preventive services. 12.3.2 Denial and Appeal Process An authorization request for outpatient pharmacy services may be denied for lack of medical necessity, or it may be denied for failure to follow administrative procedures outlined in the Provider Contract or this Provider Manual. Denial letters are generated by Passport to the member and the prescriber. The PBM faxes a denial notification to the prescriber and the pharmacy if fax numbers are available. Your office must have the area code programmed into your fax machine with a CSID (Called Subscriber Identification) in order to receive fax confirmation of PA receipt with the seven (7) digit transaction number identifier. This 7-digit identifier is required if you call regarding a PA status. Appeals for pharmacy services are handled by Passport Health Plan following the same procedure as pre-service appeals (see Section 2.11 for additional information). 12.4 Lock-In Program The Passport Health Plan Lock-In Program is designed to ensure medical and pharmacy benefits are received at an appropriate frequency and are medically necessary. The Lock-In Program is a requirement of the Kentucky Department for Medicaid Services (DMS). Inappropriate use or abuse of Medicaid benefits may include: • Excessive emergency room or practitioner office visits; • Multiple prescriptions from different prescribers and/or pharmacies; and/or • Reports of fraud, abuse, or misuse from law enforcement agencies, practitioners, Office of the Inspector General, pharmacies, and Passport staff. Page 133 of 331 Under the Lock-In Program, a member’s medical and pharmacy claim history and diagnoses are reviewed for possible overutilization. Members who meet the criteria will either be locked-in to a designated hospital for non-emergency services; and/or one prescriber, who may not necessarily be the member’s PCP, and one pharmacy for controlled substances. • Members who receive services from a non-designated or non-referred provider (i.e. via PCP) and are informed of the financial responsibility before the service is provided will be responsible for payment. • Members who receive services provided in the emergency department of a hospital for a condition that is not determined to be an emergency will also be responsible for payment. • Lock-in members must be provided the Acknowledgement of Responsibility for Payment form located at : http://www.chfs.ky.gov/dms/provider.htm. All designated providers (i.e. PCPs, controlled substance prescribers, hospitals and pharmacies) will receive written notice of the member’s Lock-In status. All members have the right to appeal within the first 30-days of the Lock-In effective date. Initially, a member will be locked-in for a minimum of 24 months. At least annually, members will be reviewed to determine whether to maintain their lock-in status for another 12-month period. The Lock-In Program is not intended to penalize or punish the member. The program is intended to: • Connect members with case managers who can identify reasons for over use of medical services and provide education on their health care needs; • • • Reduce inappropriate use of health care services; Facilitate effective utilization of health care services; and Enhance quality of care by developing a stable patient-physician and patient-pharmacist relationship. 12.4.1 How to Refer a Member To refer a member, to determine if a member is part of the Lock-In program, or for general questions regarding the program, please contact the Pharmacy Coordinator for pharmacy or controlled substance prescriber inquires or the ER Coordinator at 502-588-8564 for hospital inquiries. 12.4.2 How to Report Fraud and Abuse If you suspect fraud and/or abuse by a Passport Health Plan member or provider, it is your responsibility to report this immediately by calling one of the telephone numbers listed below: Corporate Compliance Hotline: (855) 512-8500 KyHealth Choices Medicaid Fraud Hotline: (800) 372-2970 Page 134 of 331 Provider Manual Section 13.0 Obstetrical Table of Contents 13.1 Overview 13.2 Member Access to Prenatal Care 13.3 Obstetrical Practitioner’s Role 13.4 General Procedure for Prior Authorization of Obstetrical Care And Delivery 13.5 Perinatal Labs 13.6 Change of Obstetrical Practitioners 13.7 Evaluation and/or Treatment by Perinatologists, Geneticists or Endocrinologists 13.8 Maternity Observation Stay 13.9 Prenatal Appointment Scheduling Standards 13.10 Subsequent Perinatal Care & Delivery 13.11 No-Show-Visit Protocol (Prenatal and Postpartum Appointments) 13.12 Claims Submission 13.13 Presumptive Eligibility Page 135 of 331 13.0 Obstetrical 13.1 Overview Passport Health Plan recognizes that access to effective prenatal and obstetrical care helps form a strong foundation for individual’s health for years to come. As a result Passport’s Mommy Steps Program works with obstetrical clinicians, local health departments, home health agencies, and others to identify the psychosocial, nutritional and educational needs of pregnant members. Once these needs are identified, Passport aids in coordinating the perinatal care services for these members. The care management plans that are created may include counseling, home care, health education, and referrals to appropriate community services. Our aim is to coordinate care to increase the likelihood that every pregnancy will progress to full term resulting in improved birth outcomes. By collaborating with our network clinicians and facilities we can decrease the rate of prematurity, infant mortality, low birth weight and very low birth weight babies. 13.2 Mommy Steps Passport has dedicated associates available to assist members and obstetrical providers with questions. They can be reached at (877) 903-0082 or via fax at (502) 585-7970 Monday through Friday, 8:00 a.m. to 6:00 p.m. EST (excluding business approved holidays). We will provide newly pregnant members with a welcome packet to our program that includes: education about prenatal care (including coverage for classes conducted by certified prenatal educators), community resources (eg. WIC, HANDS, and Healthy Start), smoking cessation resources, treatment options for substance use and behavioral health conditions, domestic violence support, dental and vision services, legal assistance contacts, and transportation service contact information. High-risk pregnancy members receive additional contacts and services from one of our Care Managers. Participation in the Mommy Steps Program, as with all Care Management Programs, is voluntary, and the member has the right to decline any or all parts of the program. 13.3 Member Access and/or Authorization Requirements All components of obstetrical care are directly accessible by members including testing and prenatal care. Appointment standards must be provided for prenatal care as follows: • • • • 1st Trimester-within 14 business days of request. 2nd Trimester-within 7 business days of request. 3rd Trimester-within 3 business days of request. High-risk pregnancies-within 1 business day of the identification of a high-risk condition or immediately if an emergency exists. Page 136 of 331 In addition referrals to perinatologists, geneticists, and endocrinologists are not required for high risk conditions and evaluation during pregnancy. Maternity observation stays do not require authorizations. These are defined as a hospital stay of 23 hours or less for the observation of members with medical conditions related to pregnancy. One 23-hour maternity observation stay per member within a 23-hour time frame is allowed. 13.4 Responsibility of Providers Follow the Passport Health Plan Clinical Practice Guideline for Perinatal Care which was adopted from the American College of Obstetrics and Gynecology (ACOG). Submit the initial ACOG or ACOG-like assessment which includes the member’s medical and obstetric history within two business days of the initial prenatal visit. It is the responsibility of the provider to confirm that an ACOG (or ACOG-like) form has been received by Mommy Steps if they assume the care of a member from another provider. Contact the Mommy Steps Program if the pregnancy becomes high risk. Direct members to their PCP for the evaluation and treatment of conditions not related to pregnancy. Coordinate care with the member’s PCP or other treatment clinicians as appropriate. Notify the Mommy Step’s Program via fax within two business days of all missed prenatal appointments. Following this process is required for reimbursement as outlined in the fee schedule for No-Show-Visits. Page 137 of 331 Provider Manual Section 14.0 Family Planning Table of Contents 14.1 Services 14.2 Network 14.3 Claims Page 138 of 331 14.0 Family Planning 14.1 Services Family Planning Services includes complete medical history, physical examination, laboratory and clinical test supplies, educational material, counseling and prescribed birth control methods to best suit the patient's needs. Family planning services include but are not limited to: • • • • • Routine OB/GYN exams leading to dispensing of contraceptives. Birth control/contraceptives, such as pills, sponges, condoms, jellies. Intrauterine devices (IUDs) – implantation and removal. Injectable long-acting contraceptives. Implantable contraceptive devices. Sterilization* • • • Tubal ligations. Postpartum tubal ligations. Vasectomies. Termination of Pregnancy** • • First trimester – up to 12 weeks. Second trimester – 12 to 22.5 weeks. * Requirements for Sterilization: 1. MAP 250 form must be completed (Male and Female sterilization) 2. MAP 250 form must be completed 30 days PRIOR to the scheduled procedure 3. Member must be at least 21 years of age or older 4. Consent expires 180 days from the member’s signature 5. Form must be attached to all claims If the form is not attached or the form is incomplete, the claim may be denied 6. Prior authorization IS NOT required for sterilization ** Requirements for Termination of pregnancy (Induced Abortion or Induced Miscarriage): 1. MAP 235 form must be completed 2. Termination is covered ONLY: A. In cases of Rape or Incest B. If the life of the mother would be endangered if the fetus were carried to term. If the requirements for termination of pregnancy are not met, alternative funding can be located at http://www.fundabortionnow.org/funds/AFund-Inc 3. Prior authorization IS required for termination of pregnancy. Medical Record must be submitted for review MAP 235 must be submitted for review. 4. Requests for authorization of services may be received Monday through Friday from 8:00 a.m. Page 139 of 331 to 5:30 p.m. EST, except holidays, by calling (800) 578-0636 or faxing to (502) 585-7989. Requests submitted without complete medical records and a MAP 235 form will not be able to be processed The member and the provider must complete and comply with all terms and conditions of the Kentucky Department for Medicaid Services (DMS) consent forms. Consent for Sterilization (MAP 250) and Certification Form for Induced Abortion or Induced Miscarriage (MAP 235) forms may be accessed on the DMS web site, http://chfs.ky/gov. Sample forms are located in Section 19 of this Provider Manual. The provider must ensure that non-English speaking, visually impaired and/or hearing-impaired members understand what they are signing. 14.2 Network Passport members may obtain family planning services from any participating provider. No referral from the member’s primary care practitioner (PCP) is required for family planning services. 14.3 Claims All family planning claims are to be submitted to the following address: Passport Health Plan P.O. Box 7114 London, KY 40742 For Sterilization Services: (Tubal ligations, Postpartum tubal ligations, Vasectomies) a completed MAP 250 form must be attached to all claims. Failure to submit the completed form with the claim may result in the claim being denied. Claims for presumptively eligible (PE) members should be submitted according to the guidelines in Section 18. Page 140 of 331 Provider Manual Section 15.0 Provider Billing Manual Table of Contents 15.1 Claim Submission 15.2 Provider/Claim Specific Guidelines 15.3 Understanding the Remittance Advice 15.4 Denial Reasons and Prevention Practices 15.5 Timely Filing Requirements 15.6 Corrected Claims and Requests for Reconsideration and/or Refunds 15.7 Contact Information for Claims Questions Page 141 of 331 15.0 Provider Billing Manual 15.1 Claim Submission 15.1.1 Procedures for Claim Submission Passport Health Plan (Passport) is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims. When required data elements are missing or invalid, claims will be rejected by Passport for correction and resubmission. The provider who performed the service to the Passport member must submit the claim for a billable service. Claims filed with Passport are subject to the following procedures: • • • • • • • Verification that all required fields are completed on the CMS-1500 or UB-04 forms. Verification that all diagnosis and procedure codes are valid for the date of service. Verification of the referral for specialist or non-primary care physician (PCP) claims. Verification of member eligibility for services under Passport during the time period in which services were provided. Verification that the services were provided by a participating provider or that the “out- ofnetwork” provider has received authorization to provide services to the eligible member (excluding “self-referral” types of care). Verification of whether there is Medicare coverage or any other third party resources and, if so, verification that Passport is the “payer of last resort” on all claims submitted to Passport. Verification that an authorization has been given for services that require prior authorization by Passport. As part of the agreement between Passport and the provider, the provider agrees to cooperate with Passport in its efforts to comply with all applicable Federal and State laws, including specifically the provisions of Section 6032 of the Deficit Reduction Act of 2005, PL-019-171, False Claims Act, Federal Remedies for False Claims and Statements Act, and KRS 205.8451, et. Seq. (relating to fraud). 15.1.2 Rejected and Denied Claims Rejected claims are defined as claims with invalid or missing data elements (such as the provider tax identification number) that are returned to the provider or EDI source without registration in the claims processing system. Since rejected claims are not registered in the claims processing system, the provider must re-submit corrected claims within 180 calendar days from the date of service. This requirement applies to claims submitted on paper or electronically. Page 142 of 331 Rejected claims are different than denied claims, which are registered in the claims processing system but do not meet requirements for payment Passport guidelines. For more information on denied claims, see Section 15.3 and 15.4 in this Provider Manual. 15.1.3 Claim Mailing Instructions Passport encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or the Emdeon Provider Support Line at (800) 845-6592 to arrange transmission. Additional questions may be directed to the EDI Technical Support Hotline at (877) 234-4275 or via e-mail to edi.php@kmhp.com. If you choose to utilize paper claims, please submit to Passport at the following address: Passport Health Plan P. O. Box 7114 London, KY 40742 15.1.4 Claim Filing Deadlines Original invoices must be submitted to Passport within 180 calendar days from the date services were rendered or compensable items were provided. Previously denied claims (with corrections and requests for adjustments) must be submitted within two years of the process date. 15.1.5 Exceptions Submission of claims for members retroactively enrolled in Passport by the Department for Medicaid Services is based on the date of notification of enrollment. Claims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the date of the primary insurer’s EOB. 15.1.6 Claims Status Review Providers may view claims status using any of the following methods: • • • Online – check eligibility/claims status by logging into NaviNet at https://navinet.navimedix.com Telephone – you may also check eligibility and/or claims status by calling our interactive voice response (IVR) system at (800) 578-0775. Real-Time – depending on your clearinghouse or practice management system, real-time claims status information is available to participating providers. Contact your clearinghouse to access: Emdeon Products for claims status transactions. Page 143 of 331 All other clearinghouses: Ask your clearinghouse to access transactions through Emdeon. 15.1.7 Notification of Denial via Remittance Advice When a claim is denied because of missing or invalid mandatory information, the claim should be corrected, marked as a second submission or corrected claim, and resubmitted within two years of the process date to the general claim address: Passport Health Plan P.O. Box 7114 London, KY 40742 15.1.8 Claims Adjustment/Reconsideration Requests If you believe there was an error made during claims processing or if there is a discrepancy in the payment amount, please call the Provider Claims Service Unit (PCSU) at (800) 578-0775, option 2. Our representatives can help you resolve the issue, process a claim via the phone, and advise whether a corrected claim or a written appeal needs to be submitted. 15.1.9 Claim Submission for New Providers New providers with Passport awaiting receipt of their Medicaid Identification (MAID) number are subject to the timely filing guidelines and may begin to submit claims once their Passport ID number has been assigned. These claims will initially deny for no MAID number. After Passport receives a provider’s MAID number, all claims submitted and initially denied will be reprocessed without resubmission. 15.1.10 Claim Forms and Field Requirements The following charts describe the required fields that must be completed for the standard CMS-1500 or UB-04 claim forms. If the field is required without exception, an “R” (Required) is noted in the “Required or Conditional” box. If completing the field is dependent upon certain circumstances, the requirement is listed as “C” (Conditional) and the relevant conditions are explained in the “Instructions and Comments” box. The CMS-1500 claim form must be completed for all professional medical services, and the UB-04 claim form must be completed for all facility claims. All claims must be submitted within the required filing deadline of 180 days from the date of service. Although the following examples of claim filing requirements refer to paper claim forms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic or paper). 15.1.10.1 Claim Data Sets Billed by Providers To facilitate timely and accurate claim processing, you must assure billing on the correct form for your provider type. The table below outlines the requirements as defined by Kentucky Medicaid: Page 144 of 331 CMS-1500 Hospital - Acute Care Inpatient Hospital – Outpatient Hospital - Long Term Care Inpatient Rehabilitation Facility Inpatient Psychiatric Facility Home Health Care Skilled Nursing Facility Ambulance (Land and Air) Ambulatory Surgical Center Dialysis Facility (Chronic, Outpatient) Durable Medical Equipment Drugs (Part B) Laboratory Physician and Practitioner Services Federally Qualified Health Centers Rural Health Clinics UB-04 (CMS-1450) X X X X X X X X X X X X X X X X 15.1.10.2 CMS-1500 Claim Form and Required Fields Use of the CMS-1500 form (08/05) was required as of April 1, 2007. The form includes several fields that accommodate the use of your National Provider Identifier (NPI). Although the form requires use of the NPI, we recommend you continue to report your current plan-assigned Provider Identification Numbers in the appropriate shaded areas of the form (17A, 24J, 32B, and 33B). Current Provider Identification Numbers must be preceded by a two-character qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If you do not currently bill electronically, please use G2 as your qualifier ID. Providers are also required to populate filed 19 with the ZZ qualifier ID and the Billing & Rendering Provider’s Primary Taxonomy Code (Box 33b for Billing and Box 19 for Rendering). Required Fields for the CMS-1500 Claim Form NOTE: *Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. CMS 1500 Claim Field 1 Field Description INSURANCE PROGRAM IDENTIFICATION Instructions and Comments Check only the type of health coverage applicable to the claim. This field indicates the payer with whom the claim is being filed. Select “D”, other. Page 145 of 331 Required or Conditional* R Passport’s member identification number as it appears on the member’s Passport ID card. EDI details ASC X12 4010A. Subscriber R number less than 11 digits. 2010BA, NM108=MI NM109 less than 11 digits. Subscriber is required. 1A INSURED I.D. NUMBER 2 PATIENT’S NAME (Last Name, First Name, Middle Initial) 3 Enter the member’s name as it appears on the member’s Passport ID card. R PATIENT’S BIRTH DATE / SEX MMDDCCYY R 4 INSURED’S NAME (Last Name, First Name, Middle Initial) Enter the member’s name as it appears on the member’s Passport ID card, or enter the mother’s name when the member is a newborn. R 5 PATIENT’S ADDRESS (Number, Street, City, State, Zip Code, and Telephone, Including Area Code) R 6 PATIENT RELATIONSHIP TO INSURED Enter the member’s complete address and telephone number (Do not punctuate the address or phone number). Always indicate self. R 7 INSURED’S ADDRESS (Number, Street, City, State, Zip Code) Telephone (include area code) Enter the member’s complete address and telephone number (Do not punctuate the address or phone number). R 8 PATIENT STATUS Enter the member’s marital status. Indicate if the member is employed or is R a student. 9 OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) Refers to someone other than the member. REQUIRED if member is C covered by another insurance plan. Enter the complete name of the insured. 9A OTHER INSURED’S POLICY OR GROUP NUMBER REQUIRED if field 9 is completed. Page 146 of 331 / M or F C CMS 1500 Claim Field Field Description Instructions and Comments 9B OTHER INSURED’S BIRTH DATE / SEX 9C EMPLOYER’S NAME OR SCHOOL NAME 9D INSURANCE PLAN NAME OR PROGRAM NAME REQUIRED if field 9 is completed. MM C DD YY / Sex must be indicated by “M” or “F.” This field is related to the insured in field 9. C REQUIRED if # 9 is completed. C 10A,B,C IS PATIENT’S CONDITION RELATED Indicate Yes or No for each category. TO: 10D Required or Conditional* RESERVED FOR LOCAL USE R Not required 11 INSURED’S POLICY GROUP OR FECA NUMBER Required when other insurance is available. Complete if more than one other medical insurance is available, or if “yes” to field 10 A, B, C. 11A INSURED’S BIRTH DATE / SEX Complete information if other insurance is listed in field 11. C 11B EMPLOYER’S NAME OR SCHOOL NAME Required if employment is indicated in field # 10. C C 11C INSURANCE PLAN NAME OR PROGRAM NAME Enter name of Health Plan. REQUIRED if field 11 is completed. C 11D IS THERE ANOTHER HEALTH BENEFIT PLAN? Y or N by check box. If yes, complete 9 A-D. R 12 PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE Not required 13 INSURED’S OR AUTHORIZED PERSON’S SIGNATURE Not required 14 DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (ACCIDENT) OR PREGNANCY (LMP) MMDDYY C 15 IF PATIENT HAS SAME OR SIMILAR MMDDYY ILLNESS. GIVE FIRST DATE C Page 147 of 331 CMS 1500 Claim Field Field Description Instructions and Comments 16 DATES PATIENT UNABLE TO WORK IN CURRENT 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Required or Conditional* C REQUIRED if a provider other than the member’s primary care physician rendered invoiced services. C Enter Passport provider number for the referring physician. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of field 17A. If the other ID number is the Health C Plan ID number, enter G2. If the other ID number is another unique identifier, refer to the NUCC guidelines for the appropriate qualifier. REQUIRED if field 17 is completed. 17A I.D. NUMBER OF REFERRING PHYSICIAN 17B Enter the NPI number of the referring NATIONAL PROVIDER IDENTIFIER provider, ordering provider or other source. (NPI) REQUIRED if field 17 is completed. C 18 HOSPITALIZATION DATES REQUIRED when place of service is RELATED TO CURRENT SERVICES inpatient. MMDDYY C 19 BILLING PROVIDER’S TAXONOMY CODE Populate field with the ZZ qualifier ID and the Billing Provider’s Primary Taxonomy Code. R 20 OUTSIDE LAB CHARGES For billing diagnostic tests subject to purchase price limitations. C All diagnosis codes must be valid ICD-9 codes for the date of service. “E” codes are NOT acceptable as a primary diagnosis. List in priority order. R For resubmissions or adjustments, enter the claim ID number of the original claim. NOTE: Resubmissions may NOT currently be submitted via EDI. Original claim ID is required if claim is a corrected or resubmitted claim. C 21 22 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1, 2, 3, OR 4 TO ITEM 24E BY LINE). MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. Page 148 of 331 CMS 1500 Claim Instructions and Comments Required or Conditional* Field Field Description 23 Enter the referral or authorization number. Refer to Section 18.6 in this Provider PRIOR AUTHORIZATION NUMBER Manual to determine if services rendered require an authorization or referral. C R 24A DATE (S) OF SERVICE “From” date: MMDDYY. If the service was performed on one day, there is no need to complete the “to” date. 24B PLACE OF SERVICE Enter the CMS standard place of service code. R EMG This field was originally titled “Type of Service” and is no longer used. This is now an emergency indicator field. Enter Y for “Yes” or leave blank for “No” in the bottom (unshaded area of the field). C PROCEDURES, SERVICES OR SUPPLIES CPT/HCPCS MODIFIER Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of service. NOTE: Modifiers affecting reimbursement must be placed in the 1st position. R 24E DIAGNOSIS CODE Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, or 4). All diagnosis codes must be valid ICD-9 codes for the date of service. R 24F CHARGES Enter charges for each line item. Value entered must be greater than zero ($0.01) R 24G DAYS OR UNITS Enter quantity for each line item. Value entered must be greater than zero (EDI allows two characters). R 24H EPSDT FAMILY PLAN 24C 24D Not required Page 149 of 331 CMS 1500 Claim Field Description Instructions and Comments Required or Conditional* ID QUALIFIER If the rendering provider does not have an NPI number, the qualifier indicating what the number represents is reported in the qualifier in field 24I. If the other ID number is the Health Plan ID number, enter G2. If the other ID number is another unique identifier, refer to the NUCC guidelines for the appropriate qualifier. The shaded area allows you to identify the two-character qualifier ID of the Rendering Provider (G2). The un-shaded area is pre-filled with NPI. R 24J RENDERING PROVIDER ID The shaded area allows you to submit Passport assigned provider ID number of the Rendering Provider which coincides with the two- character qualifier ID reported in 24I. The unshaded area accommodates the Rendering Provider’s NPI. R 25 FEDERAL TAX I.D. NUMBER SSN/ EIN Physician or supplier’s Federal Tax ID number. R 26 PATIENT’S ACCOUNT NO. The provider’s billing account number. R ACCEPT ASSIGNMENT Always indicate Yes. Refer to the back of the CMS 1500 form for the section pertaining to Medicaid payments. R TOTAL CHARGE Enter the total of all charges listed on the claim. Value entered must be greater than zero dollars ($0.00). R 29 AMOUNT PAID REQUIRED when another carrier is the primary payer. Enter the payment received from the C primary payer prior to invoicing Passport. Medicaid programs are always the payers of last resort. 30 BALANCE DUE REQUIRED when field 29 is completed. Field 24I 27 28 Page 150 of 331 C CMS 1500 Claim Field Field Description Instructions and Comments Required or Conditional* 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS / DATE Signature on file, signature stamp, computer generated or actual signature is acceptable. R 32 32A 32B REQUIRED unless field 33 is the NAME AND ADDRESS OF FACILITY same information. WHERE SERVICES WERE Enter the physical location (P.O. Box RENDERED (if other than home or Numbers are not acceptable here). office). Required unless rendering provider is SERVICE FACILITY NPI NUMBER atypical and is not required. SERVICE FACILITY TWO CHARACTER QUALIFIED ID AND CURRENT PROVIDERS ID R R R 33 BILLING PROVIDER INFO & TELEPHONE NUMBER REQUIRED - Identifies the provider that is requesting to be paid for the services rendered and should always be completed. Enter physical location. P.O. boxes are not acceptable. 33A BILLING PROVIDER NPI NUMBER REQUIRED R BILLING PROVIDER TWO CHARACTER QUALIFIER ID AND PLAN ASSIGNED PROVIDER ID NUMBER REQUIRED when the Rendering Provider does not have an NPI number. Enter the two-digit qualifier identifying the non-NPI number followed by the provider ID number. Do not enter a space, hyphen, or other separator between the qualifier and the number. EDI instructions 2310B loop, REF01=G2, REF02=Plan’s Provider Network Number. Less than 13 alphanumeric digits. NOTE: Do not send the provider on the 2400 loop. Enter the health plan ID # (strongly recommended). R 33B Provider Group Taxonomy Code R Populate filed with the ZZ qualifier ID and the Group Provider’s Primary Taxonomy Code. 15.1.10.3 UB-04 Claim Form and Required Fields Although the UB-04 claim form accommodates the NPI, you are encouraged to report your current Passport Provider Identification Numbers in the appropriate areas of the form. Page 151 of 331 Required Fields UB-04 Claim Form NOTE: *Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. Required fields for the UB-04 Claim Form Field Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X Required or Required or Conditional* Conditional* 1 Billing Provider Name, Address and Telephone Number Line A: Enter the complete provider name. Line B: Enter the complete address or post office number. Line C: City, State, and Zip Code Line D: Enter the area code, telephone number. Left justified. 2 Pay-to Name and Address Enter the facility Medical Assistance I.D. (MAID) number. Left Justified. R R 3A PATIENT CONTROL NO. Provider’s patient account/control number R R 3B MEDICAL/HEALTH RECORD NUMBER The number assigned to the member’s medical/health record by the provider. R R R R 4 TYPE OF BILL Enter the appropriate three-digit or four-digit code. 1st position is a leading zero. (Note: Do not include the leading zero on electronic claims.) 2nd position indicates type of facility. 3rd position indicates type of care. 4th position indicates billing sequence. Page 152 of 331 R R Field Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* 5 FED. TAX NO. Enter the number assigned by the federal government for tax reporting purposes. R R 6 STATEMENT COVERS PERIOD FROM/ THROUGH Enter dates for the full ranges of services being invoiced. MMDDYY R R 7 UNLABELED Not used – leave blank. 8A PATIENT IDENTIFIER C C PATIENT NAME Last name, first name, and middle initial. Enter the member’s name as it appears on the member’s Passport ID card. Use a comma or space to separate the last and first names. R Titles (Mr., Mrs., etc.) should not be reported in this field. No space should be left after the prefix o a name (e.g. McKendrick). Both names should be capitalized and separated by a hyphen (no space). A space should separate a last name and suffix. R 9A-E PATIENT ADDRESS Enter the member’s complete mailing address. 9A. Street Address 9B. City 9C. State 9D. ZIP Code 9E. Country code (report if other than USA) R R 10 BIRTH DATE Member’s Date of Birth MMDDYYYY R R SEX Enter the member’s sex as recorded at the time of admission, outpatient service or start of care. Only M and F are acceptable. R 8B 11 Patient ID is conditional if the number is different from field 60. Page 153 of 331 R Field 12A 12B 13 14 15 16 17 18-28 Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* ADMISSION 12-15 The start date for this episode of care. For inpatient services, this is ADMISSION DATE the date of admission. Right Justified. The code referring to the hour during which the member was ADMISSION HOUR admitted for inpatient or outpatient care. Left justified. A code indicating the priority of this ADMISSION TYPE admission/visit. ADMISSION SRC A code indicating the source of (Source of Referral for the referral for the admission or Admission or Visit) visit. A code indicating the discharge D HR (Discharge Hour) hour of the member from inpatient care. A code indicating the disposition or discharge status of the member at Patient Discharge Status the end service for the period covered on this bill, as reported in field 6. A code(s) used to identify conditions or events relating to this bill that may affect processing. Enter one of the following codes in the second column as a Reason Code: CONDITION CODES • 35 if Medicare benefits are (the following is unique exhausted. to Medicare eligible • 50 if one of the following applies Nursing Facilities; to why Medicare does not cover condition codes should the services: be billed when Medicare No 3-day prior hospital stay; Part A does not Not within 30-days of cover Nursing hospital discharge; Facility Services) 100 benefit days are exhausted ; No 60 day break in daily skilled care; Medical necessity requirements are not met; and/or, Daily skilled requirements are Page 154 of 331 R R R R R Not required R C R R R R C C Field Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X Required or Required or Conditional* Conditional* 29 ACCIDENT STATE The accident state field contains the two digit state abbreviation where the accident occurred. REQUIRED when applicable. 30 UNLABELED FIELD Enter DRG on the lower line. REQUIRED when applicable. C C 31A, B34A, B OCCURRENCE CODES AND DATES Enter the appropriate occurrence code and date. REQUIRED when applicable. C C 35A, B36A, B OCCURRENCE SPAN CODES AND DATES A code and the related dates that identify an event that relates to the payment of the claims. REQUIRED when applicable. C C 37A, B UNLABELED FIELD 38 RESPONSIBLE PARTY The name and address of the party responsible for the bill. C C 39A, B, C, D41A, B, C, D 42 VALUE CODES AND AMOUNTS REV.CD. C C A code structure to relate amounts or values to identify data elements necessary to process this claim as qualified by the payer organization Value Codes and amounts. If more than one value code applies, list in alphanumeric order. C REQUIRED when applicable. NOTE: If a value code is populated, then the value amount must also be populated and vice versa. Codes that identify specific accommodation, ancillary service or unique billing calculations or arrangements. Page 155 of 331 R C R Field 43 44 Field Description DESCRIPTION HCPCS/RATE S/ HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* The standard abbreviated description of related revenue code categories is included on this bill. See the NUBC R instructions for field 42 for a description of each revenue/code category. 1. The Healthcare Common Procedure Coding System (HCPS) is applicable to ancillary services and outpatient bills. 2. The accommodation rate for inpatient bills. 3. Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or casemix groups) on which payment determinations are made under several prospective payment systems. Enter the applicable rate, HCPS or HIPPS code, and modifier based on the bill type of Inpatient or Outpatient. Report line item dates of service for each revenue code or HCPCS/CPT code. Report units of service. A quantitative measure of service rendered by revenue category to or for the patient to include items such as number of accommodations days, miles, pints of blood, renal dialysis treatments, etc. Total charges for the primary payer pertaining to the related revenue code for the current billing period as entered in the statement covers period. Total charges include both covered and non-covered charges. Report grand total of submitted charges. Value entered must be greater than zero dollars ($0.00). Page 156 of 331 Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* R R R R R R R R R Field Field Description 48 NONCOVERED CHARGES 49 UNLABELED FIELD Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* To reflect the non-coverage charges for the destination payer as it pertains C to the related revenue code. REQUIRED when Medicare is primary. Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* C Not required Not required PAYER Enter the name for each payer being invoiced. When the member has other coverage, list the payers as indicated below. Line A refers to the primary payer; B, secondary; and C, tertiary. R R HEALTH PLAN ID The number used by the health plan to identify itself. Passport’s Payer ID is 61129. R R 52 REL. INFO Release of Information Certification Indicator. This field is required on paper and electronic invoices. Line A refers to the primary payer; B refers to secondary; and C refers to R tertiary. It is expected that the provider/ practitioner have all necessary release information on file. It is expected that all released invoices contain “Y.” R 53 ASG. BEN. Valid entries are “Y” (yes) and “N” (no). R R 54 PRIOR PAYMENTS The A, B, C indicators refer to the information in Field 50. R R EST. AMOUNT DUE Enter the estimated amount due (the difference between “total charges” and any deductions such as other coverage). C C 50 51 55 Page 157 of 331 Field 56 57A, B C 58 59 60 61 Field Description Instructions and Comments The unique identification number assigned to the provider submitting the bill; NPI is the national provider NATIONAL identifier. REQUIRED if the health PROVIDER care provider is a Covered Entity as IDENTIFIER-BILLING defined in HIPAA Regulation. PROVIDER Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* R R OTHER (BILLING) PROVIDER IDENTIFIER A unique identification number assigned by the health plan to the provider submitting the bill. REQUIRED on or after May 23, 2007 if NPI is not mandated in field 56. The UB-04 does not use a qualifier to specify the type of Other (Billing) Provider Identifier. Use this field to report other provider identifiers as assigned by the health plan listed in field 50 A, B, C. R R INSURED’S NAME Information refers to the payers listed in field 50. In most cases, this will be the member’s name. When other coverage is available, the insured is indicated here. R R P. REL Enter the member’s relationship to insured. For Medicaid programs the member is the insured. (Code 01: Patient is Insured) R R INSURED’S UNIQUE ID Enter the member’s Passport ID, exactly as it appears on the member’s ID card, on line B or C. When other insurance is present, enter the Passport ID on line A. R R C C GROUP NAME Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B, secondary; and C, tertiary. Page 158 of 331 Field Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X Required or Required or Conditional* Conditional* 62 63 INSURANCE GROUP NO. TREATMENT AUTHORIZATI ON CODES Use this field only when a member has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B refers to secondary; and C refers to tertiary. Enter the Passport referral or authorization number. Line A refers to the primary payer; B refers to secondary; and C refers to tertiary. C C R R DCN Document Control Number. New field. The control number assigned to the original bill by the health plan or the health plan’s fiscal agent as part of their internal control. Previously, field 64 contained the Employment Status Code (ESC). The ESC field has been eliminated. NOTE: Resubmitted claims must contain the original claim ID. C C 65 EMPLOYER NAME The name of the employer that provides health care coverage for the insured individual identified in field 58. REQUIRED when the employer of C the insured is known to potentially be involved in paying this claim. Line A refers to the primary payer; B refers to secondary; and C refers to tertiary. C 66 DIAGNOSIS AND PROCEDURE CODE QUALIFIER (ICD VERSION INDICATOR) The qualifier that denotes the version of International Classification of Diseases (ICD) reported. Not required. C 64 Page 159 of 331 C Field 67 Field Description PRIN. DIAG. CD. AND PRESENT ON ADMISSION (POA) INDICATOR 67 A-Q OTHER DIAG. CODES 67A-Q 68 UNLABELED FIELD 69 70 ADM. DIAG. CD. PATIENT’S REASON FOR VISIT Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* The ICD-9-CM codes describing the principal diagnosis (i.e., the condition established after study to be chiefly responsible for occasioning the admission of the member for care). Present on Admission (POA) is defined as present at the time the order for inpatient admission occurs – R conditions that develop during an outpatient encounter, including emergency department, are considered as POA. The POA Indicator is applied to the principal diagnosis as well as all secondary diagnoses reported. The ICD-9-CM diagnoses codes corresponding to all conditions that coexist at the time of admission, that develop subsequently, or that affect C the treatment received and/or the length of stay. Exclude diagnoses that relate to an earlier episode which have no bearing on the current hospital stay. The ICD diagnosis code describing the member’s diagnosis at the time of admission. R REQUIRED for inpatient admissions. Each diagnosis code must be valid for the date of service. The ICD-9-CM diagnosis codes describing the member’s reason for visit at the time of outpatient registration. C REQUIRED for all unscheduled outpatient visits. Up to three ICD-9-CM codes may be entered in fields A,B, & C. Page 160 of 331 Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* R C C C Field 71 72 A-C 73 74 74 A-E Field Description PROSPECTIVE PAYMENT SYSTEM (PPS) CODE EXTERNAL CAUSE OF INJURY (ELC) CODE Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* The PPS code assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer. C REQUIRED when the Health Plan/ Provider contract requires this information. Up to 4 digits. The ICD diagnosis codes pertaining to external cause of injuries, poisoning, or adverse effect. C External Cause of Injury “E” diagnosis codes should not be billed as primary and/or admitting diagnosis. REQUIRED if applicable. Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* C C UNLABELED FIELD PRINCIPAL PROCEDURE CODE AND DATE OTHER PROCEDURE CODES AND DATES The ICD code that identifies the inpatient principal procedure performed at the claim level during the C period covered by this bill and the corresponding date. Inpatient Facility – ICD-9 is REQUIRED when a surgical procedure is performed. Outpatient Facility or Ambulatory Surgical Center – CPT, HCPCS or ICD-9 is REQUIRED when a surgical procedure is R performed. The ICD codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were performed. Inpatient Facility – ICD-9 is REQUIRED when C a surgical procedure is performed. Outpatient Facility or Ambulatory Surgical Center – CPT, HCPCS or ICD-9 is REQUIRED when a surgical procedure is performed. Page 161 of 331 C R C Field 75 76 Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Required or Conditional* Outpatient, Bill Types 13X, 23X, 33X Required or Conditional* UNLABELED FIELD ATTENDING PROVIDER NAME AND IDENTIFIERS NPI/QUALIFIER / OTHER ID Enter the NPI of the physician who has primary responsibility for the member’s medical care or treatment in the upper line, and their name in the lower line, last name first. If the attending physician has another R unique ID, enter the appropriate descriptive two-digit qualifier followed by the other ID. Enter the last name and first name of the Attending Physician. R Enter the NPI of the physician who performed surgery on the member in the upper line; enter the physician’s name in the lower line. (NOTE: The last name should be entered first.) If the operating physician has another C unique ID, enter the appropriate descriptive two-digit qualifier followed by the other ID. Enter the last name and first name of the Attending Physician. REQUIRED when a surgical procedure code is listed. C 78-79 Enter the NPI of any physician, other than the attending physician, who has responsibility for the member’s OTHER PROVIDER medical care or treatment in the (INDIVIDUAL) NAME upper line, and their name in the C AND IDENTIFIERS lower line, last name first. NPI/QUALIFIER/ If the other physician has another OTHER ID unique ID, enter the appropriate descriptive two-digit qualifier followed by the other ID. C 80 REMARKS 77 OPERATING PHYSICIAN NAME AND IDENTIFIERS NPI/QUALIFIERS NPI/QUALIFIER/ OTHER ID Area to capture additional information necessary to adjudicate the claim. Page 162 of 331 C C Field Field Description Instructions and Comments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Outpatient, Bill Types 13X, 23X, 33X Required or Required or Conditional* Conditional* 81CC, A-D CODE-CODE FIELD To report additional codes related to Form Locator (overflow) or to report externally maintained codes approved C by the NUBC for inclusion in the institutional data set. C Required fields for the UB-04 Claim Form 15.1.2 Electronic Data Interchange (EDI) for Medical and Hospital Claims 15.1.2.1 Procedures for Electronic Submission Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claims submission for providers. EDI, performed in accordance with nationally recognized standards, supports the health care industry’s efforts to reduce administrative costs. The benefits of billing electronically include: • • • • • Reduction of overhead and administrative costs. EDI eliminates the need for paper claims submission. It has also been proven to reduce claim rework (adjustments). Receipt of reports as proof-of-claim receipt. This makes it easier to track the status of claims. Faster transaction time for claims submitted electronically. An EDI claim averages about 24 to 48 hours from the time it is sent to the time it is received. This enables providers to easily track their claims. Validation of data elements on the claim form. By the time a claim is successfully received electronically, information needed for processing is present. This reduces the chance of data entry errors that occur when completing paper claim forms. Faster claim completion. Claims that do not need additional investigation are generally processed more quickly. Reports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt. 15.1.2.2 Requirements for Electronic Claim Filing The following sections describe the procedures for electronic submission for hospital and medical claims, including descriptions of claims and report process flows, information on unique electronic billing requirements, and various electronic submission exclusions. Page 163 of 331 15.1.2.2.1 Hardware/Software Requirements Providers may use different products to bill electronically. Providers may submit claims electronically as long as their software has the capability to send EDI claims to Emdeon (through direct submission or another clearinghouse/vendor). Emdeon has the capability to accept electronic data from numerous providers in several standardized EDI formats. Emdeon forwards the accepted information to carriers in an agreed upon format. 15.1.3 Contracting with Emdeon and Other Electronic Vendors Providers without Emdeon EDI capabilities who are interested in electronic claims submission may contact the Emdeon Sales Department at (877) 469-3263, option 6. Providers may also choose to contract with another EDI clearinghouse or vendor who already has EDI capabilities. 15.1.4 Certification Requirements After the registration process is completed and providers have received all certification material, providers must: • • Read over the instructions carefully, with special attention to the information on exclusions, limitations, and especially, the rejection notification reports. Contact their system vendor and/or Emdeon to initiate electronic submissions to Passport. (Be prepared to inform the vendor of Passport’s electronic payer identification number 61129.) 15.1.5 Specific Data Record Requirements Claims transmitted electronically must contain all the same data elements identified within Section 18 of this Provider Manual. EDI clearinghouses or vendors may require additional data record requirements. 15.1.6 Electronic Claim Flow Description To send claims electronically to Passport, all EDI claims must first be forwarded to Emdeon via a direct submission or through another EDI clearinghouse or vendor. Upon receipt of the transmitted claims, Emdeon validates the submitted information against Emdeon’s proprietary specifications and Passport specific requirements. Claims not meeting the requirements are immediately rejected and returned to the sender via an Emdeon error report. The name of this report may vary based on the provider’s contract with its intermediate EDI vendor or Emdeon. Emdeon forwards accepted claims to the Passport and immediately returns an acceptance report to the sender. Passport immediately validates claims for Emdeon for provider identification number requirements. Claims not meeting this requirement are rejected and returned to Emdeon. Emdeon then forwards this rejection notice to the original sender (i.e. its trading partner, EDI vendor or Page 164 of 331 provider.) Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Emdeon or other contracted vendors must be reviewed and validated against transmittal records daily. Passport also validates claims containing valid provider identification numbers against member eligibility records before being accepted. If a patient cannot be identified as a member of Passport, a denial letter will be forwarded directly to the provider. This letter is sent to the payment address documented in Passport’s provider file. Claims passing eligibility requirements are then passed to the claim processing queues. Claims are not considered as received under timely filing guidelines if rejected for missing or invalid member data. Since Emdeon returns acceptance reports directly to the sender, submitted claims not accepted by Emdeon are not transmitted to Passport. If you would like assistance in resolving submission issues reflected on either the Acceptance or R059 Plan Acceptance (Claim Status) reports, contact the Emdeon Helpdesk at (800) 845-6592 or the EDI Technical Support Hotline at (877) 234-4275, or by e-mail to edi.Passport@kmhp.com. 15.1.7 Invalid Electronic Claim Record Rejections/Denials All claim records sent to Passport must first pass Emdeon proprietary edits and specific edits prior to acceptance. Claim records that do not pass these edits are invalid and will be rejected without being recognized as received at Passport. In these cases, the claim must be corrected and resubmitted within the required filing deadline of 180 calendar days from the date of service. It is important for each provider to review the rejection notices (the functional acknowledgements to each transaction set) received from Emdeon in order to identify and resubmit these claims correctly. Rejected electronic claims may be resubmitted electronically once the error has been corrected. 15.1.8 Plan Specific Electronic Edit Requirements 15.1.8.1 Exclusions Certain claims are excluded from electronic billing. At this time, these claims must be submitted on paper. Excluded Claim Categories CMS-1500 Claim records for corrected billing. Claim records for medical, administrative or claim appeals. Excluded Provider Categories Providers contracted with vendors that are not transmitting through Emdeon. Important: Requests for reconsideration/adjustments may be submitted by telephone to the Provider Claims Service Unit (PCSU) at (800) 578-0775, option 2. Page 165 of 331 Common Rejections Invalid Electronic Claims Records – Common Rejections from Emdeon Claim with missing or invalid batch level records Claim records with missing or invalid required fields Claim records with invalid (unlisted, discontinued, etc.) codes (CPT, HCPCS, ICD-9, etc.) Claims without provider numbers Claims without member numbers Important: Also, unique cases are not HIPAA Compliant. Invalid Electronic Claims Records – Common Rejections from Passport (EDI Edits Within the Claims System) Claim for providers who are not approved for EDI submission including test claim Claims received with invalid provider numbers Important: Provider identification number validation is not performed at Emdeon. Emdeon will reject claims for provider information only if the provider number fields are empty. 15.1.8.2 Electronic Billing Inquiries Please direct inquiries as follows: Action Contact If you have specific EDI technical questions … Contact EDI Technical Support at: (877) 234-4275 If you have general EDI questions or questions on where to enter required data … Contact EDI Technical Support at: (877) 234-4275 If you have questions about your claims transmissions or status reports … Contact your System Vendor - call the Emdeon Corporation Help Desk at: (800) 845-6592 or access Emdeon’s web site, www.emdeon.com. If you have questions about your claim status (receipt or completion dates) … Contact Provider Claims Service Unit at: (800) 578-0775, option 2 If you have questions about claims that are reported on the Remittance Advice … Contact Provider Claims Service Unit at: (800) 578-0775, option 2 If you need to know a provider ID number … Contact Provider Services at: (800) 5780775, option 3 If you would like to update provider, payee, UPIN, tax ID number, or payment address information … For questions about changing or verifying provider Information. Notify your Provider Relations Specialist in writing at: Passport Health Plan Provider Network Management 5100 Commerce Crossings Drive Louisville, KY 40229 Fax: (502) 585-6060 Telephone: (502) 585-7943 Page 166 of 331 15.1.9 Submitting Member Encounters As a fiscal agent for the Department for Medicaid Services (DMS), Passport is required to submit encounter data to the Commonwealth of Kentucky. Provider assistance is an essential component of this requirement. The Commonwealth requires complete, accurate, and timely encounter data in order to effectively assess the availability and costs of services rendered to Medicaid members. The data we provide affects the Commonwealth’s funding of the Medicaid Program, including Passport. Data regarding encounters is also used to fulfill the Centers for Medicare & Medicaid Services (CMS) required reporting in support of the Federal funding of State Medicaid plans. According to Passport policy, providers must report all member encounters by claims submission either electronically or by mail to Passport. 15.2 Provider/Claim Specific Guidelines 15.2.1 Primary Care Practitioner 15.2.1.1 Allergy Serum Coverage for Allergy Injections/Serum is limited to members under 21 years of age; however, allergy testing is covered for all members. A referral is required from the PCP to the specialist. Services rendered by a non-participating provider require an authorization. Either an allergist or a PCP may bill the service and serum. PCPs will be paid based on Passport’s fee schedule. 15.2.1.2 Immunization Administration Immunizations are “Direct Access” services. This means members may go anywhere (i.e. their PCP, their local Department of Health, or another PCP) to receive immunizations. 15.2.1.3 Vaccines Codes and Administration Codes The immunization and vaccines codes must be billed for the payment of the administration of these services. The payment for the administration is actually generated on claim lines billed with the immunization and vaccine codes. 15.2.1.4 Family Planning Claims Family planning claims must be submitted to: Passport Health Plan P. O. Box 7114 London, KY 40742 Page 167 of 331 All other services (medical) must be billed as normal to Passport. Please note, combined ancillary charges (e.g. supplies, room use, lab/x-ray) do not need to be separated and may be included in the medical claim billed to Passport. All claims for sterilization procedures must be submitted with the appropriate Sterilization MAP 250 treatment consent form available on the Kentucky Department for Medicaid Services (DMS) web site, http://www.chfs.ky/gov. Termination requests require an authorization and MAP 235 treatment form available on the Kentucky Department for Medicaid Services (DMS) web site, http://www.chfs.ky/gov. Members and providers must complete and comply with all terms and conditions of the DMS consent forms thirty days prior to a procedure being provided. Providers must also ensure that individuals with limited English proficiency and visually impaired and/or hearing-impaired members understand what they are signing. 15.2.2 EPSDT Passport provides all preventive health benefits covered under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for members from birth to age twenty-one (21). To submit claims for EPSDT services you must: 1. Continue to bill using the same codes for comprehensive history and physical exam you use today. These codes must correspond with the member’s age. • 99381-99385 – New Patient Series • 99391-99395 – Established Patient Series 2. Add an “EP” modifier to the physical exam code only when all components of the appropriate EPSDT screening interval have been completed and documented in the member’s medical record. Do not add the EP modifier to other service being billed (i.e. immunizations). As a reminder, do not bill lab or testing components individually if they were conducted as part of an EPSDT screening interval. 3. Acknowledge the following health evaluation services have been completed* by submitting the appropriate CPT Category II codes, according to the member’s age, as outlined below. CPT II codes must include a nominal charge (i.e. $.01 or $1.00, not blank or zero) in order to adjudicate correctly. Member Age: CPT II Code: Two (2) Years and Above 3008F Nine (9) Years and Above 2014F Description To confirm the BMI has been performed and documented in the member’s medical record To confirm the member’s mental status has been assessed and documented in the member’s medical record *Please note this requirement does not apply to EPSDT services rendered prior to October 1, 2010. For more information about EPSDT, please see section 9 of this Provider Manual. Page 168 of 331 15.2.3 Specialists 15.2.3.1 Payment Requirements - Office Related (Place of Service 11) Services performed in a participating provider’s office require a valid referral unless the service is noted as an exception to referral requirements in Section 7 of this Provider Manual. Services performed in a non-participating provider’s office require an authorization. 15.2.3.2 Range of Dates on CMS-1500 Date ranges for E/M codes are unacceptable. All days must be submitted separately. For example, if the member receives services ranging from 8/1/12 to 8/5/12, and is being billed with 99232 for $400.00, bill as follows: Date Procedure Quantity Requested Amount 8/1/12 8/2/12 8/3/12 8/4/12 8/5/12 99232 99232 99232 99232 99232 1 1 1 1 1 $80.00 $80.00 $80.00 $80.00 $80.00 15.2.3.3 Surgeries If a physician bills an evaluation and management service on the same date of service as a surgical procedure, the surgical procedure is payable and the evaluation and management service is not payable. If more than one surgical procedure is performed, multiple procedures reduction logic will apply. Many surgeries include a global surgery follow-up period (0, 10 or 90 days). All care provided during the global follow-up period in which a surgery occurred is compensated through the surgical payment. Visits by the same physician on the same day as the minor surgery or endoscopy are included in the payment for the procedure, unless a separately identifiable service with an unrelated diagnosis is also performed. The appropriate modified should be used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made upon review against Passport’s clinical editing criteria. The global surgical fee includes payment for hospital observation services unless the criteria for the Appropriate CPT modifiers are met. 15.2.3.4 Obstetrical Services Referrals are not required for any obstetrical services. Members may self-refer to any Passport contracted obstetrical practitioner to obtain prenatal care and delivery services; therefore, a referral from the primary care provider is not required. Page 169 of 331 Submitting the ACOG Form assists Passport in accurately determining a member’s risk factors. Upon receipt of the completed ACOG or ACOG-like form, Passport will enroll the member in the Mommy Steps Program. All pregnant members identified will receive educational mailings and, when appropriate, be assigned to a care manager. Participation in the Mommy Steps Program is voluntary, and the member has the right to decline any or all parts of the program. The Mommy Steps Program hours of operation are Monday through Friday, 8:00 a.m. to 6:00 p.m. EST (except for business-approved holidays). If a member with the required ACOG form on file misses a perinatal appointment, the obstetrical practitioner should fax the No-Show Visit Form to the Mommy Steps Program at (502) 585-7970. All No-Show Visit Forms must be received by Passport within two business days of the missed appointment. If the obstetrical practitioner complies with this standard, Passport will reimburse the practitioner as outlined in the fee schedule. No-Show Visit Forms will be provided to OB practitioners and are not to be invoiced on the same date of service as a perinatal care visit. If a member is seen for a prenatal visit and received diagnostic testing in the participating obstetrical practitioner’s office during that visit, the practitioner may bill for both the prenatal visit and the diagnostic test. No referral or authorization is required for OB ultrasounds done at a participating facility. For a circumcision to be paid, it MUST be billed under the baby’s date of birth. If the claim is billed under the mother’s birth date, the claim will deny. Always include the first and last name of the mother and baby on the claim form. If the baby has not been named, insert “Boy” as the baby’s first name; include the baby’s last name if it is different than the mother’s. Verify that the appropriate last name is recorded for the mother and baby. 15.2.3.5 Delivery and Postpartum Care For billing of multiple deliveries and/or ultrasounds, payment is made when the designated CPT codes are billed. CPT codes for unique, individual services provided must be billed for all perinatal care, i.e. each prenatal visit, delivery code, and postpartum visit must be billed separately. 15.2.4 Departments of Health (DOHs) Services conducted by participating Departments of Health are payable without authorizations or referrals. 15.2.5 Chiropractors Chiropractic services are covered for 26 visits in a calendar year regardless of changes in providers or diagnoses. The first twelve visits do not require an authorization. Services beyond twelve visits require an authorization. 15.2.6 Home Health Home health care is encouraged as an alternative to hospitalization (when medically appropriate), and is utilized for the following types of services: Page 170 of 331 • • • • • • • • • Skilled nursing Private Duty Nursing Occupational therapy Infusion therapy Social workers Physical therapy Speech therapy Home health aides MediPlanner The Utilization Management Department will coordinate medically necessary home care needs with the PCP, hospital, home care departments, and other providers of home care services. The home health contract is revenue code based. Claims must be billed with valid revenue and HCPC codes. 15.2.6.1 Nurse Supervision When home health aides are used, registered nurse (RN) supervision is required at least once every two (2) weeks. This supervised visit is not covered by Passport, as it is considered part of the cost for the home health aides. 15.2.6.2 Services and Visits in Nursing Facilities Ancillary services (other than room and board charges) billed with POS 31 or 32 are payable for both participating and non-participating providers without an authorization or referral (benefits are not payable for facility charges). Members may be seen by any PCP (regardless of whether the PCP is the member’s PCP) and the provider will be reimbursed fee for service. 15.2.6.3 Y1 Indicator (Home Health Services Not Covered by Medicare) Services not covered by Medicare may be submitted to Passport for payment without submitting to Medicare first. Providers must submit these types of claims with a “Y1”indicator in Field 24 of the UB-04 claim form. An EOB is not required if the “Y1” indicator is on the bill. Passport authorization requirements apply for these services. 15.2.7 Hospice All hospice services must be authorized. Payment for hospice care is made at one of four predetermined rates for each day that a member is under the care of hospice. The rates paid for any particular day vary depending on the level of care provided to the member. The four levels of care by which each day is classified are described below. 15.2.7.1 Routine Home Care Hospice is paid the routine home care rate for each day the member is under the care of the hospice without receiving one of the other categories of hospice care. This rate is paid without regard to the Page 171 of 331 volume or intensity of routine home care services provided on any given day, and is also paid when the member is receiving outpatient hospital care for a condition unrelated to the terminal condition. 15.2.7.2 Continuous Home Care Hospice is paid the continuous home care rate when continuous home care is provided. The rate is paid only during a period of crisis and only as necessary to maintain the terminally ill member at home. The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate. For every hour or part of an hour of continuous care furnished, the hourly rate is paid for up to 24 hours a day. Hospice provides a minimum of eight hours of care during a 24-hour day, which begins and ends at midnight. This care need not be continuous (i.e. four hours could be provided in the morning and another four hours could be provided in the evening). The care must be predominantly nursing care provided by either a registered nurse (RN) or licensed practical nurse (LPN). In other words, at least half of the hours of care are provided by the RN or LPN. Homemaker or home health aide services may be provided to supplement the nursing care. 15.2.7.3 Inpatient Respite Care Hospice is paid at the inpatient respite care rate for each day the member stays in an approved inpatient facility and receives respite care. Payment for respite care may be made for a maximum of five continuous days at a time (including the date of admission but not counting the date of discharge). Payment for the sixth and any subsequent days is to be made at the routine home care rate. More than one respite period (of no more than five days each) is allowable in a single billing period. If the member dies under inpatient respite care, the day of death is paid at the inpatient respite care rate. 15.2.7.4 General Inpatient Care Payment at the inpatient rate is made when general inpatient care is provided. 15.2.8 DME Referrals are never required for Durable Medical Equipment (DME). The DME authorization requirements are based off of total monthly-billed charges or monthly quantity of items purchased. For a complete list of benefits requiring authorization by quantity, please refer to Section 5 of this Provider Manual. If the DME item is not mentioned in this Provider Manual, the authorization requirement is determined by cost as outlined below. • If the provider’s billed charges are greater than $500 for a monthly supply of the same item, an authorization is required. An authorization is required for all nonparticipating providers unless the service is a Medicare covered service and Medicare is primary or the member is in out-of-home placement. Page 172 of 331 15.2.8.1 DME Rentals A modifier “RR” should be used for all rented equipment. All mini-nebulizers must be purchased, with the exception of claims involving coordination of benefits. If Passport is secondary to another carrier who has reimbursed the mini-nebulizer as a rental, the benefits are coordinated as a rental. 15.2.8.2 Enteral Therapy Enteral therapy does not require an authorization unless the billed amount is greater than $500 for a month’s supply. Claims should be submitted with an NDC number so they may be reimbursed from the average wholesale price (AWP) of the drug. 15.2.9 Home Infusion All nursing visits MUST be authorized in addition to the infusion therapy services. Infusion therapy requires an authorization if the billed amount is $400.00 or greater. Catheter maintenance charges are always reimbursed based on the authorization. As of October 1, 2013, medications for Home Infusion will be authorized by the Pharmacy Benefit Manager - this includes Synagis injections. To obtain an authorization for a Home Infusion Medication, please complete the following steps: • • • Submit Home Infusion therapy authorization form to PerofrmRx via fax at 877-693-8280 for authorization of infusion therapy dosages, associated nursing vistis, and supplies. Bill all infusion therapy drug claims directly to PerformRx using the online adjudication system. Bill all associated nursing visits and supplies directly to Passport Health Plan at P. O. Box 7114, London, KY 40742 or electronically with payer ID# 61129 to receive reimbursement. 15.2.9.1 Medically Billed Drugs All claims, paper and electronic, submitted to Passport with drug codes must include valid National Drug Code (NDC) numbers and NDC units. 15.2.10 Inpatient/Outpatient Hospital Care Facility claims for inpatient services should be submitted on the hospital’s standard billing form (UB04). The prior authorization number issued at the time of admission notification should appear on the claim form. Inpatient claims must be submitted after the services were rendered or compensable items were provided within the timeframe indicated in the Passport Hospital Agreement. Claims for outpatient services should be submitted on the hospital’s standard billing form (UB-04). The Passport prior authorization number for services (if necessary) should be included on the claim form. 15.2.10.1 Initial Observation Care All related evaluation and management services provided by the physician on the same day are Page 173 of 331 included in the admission for hospital observation. Only one physician may report initial observation services. Do not use these observation codes for post-recovery in regard to a procedure considered to be a global surgical service. If a member who is admitted on an observation status is also admitted on an inpatient status before the end of the date on which the member was admitted to observation, only the inpatient service will be paid. Providers may not bill initial observation care codes for services provided on the dates they admit patients on an inpatient status. 15.2.10.2 Observation Care Discharge Service Observation discharge code 99217 is to be used only when discharge from observation status occurs on a date other than the initial date of observation status. 15.2.10.3 Hospital Inpatient Services The codes for hospital inpatient services report admissions to a hospital setting, follow-up care provided in a hospital setting, observation or inpatient care for the same day admission and discharge, and hospital discharge day management. The initial hospital care codes should be used by the admitting physician to report the first hospital inpatient encounter. All evaluation and management services provided by the admitting physician in conjunction with the admission, regardless of the site of the encounter, are included in the initial hospital care service. Services provided in the ER, observation room, physician’s office, or nursing facility specifically related to the admission cannot be reported separately. Codes 99238 and 99239 are for hospital discharge day management, but exclude discharge of the member from observation status. When a physician other than the attending physician provides concurrent care on a discharge day, these services must be billed using the subsequent hospital inpatient or outpatient codes. 15.2.10.4 Consultations Claims for inpatient consultations and subsequent procedures/treatments are covered without regard to the authorization for the inpatient stay. Consulting physicians must bill both the consultation CPT code and the procedure and/or treatment code to be paid for services rendered during the inpatient stay. 15.2.10.5 Critical Care Services Critical care codes include evaluation and management of the critically ill or injured member, requiring direct delivery of medical care. Note that 99292 is an add-on code and must be used in conjunction with 99291. Critical care of less than 30 minutes should be reported using an appropriate evaluation and management code. Critical care of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes should not be reported. 15.2.10.6 Identifying Newborn Inpatient Services Services for newborns are processed under the newborn’s Passport member ID number. Page 174 of 331 15.2.11 Free-Standing Facilities Free-standing radiology facilities who bill with a place of service of 11 (office) do not require a referral for radiology services. 15.2.12 Ambulance Services Ambulance services and emergent air transportation do not require authorization for payment. Nonemergent air transportation will require an authorization. Providers must report an origin and destination modifier for each ambulance trip in accordance with guidelines in the HCPCS manual. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha equals origin: the second position alpha code equals destination. 15.3 Understanding the Remittance Advice 15.3.1 Electronic Remittance Advice (ERA/835) Remittance Advices explain the payment of a claim and/or any adjustments made. For each claim, there is a remittance advice (RA) that lists each line item payment, reduction, and/or denial. Payment for multiple claims may be reported on one transmission of the RA. Standard adjustment reason codes are used on remittance advices. These codes report the reasons for any claim financial adjustments, and may be used at the claim or line level. Multiple reason codes may be listed as appropriate. Remark codes are used on an RA to further explain an adjustment or relay informational messages. Please see the end of this section for a sample Passport remittance advice. 15.3.1.1 Receiving the Electronic Remittance Advice (ERA/835) If you are interested in receiving ERAs, please register through Emdeon Business Services. Once registered, you will receive an ERA/835 transaction. For additional information or questions, please contact the EDI Technical Support Hotline (877) 234-4275, option 4 or by email at EDI.PHP@amerihealthcaritas.com 15.3.1.2 Adjustment/Denial Codes Description Benefit/Service Rule Denial Valid Correct NDC required for consideration. Required for J code Infusion Therapy drugs. Verify if an NDC was billed on the HCFA. Submit corrected claim. Page 175 of 331 Denial Invalid Contact Provider Claims Service Unit at (800) 578-0775, option 2. Invalid/Deleted code, modifier or description. The claim was either billed without a procedure code or billed with an invalid procedure code. Compare the codes billed on the CMS 1500 to the codes processed on the remittance advice. Submit corrected claim. Itemized Bill/Date of Service/Charges/ Invoice required. Usually required for DME misc. codes (E1399) and Renal Dialysis Claims. We need the itemized bill in order to know how much to reimburse. Submit copy of the itemized invoice to correspondence. Received after filing time limit. The timely filing deadline is 180 days. If COB related, the deadline is 60 days from the notification date on the primary carrier EOB for CMS submissions and 180 days for UB-04 submissions. Verify that all supporting documentation was included in initial claims submission. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Submit proof of timely filing documentation to Passport correspondence. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Submit corrected claim. Contact Provider Claims Service Unit at (800)5780775, option 2. Diagnosis invalid/ missing/deleted. Requires 4th/5th digit. The claim was either billed without a DX code or billed with an invalid DX code. Verify the diagnosis code in box 21 on the CMS 1500. Not enrolled on date of service. Verify if you have copy of the The member will have Medicaid care for the month to follow up with of the date of his/her caseworker. service. Resubmit with EOB from primary carrier Contact Provider Claims Service Unit at (800) 578-0775, option 2. The member is showing with primary carrier coverage. Submit primary carrier Verify if EOB was included EOB to Passport with initial claim submission. correspondence. Page 176 of 331 Mail copy of Medicaid card to Passport correspondence Resubmit claim with primary carrier information. Description Benefit/Service Rule Carrier of Service Block Vision Assistant Surgeon Payment Denial Valid Submit claim to Block Vision This is a processing explanation code, not a denial. Final Denial Invalid Block Vision Claims & Eligibility at (866) 819-4298 from 9 a.m. to 8 p.m. Contact Provider Claims Service Unit at (800) 578-0775, option 2. This code is usually used on claims for a newborn. Combined payment mother & baby. The newborn claim is written off by the provider, and they Final receive payment for the mother’s delivery claim instead. Not enrolled on date of service. Verify if you have a copy of the Medicaid ID card for the month of the date of service. The member will have to follow up with his/her caseworker. Duplicate claim previously paid at correct rate. Passport has previously processed a claim submitted for the same date of service and from the same provider. Final Used to signify a payment reduction due to multiple surgical or therapy procedures billed on the same date of service. Final Over max procedure/ benefit limit. This denial code could be used for a variety of claim processing scenarios. Final Payment reflects coordination of benefits, if $0, max liability met. COB, secondary payment. If Passport payment is $0, then the primary carrier paid over the Passport allowable amount. Final This is a processing explanation code, not a denial. Page 177 of 331 Contact Provider Claims Service Unit at (800) 578-0775, option 2. Mail copy of Medicaid card to Passport correspondence. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at 1-800578-0775, option 2. Description Same procedure paid to a different provider. Service not covered. Benefit/Service Rule Denial Valid Passport has previously paid a claim submitted with the same procedure code for the Final same date of service to a different provider. This denial code could be used for a variety of claim processing scenarios. Services were not provided. This rejection code is usually used when the provider has called in to request a payment recoupment. Submit charges to MA fee for service program. Administrative approval. Final Pre-cert/Auth not obtained, denied or invalid. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Final Contact Provider Claims Service Unit at (800) 578-0775, option 2. This claim is considered mental health related. Final Contact Provider Claims Service Unit at (800) 578-0775, option 2. This is a processing explanation code, not a denial code. Final It is usually used when the Medical Review or Appeals department has overturned a previous processing. No PCP referral. Denial Invalid Contact Provider Claims Service Unit at (800) 578-0775, option 2. No referral on file. Verify if copy of referral was included with initial claim submission. Contact Provider Submit copy of referral to Claims Passport correspondence. Service Unit at (800) 578-0775, option 2. No authorization on file. Provider may contact the Utilization Management Department at (800) 578-0636 for retro authorization options. Page 178 of 331 Contact Provider Claims Service Unit at (800) 578-0775, option 2. Description Duplicate of previously submitted EPSDT screening. Provider wasn’t the member’s PCP. Charges considered included in inpatient admission. Inappropriate coding for contract agreement. Benefit/Service Rule Denial Valid This means that a member has already received an EPSDT screening or checkup for the particular interval or timeframe. Verify this member’s periodicity schedule Final with the EPSDT calculator, then review his/her EPSDT screening history. Contact Provider Claims Service Unit at (800) 578-0775, option 2. This member is showing a different PCP for the date of Final service. Contact Provider Claims Service Unit at (800) 578-0775, option 2. This denial code could be used for a variety of claim processing scenarios. Final Contact Provider Claims Service Unit at (800) 578-0775, option 2. This denial code could be used for a variety of claim processing scenarios. Final Carrier of service - MCNA. Final Carrier of service - AmeriHealth, Inc. Final Payment included in other billed services. Denial Invalid This denial code could be used for a variety of claim processing scenarios. Final This rejection means that EOB/Attachments were there is a complication incomplete/ illegible. with the primary carrier EOB. Review the primary carrier EOB for any inconsistencies. Need newborn member number. Resubmit corrected claim. Resubmit claim with the ID for the newborn. Page 179 of 331 Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 3. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578 0775 i 3 Description Benefit/Service Rule Denial Valid Denial Invalid Resubmit to primary carrier for appeals process. Passport can only coordinate secondary payment with a final processing documented on a primary carrier EOB. Provider must resubmit claim to primary carrier appeals process. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Provider must resubmit corrected claim with physician ID/name. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Provider must resubmit a corrected claim with POS. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Attending physician ID/name missing/ invalid. Missing place of service. Member’s age not valid for procedure code. This occurs most frequently when a hospital bills a UB04 without an attending physician’s name or ID. Review claim to verify if physician name/ID was included with initial submission. This claim wasn’t billed with a place of service. This denial code could be used for a variety of claim processing scenarios. Review member’s age. Final Member’s sex not valid for procedure code. Review the State system to verify the gender loaded for this member. Not covered for presumptive eligibility member. The particular type of service that is being billed is not a service that is covered for a presumptive eligibility member. Missing charges/units This procedure code billed on this claim didn’t include any unites. Review claim form to Submit corrected claim. verify units billed. Final Member will have to contact his/her caseworker for options regarding eligibility reinstatement. Page 180 of 331 Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Description Inappropriate claim form for professional services. Benefit/Service Rule This occurs when an individual practitioner bills his/her professional services on a UB-04. This mistake most commonly occurs with ER professional fees. Denial Valid Submit a corrected claim on a CMS-1500 to ACS. Denial Invalid Contact Provider Claims Service Unit at (800) 578-0775, option 2. Provider may contact the Utilization Management Department at 1-800578-0636 for retro authorization options. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Contact Provider Claims Service Unit at (800) 578-0775, option 2. Dates and/or services outside auth. The information approved on the authorization does not match what was billed on the claim. Authorization expired. The date of service billed is outside the last approved date on the authorization. Provider may contact the Utilization Management Department at 1-800578-0636 for retro authorization options. Group ID not payable. Passport will not accept provider group IDs. The provider must bill with the individual provider ID. Provider must submit a corrected claim with the individual provider ID. Subset/Incidental Procedure disallow. The rejected procedure code is considered inclusive or incidental to another paid procedure code. Redundant procedure. This rejection is very similar to the subset reject. Final Final Page 181 of 331 Contact Provider Claims Service Unit at (800) 578-0775, option 2. Fax in medical records to Provider Claims for medical claim review. Fax in medical records to Provider Claims for medical claim review. Description Benefit/Service Rule Denial Valid Denial Invalid Manual Denial. This is a generic denial code used by adjusters to manually deny a claim. There should be additional denial code information listed explaining the manual denial. Follow the applicable denial response guideline located on this grid. Follow the applicable denial response guideline located on this grid. MAID Missing or Invalid. Passport does not have the billing provider’s Kentucky Medicaid ID (MAID). The MAID is expired. Contact your Provider Relations Specialist or Provider Services at (800) 578-0775 Contact Provider Claims Service Unit at (800) 578-0775, option 2. Page 182 of 331 PASSPORT HEALTH * PLAN Passport Health Plan 5100 Commerce Crossi ngs For further inquiries on this remittance advise contact: Louisville, ,KY 40229 Passport Health Plan 5100 Commerce Crossings R eturn Service R equested Louisville, KY 40229 Or call l·8CJ0.578·0775 Dave P Smith, MD 1 23 Main Street Anywhere.KY 40229 Payee 10: Tax iO: 1234567 123456789 NPI #: Check No.: 1234567890 50000676 20011002101019 Check R ef.: Payment: Remittance Advice Provider 10: 1234567 NPI #:0123456789 Provider Name: Smith Dave o, teor$eMoe <!II Moe!" I 1/l(U.-J J U OftGColl• I 2U I Member 10: 98765432 Patient 10: 00246879 Claim iD: 123450123400 Member Name: Doe T Jane I o. """'' I O !wip!ion Amoum ''" ""' Ofl'i.:.t Vi.>il Claim Total Amoo.uot Am011nt 65.00 32.00 $0.00 <S.OO A low.,! Am010nt ,)2;,00 coo ""' :em:'t, llher t.'leStlltc.:ne•t fgtQ. .., .... 000 Prlor Pnt ..,..,.., Sta temen t Totals 0.00 000 0.00 •.•,•. 000 000 .... .... coo 000 001 0.11mRewne:O le1sOti1tor TransactionCl!::tuns: payment retractions and <L'Ie-J p '!- O.. T•n ctions .... r eduction. wh:e...l!Je detailed in the Pl!y:nertt redl.lctiorSectiol). tct.l hld wl";:! - Coord1nat1on of Benefits Poll yNo. Payment Reduct on Summary l);:le ofor Adj/ Amol'nl '. .'.". .... !r teret P nt 000 0.00 / P!se note that these section eri! kid!ted at the end or the ... .... ... I•" I c.;., I co• I """""'"• I..,., 000 32.00 COB Rc«< s ftl!d uction APPI oetwrent 0.11m Reduc!on1\mou Oilirn5 re<.:wl!o fd tU Ii! Messages R36 Cep:ttlted Service ThePayrr..ertt Reducti< n Su·nmllrywill include the oriQi: lll O:!te or serv, Check l>lte,llrtd G"1e-C1 t."ombc.:. Page 183 of 331 ho'Ader 'tNC! ' PIS lOOitt Remo11n1f!gSo1n(,(' 15.4 Denial Reasons and Prevention Practices 15.4.1 Billed Charges Missing or Incomplete A billed charge amount must be included for each service/procedure/supply on the claim form. 15.4.2 Diagnosis Code Missing 4th or 5th Digit Precise coding sequences must be used in order to accurately complete processing. Review the ICD9-CM manual for the 4th and 5th digit extensions. The 4th symbol indicates a 4th digit must be included. The 5th symbol indicates a 4th and 5th digit must be included. 15.4.3 Diagnosis, Procedure or Modifier Codes Invalid or Missing Coding from the most current coding manuals (ICD-9-CM, CPT or HCPCS) is required to accurately complete processing. All applicable diagnosis, procedure, and modifier fields must be completed. 15.4.4 DRG Codes Missing or Invalid Hospitals contracted for payment based on DRG codes must include this information on the claim form. 15.4.5 Corrected Claims Corrected or resubmitted claims must be sent to Passport on paper, with either “corrected” or “resubmitted” noted on the claim as appropriate. Claims that originally denied for missing/invalid information or for inappropriate coding must be submitted as a corrected claim. In addition to writing “Corrected Claim,” the corrected information should be circled to easily identify the corrected information. Claims that have been denied for additional information must be submitted as a resubmitted claim. “Resubmitted Claim” must be written on the form and the new information must be attached. It is important to remember that these claims are scanned as part of the resubmission process. Red ink and/or highlighted text is not legible. NOTE: Please use BLUE or BLACK ink only. 15.4.6 EOBs (Explanation of Benefits) A copy of the EOB from all third party insurers must be submitted with the original claim form if billing via paper. Include pages with run dates, coding explanation and messages. 15.4.7 EPSDT Information Missing or Incomplete All tests and services listed on the Passport EPSDT Program Periodicity and Screening Schedule must be performed within the indicated time periods. Page 184 of 331 15.4.8 Illegible Claim Information Information on the claim form must be legible to avoid delays or inaccuracies in processing. Review billing processes to ensure forms are typed or printed in black ink, no fields are highlighted (this causes information to darken when scanned or filmed), and spacing and alignment are appropriate. Handwritten information often causes delays or inaccuracies due to reduced clarity. 15.4.9 Incomplete Forms All required information must be included on the claim form to ensure prompt and accurate processing. 15.4.10 Newborn Claim Information Missing or Invalid Always include the first and last name of the mother and baby on the claim form. If the baby has not been named, insert “Girl” or “Boy” as the baby’s first name; include the baby’s last name if it is different than the mother’s. Verify the appropriate last name is recorded for the mother and baby. Please include the baby’s date of birth. 15.4.11 Payer or Other Insurer Information Missing or Incomplete Include the name, address and policy number for all insurers covering the Passport member. 15.4.12 Place of Service Code Missing or Invalid A valid and appropriate two-digit numeric code must be included on the claim form. 15.4.13 Provider Name Missing The name of the provider of service must be present on the claim form and must match the service provider name and Tax Identification Number (TIN) on file with Passport. 15.4.14 Provider Identification Number Missing or Invalid Passport’s assigned individual and group identification numbers must be included on the claim form for the provider of service. 15.4.15 Revenue Codes Missing or Invalid Facility claims must include a valid revenue code. Refer to UB-04 reference material for a complete list of revenue codes. 15.4.16 Signature Missing The signature of the provider of service must be present on the claim form and must match the service provider name and TIN on file with the Passport. See Section 18.1.12.2 CMS-1500 Claim Form and Required Fields for additional information on acceptable signature formats. Page 185 of 331 15.4.17 Spanning Dates of Service Do Not Match the Listed Days/Units Span dating is only allowed for identical services provided on consecutive dates of service. Always enter the corresponding number of consecutive days in the days/unit field. 15.4.18 Tax Identification Number (TIN) Missing or Invalid The Tax ID number must be present and must match the service provider name and payment entity (vendor) on file with the Passport. 15.4.19 Third Party Liability (TPL) Information Missing or Incomplete Any information indicating a work related illness/injury, no fault, or other liability condition must be included on the claim form. Additionally, if billing via paper, a copy of the primary insurer’s explanation of benefits (EOB) or applicable documentation must be forwarded along with the claim form. 15.4.20 Type of Service Code Missing or Invalid A valid alpha or numeric code must be included on the claim form. 15.4.21 Billing Bilateral Procedures Modifier ‘50’ is used to report bilateral procedures performed in the same session. The use of modifier ‘50’ is applicable only to services and/or procedures performed on identical anatomical sites, aspects, or organs. The intent of this modifier is to be appended to the appropriate unilateral code as a one-line entry on the claim form indicating that the procedure was performed bilaterally. When a procedure code is appended with modifier ‘50’, the units box on the claim form should indicate that “1” unit of service was provided, since one procedure was performed bilaterally. Placing the procedure on two lines will bill for two charges, and will result in a denial for one of the billed lines. When a procedure code is billed with a ‘50’ modifier and a ‘1’ in the unit field, the code will reimburse at 150% of the allowable amount. Some CPT codes were developed for unilateral and bilateral procedures, so it may not always be appropriate to append modifier ‘50’ if there is a CPT code to report the bilateral procedure. 15.4.22 Billing with Modifiers ‘25’ and ‘59’ Use modifier ‘25’ when the E/M service is separate from that required for the procedure and a clearly documented, distinct and significantly identifiable service was rendered, or the procedure performed was above and beyond the usual preoperative and postoperative care. The modifier ‘25’ must be placed on the E/M code to assure appropriate review of your claim. Modifier ‘59’ is used to indicate a procedure or service was distinct or independent from other services performed on the same day. When another already established modifier is appropriate it should be used rather than modifier ‘59’. Only if a more descriptive modifier is not available, and the use of modifier ‘59’ best explains the circumstances, should modifier ‘59’ be used. Page 186 of 331 15.5 Timely Filing Requirements Original invoices must be submitted to Passport within 180 calendar days from the date services were rendered or compensable items were provided. Resubmission of previously processed claims with corrections and/or requests for adjustments must be submitted within two years of the last process date. Claims originally rejected for missing or invalid data elements must be corrected and resubmitted within 180 calendar days from the date of service. Rejected claims are not registered as received in the claims processing system. 15.5.1 Timely Filing Exceptions • • • • • • Submission of claims for members retroactively enrolled in Passport by the Department for Medicaid Services must be submitted within 180 days from the date of notification to Passport of enrollment by DMS. Claims with Explanation of Benefits (EOBs) from Medicare Part A must be submitted within 180 days of the date of the Medicare EOB. Claims with Explanation of Benefits (EOBs) from primary insurers other than Medicare Part A must be submitted within 60 days of the date of the primary insurer’s EOB. Out of home placement services are exempt from timely filing guidelines. Mommy Steps services are exempt from timely filing guidelines. Medicare crossover claims are exempt from timely filing guidelines. 15.6 Corrected Claims and Requests for Reconsideration and/or Refunds If you would like to discuss claims payments, you may call the Provider Claims Services Unit (PCSU) at (800) 578-0775, option 2. Providers have the right to appeal the outcome of a claim. The appeal must be submitted in writing and received within two (2) years of the last process date and include supporting documentation. The Plan will respond to the appeal within thirty (30) days from the receipt date with a determination or status of the review. The provider will receive written notification of the outcome of the appeal whether it is upheld or overturned. All upheld determinations will be sent to the provider in a letter with the reason the plan upheld the appeal. Any appeals overturned by the plan will be reprocessed and the provider will receive an explanation of benefits (EOB) as notification. Corrected/resubmitted claims should be resubmitted on paper. The word “corrected” or “resubmitted” must be noted on the claim as appropriate: • Claims originally denied for missing/invalid information for inappropriate coding should be submitted as corrected claims. In addition to writing “corrected” on the claim, the corrected information should be circled so that it can be identified. Page 187 of 331 • • Claims originally denied for additional information should be sent as a resubmitted claim. In addition to writing “resubmitted” on the claim, the additional/new information should be attached. Corrected and resubmitted claims are scanned during reprocessing. Please remember to use blue or black ink only and refrain from using red ink and/or highlighting that could affect the legibility of the scanned claim. Corrected/Resubmitted claims should be sent to: Passport Health Plan P.O. Box 7114 London, KY 40742 Following these instructions will reduce the probability of erroneous or duplicate claims and timely filing denials on second submissions. When the need for a refund is identified, the provider should call the PCSU at (800) 578-0775, option 2, to report the over-payment. Claim details will need to be provided such as reason for refund, claim number, member number, dates of service, etc. The claim will be adjusted, the money will be recovered and the transaction will be reported on the Remittance Advice. There is no need to submit a refund check. If Passport recognizes the need for a refund, a letter outlining details will be sent 30 days prior to the recovery occurring. These adjustments will also be reported on the Remittance Advice. 15.7 Contact Information for Claims Questions Passport encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or Emdeon (formerly WebMD) to arrange transmission. For additional questions, call the EDI Technical Support Hotline at (877) 234-4275 or send an email to EDI.PHP@amerihealthcaritas.com. 15.7.1 Claim Mailing Instructions Submit claims-related correspondence, corrected claims, requests for reconsiderations, and refunds to Passport at the following address: Passport Health Plan P.O. Box 7114 London, KY 40742 15.7.2 Claims Status Review Providers may view claims status using any of the following methods: • • Online – check eligibility/claims status by logging into NaviNet at https://navinet.navimedix.com Telephone – you may also check eligibility and/or claims status by calling our interactive voice response (IVR) system at (800) 578-0775. Page 188 of 331 • Real-Time – depending on your clearinghouse or practice management system, real-time claims status information is available to participating providers. Contact your clearinghouse to access: Emdeon Products for claims status transactions. All other clearinghouses: ask your clearinghouse to access transactions through Emdeon. Page 189 of 331 Provider Manual Section 16.0 Behavioral Health Table of Contents 16.1 Administrative Procedures 16.2 Access to Care 16.3 Behavioral Health Benefits 16.4 Care Management and Utilization Management 16.5 Authorization Procedures and Requirements 16.6 Quality Improvement 16.7 Behavioral Health Provider Billing Manual Page 190 of 331 16.0 Behavioral Health Passport Health Plan (Passport) has contracted with Beacon Health Strategies, LLC to coordinate the delivery of behavioral health services for its members. Passport’s behavioral health program provides members with access to a full continuum of recovery and resiliency-focused behavioral health and substance disorders services through a network of contracted providers. The primary goal of the program is to provide medically necessary care in the most clinically appropriate and cost-effective therapeutic settings. By ensuring that all Passport members receive timely access to clinically appropriate behavioral health and substance disorder services, Passport believes that quality clinical services can achieve improved outcomes for our members. 16.1 Administrative Procedures Passport has contracted with Beacon Health Strategies, LLC to manage the delivery of behavioral health and substance disorder services for its members. Beacon’s website, www.beaconhealthstrategies.com, contains answers to frequently asked questions, Beacon's clinical practice guidelines, clinical articles, links to numerous clinical resources, and important news for providers. eServices, Beacon’s secure web portal, supports all provider transactions, such as verifying member’s eligibility, claims status, and authorization submission and inquiry while saving providers’ time, postage expense, billing fees, and reducing paper waste. eServices provides important Provider communications and is completely free to Passport contracted providers. Providers may register and access these services through www.beaconhealthstrategies.com twenty four hours a day, seven days a week. Interactive voice recognition (IVR ) is available to providers as an alternative to eServices. It provides accurate, up-to-date information by telephone, and is available for selected transactions at (888) 2102018. In order to maintain compliance with HIPAA and all other federal and state confidentiality/privacy requirements, providers must have their practice or organizational tax identification number (TIN), national provider identifier (NPI), as well as the member’s full name, Plan ID and date of birth when verifying eligibility. Electronic data interchange (EDI) is available for claim submission and eligibility verification directly by the provider to Beacon or via an intermediary. For information about testing and setup for EDI, download Beacon’s 837 & 835 companion guides at the following web site locations: http://www.beaconhealthstrategies.com/private/pdfs/Beacon_835CompanionGuide_v1.pdf http://www.beaconhealthstrategies.com/private/pdfs/Beacon_837CompanionGuide.pdf For technical and business related questions, email edi.operations@beaconhs.com. To submit EDI claims through an intermediary, contact the intermediary for assistance. If using Emdeon, use Beacon’s Emdeon Payer ID (43324) and Beacon’s Passport Health Plan ID (028). Page 191 of 331 Electronic Transactions Availability: Available 24/7 On eServices at www.beaconhealt hstrategies.com IVR 888.210.2018 • Verify member eligibility, benefits and copayment • Check number of visits available Yes Yes Yes Yes • • • • • Yes Yes Yes Yes Yes Transaction / Capability • • • • • • Submit authorization requests View authorization status Update practice information Submit claims Upload EDI claims to Beacon and view EDI upload history View claims status and print EOBs Print claims reports and graphs Download electronic remittance advice EDI acknowledgment & submission reports Pend authorization requests for internal approval Access Beacon’s level-of-care criteria & provider manual Yes Yes Yes Yes EDI at www.beaconhealth strategies.com Yes (HIPAA 270/271) Yes (HIPAA 270/271) Yes Yes (HIPAA 837) Yes (HIPAA 837) Yes Yes (HIPAA 835) Yes (HIPAA 835) Yes (HIPAA 835) Yes Yes 16.2 Access to Care Passport members may access behavioral health services 24 hours a day, seven days a week by contacting Passport’s Behavioral Health Hotline, administered by Beacon Health Strategies, at (855) 834-5651. Members do not need a referral to access behavioral health services and authorization is never required for emergency services. Passport and Beacon adhere to State and National Committee for Quality Assurance (NCQA) guidelines for access standards for member appointments. Contracted providers may only provide such behavioral health and physical health services within the scope of their license and must adhere to the following: Appointment Standards and After Hours Accessibility: Type of Care Emergency Care with Crisis Stabilization Urgent Care Post Discharge from Acute Hospitalization Other routine referrals/appointments Appointment Availability Within twenty four (24) hours Within forty eight (48) hours Within 7 days of discharge Within ten (10) days Page 192 of 331 In addition, Passport providers must adhere to the following guidelines to ensure members have adequate access to services: Service Availability On-Call Crisis Intervention Hours of Operation: • 24-hour on-call services for all members in treatment; and, Ensure that all members in treatment are aware of how to contact the treating or covering provider after hours and during provider vacations. • Services must be available 24 hours per day, 7 days per week; Outpatient facilities, physicians and practitioners are expected to provide these services during operating hours; and After hours, providers should have a live telephone answering service or an answering machine that specifically directs a member in crisis to a covering physician, agency-affiliated staff, crisis team, or hospital emergency room. • Outpatient providers should have services available Monday through Outpatient Services Friday from 9:00 a.m. to 5:00 p.m. EST at a minimum; and, Evening and/or weekend hours should also be available at least two (2) days per week. All members receiving inpatient psychiatric services should be scheduled for outpatient follow-up and/or continuing treatment prior to discharge. Outpatient treatment must occur within seven (7) days from the date of discharge (note: subject to latest statewide changes). Providers are required to contact members who have missed appointments within twenty-four (24) hours to reschedule appointments. 16.2.1 Out of Network Providers Out of network behavioral health benefits are limited to those services that are not available in the existing Passport network, emergency services and transition services for members who are currently in treatment with an out of network provider who is either not a part of the network or who is in the process of joining the network. Out of network providers must complete a Behavioral Health single case agreement with Passport. Out of network providers may provide one evaluation visit for Passport members without an authorization upon completion and return of the signed single case agreement. After the first visit, services provided must be authorized. Authorization requests for outpatient services can be obtained through Beacon’s electronic outpatient request for (eORF) which can be requested by calling Beacon at (855)834-5651 or on Beacon’s website www.beaconhealthstrategies.com. If this process is not followed, Beacon may administratively deny the services and the out of network provider must hold the member harmless. Notifications of authorization will be provided by Beacon within seven (7) days of the request. Beacon will verify member eligibility at the time of authorization. However, the member’s eligibility Page 193 of 331 is subject to change. Out of network providers are encouraged to verify eligibility. 16.3 Behavioral Health Benefits Passport covers behavioral health and substance disorder services to members located within the Commonwealth. Under Passport, the following levels of care are covered, provided that services are medically necessary, delivered by contracted network providers, and that the authorization procedures outlined in this manual are followed. DSM-IV (or DSM-V upon DMS implementation) multi-axial classification should be used when assessing members for services and documented in the member’s medical record. Covered Services include: • • • • • • • • • • • • • • • • • • Inpatient mental health Crisis stabilization – adult and child Emergency room visits Medical detoxification Psychiatric Residential Treatment Facilities (PRTF) Extended Care Units (ECU) Residential substance abuse rehabilitation (EPSDT special service through age 21 only) Outpatient mental health services, such as therapy, groups, peer support, parent training, etc. Electroconvulsive Therapy (ECT) Psychological and neuropsychological testing Community Mental Health Center Services, such as therapeutic rehabilitation, tiered case management services, etc. IMPACT Plus services Behavioral health and substance disorder EPSDT special services Mobile Crisis Substance Disorder Inpatient (detox, rehabilitation, SUDS) and Outpatient (individual/group/PHP, Day Treatment, Wellness Recovery) services for adults Partial Hospitalization (BH and SA) Assertive Community Outreach Team (ACT) Medication Assisted Treatment (MAT) Access to behavioral health and substance disorder treatment is an essential component of a comprehensive health care delivery system. Plan members may access behavioral health and substance disorder services by self-referring to a network provider, by calling Beacon, or by referral through acute or emergency room encounters. Members may also access behavioral health and substance disorder services by referral from their primary care provider (PCP); however, a PCP referral is not required for behavioral health or substance disorder services. Network providers are expected to coordinate care with a member’s primary care and other treating providers whenever possible. 16.4 Care Management and Utilization Management Page 194 of 331 16.4.1 Care Management Beacon’s Intensive Clinical Management Program (ICM), a component of Beacon’s Care Management Program (CM), through collaboration with members and their treatment providers, PCPs, Passport’s medical care managers, and state agencies (DHM and DCF) is designed to ensure the coordination of care, including individualized assessment, care management planning, discharge planning and mobilization of resources to facilitate an effective outcome for members whose clinical profile or usage of service indicates that they are at high risk for readmission into 24-hour psychiatric or substance disorder treatment settings. The primary goal of the program is stabilization and maintenance of members in their communities through the provision of community-based support services. These community-based providers can provide short-term service designed to respond with maximum flexibility to the needs of the individual member. The intensity and amount of support provided is customized to meet the individual needs of members and will vary according to the member’s needs over time. When clinical staff or providers identify members who demonstrate medical co-morbidity (i.e., pregnant women), a high utilization of services, and an overall clinical profile which indicates that they are at high-risk for admission or readmission into a 24-hour behavioral health or substance disorder treatment setting, they may be referred to Beacon’s CM Program. The ICM program utilizes specialty community support providers that offer outreach programs uniquely designed for adults with severe and persistent mental illness, dually diagnosed adults, members with behavioral health or substance disorders, and children with serious emotional disturbance. Criteria for ICM include but are not limited to the following: • • • • • • • • Member has a prior history of acute psychiatric or substance use admissions authorized by Beacon with a readmission within a 60 day period; First inpatient hospitalization following lethal suicide attempt, or treatment for first psychotic episode; Member has combination of severe, persistent psychiatric clinical symptoms, and lack of family or social support, along with an inadequate outpatient treatment relationship which places the member at risk of requiring acute behavioral health services; Presence of a co-morbid medical condition that when combined with psychiatric and/or substance use issues could result in exacerbation of fragile medical status; Member that is actively using substances, or requires acute behavioral health treatment services; A child living with significant family dysfunction and continued instability following discharge from inpatient or intensive outpatient family services that requires support to link family, providers and state agencies, which places the member at risk of requiring acute behavioral health services; Multiple family members that are receiving acute behavioral health and/or substance disorder treatment services at the same time; and, Other, complex, extenuating circumstances where the ICM team determines the benefit of Page 195 of 331 inclusion beyond standard criteria. Members who do not meet criteria for ICM may be eligible for Care Coordination. Members identified for Care Coordination have some clinical indicators of potential risk due to barriers to services, concern related to adherence to treatment recommendations, new onset psychosocial stressors, and/or new onset of co-morbid medical issues that require brief targeted care management interventions. Care Coordination is a short term intervention for members with potential risk due to barriers in services, poor transitional care, and/or co-morbid medical issues that require brief targeted care management interventions. ICM and Care Coordination are voluntary programs and member consent is required for participation. For further information on how to refer a member to care management services, please contact the Beacon Health Strategies at (855) 834-5651. 16.4.2 Utilization Management Utilization management (UM) is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include, but are not limited to, ambulatory review, prospective review, second opinion, certification, concurrent review, care management, discharge planning and retrospective review. Beacon’s UM program is administered by licensed, experienced clinicians who are specifically trained in utilization management techniques and in Beacon’s standards and protocols. All Beacon employees with responsibility for making UM decisions have been made aware that: • All UM decisions are based upon Beacon’s Level of Care /medical necessity Criteria (LOCC); • Financial incentives based on an individual UM clinician’s number of adverse determinations or denials of payment are prohibited; and, • Financial incentives for UM decision makers do not encourage decisions that result in underutilization. 16.4.2.1Medical Necessity All requests for authorization are reviewed by Beacon clinicians based on the information provided according to the definition of medical necessity that is outlined in the Kentucky Administrative Regulations. 907 KAR 3:130 defines medical necessity in the following way: "Medical necessity means a covered benefit is: Reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition, including pregnancy; Clinically appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical practice; Provided for medical reasons rather than primarily for the convenience of the individual, the individual's caregiver, or the health care provider, or for cosmetic reasons; Provided in the most appropriate location, with regard to Page 196 of 331 generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided; Needed, if used in reference to an emergency medical service, to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard; Provided in accordance with early and periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 U.S.C. 1396d(r) and 42 CFR Part 441 Subpart B for individuals under twenty-one (21) years of age; and Provided in accordance with 42 CFR 440.230." 16.4.2.2 Level-of-Care Criteria (LOCC) Beacon’s LOCC are the basis for all medical necessity determinations, are accessible through eServices, and includes Beacon’s specific LOCC for Kentucky for each level-of-care. Providers can also contact Beacon at (855) 834-5651 to request a printed copy of Beacon’s LOCC. Beacon’s LOCC were developed from the comparison of national, scientific and evidence-based criteria sets, including but not limited to those publicly disseminated by the American Medical Association (AMA), the American Psychiatric Association (APA), the Substance & Mental Health Services Administration (SAMHSA), and the American Society of Addiction Medicine (ASAM). They are reviewed and updated annually or more often as needed to incorporate new treatment applications and technologies that are adopted as generally accepted professional medical practice. Beacon’s LOCC are applied to determine appropriate care for all members. In general, members are certified only if they meet the specific medical necessity criteria for a particular level-of-care. However, the individual’s specific needs and the characteristics of the local service delivery system may also be taken into consideration. Behavioral Health Providers must refer members with known or suspected and untreated physical health problems or disorders to their PCP for examination and treatment with the Members or the Members’ legal guardian’s consent. Behavioral Health providers may only provide physical health care services if they are licensed to do so. 16.4.2.3 Utilization Management Terms and Definitions The definitions below describe utilization review including the types of the authorization requests and UM determinations used to guide Beacon’s UM reviews and decision making. All determinations are based upon review of the information provided and available to Beacon at the time. Adverse Determination: A decision to deny, terminate, or modify (an approval of fewer days, units or another level-of-care other than was requested, which the practitioner does not agree with) an admission, continued inpatient stay, or the availability of any other behavioral health care service, for: a) failure to meet the requirements for coverage based on medical necessity, b) appropriateness of health care setting and level-of-care effectiveness, or c) Health plan benefits. Page 197 of 331 Adverse Action: The following actions or inactions by Beacon or the provider organization: 1. Beacon’s denial, in whole or in part, of payment for a service; failure to provide covered services in a timely manner in accordance with the waiting time standards; 2. Beacon’s denial or limited authorization of a requested service, including the determination that a requested service is not a covered service; 3. Beacon’s reduction, suspension, or termination of a previous authorization for a service; 4. Beacon’s denial, in whole or in part, of payment for a service, where coverage of the requested service is at issue, provided that procedural denials for requested services do not constitute adverse actions, including but not limited to denials based on the following: a. Failure to follow prior authorization procedures b. Failure to follow referral rules c. Failure to file a timely claim 5. Beacon’s failure to act within the timeframes for making authorization decisions; 6. Beacon’s failure to act within the timeframes for making appeal decisions. Non-Urgent Any review for an extension of a previously approved, ongoing course of treatment Concurrent over a period of time or number of days or treatments. A non-urgent concurrent decision Review & Decision may authorize or modify requested treatment over a period of time or a number of days or treatments, or deny requested treatment, in a non-acute treatment setting. Non-Urgent PreService Review & Decision Any case or service that must be approved before the member obtains care or services. A non-urgent pre-service decision may authorize or modify requested treatment over a period of time or number of days or treatments, or deny requested treatment, in non-acute treatment setting. Post-Service Review & Decision (Retrospective Decision) Any review for care or services that have already been received. A post-service decision would authorize, modify, or deny payment for a completed course of treatment where a pre-service decision was not rendered, based on the information that would have been available at the time of a pre-service review. Urgent Care Request & Decision Any request for care or treatment for which application of the normal time period for a non-urgent care decision: • Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment; or, • In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that could not be adequately managed without the r r trfor tm nt th t isextension r q st dof a previously approved, ongoing course of Any review a requested Urgent Concurrent Review Decision Urgent Pre-Service Decision treatment over a period of time or number of days or treatments in an acute treatment setting, when a member’s condition meets the definition of urgent care above. Formerly known as a pre-certification decision. Any case or service that must be approved before a member obtains care or services in an inpatient setting for a member whose condition meets the definition of urgent care above. An urgent pre-service decision may authorize or modify requested treatment over a period of time or number of days or treatments, or deny requested treatment in an acute treatment setting. Page 198 of 331 16.5 Authorization Procedures and Requirements Authorization Procedures and Requirements This section describes the processes for obtaining authorization for inpatient, diversionary and outpatient levels of care, and for Beacon’s medical necessity determinations and notifications. In all cases, the treating provider, whether admitting facility or outpatient practitioner, is responsible for following the procedures and requirements presented in order to ensure payment for properly submitted claims. Administrative denials may be rendered when applicable authorization procedures, including timeframes, are not followed. Members cannot be billed for services that are administratively denied due to a provider not following the requirements listed in this manual. 16.5.1 Member Eligibility Verification The first step in seeking authorization is to determine the member’s eligibility. Since member eligibility changes occur frequently, providers are advised to verify a plan member’s eligibility upon admission to, or initiation of treatment, as well as on each subsequent day or date of service to facilitate reimbursement for services. Member eligibility can change and possession of a health plan member identification card does not guarantee that the member is eligible for benefits. Providers are strongly encouraged to check Beacon’s eServices, or by calling their IVR line at (888) 210-2018. 16.5.2 Emergency Services Definition Emergency services are those physician and outpatient hospital services, procedures, and treatments, including psychiatric stabilization and medical detoxification from drugs or alcohol, needed to evaluate or stabilize an emergency medical condition. The definition of an emergency is listed in your Behavioral Health Services agreement with Passport. Emergency care will not be denied, however subsequent days do require pre-service authorization. The facility must notify Beacon as soon as possible and no later than 24 hours after an emergency admission and/or learning that the member is covered by the health plan. If a provider fails to notify Beacon of an admission, Beacon may administratively deny any days that are not prior-authorized. 16.5.2.1 Passport Health Plan Behavioral Health Crisis Line Our toll-free crisis line, (855) 834-5651, is available to members in the event of an emergency and is staffed by trained personnel twenty-four (24) hours a day, seven (7) days a week, three hundred sixty-five (365) days a year. Behavioral Health Services professionals are available to assess, triage and address behavioral health emergencies through this crisis line. Passport can arrange for Page 199 of 331 emergency and crisis Behavioral Health Services through mobile crisis teams in the member’s community. Face to face emergency services are available twenty-four (24) hours a day, seven (7) days a week through Passport’s behavioral health network. 16.5.2.2 Emergency Screening and Evaluation Passport members must be screened for an emergency medical condition by a qualified behavioral health professional from the hospital emergency room, mobile crisis team, or by an emergency service program (ESP). This process allows members access to emergency services as quickly as possible and at the closest facility or by the closest crisis team. After the evaluation is completed, the facility or program clinician should call Beacon to complete a clinical review, if admission to a level-of-care that requires pre-certification is needed. The facility/program clinician is responsible for locating a bed, but may request Beacon’s assistance. Beacon may contact an out-of-network facility in cases where there is not a timely or appropriate placement available within the network. In cases where there is no in-network or out-of-network psychiatric facility available, Beacon will authorize boarding the member on a medical unit until an appropriate placement becomes available. 16.5.2.3 Beacon Clinician Availability All Beacon clinicians are experienced licensed clinicians who receive ongoing training in crisis intervention, triage and referral procedures. Beacon clinicians are available 24 hours a day, 7 days a week, to take emergency calls from members, their guardians, and providers. If Beacon does not respond to the call within 60 minutes, authorization for medically necessary treatment can be assumed and the reference number will be communicated to the requesting facility/provider by the Beacon UR clinician within four hours. Disagreement between Beacon and Attending Physician For acute services, in the event that Beacon’s physician advisor (PA) and the emergency service physician do not agree on the service that the member requires, the emergency service physician’s judgment shall prevail and treatment shall be considered appropriate for an emergency medical condition, if such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under the member’s program of medical assistance or medical benefits. All Beacon clinicians are experienced, licensed clinicians who receive ongoing training in crisis intervention, triage and referral procedures. 16.5.2.4 Authorization Requirements 16.5.2.4.1 Outpatient Treatment (Initial Encounters): Passport members are allowed thirty (30) initial therapy sessions without prior authorization. These sessions, called initial encounters or IEs, must be provided by contracted in-network providers and are subject to meeting medical necessity criteria. Page 200 of 331 To ensure payment for services, providers are strongly encouraged to ask new patients if they have been treated by other therapists. Via eServices, providers can look up the number of IEs that have been billed to Beacon; however, the member may have used additional visits that have not been billed. If the member has used some IEs elsewhere, the new provider is encouraged to contact Beacon before beginning treatment. The following services count against the member’s 30 IEs: 1. Outpatient behavioral health, including individual and family therapy 2. Outpatient substance use services 3. Combined psychopharmacology and therapy visits (CPT Codes 90805 and 90807). The following services require no authorization and do not count against the member’s IEs. 1. Medication management sessions (90862, 96372); and E&M codes 2. Group therapy sessions (CPT code 90853); and, 3. Collateral therapy (90887) The following table outlines the authorization requirements for each service. Services that indicate “eRegister” will be authorized via Beacon’s eServices portal. Providers will be asked a series of clinical questions to support medical necessity for the service requested. If sufficient information is provided to support the request, the service will be authorized. If additional information is needed, the provider will be prompted to contact Beacon via phone to continue the request for authorization. While it is preferred that providers make requests via eServices, Beacon will work with providers who do have technical or staffing barriers to requesting authorizations in this way. Outpatient Services: Benefit/Service Medication Management Injection Administration Diagnostic Interview Assessment Individual Therapy Family Therapy Group Therapy Collateral Services (under 21) Parent/Peer Support Authorization Requirements No authorization required for medication management injection, group counseling, collateral therapy or evaluations. Psychological & Neuropsychological Testing ECT Faxed Prior Authorization Required to (781) 994-7633. For all other services, provider may see member for 30 visits without prior authorization. Submission of Electronic Outpatient Request Form (eORF) required before the 31st visit. This form can be faxed to (781) 994-7633. Community Based Services: Benefit/Service Notification Requirement Page 201 of 331 Initial Authorization Parameters (All determinations based on medical necessity) Therapeutic Rehabilitation Services (Adult and Child) eRegister within 2 weeks of initial date of service Authorization as requested, up to 6 hours daily for initial 30 days. Submit eServices request prior to 30th day for continued stay review. Intensive Outpatient Telephonic Prior Authorization Initial authorization up to 6 hours days/per week; weekly telephonic continued stay review. Partial Hospitalization Telephonic Prior Authorization Initial authorization up to 5 hours daily/per week; weekly telephonic continued stay review Assertive Community Treatment (ACT) Telephonic Prior Authorization Initial authorization up to max monthly; monthly telephonic continued stay review Day Treatment Telephonic Prior Authorization Initial authorization up to max weekly; weekly telephonic continued stay review Medication Assisted Treatment Telephonic Prior Authorization Initial authorization up to weekly allowable amount; weekly telephonic continued stay review Tiered Case Management- Register within 2 weeks of initial date of Adult service Emergency No authorization Services/Mobile Crisis Required Initial authorization for 3 months; submit continued stay request through eServices prior to 90th day of service. No authorization required Authorization decisions are posted on eServices within the decision timeframes outlined below. Providers receive an email message alerting them that a determination has been made. Beacon also faxes authorization letters to providers upon request; however providers are strongly encouraged to use eServices instead of receiving paper notices. Providers can opt out of receiving paper notices on Beacon’s eServices portal. All notices clearly specify the number of units (sessions) approved, the timeframe within which the authorization can be used, and explanations of any modifications or denials. All denials can be appealed according to the policies outlined in this Manual. All forms can be found on the Beacon web site under Provider Tools http://www.beaconhealthstrategies.com/private/provider/provider_tools.aspx. 16.5.2.4.2 Inpatient Services All inpatient services (including inpatient ECT and inpatient EPSDT special services such as chemical dependency, residential substance abuse services, and extended care units) require telephonic prior authorization within 24 hours of admission. Providers should call Beacon at (855) 834-5651 for all inpatient admissions, including detoxification that is provided on a psychiatric floor or in freestanding psychiatric facilities. All other requests for authorization for detoxification should be directed to Passport’s UM Department at (800) 578-0636, option 2. Admissions to Crisis Stabilization Units (for children only) do not require authorization until after the first 48 hours and are authorized for up to a maximum of 10 days. Beacon typically authorizes inpatient stays in 2-3 day increments, depending on medical necessity. Continued stay reviews require updated clinical information that demonstrates active treatment. Additional information about what is required during pre-service and concurrent stay reviews is listed below. Page 202 of 331 UM Review Requirements – Inpatient and Diversionary Pre-Service Review The facility clinician making the request needs the following information for a pre-service review: • Member’s health plan identification number; • Member’s name, gender, date of birth, and city or town of residence; Admitting facility name and date of admission; • DSMIV diagnosis: All five axes are appropriate; Axis I and Axis V are required. (A provisional diagnosis is acceptable); • Description of precipitating event and current symptoms requiring inpatient psychiatric care; • Medication history; • Substance use history; • Prior hospitalizations and psychiatric treatment; • Member’s and family’s general medical and social history; and, • Recommended treatment plan relating to admitting symptoms and the member’s anticipated response to treatment. Continued Stay (Concurrent) Review To conduct a continued stay review, call a Beacon UR clinician with the following required information: • Member’s current diagnosis and treatment plan, including physician’s orders, special procedures, and medications; • Description of the member’s response to treatment since the last concurrent review; • Member’s current mental status, discharge plan, and discharge criteria, including actions taken to implement the discharge plan; • Report of any medical care beyond routine is required for coordination of benefits with health plan (Routine medical care is included in the per diem rate). Post-Service Review Post-service reviews may be conducted for inpatient, diversionary or outpatient services rendered when necessary. To initiate a post-service review, call Beacon. If the treatment rendered meets criteria for a postservice review, the UR clinician will request clinical information from the provider including documentation of presenting symptoms and treatment plan via the member’s medical record. Beacon requires only those section(s) of the medical record needed to evaluate medical necessity and appropriateness of the admission, extension of stay, and the frequency or duration of service. A Beacon physician or psychologist advisor completes a clinical review of all available information, in order to render a decision. Authorization determinations are based on the clinical information available at the time the care was provided to the member. Notice of inpatient authorization is mailed to the admitting facility. Members must be notified of all pre-service and concurrent denial decisions. Members are notified by courier of all acute preservice and concurrent denial decisions. For members in inpatient settings, the denial letter is delivered by courier to the member on the day the adverse determination is made, prior to discharge. The service is continued without liability to the member until the member has been notified of the adverse determination. The denial notification letter sent to the member or member’s guardian, practitioner, and/or provider includes the specific reason for the denial decision, the member’s presenting condition, diagnosis and treatment interventions, the reason(s) why such information does not meet the medical necessity criteria, reference to the applicable benefit provision, guideline, protocol or criterion on which the denial decision was based, and specific alternative treatment option(s) offered by Beacon, if any. Based on state and/or federal statutes, an explanation of the member’s appeal rights and the appeals process is enclosed with all Page 203 of 331 denial letters. Providers can request additional copies of adverse determination letters by contacting Beacon. 16.5.2.4.3 IMPACT Plus Impact Plus services are available to Passport members according to the eligibility criteria outlined in 907 KAR 3:030. Beacon is responsible for screening members for eligibility and for making medical necessity determinations for IMPACT Plus Services. Providers requesting services for IMPACT Plus for Passport members must submit IMPACT Plus member eligibility applications directly to Beacon via fax at (781) 994-7633 through or eServices. Incomplete applications will not be accepted. Eligibility materials can be found on eServices or on the following Kentucky DBHDID link: http://dbhdid.ky.gov/dbh/impactplusforms.asp. Eligibility packets must be signed by a behavioral health professional or a behavioral health professional under supervision. Documentation of clinical need must be sufficient to support the intensity of service provided under IMPACT Plus. Providers must follow the guidelines outlined in the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) Impact Plus User’s Manual for the provision and documentation of Impact Plus Services. Beacon will adhere to the maximum service limits outlined in the DBHDID IMPACT Plus User’s Manual. Covered services and authorization requirements are outlined in the table below. Benefits/Services Targeted Case Management Cap Limit 4 units per month Minimum Behavioral Health Evaluation Therapeutic Child Support Services (professional and paraprofessional) Max 5 hours per Evaluation Max 16 units per day Parent to Parent Services After School Program Summer Program Individual Therapy (including w/ MD) Max 16 units per day Partial Hospitalization Intensive Outpatient Day Treatment Max 16 units per day Max 24 units per day Max of 16 units of 90884 and 90887 combined per day; Max of 48 units combined per week Notification Requirements Members must be determined eligible for IMPACT Plus prior to receiving services with the exception of crisis stabilization. Collaborative Service Plans and requests for authorization are required within 14 days of eligibility determination. Services will be authorized based on medical necessity. Initial continued stay review required again in 30 days via Fax or eServices. Telephonic review may be required if additional clinical information is needed. Continued stay review (frequency) to be determined based on clinical documentation presented during the first continued stay review. Max 5 hours per day Max 3 units per day; 9 units per week Max 7 units per day Page 204 of 331 Therapeutic Foster Care Therapeutic Group Residential Crisis Stabilization N/A N/A Max of 10 consecutive units Telephonic or eServices prior authorization required. Telephonic or eServices prior authorization required No authorization required for first 48 hours, then telephonic continued stay review. 16.5.2.4.4 Return of Inadequate or Incomplete Treatment Requests All requests for authorization must be original and specific to the dates of service requested and tailored to the member’s individual needs. Beacon reserves the right to reject or return authorization requests that are incomplete, lacking in specificity, or incorrectly filled out. Beacon will provide an explanation of action(s) which must be taken by the provider to resubmit the request. 16.5.2.4.5 Notice of Inpatient/Diversionary Approval or Denial Verbal notification of approval is provided at the time of pre-service or continuing stay review. Notice of admission or continued stay approval is mailed to the member or member’s guardian and the requesting facility within the timeframes specified later in this chapter. If the clinical information available does not support the requested level-of-care, the UR clinician discusses alternative levels of care that match the member’s presenting clinical symptomatology with the requestor. If an alternative setting is agreed to by the requestor, the revised request is approved. If agreement cannot be reached between the Beacon UR clinician and the requestor, the UR clinician consults with a Beacon psychiatrist or psychologist advisor (for outpatient services only). All denial decisions are made by a Beacon physician or psychologist (for outpatient services only) advisor. The UR clinician and/or Beacon physician advisor offers the treating provider the opportunity to seek reconsideration if the request for authorization is denied. All member notifications include instructions on how to access interpreter services, how to proceed if the notice requires translation or a copy in an alternate format, and toll-free telephone numbers for TDD/TTY capability in established prevalent languages, (Babel Card). 16.5.2.4.6 Termination of Outpatient Care Beacon requires that all outpatient providers set specific termination goals and discharge criteria for members. Providers are encouraged to use the LOCC (accessible through eServices) to determine if the service meets medical necessity for continuing outpatient care. 16.5.2.4.7 Decision and Notification Timeframes Beacon is required by the state, federal government, NCQA and the Utilization Review Accreditation Commission (URAC) to render utilization review decisions in a timely manner to accommodate the clinical urgency of a situation. Beacon has adopted the strictest time frame for all Page 205 of 331 UM decisions in order to comply with the various requirements. The timeframes below present Beacon’s internal timeframes for rendering a UM determination, and notifying members of such determination. All timeframes begin at the time of Beacon’s receipt of the request. Please note, the maximum timeframes may vary from those on the table below on a case-by-case basis in accordance with state, federal government, NCQA or URAC requirements that have been established for each line of business. Decision and Notification Timeframes: Type of Decision Decision Timeframe Verbal Notification Written Notification Within 24 hours Within 24 hours Within 24 hours Urgent Within 72 hours Within 24 hours Within 24 hours Standard Within 2 Calendar Days Within 2 Calendar Days Within 2 Calendar Days Urgent/ Within 24 hours Within 24 hours Within 24 hours Non-Urgent/ Standard Within 2 Calendar Days Within 2 Calendar Days Within 2 Calendar Days NonUrgent/ Standard Within 10 Calendar Days Within 10 Calendar Days Within 10 Calendar Days Pre-Service Review Initial Auth for Inpatient Behavioral Health Urgent Initial Auth for Other Urgent Behavioral Health Services Initial Auth for NonUrgent Behavioral Health Services Concurrent Review Continued Auth for Inpatient and Other Urgent Behavioral Health Services Continued Auth for Non Urgent Behavioral Health Services Post Service Authorization for Behavioral Health Services Already Rendered Expedited When the specified timeframes for standard and expedited prior authorization requests expire before Beacon makes a decision, an adverse action notice will go out to the member on the date the timeframe expires. 16.6 Quality Improvement Passport and Beacon strongly encourage and support providers in the use of outcome measurement tools for all members. Outcome data is used to identify potentially high-risk members who may need Page 206 of 331 intensive behavioral health, medical, and/or social care management interventions. Providers are also required to communicate (with member consent) with Primary Care Providers (PCPs) on a regular basis. Providers are required to send initial and quarterly (or more frequently if clinically indicated) summary reports of a members' behavioral health status to the PCP (with the member's or the member's legal guardian's consent). The purpose of this reporting is to ensure coordination between the PCP and behavioral health provider and improve the quality of member care. Passport and Beacon receive aggregate data by provider including demographic information and clinical and functional status without member-specific clinical information. Communication between Behavioral Health Providers and Other Service Providers: Communication between Outpatient Behavioral Health Providers and PCPs, Other Service Providers Outpatient behavioral health providers are expected to communicate with the member’s PCP and other OP behavioral health providers if applicable, as follows: • Notice of commencement of outpatient treatment within 4 visits or 2 weeks, whichever occurs first; • Updates at least quarterly during the course of treatment; • Notice of initiation and any subsequent modification of psychotropic medications; and, • Notice of treatment termination within 2 weeks. • Refer for known or suspected and untreated physical health problems or disorders for examination and treatment. Behavioral health providers may use Beacon’s Authorization for Behavioral Health Provider and PCP to Share Information and the Behavioral Health-PCP Communication Form available for initial communication and subsequent updates, in Appendix B, or their own form that includes the following information: • Presenting problem/reason for admission; • Date of admission; • Admitting diagnosis; • Preliminary treatment plan; • Currently prescribed medications; • Proposed discharge plan; and • Behavioral health provider contact name and telephone number. Request for PCP response by fax or mail within 3 business days of the request to include the following Page 207 of 331 Communication between Inpatient/ Diversionary Providers and PCPs, Other Outpatient Service Providers With the member’s informed consent, acute care facilities should contact the PCP by phone and/or by fax, within 24 hours of a member’s admission to treatment. Inpatient and diversionary providers must also alert the PCP 24 hours prior to a pending discharge, and must fax or mail the following member information to the PCP within 3 days postdischarge: • Date of Discharge; • Diagnosis; • Medications; • Discharge plan; and • Aftercare services for each type, including: - Name of provider; - Date of first appointment; - Recommended frequency of appointments; - Treatment plan. Inpatient and diversionary providers should make every effort to provide the same notifications and information to the member’s outpatient therapist, if there is one. Acute care providers’ communication requirements are addressed during continued stay and discharge reviews and documented in Beacon’s member record. health information: • Status of immunizations; • Date of last visit; • Dates and reasons for any and all hospitalizations; • Ongoing medical illness; • Current medications; • Adverse medication reactions, including sensitivity and allergies; • History of psychopharmacological trials; and, • Any other medically relevant information Outpatient providers’ compliance with communication standards is monitored through requests for authorization submitted by the provider, and through chart reviews. 16.6.1 Transitioning Members from one Behavioral Health Provider to Another If a member transfers from one behavioral health provider to another, the transferring provider must communicate the reason(s) for the transfer along with the information above (as specified for communication from behavioral health provider to PCP), to the receiving provider. Routine outpatient behavioral health treatment by an out-of-network provider is not an authorized service covered by Beacon. Members may be eligible for transitional care within 30 days after joining the health plan, or to ensure that services are culturally and linguistically sensitive, individualized to meet the specific needs of the member, timely per Beacon’s timeliness standards, and/or geographically accessible. 16.6.2 Follow Up After Mental Health Hospitalization Members discharged from inpatient levels of care are assigned an aftercare coordinator/case manager by Beacon prior to or on the date of discharge. The Beacon case managers and other behavioral health service providers participate in discharge planning meetings to ensure compliance with federal Olmstead and other applicable laws. Members being discharged from inpatient levels of care are scheduled for follow up appointments within 7 days of discharge from an acute care setting. Providers are responsible for seeing members within that timeframe and for outreaching members who miss their appointments to reschedule. Beacon’s case managers and aftercare coordinators work with providers to assist in this process by sending reminders to members; working to remove barriers that may prevent a member from keeping his or her discharge appointment and coordinating with treating providers. Network providers are expected to aid in this process as much as possible to ensure that members have the supports they need to maintain placement in the community and to prevent unnecessary readmissions. 16.6.3 Accessing Medications Page 208 of 331 Behavioral health service providers will assist member in accessing free or discounted medication through the Kentucky Prescription Assistance Program (KPAP) or other similar assistance programs. 16.6.4 Reportable Incidents and Events Beacon requires that all providers report adverse incidents, other reportable incidents and sentinel events involving the Passport members to Beacon as follows: Adverse Incidents Incident / Event Description: Sentinel Events An adverse incident is an occurrence that represents actual or potential serious harm to the wellbeing of a health plan member who is currently receiving or has been recently discharged from behavioral health services. A sentinel event is any situation occurring within or outside of a facility that either results in death of the member or immediately jeopardizes the safety of a health plan member receiving services in any level-ofcare. • All medico-legal or non-medico•All medico-legal deaths; legal deaths; •Any medico-legal death is • Any Absence without any death required to be Authorization (AWA) involving a reported to the Medical member who does not meet the Examiner or in which the criteria above; Medical Examiner takes • Any injury while in a 24-hour jurisdiction; program that could or did result in •Any absence without transportation to an acute care authorization (AWA) hospital for medical treatment or involving a patient hospitalization; involuntarily admitted or • Any sexual assault or alleged sexual committed and/or who is at assault; high risk of harm to self or • Any physical assault or alleged others; physical assault by a staff person or •Any serious injury resulting another patient against a member; in hospitalization for medical • Any medication error or suicide treatment; attempt that requires medical •A serious injury is any injury attention beyond general first aid that requires the individual to be procedures; transported to an acute care • Any unscheduled event that results in hospital for medical treatment the temporary evacuation of a and is subsequently medically program or facility (e.g. fire resulting admitted; in response by fire department; Page 209 of 331 Other Reportable Incidents An “other reportable incident” is any incident that occurs within a provider site at any level-ofcare, which does not immediately place a health plan member at risk but warrants serious concern. •Any non-medico-legal death; •Any absence without authorization from a facility involving a member who does not meet the criteria for a sentinel event as described above; •Any physical assault or alleged physical assault by or against a member that does not meet the criteria of a sentinel event; •Any serious injury while in a 24hour program requiring medical treatment, but not hospitalization; •A serious injury, defined as any injury that requires the individual to be transported to an acute care hospital for medical treatment and is not •Any medication error or suicide attempt that requires medical attention beyond general first aid procedures; •Any sexual assault or alleged sexual assault; • Any physical assault or alleged physical assault by a staff person against a member; and •Any unscheduled event that results in the evacuation of a program or facility whereby regular operations will not be in effect by the end of the business day and may result in the need for finding alternative placement options for member. subsequently medically admitted; and • Any unscheduled event that results in the temporary evacuation of a program or facility such as a small fire that requires fire department response. Data regarding critical incidents is gathered in the aggregate and trended on a quarterly basis for the purpose of identifying opportunities for quality improvement. Reporting Method: • Beacon’s Clinical Department is available 24 hours a day; • Providers must call, regardless of the hour, to report such incidents; • Providers should direct all such reports to their Beacon clinical manager or UR clinician by phone; • In addition, providers are required to fax a copy of the Adverse Incident Report Form (for adverse and other reportable incidents and sentinel events) to Beacon’s Ombudsperson at (888)204-5581; and, • Incident and event reports should not be emailed unless the provider is using a secure messaging system. Prepare to Provide the Following: Providers should be prepared to present: • All relevant information related to the nature of the incident; • The parties involved (names and telephone numbers); and, • The member’s current condition. 16.7 Behavioral Health Provider Billing Manual 16.7.1 Billing Transactions This chapter presents all information needed to submit claims to Beacon. Beacon strongly encourages providers to rely on electronic submission, either through EDI or eServices in order to achieve the highest success rate of first-submission claims payment. 16.7.2 General Claim Policies Beacon requires that providers adhere to the following policies with regard to claims: 16.7.3 Definition of “Clean Claim” A clean claim, as discussed in this provider manual, the provider services agreement, and in other Beacon informational materials, is defined as one that has no defect and is complete including Page 210 of 331 required, substantiating documentation of particular circumstance(s) warranting special treatment without which timely payments on the claim would not be possible. 16.7.4 Electronic Billing Requirements The required edits, minimum submission standards, signature certification form, authorizing agreement and certification form, and data specifications as outlined in this manual must be fulfilled and maintained by all providers and billing agencies submitting electronic medical claims to Beacon. 16.7.5 Provider Responsibility The individual provider is ultimately responsible for accuracy and valid reporting of all claims submitted for payment. A provider utilizing the services of a billing agency must ensure through legal contract (a copy of which must be made available to Beacon upon request) the responsibility of a billing service to report claim information as directed by the provider in compliance with all policies stated by Beacon. 16.7.6 Limited Use of Information All information supplied by Beacon or collected internally within the computing and accounting systems of a provider or billing agency (e.g., member files or statistical data) can be used only by the provider in the accurate accounting of claims containing or referencing that information. Any redistributed or dissemination of that information by the provider for any purpose other than the accurate accounting of behavioral health claims is considered an illegal use of confidential information. 16.7.7 Prohibition of Billing Members Providers are not permitted to bill health plan members under any circumstances for covered services rendered, excluding co-payments when appropriate. 16.7.8 Beacon’s Right to Reject Claims At any time, Beacon can return, reject or disallow any claim, group of claims, or submission received pending correction or explanation. 16.7.9 Recoupments and Adjustments by Beacon Beacon reserves the right to recoup money from providers due to errors in billing and/or payment, in accordance with Kentucky law and regulations. In that event, Beacon applies all recoupments and adjustments to future claims processed, and reports such recoupments and adjustments on the EOB with Beacon’s record identification number (REC.ID) and the provider’s patient account number. 16.7.10 Claim Turnaround Time All clean claims will be adjudicated within thirty (30) days from the date on which Beacon Health Page 211 of 331 Strategies receives the claim. 16.7.11 Claims for Inpatient Services • The date range on an inpatient claim for an entire admission (i.e., not an interim bill) must include the admission date through the discharge date. The discharge date is not a covered day of service but must be included as the “to” date. Refer to authorization notification for correct date ranges. • • • Beacon accepts claims for interim billing that include the last day to be paid as well as the correct bill type and discharge status code. On bill type X13, where X represents the “type of facility” variable, the last date of service included on the claim will be paid and is not considered the discharge day. Providers must obtain authorization from Beacon for all ancillary medical services provided while a plan member is hospitalized for a behavioral health condition. Such authorized medical services are billed directly to the health plan. Beacon’s contracted reimbursement for inpatient procedures reflect all-inclusive per diem rates. 16.7.12 Coding When submitting claims through eServices, users will be prompted to include appropriate codes in order to complete the submission, and drop-down menus appear for most required codes. See EDI Transactions – 837 Companion Guide on the Beacon web site www.beaconhealthsolutions.com for placement of codes on the 837 file. Please note the following requirements with regard to coding: • • • • • • Providers are required to submit HIPAA-compliant coding on all claim submissions; this includes HIPAA-compliance revenue, CPT, HCPCS, and ICD-9 codes. Providers should refer to their exhibit A for a complete listing of contracted, reimbursable procedure codes. Beacon accepts only ICD-9 diagnosis codes listed as approved by CMS and HIPAA. In order to be considered for payment by Beacon, all claims must have a Primary ICD-9 diagnosis in the range of 290-298.9, 300.00-316. All diagnosis codes submitted on a claim form must be a complete diagnosis code with appropriate check digits. Claims for inpatient and institutional services must include the appropriate discharge status code. Table 6-1 lists HIPAA-compliant discharge status codes. DSM-IV (or most recent) classification should be used for behavioral health billing. Table 6-1 Discharge Status Codes Code 01 02 03 04 05 06 Description Discharged to Home / Self Care Discharged/Transferred to Another Acute Hospital Discharged/Transferred to Skilled Nursing Facility Discharged/Transferred to Intermediate Care Facility Discharged/Transferred to Another Facility Discharged/Transferred to Home / Home Health Agency Page 212 of 331 07 08 09 20 30 Left Against Medical Advice or Discontinued Care Discharged/Transferred Home / IV Therapy Admitted as Inpatient to this Hospital Expired Still a Patient * All UB04 claims must include the 3-digit bill type codes according to the Table below: Table 6-2 Bill Type Codes Type of Facility 1st Digit Bill Classification 2nd Digit Frequency – 3rd Digit 1.Admission through Discharge Claim 1.Hospital 1.Inpatient 1.Skilled Nursing Facility 2.Inpatient Professional Component 2.Home Health Care 3.Outpatient 3.Interim Continuing Claims 4.Diagnostic Services 4.Interim – Last Claim 5.Intermediate Care – Level I 5. Late Charge Only 6.Intermediate Care – Level II 6 – 8. Not Valid 3.Christian Science Hospital 5.Christian Science Extended Care Facility 6.Intermediate Care Facility 2.Interim – First Claim 6.7.13 Modifiers Modifiers can reflect the discipline and licensure status of the treating practitioner or are used to make up specific code sets that are applied to identify services for correct payment. Table lists HIPAA-compliant modifiers accepted by Beacon. Table 6-3 Modifiers Professional Provider Type Psychiatrist Licensed Psychologist Licensed Clinical Social Worker Psychiatric Resident, Physician Certified Prevention Professional, Community Support Staff Member, Peer Counselor Professional Equivalent Licensed Marriage and Family Therapist, Licensed Psychological Practitioner, Certified Professional Counselor, Certified Professional Art Therapist, Advance Registered Nurse Practitioner Physician Assistant Psychiatric Nurse, Registered Nurse AD or Diploma Degree, Registered Nurse with BS Degree Certified Social Worker, Licensed Professional Counselor Associate, Licensed Psychological Associate, Marriage and Family Therapy Associate Page 213 of 331 Modifier AF AH AJ AM HM HN HO SA U1 U2 U4 Mental Health Associate Certified Alcohol and Drug Counselor U5 U6 6.7.14 Time Limits for Filing Claims Beacon Health Strategies must receive claims for covered services within the designated filing limit: • Within 180 days of the dates of service on outpatient claims, or • Within 180 days of the date of discharge on inpatient claims Providers are encouraged to submit claims as soon as possible for prompt adjudication. Claims submitted after the 180-day filing limit will deny unless submitted as a waiver or reconsideration request, as described in this chapter. 6.7.15 Coordination of Benefits (COB) Passport follows a Coordination of Benefits policy when members have other medical insurance including Medicare. Because Passport administers a Medicaid program, it is considered the “payer of last resort” on all claims. All insurance including any automobile (personal protection) coverage or other medical coverage, including Medicare, pays the member’s claims before Passport. These types of coverage are considered “primary” coverage. In accordance with The National Association of Insurance Commissioners (NAIC) regulations, Beacon Health Strategies coordinates benefits for behavioral health and substance use claims when it is determined that a person is covered by more than one health plan, including Medicare: • • When it is determined that Passport / Beacon Health Strategies is the secondary payer, claims must be submitted with a copy of the primary insurance’s explanation of benefits report and received by Beacon within 60 days of the date on the EOB. Beacon Health Strategies reserves the right of recovery for all claims in which a primary payment was made prior to receiving COB information that deems Beacon the secondary payer. Beacon applies all recoupments and adjustments to future claims processed, and reports such recoupments and adjustments on the EOB. 6.7.16 Claim Inquiries and Resources Additional information is available through the following resources: Email Contact • Provider.relations@beaconhs.com • EDI.Operations@beaconhs.com Telephone • Interactive Voice Recognition (IVR): (888)210-2018 You will need your practice or organization’s tax ID, the member’s identification number and date of birth, and the date of service. Page 214 of 331 • • Claims Hotline: (888)249-0478 Hours of operation are 8:30 a.m. to 5:30 p.m. EST Monday through Thursday and 9:00 a.m. to 5:00 p.m. EST on Friday. Beacon’s Main Telephone Numbers Provider Relations (855)834-5651 EDI (855)834-5651 TTY (866)727-9441 6.7.17 Electronic Media Options Providers are expected to complete claim transactions electronically through one of the following, where applicable: Electronic Data Interchange (EDI) supports electronic submission of claim batches in HIPAA- compliant 837P format for professional services and 837I format for institutional services. Providers may submit claims using EDI/837 format directly to Beacon or through a billing intermediary. If using Emdeon as the billing intermediary, two identification numbers must be included in the 837 file for adjudication: o Beacon’s payor ID is 43324; and o Beacon’s health plan-specific ID is 028. • eServices enables providers to submit inpatient and outpatient claims without completing a CMS 1500 or UB04 claim form. Because much of the required information is available in Beacon’s database, most claim submissions take less than one minute and contain few, if any errors. • IVR provides telephone access to member eligibility, claim status and authorization status. • 6.7.18 Claim Transaction Overview Table 6-4 below, identifies all claim transactions, indicates which transactions are available on each of the electronic media, and provides other information necessary for electronic completion. Watch for updates as additional transactions become available on EDI, eServices and IVR. Table 6-4: Claim Transaction Overview Member Eligibility Verification Submit Standard Claim Applicable When: IVR EDI Transaction eServices Access on: • Completing any claim transaction; and • Submitting clinical authorization requests Y Y Y Y Submitting a claim for Y N authorized, covered services, within the timely filing limit Page 215 of 331 Timeframe for Receipt by Beacon Other Information n/a n/a Within 180 days after the date of service n/a Resubmission of Denied Claim Y 180-Day Waiver* (Request for waiver of timely filing limit) Previous claim was denied for Y N any reason except timely filing Within 180 days after the date on the EOB. A claim being submitted for the first time will be received by Beacon after the original 180day filing limit, and must include evidence that one of the following conditions is met: N • Provider is eligible for reimbursement retroactively; or • Member was enrolled in Plan retroactively; or • Services were authorized retroactively. • Third party coverage is available and was billed first. (A copy of the other N N insurance’s explanation of benefits or payment is required); Page 216 of 331 Within 180 days from the qualifying event. • Claims denied for late filing may be resubmitted as reconsiderations. • Rec ID is required to indicate that claim is a resubmission. • Waiver requests will be considered only for these 3 circumstances. A waiver request that presents a reason not listed here will result in a claim denial on a future EOB. • A claim submitted beyond the filing limit that does not meet the above criteria may be submitted as reconsideration request. • Beacon’s waiver determination is reflected on a future EOB with a message of Waiver Approved or Waiver Denied: if waiver of the filing limit is approved, the claim appears adjudicated; if the request is denied, the denial reason appears. Request for Reconsideration of Timely Filing Limit* N Request to Void Payment N Y N Claim falls out of all timeframes and requirements for resubmission, waiver and adjustment. • Claim was paid to provider in error; and, N N • Provider needs to return the entire paid amount to Beacon. Request for Adjustment Within 180 days from the date of payment or nonpayment. n/a • The amount paid to provider on a claim, was incorrect; • Adjustment may be requested to correct: o Underpayment (positive request); or, o Overpayment (negative request) Y • Positive request must be received by Beacon within 180 days from the date of original payment; Y N • No filing limit applies to negative requests. Obtain Claim Status View/Print Remittance Advice (RA) N Available 24/7 for all claim Y Y transactions submitted by provider. n/a N Available 24/7 for all claim Y N transactions received by Beacon. n/a Page 217 of 331 Future EOB shows “Reconsideration” “Approved” or “Reconsideration Denied” with denial Do NOT send a refund check to Beacon. • Do NOT send a refund check to Beacon • A RecID is required to indicate that the claim is an adjustment. • Adjustments are reflected on a future EOB as recoupment of the previous (incorrect) amount and, if money is owed to provider, repayment of the claim at the correct amount. • If an adjustment appears on an EOB and is not correct, another adjustment request may be submitted based on the previous incorrect adjustment. • Claims that have been denied cannot be adjusted, but may be resubmitted. Claim status is posted within 48 hours after receipt by Beacon. Printable RA is posted within 48 hours after receipt by Beacon. *Please note that waivers and reconsiderations apply only to the claims filing limit; claims are still processed using standard adjudication logic and all other billing and authorization requirements must be met. Accordingly, an approved waiver or reconsideration of the filing limit does not guarantee payment, since the claim could deny for another reason. 6.7.19 Paper Claim Transactions Providers are strongly discouraged from using paper claim transactions where electronic methods are available, and should be aware that processing and payment of paper claims is slower than that of electronically submitted claims. Electronic claim transactions take less time and have a higher rate of approval since most errors are eliminated. For paper submissions, providers are required to submit clean claims on the National Standard Format CMS1500 or UB04 claim form. No other forms are accepted. Mail paper claims to: Beacon Health Strategies Passport Health Plan Claims Department 500 Unicorn Park Drive, Suite 401 Woburn, MA 01801-3393 Beacon does not accept claims transmitted by fax. Beacon discourages paper transactions. B EFOR E SUB M IT T IN G PAPER CL AIM S, PL EASE R EVIEW ELECT R ON IC OPT ION S EARLIER IN TH IS CH APTER. Paper submissions have more fields to enter, a higher error rate / lower approval rate, and slower payment. 16.7.20 Professional Services: Instructions for Completing the CMS 1500 Form Table 6-5 below lists each numbered block on the CMS 1500 form with a description of the requested information, and indicates which fields are required in order for a claim to process and pay. Page 218 of 331 Table 6-5: CMS 1500 Form Table Block # 1 1a 2 3 4 5 6 7 8 9 9a 9b 9c 9d 10a-c 11 11a 11b 11c 11d 12 13 14 15 16 17 17 B 18 19 20 21 22 23 24a 24b Required? No Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes No No No No No Yes No No No No No No No Yes No Yes No Yes Yes Yes 24d Yes 24e 24f 24g Yes Yes Yes Description Check Applicable Program Member’s Health Plan ID Number Member’s Name Member’s Birth date and Sex Insured’s Name Member’s Address Member’s Relationship to Insured Insured’s Address Member’s Status Other Insured’s Name (If Applicable) Other Insured’s Policy or Group Number Other Insured’s Date of Birth and Sex Employer’s Name or School Name Insurance Plan Name or Program Name Member’s Condition Related to Employment Member’s Policy, Group or FICA Number (If Applicable) Member’s Date of Birth (MM, DD, YY) and Sex (check box) Employer’s Name or School Name (If Applicable) Insurance Plan Name or Program Name (If Applicable) Is there another health benefit plan? Member’s or Authorized Person’s Signature and Date On File Member’s or Authorized Person’s Signature Date of Current Illness Date of Same or Similar Illness Date Client Unable to Work in Current Occupation Name of Referring Physician or Other Source (If Applicable) NPI of referring Physician Hospitalization Dates Related to Current Services (If Applicable) Former Control Number (Record ID If Applicable) Outside Lab? Diagnosis or Nature of Illness or Injury Medicaid Resubmission Code Prior Authorization Number (If Applicable) Date of Service Place of Service code (HIPAA Compliant) Procedure Code (HIPAA-compliant between 290 and 319) and Modifier when applicable (See Table 6-3 for acceptable modifiers) Diagnosis Code- 1,2,3 or 4 Charges Days or Units Page 219 of 331 24h 24i 24 j 25 26 27 28 29 30 31 No No Yes Yes No No Yes Yes Yes Yes 32 Yes 32a 33 33 a 33 b No Yes Yes No EPSDT ID Qualifier Rendering Provider Name and Rendering Provider NPI Federal Tax ID Number Provider’s Member Account Number Accept Assignment (check box) Total Charges Amount Paid by Other Insurance (If Applicable) Balance Due Signature of Physician/Practitioner NPI Name and Address of Facility where services were rendered (Site ID). If missing, a claim specialist will choose the site shown as ‘primary’ in Beacon’s database NPI of Servicing Facility Provider Name Billing Provider NPI Pay to Provider Beacon ID Number Institutional Services: Instructions for Completing the UB04 Form Beacon discourages paper transactions. BEFORE SUBMITTING PAPER CLAIMS, PLEASE REVIEW ELECTRONIC OPTIONS EARLIER IN THIS CHAPTER Paper submissions have more fields to enter, a higher error rate/lower approval rate, and slower payment. Table 6-6 below lists each numbered block on the UB-04 claim form, with a description of the requested information and whether that information is required in order for a claim to process and pay. Table 6-6 UB-04 Claim Form Block # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Required? Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Description Provider Name, Address, Telephone # Untitled Provider’s Member Account Number Type of Bill (See Table 6-2 for 3-digit codes) Federal Tax ID Number Statement Covers Period (Include date of Discharge) Covered Days (Do not include date of Discharge) Member Name Member Address Member Birth Date Member Sex Admission Date Admission Hour Admission Type Page 220 of 331 15 16 17 18 -28 29 30 31-34 35-36 37 38 39-41 42 43 44 Yes Yes Yes No No No No No No No No Yes Yes Yes 45 46 47 48 49 50 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 Yes Yes Yes No Yes Yes Yes Yes Yes Yes No Yes No No No Yes No No Yes No No No Yes No Yes No No No No No No Admission Source Discharge Hour Discharge Status (See Table 6-1: Discharge Status Codes) Condition Codes ACDT States Unassigned Occurrence Code And Date Occurrence Span REC.ID For Resubmission Untitled Value CD/AMT Revenue Code (If Applicable) Revenue Description Procedure Code (CPT) (Modifier may be placed here beside the HCPCS code. See Table 6-3 for acceptable modifiers) Service Date Units Of Service Total Charges Non-Covered Charges Modifier (If Applicable - See Table 6-3 for acceptable modifiers) Payer Name Beacon Provider Id Number Release Of Information Authorization Indicator Assignment Of Benefits Authorization Indicator Prior Payments (If Applicable) Estimated. Amount Due Facility NPI Other ID Insured’s Name Member’s Relationship To Insured Member’s Identification Number Group Name Insurance Group Number Prior Authorization Number (If Applicable) Document Control Number Employer Name Employer Location Principal Diagnosis Code A-Q Other Diagnosis Admit Diagnosis Patient Reason Diagnosis PPS Code ECI Unassigned Principle Procedure Unassigned Page 221 of 331 7 7 78 -79 8 8 Yes No No No No Attending Physician NPI First And Last Name (Required) Operating Physician NPI Other NPI Remarks Code-Code 6.7.21 Paper Resubmission Beacon discourages paper transactions. BEFORE SUBMITTING PAPER CLAIMS, PLEASE REVIEW ELECTRONIC OPTIONS EARLIER IN THIS CHAPTER Paper submissions have more fields to enter, a higher error rate/lower approval rate, and slower payment. • • See Table 6-4 for an explanation of claim resubmission, when resubmission is appropriate, and procedural guidelines. If the resubmitted claim is received by Beacon more than 180 days from the date of service. The REC.ID from the denied claim line is required and may be provided in either of the following ways: Enter the REC.ID in box 64 on the UB04 claim form or in box 19 on the CMS 1500 form. Submit the corrected claim with a copy of the EOB for the corresponding date of service; or • The REC.ID corresponds with a single claim line on the Beacon EOB. Therefore, if a claim has multiple lines there will be multiple REC.ID numbers on the Beacon EOB. • The entire claim that includes the denied claim line(s) may be resubmitted regardless of the number of claim lines; Beacon does not require one line per claim form for resubmission. When resubmitting a multiple-line claim, it is best to attach a copy of the corresponding EOB. Resubmitted claims cannot contain original (new) claim lines along with resubmitted claim lines. Resubmissions must be received by Beacon within 180 days after the date on the EOB. A claim package postmarked on the 180th day is not valid. If the resubmitted claim is received by Beacon within 180 days from the date of service, the corrected claim may be resubmitted as an original. A corrected and legible photocopy is also acceptable • • • 6.7.21.1 Paper Submission of 180-Day Waiver • • • • • • • See Table 6-4 for an explanation of waivers, when a waiver request is applicable, and procedural guidelines; Watch for notice of waiver requests becoming available on eServices. Download the 180-Day Waiver Form; Complete a 180-Day Waiver Form for each claim that includes the denied claim(s),per the instructions below; Attach any supporting documentation; Prepare the claim as an original submission with all required elements; Send the form, all supporting documentation, claim and brief cover letter to: Page 222 of 331 Beacon Health Strategies Claim Department / Waivers 500 Unicorn Park Drive, Suite 401 Woburn, MA 01801-3393 6.7.21.2 Completion of the Waiver Request Form To ensure proper resolution of your request, complete the 180-Day Waiver Request Form as accurately and legibly as possible. 1. Provider Name: Enter the name of the provider who provided the service(s). 2. Provider ID Number: Enter the provider ID Number of the provider who provided the service(s). 3. Member Name: Enter the member’s name. 4. Health Plan Member ID Number: Enter the Plan member ID Number. 5. Contact Person Enter the name of the person whom Beacon should contact if there are any questions regarding this request. 6. Telephone Number Enter the telephone number of the contact person. 7. Reason for Waiver Place an “X” on all the line(s) that describe why the waiver is requested. 8. Provider Signature A 180-day waiver request cannot be processed without a typed, signed, stamped, or computergenerated signature. Beacon will not accept “Signature on file.” 9. Date Indicate the date that the form was signed. 6.7.22 Paper Request for Adjustment or Void Beacon discourages paper transactions. BEFORE SUBMITTING PAPER CLAIMS, PLEASE REVIEW ELECTRONIC OPTIONS EARLIER IN THIS CHAPTER Paper submissions have more fields to enter, a higher error rate/lower approval rate, and slower payment. • See Table 6-4 for an explanation of adjustments and voids, when these requests are applicable, and procedural guidelines; • Do not send a refund check to Beacon. A provider who has been incorrectly paid by Beacon must request an adjustment or void; • Prepare a new claim as you would like your final payment to be, with all required elements; place the REC.ID in box 19 of the CMS 1500 claim form, or box 64 of the UB04 form or; • Download and complete the Adjustment/Void Request Form per the instructions below; • Attach a copy of the original claim; • Attach a copy of the EOB on which the claim was paid in error or paid an incorrect Page 223 of 331 amount; Send the form, documentation and claim to: Beacon Health Strategies Claim Departments – Adjustment Requests 500 Unicorn Park Drive, Suite 401 Woburn, MA 01801-3393 6.7.22.1 To Complete the Adjustment/Void Request Form To ensure proper resolution of your request, complete the Adjustment/Void Request form as accurately and legibly as possible and include the attachments specified above. 1. Provider Name Enter the name of the provider to whom the payment was made. 2. Provider ID Number Enter the Beacon provider ID Number of the provider that was paid for the service. If the claim was paid under an incorrect provider number, the claim must be voided and a new claim must be submitted with the correct provider ID Number. 3. Member Name Enter the member’s name as it appears on the EOB. If the payment was made for the wrong member, the claim must be voided and a new claim must be submitted. 4. Member Identification Number Enter the Plan member ID Number as it appears on the EOB. If a payment was made for the wrong member, the claim must be voided and a new claim must be submitted. 5. Beacon Record ID number Enter the record ID number as listed on the EOB. 6. Beacon Paid Date Enter the date the check was cut as listed on the EOB. 7. Check Appropriate Line Place an “X” on the line that best describes the type of adjustment/void being requested. 8. Check All that Apply Place an “X” on the line(s) which best describe the reason(s) for requesting the adjustment/void. If “Other” is marked, describe the reason for the request. 9. Provider Signature An adjustment/void request cannot be processed without a typed, signed, stamped, or computer- generated signature. Beacon will not accept “Signature on file”. 10. Date List the date that the form is signed. 6.7.23 Provider Education and Outreach Summary In an effort to help providers that may be experiencing claims payment issues, Beacon runs quarterly reports identifying those providers than may benefit from outreach and education. Providers with low approval rates are contacted and offered support and documentation material to assist in reconciliation of any billing issues that are having an adverse financial impact and ensure proper Page 224 of 331 billing practices within Beacon’s documented guidelines. Passport’s goal in this outreach program is to assist providers in as many ways as possible to receive payment in full, based upon contracted rates, for all services delivered to members. 6.7.23.1 How the Program Works • • • A quarterly approval report is generated that lists the percentage of claims paid in relation to the volume of claims submitted. All providers below 75% approval rate have an additional report generated listing their most common denials and the percentage of claims they reflect. An outreach letter is sent to the provider’s Billing Director as well as a report indicating the top denial reasons. A contact name is given for any questions or to request further assistance or training. 6.7.24 Grievances Providers with grievances or concerns should contact Beacon at the number provided below and ask to speak with the clinical manager for Passport. All provider complaints are resolved within thirty (30) days of receipt. The Provider or Passport may request a fourteen (14) day extension for resolution of the grievance or appeal. If a Passport member complains or expresses concern regarding Beacon’s procedures or services, Plan procedures, covered benefits or services, or any aspect of the member’s care received from providers, he or she should be directed to call Beacon’s Ombudsperson at (855)834-5651 or TTY at (866)727-9441. 6.7.24.1 Appeals and Grievances Please see Section (2.9) for information concerning provider appeals and grievances. 6.7.24.2 Peer Review A peer review conversation may be requested at any time by the treating provider, and may occur prior to or after an adverse determination, upon request for a reconsideration. Beacon UR clinicians and PAs are available daily to discuss denial cases by phone at (855)834-5651. Page 225 of 331 Provider Manual Section 17.0 Forms and Documents Table of Contents 17.1 Preventive Health, Disease Management & Risk Assessment Forms 17.2 Claim Forms 17.3 Provider Contracting and Provider Network Management Forms 17.4 MAP Forms 17.5 Utilization Management Forms 17.6 Mommy Steps Forms Page 226 of 331 17.0 Forms and Documents 17.1 Preventive Health, Disease Management & Risk Assessment Forms 17.1.1 Diabetes Care Tool 17.2 Claim Forms 17.2.1 17.2.2 17.2.3 17.2.4 17.2.5 Claim Issue Form Recoupment Form UB-04 Form and Instructions CMS-1500 Claim Form and NPI Instructions Third Party Liability Lead Form 17.3 Provider Contracting and Provider Network Management Forms 17.3.1 17.3.2 17.3.3 17.3.4 Provider Information Change Form Adding a Practitioner to a Current Participating Provider Group Nonparticipating Provider Registration Form Registration of Locum Tenens Physician 17.4 MAP Forms 17.4.1 17.4.2 17.4.3 17.4.4 MAP-250 Consent for Sterilization MAP-251 Hysterectomy Consent Form MAP-235 Certification Form for Induced Abortion or Induced Miscarriage MAP-236 Certification Form for Induced Premature Birth 17.5 Utilization Management Forms 17.5.1 17.5.2 17.5.3 17.5.4 17.5.5 17.5.6 17.5.7 17.5.8 17.5.9 17.5.10 17.5.11 17.5.12 Referral Form Home Health Authorization Form DME Authorization Form Home Infusion Authorization Form Pain Management Medical Necessity Review Check List Cosmetic Prior Authorization Form Initial Therapy Authorization Form Continued Therapy Authorization Form Chiropractic Service Prior Authorization Request Form Behavioral Health Liaison Form Care Coordination Referral Form Private Duty Nursing Form 17.6 Mommy Steps Forms 17.6.1 No-Show Visit for OB Appointment Form Page 227 of 331 DIABETES CARE TOOL Patient Name: DOB: Height: Smoker: Yes No (circle one) Type of Diabetes: 1 2 (circle one) Pneumococcal Vaccine Date(s): KENTUCKY DIABETES NETWORK, INC. _ A statewide partnership striving to improve the treatment and outcomes for Kentuckians with diabetes. Year of Diabetes Diagnosis: This tool is based on the 2009 American Diabetes Association’s “Standards of Medical Care for Patients with Diabetes Mellitus” and indicates minimum services to be provided in the continuing (initial visits have additional components) care of adults with diabetes. It is not intended to replace or preclude clinical judgment or more intensive management where medically indicated. Use it as a reminder for exams or important tests, to simplify record keeping and as a way to continually improve care to all patients with diabetes. Enter result, checkmark, or date as you deem appropriate. DATE OF VISIT EVERY VISIT Weight B/P (Goal <130/80) A1C Hemoglobin A1c every 3–6 mo. (Goal <7%) Foot Exam: V = Visual Review Self-Management Goals and BG Log Foot Exam: • Monofilament (sensation), foot structure, biomechanics, vascular, and skin integrity ANNUAL Fasting Lipid Profile: • Total Cholesterol (Goal < 200) • LDL (Goal < 100) • HDL (Goal Men > 40, Women > 50) • Triglycerides (Goal < 150) Microalbumin: Unless urine dipstick (+) for protein Serum Creatinine: For estimation of glomerular filtration rate (GFR) Dilated Eye Exam/ Referral Date Flu Vaccine SELFMANAGEMENT Oral Visualization Exam Self-Management Education/ Referral Date Exercise /Physical Activity Medical Nutrition Therapy Referral Tobacco Cessation (1-800-QUIT NOW or 1-800-784-8669) Preconception Counseling (women of childbearing age) OTHER Aspirin Therapy St=start, Cont=continue, D/C=discontinue, CI/MA=contraindicated/medical allergy, Dec=declined Circle: ACE-I or ARB St, Cont, D/C, CI/MA, Dec Statin or Lipid Lowering Agent: St, Cont, D/C, CI/MA, Dec Assess Mental/Behavioral Health This tool may be obtained from www.kentuckydiabetes.net and reprinted in its entirety without permission. Revisions in content may not be endorsed by the Kentucky Diabetes Network, Inc. 04/2009 Passport Health Plan Attn: Provider Claims Unit P.O. Box 7114 London, KY 40742 Phone: 800-578-0775 Fax: 502-585-8339 CLAIM ISSUE FORM Date: Provider ID: Provider Name: Phone Number: Email Address: Contact Name: Submitted By: Please provide the following information regarding the issue: Member ID: Claim Number: Remittance Number: Remittance Date: Please explain the issue you have with the claim: □Underpayment □Overpayment □COB/TPL □Claim processed incorrectly □Authorization issues □Referral issues □Claim paid to the wrong provider □ Duplicate payment □ Other (explanation required) FOR PHP US E ON LY Rep. Name: Response Date Comments RECOUPMENT FORM Provider Name Provider ID Contact Name Phone # Passport Health Plan Attn: Recoupments P.O. Box 7114 London, KY 40742 Phone: 800-578-0775 Fax: 502-585-8339 Provider Email Address Member’s ID Member Name Claim(s) # Remit # Date of Service Total Amount Billed Check Number (from Passport Health Plan) Recoupment Amount Reason for recoupment: CONFIDENTIALITY NOTICE: This fax is intended for the sole use of the individual and entity to whom it is addressed and may contain information that is confidential and exempt from disclosure under applicable law. If you are not the intended addressee nor authorized to receive for the intended addressee, you are hereby notified that you may not use, copy, disclose or distribute to anyone the message or any information contained in the message. If you have received this fax in error, please immediately advise the sender at the phone number at the top of the page and shred the fax. Thank you very much. New UB-04 Form & Instructions The Office of Management and Budget (OMB) and the National Uniform Billing Committee (NUBC) previously approved the UB-04 claim form, also known as the CMS-1450 form. The UB-04 claim form accommodates the National Provider Identifier (NPI) and incorporated other important changes. This form replaced the UB-92 claim form and was phased in over a transition period beginning March 1, 2007.The UB-04 form has been used exclusively for institutional billing beginning May 23, 2007. Sample UB-04 forms for inpatient and outpatient services are enclosed. The UB-04 Claim Form and NPI The UB-04 claim form includes several fields that accommodate the use of your NPI. Although the form accommodates the NPI, you must continue to report your current provider identification numbers in the appropriate areas of the form. UB-04 Data Field Requirements FIELD LOCATION UB-04 DESCRIPTION 1 Provider Name and Address Required Required 2 Pay-To Name and Address Situational Situational 3a Patient Control Number Required Required 3b Medical Record Number Required Required 4 Type of Bill Required Required 5 Federal Tax Number Required Required 6 Statement Covers Period Required Required 7 Future Use N/A N/A 8a Patient ID Situational Situational 8b Patient Name Required Required INPATIENT OUTPATIENT 9 Patient Address Required Required 10 Patient Birthdate Required Required 11 Patient Sex Required Required 12 Admission Date Required Required 13 Admission Hour Required Required 14 Type of Admission/Visit Required N/A 15 Source of Admission Required Required 16 Discharge Hour Required Required 17 Patient Discharge Status Required Required 18-28 Condition Codes Required if Applicable Required if Applicable 29 Accident State Situational Situational 30 Future Use N/A N/A 31-34 Occurrence Code and Dates Required if Applicable Required if Applicable 35-36 Occurrence Span Codes and Dates Required if Applicable Required if Applicable 37 Future Use N/A N/A 38 Subscriber Name and Address Required Required 39-41 Value Codes and Amounts Required if Applicable Required if Applicable 42 Revenue Code Required Required 43 Revenue Code Description Required Required 44 HCPCS/Rates Required if Applicable Required if Applicable *For additional information on the completion of fields, please refer to the NUBC Official UB-04 Data Specifications Manual. © 2012 PASSPORT HEALTH PLAN (PA-111378) FIELD LOCATION UB-04 DESCRIPTION INPATIENT OUTPATIENT 45 Service Date N/A Required 46 Units of Service Required Required 47 Total Charges (By Rev. Code) Required Required 48 Non-Covered Charges Required if Applicable Required if Applicable 49 Future Use N/A N/A 50 Payer Identification (Name) Required Required 51 NPI Required Required 52 Release of Info Certification Required Required 53 Assignment of Benefit Certification Required Required 54 Prior Payments Required if Applicable Required if Applicable 55 Estimated Amount Due Required Required 56 NPI Required Required 57 Health Plan IDs Required Required 58 Insured’s Name Required Required 59 Patient’s Relation to the Insured Required Required 60 Insured’s Unique ID Required Required 61 Insured Group Name Situational Situational 62 Insured Group Number Situational Situational 63 Treatment Authorization Codes Required if Applicable Required if Applicable 64 Document Control Number Situational Situational 65 Employer Name Situational Situational 66 Diagnosis/Procedure Code Qualifier Required Required 67 Principal Diagnosis Code/Other Diagnosis Codes Required Required 68 Future Use N/A N/A 69 Admitting Diagnosis Code Required Required if Applicable 70 Patient’s Reason for Visit Code Situational Situational 71 PPS Code Situational Situational 72 External Cause of Injury Code Situational Situational 73 Future Use N/A N/A 74 Principal Procedure Code/Date Required if Applicable Required if Applicable 75 Future Use N/A N/A 76 Attending Name/ ID-Qualifier Required Required 77 Operating ID Situational Situational 78-79 Other ID Situational Situational 80 Remarks Situational Situational 81 Code-Code Field/Qualifiers *0-A0 N/A N/A *A1-A4 Situational Situational *A5-B0 N/A N/A *B1-B2 Situational Situational *B3 Required Required We would also like to remind you of the requirements for electronic transactions. As a reminder, Passport Health Plan strongly recommends the continued use of plan identification numbers in addition to NPI. © 2012 PASSPORT HEALTH PLAN (PA-111378) 837 I Data Field Requirements ====================== 837 I ====================== BILLING TAXONOMY LOOP ====================== LOOP ID Loop Name Segment Name PRV01 Qualifier PRV02 Qualifier PRV03 Value 2000A Billing/Pay-To Provider Specialty Information PRV BI PT ZZ = Taxonomy NM101 Qualifier NM108 Qualifier NM109 Value 85 24 34 = TAX ID = SSN XX = NPI ====================== 837 I ====================== BILLING PROVIDER LOOP ====================== LOOP ID 2010AA Loop Name Billing Provider Segment Name NM1 LOOP ID Loop Name Segment Name REF01 Qualifier REF02 Value 2010AA Billing Provider Secondary Identification REF SY EI = SSN = TAX ID 1D = MAID ====================== 837 I ====================== PAY TO PROVIDER LOOP ====================== LOOP ID 2010AB LOOP ID Loop Name Pay-To-Provider Loop Name Segment Name NM1 Segment Name NM109 Value NM101 Qualifier NM108 Qualifier 87 24 34 = TAX ID = SSN XX = NPI REF02 Value REF01 Qualifier SY 2010AB Pay-To-Provider Secondary Identification REF EI 1D ====================== 837 I ====================== ATTENDING PROVIDER LOOP ====================== LOOP ID 2310A Loop Name Attending Physician Segment Name NM1 NM109 Value NM101 Qualifier NM108 Qualifier 82 24 34 = TAX ID = SSN XX = NPI LOOP ID Loop Name Segment Name REF01 Qualifier REF02 Value 2310A Attending Physician Secondary Identification REF N5 = Facets ID ====================== 837 I ====================== SERVICE FACILITY LOOP ====================== LOOP ID 2310E Loop Name Service Facility Location Segment Name NM1 NM109 Value NM101 Qualifier NM108 Qualifier 82 24 34 = TAX ID = SSN XX = NPI LOOP ID Loop Name Segment Name REF01 Qualifier REF02 Value 2310E Service Facility Location Secondary Identification REF N5 = Facets ID Please let us know if you have any questions regarding these instructions. In addition, if you have any questions regarding the NPI, the application process, or reporting your NPIs to us, please contact your Provider Relations representative. Sample INPATIENT UB-04 Form 4 3a PAT. CNTL # b. MED. REC. # 2 __ 1 6 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a b STATEMENT COVERS PERIOD FROM THR OUGH 11 SEX 31 OCCURRENCE CODE DATE 12 DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 32 OCCURRENCE CODE DATE 33 OCCURRENCE DATE CODE 18 7 a b 10 BIRTHDATE TYPE OF BILL 19 20 34 OCCURRENCE CODE DATE CONDITION CODES 22 23 24 21 35 CODE 25 26 OCCURRENCE SPAN FROM THROUGH 27 36 CODE d 28 e 29 ACDT 30 STATE OCCURRENCE SPAN FROM THROUGH 37 a a b b 38 39 CODE VALUE CODES AMOUNT 40 CODE VALUE CODES AMOUNT 41 CODE VALUE CODES AMOUNT a b c d 42 REV. CD. 44 HCPCS / RATE / HIPPS CODE 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 PAGE 23 OF CREATION DATE 50 PAYER NAME 52 REL. INFO 51 HEALTH PLAN ID 53 ASG. BEN. TOTALS 54 PRIOR PAYMENTS 23 55 EST. AMOUNT DUE 56 NPI A 57 A B OTHER B C PRV ID C 58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A A B B C C 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A A B B C C 66 DX 67 I A J REASON DX 69 ADMIT 70 PATIENT DX 74 PRINCIPAL PROCEDURE a. CODE DATE B K a b OTHER PROCEDURE CODE DATE C L D M c E N CODE 71 PPS ECI 72 b. OTHER PROCEDURE CODE DATE e. OTHER PROCEDURE 75 F O a 76 ATTENDING G P b NPI LAST c. PR CODE DATE OTHER OCEDURE d. OTHER PR CODE DATE OCEDURE CODE DATE 77 OPERATING QUAL FIRST NPI QUAL 81CC a 80 REMARKS UB-04 CMS-1450 QUAL FIRST NPI LAST 78 OTHER H Q c APPROVED OMB NO. b LAST c 79 OTHER d LAST FIRST NPI . Green = Required/Preferred Black = situational/Required if applicable/Reserved © 2012 PASSPORT HEALTH PLAN (PA-111378) QUAL FIRST 68 73 Sample OUTPATIENT UB-04 Form 4 3a PAT. CNTL # b. MED. REC. # 2 __ 1 6 5 FED. TAX NO. 8 PATIENT NAME 9 PATIENT ADDRESS a b STATEMENT COVERS PERIOD FROM THR OUGH 11 SEX 31 OCCURRENCE CODE DATE 12 DATE 32 OCCURRENCE CODE DATE c ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 33 OCCURRENCE DATE CODE 18 7 a b 10 BIRTHDATE TYPE OF BILL 19 20 34 OCCURRENCE CODE DATE CONDITION CODES 22 23 24 21 35 CODE 25 26 OCCURRENCE SPAN THROUGH FROM 27 36 CODE d 28 e 29 ACDT 30 STATE OCCURRENCE SPAN THROUGH FROM 37 a a b b 38 39 CODE VALUE CODES AMOUNT 40 CODE VALUE CODES AMOUNT 41 CODE VALUE CODES AMOUNT a b c d 42 REV. CD. 44 HCPCS / RATE / HIPPS CODE 43 DESCRIPTION 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 PAGE 23 OF CREATION DATE 50 PAYER NAME 51 HEALTH PLAN ID 52 REL. 53 ASG. INFO BEN. TOTALS 54 PRIOR PAYMENTS 23 55 EST. AMOUNT DUE 56 NPI A 57 A B OTHER B C PRV ID C 58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A A B B C C 63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A A B B C C 67 I 66 DX X 69 ADMIT D A J B K a REASON DX 70 PATIENT b C L c D M E N CODE 71 PPS 74 PRINCIPAL PROCEDURE CODE DATE a. OTHER PROCEDURE CODE DATE b. OTHER PROCEDURE CODE DATE c. OTHER PROCEDURE CODE DATE d. OTHER PROCEDURE CODE DATE e. OTHER PROCEDURE CODE DATE ECI 72 75 F O a 76 ATTENDING G P b NPI LAST 77 OPERATING 81CC a UB-04 CMS-1450 APPROVED OMB NO. 78 OTHER b LAST c 79 OTHER d LAST NUBC ™ National Uniform Billing Committee 68 73 QUAL FIRST NPI LAST 80 REMARKS H Q c QUAL FIRST NPI QUAL FIRST NPI QUAL FIRST THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. LIC9213257 Green = Required/Preferred Black = situational/Required if applicable/Reserved © 2012 PASSPORT HEALTH PLAN (PA-111378) Revised 1500 Claim Form and NPI instructions The National Uniform Claim Committee (NUCC) released a revised 1500 Claim Form, which is commonly referred to as the CMS-1500. The revised CMS-1500 (08/05) replaced the former CMS-1500 (12/90). Use of the revised form was required as of April 1, 2007. A sample form is attached for your review. The 1500 Claim Form and NPI Revisions to the 1500 Claim Form include several fields that accommodate the use of your National Provider Identifier (NPI). Though the revised form accommodates NPI, you must continue to report current plan assigned provider identification numbers in the appropriate shaded areas of the form (17a, 24J, 32b, and 33b). Current provider identification numbers must be preceded by a two-character qualifier ID. This qualifier ID is the same as the qualifier ID used when billing electronically. If you do not currently bill electronically, please use the following ID: N5 Important Revisions to the 1500 Claim Form The revised 1500 Claim Form expands the length of some existing fields, incorporates several new fields, and accommodates use of your NPI. Some important fields that have been revised or added are listed below [new fields are highlighted]: Please Note: In addition to the revised fields, we will now require you to populate Field 19 with the ZZ qualifier ID and the Billing Provider’s Primary Taxonomy Code (Example: ZZ207LP2900X). Field 19 Field must be populated with the ZZ qualifier ID and the Billing Provider’s Primary Taxonomy Code (Example: ZZ207LP2900X) Field 21, parts 1-4 Diagnosis code fields have been updated to allow four characters of information following the pre-filled decimal point. Field 24 The shaded area extending from fields 24A through 24G will accommodate supplemental information, such as the narrative description of unspecified codes. Field 24C “EMG” (previously “Type of Service”). EMG was previously Field 24I. Field 24D “Procedures, Services, or Supplies” has been extended by three characters; you may now record up to four modifiers on the same line. Field 24E Now titled “Diagnosis Pointer” (previously “Diagnosis Code”); size decreased by three characters. Field 24H “EPSDT Family Plan” decreased in size by one character. Field 24I “ID. Qual” (previously “EMG”). The shaded area of this field (part 1) allows you to identify the two-character qualifier ID of the Rendering Provider (Example: N5). The unshaded area (part 2) is pre-filled with “NPI.” Field is required. Field 24J “Rendering Provider ID #” (previously “COB”). The shaded area of this field (part 1) allows you to submit the current provider identification number of the Rendering Provider that coincides with the two-character qualifier ID reported in the shaded area of 24I (part 1). The unshaded area (part 2) accommodates the Rendering Provider NPI. Both areas of this field are required. Field 33a Billing Provider NPI (previously “PIN#”). Field 33b Billing Provider two-character qualifier ID and current provider identification number (Example: N51234567001) (previously “GRP#) Field is required. For additional information about the 1500 Claim Form, please visit the NUCC’s website at www.nucc.org.The NUCC offers a helpful Instruction Manual titled 1500 Health Insurance Claim Form Reference Instruction Manual for 08/05 Version, which features walkthroughs of each field of the 1500 Claim Form. You can currently access the guide in PDF form at the following location: http://www.nucc.org/images/stories/PDF/claim_form_manual_v1-3_7-06.pdf © 2012 PASSPORT HEALTH PLAN (PA-111379) We would also like to remind you of the requirements for electronic transactions. As a reminder, Passport Health Plan strongly recommends the continued use of plan identification numbers in addition to NPI. 837 P Data Field Requirements ====================== 837 P ====================== BILLING TAXONOMY LOOP ====================== LOOP ID 2000A Loop Name Billing/Pay-To Provider Specialty Information Segment Name PRV01 Qualifier PRV02 Qualifier PRV03 Value PRV BI PT ZZ = Taxonomy NM109 Value = TAX ID ====================== 837 P ====================== BILLING PROVIDER LOOP ====================== LOOP ID Loop Name Segment Name NM101 Qualifier NM108 Qualifier 24 2010AA Billing Provider NM1 85 34 XX LOOP ID Loop Name Segment Name REF01 Qualifier 2010AA Billing Provider Secondary Identification REF SY EI = SSN = TAX ID 1D = MAID = SSN = NPI REF02 Value ====================== 837 P ====================== PAY TO PROVIDER LOOP ====================== LOOP ID Loop Name Segment Name NM101 Qualifier NM108 Qualifier 24 NM109 Value = TAX ID 2010AB Pay-To-Provider NM1 87 34 XX LOOP ID Loop Name Segment Name REF01 Qualifier 2010AB Pay-To-Provider Secondary Identification REF SY EI = SSN = TAX ID 1D = MAID = SSN = NPI REF02 Value ====================== 837 P ====================== RENDERING PROVIDER LOOP ====================== LOOP ID Loop Name Segment Name NM101 Qualifier NM108 Qualifier 24 2310B Rendering Provider NM1 82 34 XX LOOP ID Loop Name Segment Name REF01 Qualifier USED IN LOB 2310B Rendering Provider Secondary Identification REF N5 NM109 Value = TAX ID = SSN = NPI REF02 Value = Facets ID ====================== 837 P ====================== RENDERING PROVIDER TAXONOMY LOOP ====================== LOOP ID 2310B Loop Name Rendering Provider Specialty Information Segment Name PRV PRV01 Qualifier PE PRV02 Qualifier ZZ PRV03 Value = Taxonomy NM109 Value ====================== 837 P ====================== SERVICE FACILITY LOOP ====================== LOOP ID Loop Name Segment Name NM101 Qualifier NM108 Qualifier 2310D Service Facility Location NM1 82 24 34 = TAX ID = SSN XX = NPI LOOP ID Loop Name Segment Name 2310D Service Facility Location Secondary Identification REF REF01 Qualifier 77 REF02 Value = Service Location FA LI = Facility = Independent Lab TL = Testing Laboratory Please let us know if you have any questions regarding these instructions. In addition, if you have any questions regarding the NPI, the application process, or repor ting your NPIs to us, please contact your Provider Relations representative. REVISED ABC1234567800 Doe, John B. 03 20 Doe, John B. 71 1234 Main Street 1234 Main Street Anytown Anytown NJ 08999 856 555-2222 15974 72431 21 NJ 08999 856 555-2222 Doe, Mary 10 Member I.D. Number (No Suffix for CompSelect®/ Comprehensive Major Medical [CMM]) 03 20 71 Watch Repair, Inc. 70 self-employed AmeriHealth PPO HMO, Inc. Referring Provider’s Current Provider ID Referring Provider’s two-character qualifier ID 10 28 06 G2 0123456789 999999999 Josephine Smith, M.D. ZZ207LP2900X ZZ qualifier ID and Billing Provider’s Primary Taxonomy Code 11 01 06 11 04 06 Referring Provider’s NPI 401 251 8 123456789 11 02 06 11 02 06 21 11 03 06 11 03 06 21 6 99205 6 20600 25 Referral/Preauthorization Number 1 $50 00 1 2 $250 00 1 N5 1234567000 8888888888 Two-character qualifier ID of the Rendering Provider Modifier (if applicable) Provider’s Federal Tax ID # (Billing Entity) Service Facility NPI 22-1234567 Richard B. Smith, M.D. 11/5/06 Service Facility two-character qualifier and Current Provider ID number ABC Hospital 123 Street Anytown, NJ 08999 0000001234 G21234567002 Green items are required. Blue items are required when applicable to the patient’s condition/situation. Black items are optional. 100 Billing Provider NPI 00 0 00 100 00 856 555-5555 ABC Medical Group 8 North American Street Anytown, NJ 08999 2222222222 Billing Provider two-character qualifier ID and current provider identification number N51234567001 Indicates new field and/or requirement. Indicates field required for processing. Third Party Liability Lead Form Provider Name: Provider Phone Number: Provider ID Number: Member Name: Member Phone Number: Member ID Number: Address: Date of Birth: From Date of Service: To Date of Service: Date of Admission: Date of Discharge: Insurance Carrier Name: Address: Policy Number: Start Date: End Date: Date Claim was Filed with Insurance Carrier: Please check the one that applies: * No Response in Over 120 Days * Policy Termination Date: * Other: (Please explain in the space provided below) Contact Name: Contact Telephone Number: Signature: Date: Mail with claim to: Passport Health Plan • P.O. Box 7114 • London, KY 40742 Provider Information Change Form You have requested a change to your Passport Health Plan provider information. To verify the change, please complete the information below and send to: FAX: (502) 585-6060 -OR- MAIL: Passport Health Plan ATTN: Provider Relations 5100 Commerce Crossings Drive, Louisville, KY 40229 Plan ID #: NPI: Medicaid Individual #: Group Medicaid ID #: PRACTICE NAME OLD: NEW: TAX ID NUMBER TELEPHONE NUMBER OLD: OLD: NEW: NEW: FAX NUMBER E-MAIL ADDRESS OLD: OLD: NEW: NEW: REMIT ADDRESS SITE ADDRESS OLD: OLD: NEW: NEW: 1099 / TAX ADDRESS (IF DIFFERENT FROM REMIT) q USE REMIT ADDRESS OLD: NEW: Effective Date of Change: Signature of Person Providing Information Telephone # Date © 2013 Passport Health Plan (PMN-13111) MAIL TO: PASSPORT HEALTH PLAN Attn: Provider Enrollment 5100 Commerce Crossings Drive Louisville, KY 40229 (502) 588-8578 Fax: (502) 585-7987 Passport.Credentialing@passporthealthplan.com Adding a Practitioner to a Participating Group (use one form per group attachment) FACILITY BASED PRACTITIONER? YES NO (Does this practitioner provide services strictly in an inpatient or ER/facility setting?) Please add Name , Title to the group indicated below, effective Individual NPI #: Individual KY Medicaid #: Date Taxonomy Code: nd (The KY Medicaid # must be active. See Requirements on 2 page.) MAP Forms Directly Sent to Kentucky Medicaid: MAP 811 Medicaid MAP 347 Medicare #: Social Security #: Practitioner’s Specialty: Date of Birth: CAQH #: (Include any Subspecialty) Provider Group Name: Add Practitioner to: • Primary location only: • All locations: • Other: Grp NPI #: Passport group #: YES NO YES NO Attach a list of specific locations Grp KY MAID #: Grp Taxonomy Code: Tax ID #: If the group is new, please complete and submit a “New Group Set-Up Form” and indicate pending for the Passport group number. Page 1 of 2 PANEL LIMITATIONS (If Applicable) Please confirm the Panel Limitations that should be placed on this practitioner. Please remember that any limitations should be consistent with what has already been established for your group: PANEL LIMITATIONS: Min GROUP PANEL STATUS: Max Open Male Only Female Only Both Closed CURRENT AFFILIATIONS (If Applicable) Please indicate from which provider group(s) the practitioner should be terminated upon joining your group. Group Name: Group Tax ID #: Group Name: Group Tax ID #: REQUIREMENTS To expedite your request, please include: • A signed W-9 form with the appropriate tax information. • A completed KY Medicaid MAP 811 form, if applicable. • A completed KY Medicaid MAP 347 form which will connect the practitioner to your Group KY Medicaid ID #, if applicable. • A completed MCO KY MAP 347 form which will connect the practitioner to Passport Health Plan. • KY Medicaid MAP forms are available at http://chfs.ky.gov/dms/provEnr/Provider+Types.htm • Plan notices will be sent electronically via POIS (Passport Online Information Service) and posted on the Plan’s website. Name of person submitting this request Telephone Number Date Email Address: Any questions regarding this form, please call the Provider Enrollment department at (502) 588-8578 or you may email us at Passport.Credentialing@passporthealthplan.com. Page 2 of 2 REGISTRATION FOR NON-PARTICIPATING PROVIDERS A. CONTACT INFORMATION Contact Name: Phone: Date: Fax: Email address: B. PRACTICE INFORMATION Last Name Specialty: First Name: NPI Number: MI: Title/Degree: Taxonomy Code: Specialty: NPI Number: Taxonomy Code: Physical Address: City: Phone: *Kentucky Medicaid Number: State: Fax: Group/Facility Name: Zip: County: SSN: *Required for payment of services rendered* State License Number: State: Medicare Number: C. BILLING INFORMATION: Tax Identification Number: Tax Name: Billing Contact: Billing Address: City: Phone: State: Zip: County: Please fax completed form along with a W-9 to: Provider Maintenance (484) 496-7685 or email to DL-KMHPProviderMaintProductionSupport@KMHP.com Upon receipt of completed form, a provider ID number will be assigned and returned to you via fax. Passport Health Plan claims will not be processed without an active Kentucky Medicaid Number. Questions? Please contact Provider Services at (800) 578-0775. To apply for a Kentucky Medicaid Number, please visit: http://chfs.ky.gov/dms/provenr/application+information.htm IMPORTANT INFORMATION, PLEASE READ It is important that you review the Plan’s Member Rights and Responsibilities. To review this document as well as any other provider communications and/or the Provider Manual, please visit www.passporthealthplan.com. If you are unable to access this information online, please contact Provider Services at (800) 578-0775 to obtain a printed copy. OFFICE USE ONLY – PROVIDER ID NUMBER ASSIGNMENT Date Reviewed: Assigned PM Rep: Plan ID #: Effective Date: © 2012 PASSPoRT HEALTH PLAN (PNM-12145) LAST REvISIoN: 04/13/2012 REGISTRATION OF LOCUM TENENS PHYSICIAN The maximum time may not exceed sixty (60) continuous days. I certify and attest, by my signature below, under penalty of perjury, that the information contained herein is true and faithful. This physician is the TEMPORARY REPLACEMENT who applies and will actually perform the services on a short term basis. This physician will be ABSENT during the billing and will not perform the services. Applicant (Locum Tenens Provider) Full Name Regular Physician Full Name Permanent Address 1 (May not use a PO Box) Office Address 1 (May not use a PO Box) Address 2 Address 2 City, State, Zip City, State, Zip Specific Duration – Not to exceed 60 consecutive days: Social Security Number NPI # Exp. date DEA # Exp. date Kentucky Medical License Number to MM/DD/YY NPI # MM/DD/YY Exp. date DEA # Exp. date Is a CONTRACT AGENCY involved in this placement? Passport Health Plan Provider ID Number CHECK OFF REQUIRED ATTACHMENTS: _ NO _ YES – If yes, please supply name and address of agency: Address _ Copy of valid physician license, DEA certificate, and a copy of any applicable board certification for the locum tenens physician _ PROOF of malpractice insurance coverage for the locum tenens physician for period of physician substitution 1 The Q-6 Modifier must be used for billing services performed by a locum tenens physician. Address 2 City, State, Zip To my knowledge, I attest that I am not subject to any of the following: • A pending criminal or civil investigation regarding the provision of health care services; • Formal disciplinary sanctions from any board or professional association pursuant to KRS311.565; and/or • A federal or state sanction or penalty that would prevent me from participation in Medicare or Medicaid. The holder of the valid provider number is required to bill the services of any locum tenens physician by utilizing the Health Care Procedure Coding System with the procedure modified code Q-6 in item 24d of form HCFA-1500 for every procedure performed by the locum tenens physician. Failure to bill cor- rectly may be considered a violation of the terms of the Provider Agreement. Signature (regular physician) Date RETURN THIS FORM TO: FAX: (502) 585-6060 MAIL: Passport Health Plan Attn: Provider Network Management 5100 Commerce Crossings Drive Louisville, KY 40229 © 2012 PASSPORT HEALTH PLAN (PNM-12156) Form Approved: OMB No. 0937-0166 Expiration date: 11/30/2009 CONSENT FOR STERILIZATION NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. STATEMENT OF PERSON OBTAINING CONSENT CONSENT TO STERILIZATION I have asked for and received information about sterilization from . When I first asked doctor or clinic for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal Funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a . The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years of age and was born on: Before signed the name of individual consent form, I explained to him/her the nature of sterilization operation , the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure. Signature of person obtaining consent Facility Address PHYSICIAN’S STATEMENT Shortly before I performed a sterilization operation upon on Month Day Year I, , hereby consent of my own name of individual , the fact that it is doctor by a method called . My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services, or Employees of programs or projects funded by the Department but only for determining if Federal laws were observed. I have received a copy of this form. Date: Signature Month Day Year You are requested to supply the following information, but it is not required: (Ethnicity and Race Designation) (please check) Race (mark one or more): American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White INTERPRETER’S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. Interpreter’s Signature HHS-687 (11/2006) . date of sterilization I explained to him/her the nature of the sterilization operation free will to be sterilized by Ethnicity: Hispanic or Latino Not Hispanic or Latino Date Date specify type of operation intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual’s signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least thirty days have passed between the date of the individual’s signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual’s signature on this consent form because of the following circumstances (check applicable box and fill in information requested): Premature delivery Individual’s expected date of delivery: Emergency abdominal surgery (describe circumstances) : Physician’s Signature Date PSC Graphics (301) 443-1090 EF PAPERWORK REDUCTION ACT STATEMENT A Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays the currently valid OMB control number. Public reporting burden for this collection of information will vary; however, we estimate an average of one hour per response, including for reviewing instructions, gathering and maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or any other aspect of this collection of information to the OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Respondents should be informed that the collection of information requested on this form is authorized by 42 CFR part 50, subpart B, relating to the sterilization of persons in federally assisted public health programs. The purpose of requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks, benefits and consequences, and to assure the voluntary and informed consent of all persons undergoing sterilization procedures in federally assisted public health programs. Although not required, respondents are requested to supply information on their race and ethnicity. Failure to provide the other information requested on this consent form, and to sign this consent form, may result in an inability to receive sterilization procedures funded through federally assisted public health programs. All information as to personal facts and circumstances obtained through this form will be held confidential, and not disclosed without the individual’s consent, pursuant to any applicable confidentiality regulations. HHS-687 (11/2006) MAP-251 Commonwealth of Kentucky CABINET FOR HEALTH AND FAMILY SERVICES Department for Medicaid Services (Rev. 10/2010) HYSTERECTOMY CONSENT FORM Medicaid Recipient Name Medicaid ID # Physician’s Name Date of Hysterectomy >>>>COMPLETE ONLY ONE OF THE REMAINING SECTIONS & COMPLETE ALL BLANKS IN SECTION<<<< SECTION A: COMPLETE THIS SECTION FOR RECIPIENT WHO ACKNOWLEDGES RECIEPT PRIOR TO HYSTERECTOMY I HAVE BEEN INFORMED ORALLY AND IN WRITING THAT A HYSTERECTOMY WILL RENDER ME PERMANENTLY INCAPABLE OF REPRODUCING. PATIENT’S SIGNATURE DATE WITNESS’ SIGNATURE DATE SECTION B: COMPLETE THIS SECTION WHEN ANY OF THE EXCEPTIONS LISTED BELOW IS APPLICABLE. CHECK ONLY ONE SELECTION. I certify that before I performed the hysterectomy procedure on the recipient listed below: 1 [ ] I informed her that this operation would make her permanently incapable of reproducing. (This certification for retroactively eligible recipient only – a copy of the Medicaid card which covers the date of the hysterectomy, or a copy of the retroactive approval notice, must accompany this form before the reimbursement can be made.) 2 [ ] She was already sterile due to CAUSE OF STERLITY 3 [ ] She had a hysterectomy performed because of a life-threatening situation due to DESCRIBE EMERGENCY SITUATION And the information concerning sterility could not be given prior to the hysterectomy. Life-threatening should indicate that the patient is unable to respond to the information pertaining to the acknowledgement agreement. PHYSICIAN’S SIGNATURE SECTION C: DATE COMPLETE THIS SECTION FOR MENTALLY-INCOMPETENT RECIPIENT ONLY I acknowledge receipt of information, both orally and in writing, prior to the hysterectomy’s being performed, that if a hysterectomy is performed on the above recipient, it will render her permanently incapable of reproducing. WITNESS’ SIGNATURE DATE PATIENT REPRESENTATIVE SIGNATURE PHYSICIAN’S STATEMENT I affirm that the hysterectomy I performed on the above recipient was medically necessary due to DATE REASON FOR HYSTERECTOMY And was not done for sterilization purposes, and that to the best of my knowledge the individual on whom the hysterectomy was performed is mentally incompetent. Before I performed the hysterectomy on her I counseled her representative, orally and in writing that the hysterectomy would render that individual permanently incapable of reproducing; and the individual’s representative has signed a written acknowledgement of receipt of the foregoing information. PHYSICIAN’S SIGNATURE DATE CERTIFICATION FORM FOR INDUCED ABORTION OR INDUCED MISCARRIAGE I, , certify that on the basis of (Physician’s Name) my professional judgment, the life of (Patient’s Name) of (MAID #) (Patient’s Address) (Please check appropriate box) Suffered from a physical disorder, physical injury, and/or physical illness that placed her in danger of death if the fetus were carried to term. I further certify that the following procedure(s) were medically necessary to induce an abortion or miscarriage. (Please indicate date and the procedure that was performed) Physician’s Signature Name of Physician License Number Date MAP-235 (2/00) MAP-236 (8/78) CERTIFICATION FORM FOR INDUCED PREMATURE BIRTH I, , certify that on the basis of (Physician’s Name) my professional judgment, it was necessary to perform the following procedure on to induce premature birth intended to produce a live viable child. This Procedure was necessary for the health of (MAID #) (Date) (Procedure) (Name of Mother) of (Address) and/or her unborn child. Physician’s Signature Name of Physician License Number Date Referral Form Member’s Name Member’s Passport Health Plan ID Number PCP Group Name Member’s Date of Birth PCP Group ID Number Passport Health Plan Members and Providers Please Note: • • • • • • This referral form may only be used for referral from a PCP to a participating specialist and/or participating Urgent Care Center. Referrals to non-participating providers require prior authorization. Passport Health Plan will pay for only those services specifically noted and requested by the PCP and covered under the Benefit plan. Services rendered without a referral will not be covered by Passport Health Plan. Specialists cannot refer to other specialists. Additional specialty services must be coordinated by the PCP. Referral by the PCP does not guarantee payment. Please refer to the Provider Manual for information on services that do not require a referral. This member is being referred to: (the following information is required.) (Please use group or facility name/ID unless provider is a sole practitioner.) Provider Name Specialty Type Street Address City Diagnosis and ICD-9 Code (Please provide all available diagnoses) Is this referral related to an EPSDT screen? _ Yes Passport Health Plan Provider ID Number Zip Code _ No PCP must check ONE of the following: _ Referral for CONSULTATION, DIAGNOSTIC STUDIES and TREATMENT. Good for unlimited visits within: q 3 months, q 6 months, q 9 months, q 12 months _ Referral for CONSULTATION, DIAGNOSTIC STUDIES and TREATMENT. Number of visits approved: q 1 visit, q 2 visits, q 3 visits, q 4 visits, q 5 visits, q 6 visits _ Referral for CONSULTATION and DIAGNOSTIC STUDIES. Number of visits approved: q 1 visit, q 2 visits, q 3 visits, q 4 visits, q 5 visits, q 6 visits _ Referral for CONSULTATION only (second opinion). PCP must forward all lab/x-rays, etc. _ Unlimited referrals for cancer diagnosis and transplants. _ Referral for urgent care services at an Urgent Care Center administered on . (Must be issued within five [5] business days of the service.) Authorizing Signature Date X If you have any questions, please call Provider Services at (800) 578-0775. Send a copy of this completed form to: Passport Health Plan PO Box 7114 London, KY 40742 PLEASE PROVIDE A COPY OF THIS REFERRAL TO THE SPECIALIST AND MEMBER. © 2012 PASSPORT HEALTH PLAN (RR-12155) 19.6.2 Date: Auth #: Fax to: 502-585-8204 PHP R.N. Initials: Attn: PHP Home Health HOME HEALTH AUTHORIZATION FORM MEMBER INFORMATION AUTHORIZATION NUMBER ____________________________________ MEMBER’S NAME ___________________________________________ PASSPORT ID ____________________________ MEMBER’S DOB ____________________________ PROVIDER INFORMATION ORDERING MD _____________________________________ PROVDER ID ___________________________ PROVIDER CONTACT ________________________________ REQUESTING PROVIDER _____________________________________________________________________ PROVIDER PHONE____________________________ PROVIDER FAX _________________________________ CLINICAL INFORMATION INITIAL REQUEST? YES NO IF NO: NUMBER OF VISITS TO DATE _______ DATE OF LAST VISIT__________ DIAGNOSIS _______________________________________________________________________________ DIAGNOSIS ICD 9 CODE _____________________________________________________________________ DISCIPLINE AND NUMBER OF VISITS FOR EACH: _________________________________________________ Discipline # visits RN HH PT DATES OF SERVICE: FROM _____________________ OT ST TO _________________________ CLINICAL SUMMARY: (INCLUDE WOUND MEASUREMENTS AND LABS IF APPLICABLE) WHY ARE VISITS REQUIRED? SW RD 20.5.3 Date: Attn: Auth #: PASSPORTPASSPORT DME Fax to: 502-585-7990 DME AUTHORIZATION FORM MEMBER INFORMATION AUTHORIZATION NUMBER MEMBER’S NAME PASSPORT ID MEMBER’S DOB PROVIDER INFORMATION NAME PROVIDER ID ADDRESS PHONE FAX PASSPORT DME PROVIDER CONTACT NAME MD INFORMATION DME PROVIDER INFORMATION N/A FOR MD N/A FOR MD N/A FOR MD DME INFORMATION Rental Purchase Yes No Yes No Date Range for rental: Date for purchase: Diagnosis Code(s): Diagnosis Description: LINE # DESCRIPTION HCPCS QUANTITY BILLABLE CHARGES 1 2 3 4 5 6 7 8 9 10 Please attach documentation on the patient’s abilities and limitations as they relate to the need for the equipment. Call 1-800-578-0636 ext. 7310 with any questions or for further information. PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN 20.5.4 Date: Auth #: Fax to: 502-585-8204 PASSPORT R.N. Initials: Attn: PASSPORT Home Health HOME INFUSION AUTHORIZATION FORM MEMBER INFORMATION AUTHORIZATION NUMBER MEMBER’S NAME PASSPORT ID MEMBER’S DOB IF MEDICARE PRIMARY, PROVIDE REASON AS TO UABLE TO BILL MEDICARE: PROVIDER INFORMATION ORDERING MD PROVDER ID PROVIDER CONTACT REQUESTING PROVIDER PROVIDER PHONE PROVIDER FAX CLINICAL INFORMATION INITIAL REQUEST? YES NO IF NO: NUMBER OF VISITS TO DATE DATE OF LAST VISIT DIAGNOSIS DIAGNOSIS ICD 9 CODE INFUSION THERAPY REQUESTED WITH DATES OF SERVICE CLINICAL SUMMARY: PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN 20.5.5 Pain Management Medical Necessity Review Check List Patient Name Passport ID 1. Procedure requested Number and frequency 2. Diagnosis 3. Number of previous injections (if known) 4. Relative history & physical (including ht & wt of member) – signs and symptoms Date symptoms began: 5. Radiologic studies (date and results) 6. Functional/physical disability – Including extent of any change on a 1-10 scale where applicable Symptoms: (0 = no pain, 10 = extreme pain) Impairment (0 = no impairment, 3 = severe impairment) Personal Care Driving Pain Working Sleep Headache Difficulty Lifting Recreation Other 7. Medication(s) – address duration Name of medication(s) & dose/how long 8. Previous interventions (PT, Chiro, (address response) Type/site of injection/when Response Relief Yes No Yes No Yes No Yes No 9. Treatment plan with all relevant CPT codes PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN Provider Name: Date of service: (Please print) Place of Service (Passport provider ID if known): Provider Phone & Fax Your Name: Passport Fax #: 502-585-7989 Your Authorization #: Attach additional sheets if needed PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN 20.5.6 Date: Fax to: 502-585-7989 Attn: PASSPORT Home Health Auth #: PASSPORT R.N. REQUEST CAN BE SENT VIA SECURE EMAIL TO: UMCosmetics@passporthealth.com CHECK MARK FOR DATE OF SERVICE CHANGE - COMPLETE ASTERISKS ** ONLY COSMETIC PRIOR AUTHORIZATION FORM Please complete this form and attach to all cosmetic requests MEMBER INFORMATION MEMBER’S NAME ** PASSPORT ID ** MEMBER’S DOB PROVIDER INFORMATION ORDERING MD CONTACT PHONE # ** PROVIDER / MD CONTACT ** PROVIDER MD FAX ** INPATIENT OUTPATIENT 23 HOUR OBSERVATION FACILITY CLINICAL INFORMATION DATE OF SERVICE ** DIAGNOSIS CPT CODE WITH DESCRIPTION PREVIOUS ASSOCIATED SURGERIES CLINICAL SUMMARY: If photos are required, request must be mailed to Passport Health Plan – Attention Cosmetics 5100 Commerce Crossing Louisville, Ky. 40229 PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN 20.5.7 INITIAL THERAPY AUTHORIZATION FORM PATIENT NAME DOB PASSPORT ID# ORDERING MD DIAGNOSIS PT START DATE TIMES/WEEK # OF WEEKS OT START DATE TIMES/WEEK #OF WEEKS ST START DATE TIMES/WEEK #OF WEEKS INJURY/ACCIDENT/DATES: TPL Information: Note any therapy provided by 1st Steps or the school system, type and frequency. Note any previous therapy received, type, frequency, dates and provider. Requesting Provider Provider ID# Contact Person Phone # PROPRIETARY AND CONFIDENTIAL Fax # PASSPORT HEALTH PLAN 1 SERVICES APPROVED: PASSPORT TO COMPLETE Total Visits Times/Week #/Weeks Authorization # Date of Service Approved Date Authorized By _ PROPRIETARY AND CONFIDENTIAL to PASSPORT HEALTH PLAN 2 INITIAL THERAPY EVALUATION FORM NAME DATE OF EVAL HISTORY AND PHYSICAL SUMMARY OF CURRENT STATUS RECOMMENDATIONS / TREATMENT PLAN SHORT TERM GOALS PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN 3 LONG TERM GOALS THERAPIST SIGNATURE / DATE PROPRIETARY AND CONFIDENTIAL PASSPORT HEALTH PLAN 4 20.5.8 CONTINUED THERAPY AUTHORIZATION FORM PATIENT NAME DOB PASSPORT ID# ORDERING MD DIAGNOSIS PT START DATE TIMES/WEEK # OF WEEKS OT START DATE TIMES/WEEK #OF WEEKS ST START DATE TIMES/WEEK #OF WEEKS INJURY/ACCIDENT/ TPL: INCLUDE DATES Note any therapy provided by 1st Steps or the school system, type and frequency. Note any previous therapy received, type, frequency, dates and provider. Requesting Provider Provider ID# Contact Person Phone # PROPRIETARY AND CONFIDENTIAL Fax # PASSPORT HEALTH PLAN SERVICES APPROVED: PASSPORT TO COMPLETE Total Visits Times/Week Authorization # Date Authorized PROPRIETARY AND CONFIDENTIAL #/Weeks Date of Service Approved to By PASSPORT HEALTH PLAN Continued Therapy Evaluation Form NAME ____________________________________________________________ DATE OF EVALUATION _______________________________________________ UPDATE HISTORY & PHYSICAL & THERAPEUTIC EVENTS: e.g. BOTOX INJECTIONS, SURGERIES, UPDATED EQUIPMENT, OR ORTHOTICS. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________ PROGRESS TOWARDS PREVIOUS GOALS (BE SPECIFIC) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________ CURRENT GOALS __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________ TREATMENT PLAN __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________ THERAPIST SIGNATURE/DATE __________________________________________________________________ PROPRITARY AND CONFIDENTIAL PASSPORT HEALTH PLAN CHIROPRACTIC SERVICE PRIOR AUTHORIZATION REQUEST FORM FAX (502) 585-8205 The chiropractic provider must be a participating Passport Health Plan Provider. The provider must contact Passport Health Plan during regular business hours, MondayFriday 8:00 a.m.-5:30 p.m., to communicate the requested continued chiropractic services. No prior authorization is required for the initial 12 chiropractic visits in one rolling calendar year. PATIENT NAME DATE PASSPORT ID# DOB ORDERING MD PHONE FAX DIAGNOSIS INITIAL 12 VISITS: DATES OF SERVICE AND PROGRESS MADE TOWARDS GOALS WHEN DID PAIN BEGIN? DESCRIBE PAIN (constant, intermittent, dull, ache, stabbing, sharp, intense, radiation of pain.) INITIAL (date) CURRENT (date) RADIOLOGICAL FINDINGS, IF DONE INITIAL (date) CURRENT (date) PROPRITARY AND CONFIDENTIAL PASSPORT HEALTH PLAN RANGE OF MOTION INITIAL (date) CURRENT (date) STRENGTH / OTHER PERTINENT PHYSICAL FINDINGS INITIAL (date) CURRENT (date) SUBLUXATION: PRESENCE AND LOCATION INITIAL (date) CURRENT (date) # of visits requested, frequency, dates of service Types of Services receiving: Chiropractic manipulative treatment Diagnostic services Application of hot and cold packs to one or more areas Application of electrical stimulation to one or more areas Application of ultrasound to one or more areas Application of mechanical traction to one or more areas Other GOALS INITIAL PROGRESS TOWARDS GOALS PROPRITARY AND CONFIDENTIAL PASSPORT HEALTH PLAN GOALS COMMENTS PROPRITARY AND CONFIDENTIAL PASSPORT HEALTH PLAN MAIL TO: PASSPORT HEALTH PLAN 5100 Commerce Crossings Drive Louisville, KY 40229 PH: (877) 903-0082 FX: (502) 585-7970 NO-SHOW VISIT FOR OB APPOINTMENT NOTE: For payment, fax to Mommy Steps staff at (502) 585-7970 within 48 hours of scheduled visit PROVIDER INFORMATION Provider Name: Provider ID #: Provider Fax #: MEMBER INFORMATION Member ID #: EDC: Member Name: Member’s Current Address: Apt./Bldg#: City: State: Member’s Current Phone #: Zip: Alternative #: NO-SHOW INFORMATION Date of No-Show: Procedure = 99499 Time of Appointment: Charge = $25.00 COMMENTS DATE FOLLOW-UP COMMENTS FAXED BACK TO OB PROVIDER OFFICE: a.m./p.m. Provider Manual Section 18.0 Important Contact Information Table of Contents 18.1 Passport Health Plan Important Contact Information 18.2 Other Important Contact Information Page 268 of 331 18.0 Important Contact Information 18.1 Passport Health Plan Important Contact Information Main Switchboard Telephone: (502) 585-7900 Web site www.passporthealthplan.com Appeals Submit medical-necessity and administrative appeals to: Passport Health Plan Attn: Appeals Coordination 5100 Commerce Crossings Drive Louisville, KY 40229 Behavioral Health Beacon Health Strategies, LLC Toll-Free: Web site: (855) 834-5651 www.beaconhealthstrategies.com Case Management Telephone: Fax: (877) 903-0082 (502)585-7997 Claims Filing Address New and corrected claims, claims for reconsideration/recoupment, and medical record requests: Passport Health Plan P.O. Box 7114 London, KY 40742 Dental Provider Contractor Avesis Toll-free: Website: www.avesis.com (866) 909-1083 Drug Prior Authorization (PA) PA Standard Fax: PA Urgent Fax: Hospital Discharge: (877) 693-8280 (877) 693-8476 (877) 693-8476 EDI Technical Support Hotline: E-mail: (877) 234-4275, option 4 edi.php@kmhp.com Page 269 of 331 EPSDT Eligibility: Fax: (502) 585-8210 (502) 585-8457 Interactive Voice Response (IVR) Toll-free: (800) 578-0775, option 1 Medical Authorization General Utilization Management (UM) Fax: Durable Medical Equipment (DME) Fax: Home Health/Home Infusion Fax: Retro Auth Fax: Therapy Auth (PT, OT, Speech) Fax: Radiology – MedSolutions - Toll-Free: (502) 585-7989 (502) 585-7990 (502) 585-8204 (502) 585-8207 (502) 585-8205 (877) 791-4099 Member Services Toll-free: (800) 578-0603 Mommy Steps Program Telephone: Fax: (877) 903-0082 (502) 585-7970 Pharmacy Benefits Manager Help Desk PerformRx - Toll-free: (800) 578-0898 Hours: Pharmacy Director Telephone: 24 Hours/7 days a week (502) 585-8445 Pharmacy/Provider Mailbox for General Inquiries Telephone: (502) 585-8249 Provider Claims Service Unit (PCSU) Toll-free: (800) 578-0775 Provider Enrollment Telephone: (502) 588-8578 Provider Lock-In Pharmacy Coordinator Telephone: (502) 585-7947 Provider Network Management Department Telephone: Fax: (502) 585-7943 (502) 585-6060 Provider Services Toll-free: (800) 578-0775 Page 270 of 331 Rapid Response Telephone: Fax for the Diabetes, Yes, You Can! (Quit Smoking), CAD, CHF, Chronic Respiratory Program, and Obesity Programs (877) 903-0082 (502)585-7997 Behavioral Health Liaison Telephone: (877) 903-0082 Utilization Management Toll-free: Fax: (800) 578-0636, option 2 (502) 585-7989 Vison Provider Contractor Block Vision Provider Relations Webiste: www.blockvision.com (800) 243-1401 9:00 a.m. – 6:00 p.m. Yes, You Can! Quit Smoking Program Toll-free: Fax: (877) 903-0082 (502) 585-8458 24-Hour Nurse Advice Line McKesson Toll-free: (800) 606-9880 Page 271 of 331 18.2 Other Important Contact Information Department for Medicaid Services MCO Hotline Toll-free: (855) 446-1245 Emdeon Business Solutions Client Services Toll-free: Web site: (800) 845-6592 www.emdeon.com/epayment Kentucky Medical Ombudsman Toll-free: TDD/TTY: Address: (800) 372-2973 (800) 627-4702 Kentucky Department for Medicaid Services Office of the Ombudsman 275 East Main Street Frankfort, KY 40621 State Hearing Request Toll-free: Address: (800) 635-2570 Kentucky Department for Medicaid Services 275 East Main Street Frankfort, KY 40621 Page 272 of 331 Provider Manual Section 19.0 Dental Network Table of Contents 19.1 Important Contact Information 19.2 Administrative Procedures 19.3 Credentialing/Re-credentialing 19.4 Provider Terminations/Changes in Provider Information 19.5 Standards of Care for Dental Offices 19.6 Dental Benefits 19.7 Care Management and Utilization Management 19.8 Authorization Procedures and Requirements 19.9 Quality Improvement 19.10 Dental Provider Billing Manual 19.11 Fraud, Waste and Abuse 19.12 Cultural Competency Page 273 of 331 19.0 Dental Passport Health Plan (Passport) is pleased to partner with Avesis Incorporated (Avesis) for the administration of our Dental Program. Passport and Avesis recognize the importance of promoting and providing good oral hygiene for Medicaid members in Kentucky. We understand the linkage between good oral health and overall health. By helping to ensure all Passport members receive appropriate and timely dental services, we can continually improve the oral health of members. The provisions set out in this Section of Passport’s Provider Manual supplement the provisions in previous sections as applicable, and include additional information specific to dental providers. Updates to this Dental Section of the Provider Manual will be provided on a periodic basis and available on the below-stated websites. As your office receives communications from Avesis and Passport, it is important that you and/or your office staff read these Dental Network Alerts and other special mailings and retain them with this Provider Manual so you can integrate the changes into your practice. All provider materials, including this Provider Manual and the Provider Directory, are available online at www.passporthealthplan.com and www.avesis.com. Please take the time to familiarize yourself with this Provider Manual, including this Section. If you have any questions, require clarification regarding the Provider Manual, or need assistance or information that is not included within this Provider Manual, please contact Provider Services: (866) 909-1083 Monday - Friday 7:00 a.m. to 8:00 p.m. (EST) All offices will be notified thirty (30) days prior to the effective date of any changes or revisions to this Provider Manual affecting their practice, unless the change is required by law or regulation. Information in this Provider Manual will be updated on the Avesis and Passport websites at www.avesis.com. and www.passporthealthplan.com. It is the provider’s responsibility to stay abreast of changes to this Provider Manual. The Avesis website also contains important information including but not limited to Dental Alerts, eligibility verification, claims submission and claims status. Providers may also visit the Passport website for information on Passport and the Dental Program. 19.1 Important Contact Information 19.1.1 Dental Provider Services Call Center (866) 909-1083 The Dental Provider Services Call Center is available Monday through Friday, 7:00 a.m. to 8:00 p.m. EST to assist providers with questions about policies, procedures, member eligibility, and benefits. Representatives are also available if providers need to request forms or literature, or to report member noncompliance. A Dental Provider Field Representative can offer orientations and in-service meetings for providers Page 274 of 331 and their staff. This representative can also provide service calls and process any changes in provider status, such as addresses and telephone numbers. 19.1.2 Provider Services and Utilization Management Provider Services (866) 909-1083 Monday – Friday, 7:00 a.m. - 8:00 p.m. EST Utilization Management (866) 653-5544 (secure fax) Monday – Friday, 7:00 a.m. - 8:00 p.m. EST 19.1.3 Avesis Chief Dental Officer and State Dental Director Avesis Chief Dental Officer Fred L. Sharpe, DDS fsharpe@avesis.com (800) 522-0258 x 11288 Avesis State Dental Director Dr. Jerry Caudill jcaudill@avesis.com (502) 662-2101 19.1.4 Claims Submission and EFT Initial Claims Submission: Avesis Third Party Administrators, Inc. Attn: Dental Claims P.O. Box 7777 Phoenix, Arizona 85011-7777 For Claims Correction: Avesis Third Party Administrators, Inc. Attn: Corrected Dental Claims P.O. Box 7777 Phoenix, Arizona 85011-7777 Avesis EFT Contact: Avesis Third Party Administrators, Inc. Attn: Finance P.O. Box 782 Owings Mills, Maryland 21117 19.1.5 Pre-Treatment Estimate and Post Review Avesis Pre-Treatment Estimate: Avesis Third Party Administrators, Inc. Attn: Pre-Treatment Estimate P.O. Box 7777 Phoenix, Arizona 85011-7777 Avesis Post Review: Avesis Third Party Administrators, Inc. Attn: Post Review P.O. Box 7777 Phoenix, Arizona 85011-7777 19.2 Administrative Procedures 19.2.1 Member Identification and Eligibility Verification Member eligibility information is detailed in Section 2.0. of the Provider Manual. As noted, Passport member eligibility varies by month. Therefore, each participating provider is responsible for verifying member eligibility before providing services. Dental providers may verify eligibility using Page 275 of 331 any of the methods below. Please be mindful, verification of coverage only is provided, utilization of benefit information is not available when checking eligibility. IVR (Interactive Voice Response System) 1. 2. 3. 4. Call the IVR at: (866) 234-4806. Enter your Provider PIN number. Enter the member’s KY Medicaid Identification number. You will receive a real time response. Website/Internet 1. 2. 3. 4. 5. Go to www.avesis.com. Enter your User Name and Password. Click “Check Eligibility.” Enter the member’s KY Medicaid Identification number. You will receive a real time response. FAX 1. Complete the Avesis Eligibility Verification Fax Form (included as Attachment D of this Dental Section). 2. Fax toll free to: (866) 332-1632. 3. You will receive a reply to the fax within one (1) business day. Provider Services 1. Call Dental Provider Services toll free at (866) 909-1083. 2. Provide your Provider PIN number. 3. Provide the member‘s KY Medicaid Identification number. Remember: Eligibility verification is not a guarantee of payment. Benefits are determined at the time the claim is received for processing. These options will only provide eligibility information for Passport. Eligibility for other health plans is not provided. Please note that Passport Health Plan cards are not returned to Passport when a member becomes ineligible. Therefore, the presentation of a Passport ID card is not sole proof that a person is currently enrolled in Passport. As a way to help prevent Medicaid “card sharing,” remember to always ask to see the member’s Passport ID card or the member’s Kentucky Medicaid ID card and request a picture ID to verify that the person presenting is indeed the person named on the ID card. Services may be refused if the provider suspects the presenting person is not the card owner and no other ID can be provided. If you suspect a non-eligible person is using a member’s ID card, please report the occurrence to the Passport Fraud and Abuse Hotline at (855)-512-8500 or the Medicaid Fraud Hotline at (800) 372-2970. Page 276 of 331 It is not necessary to refuse treatment to a member who does not present with his/her Passport identification card. Eligibility can be verified 24 hours a day 7 days a week as detailed above. Members may also produce their KY Medicaid ID Card. 19.2.2 Dental Claim Submission Paper claims and correspondence for reconsideration or recovery are to be submitted to the following address: Avesis Third Party Administrators, Inc. Attention: Dental Claims P.O. Box 7777 Phoenix, AZ 85011-7777 To submit claims electronically, register on the Avesis website at www.avesis.com. An active valid Kentucky Medicaid Provider Identification (MAID) number, assigned by the Kentucky Department for Medicaid Services (DMS), is required to receive any payment for services rendered. 19.2.3 Statement of Providers’ Rights and Responsibilities Providers shall have the right and responsibility to: • • • • • • • • • • Communicate openly and freely including, but not limited to, support of Provider Services and Customer Services representatives and information on participating providers for the purpose of referrals; Obtain written parental or guardian consent for treatment to be rendered to members who have not yet reached the age of maturity in accordance with State Dental Board rules or ADA guidelines; Obtain information regarding claim status and pre-treatment estimates for services to be rendered and re-submit claims with additional information by following the guidelines set forth herein; Receive prompt payments for clean claims; Make a complaint or file an appeal on behalf of a member with the member’s consent and inform the member of the status of the appeal; Question policies and/or procedures implemented on behalf of Passport; Request Pre-Treatment Estimate for services identified herein as requiring pre-treatment estimates; Refer members to participating specialists for treatment that is outside the provider’s normal scope of practice; Inform Avesis in writing immediately upon notification of any revocation, suspension and/or limitation of your license to practice, certification(s), and/or DEA number by any licensing or certification authority; Consistent with credentialing and re-credentialing policies, inform Avesis in writing prior to changes in licensure status, tax identification numbers, telephone numbers, addresses, loss or Page 277 of 331 • • • • modification of insurance or any other change that would affect status. Failure to notify prior to these changes may result in delays in claims processing and payment; Consistent with the terms of the Provider Agreement, notice of termination of participation must be submitted at least ninety (90) days prior to the termination effective date; Maintain an environmentally safe office with equipment in proper working order to comply with city, county, state and federal regulations concerning safety and public hygiene; Respond promptly to requests for dental records as needed to review appeals and/or quality of care issues; and, Abide by the rules and regulations set forth under applicable provisions of State or Federal law. All provides are prohibited from: • • • • • • • Discriminating against members on the basis of race, color, national origin, disability, age, religion, mental or physical disability, or limited English proficiency. Provider agrees to comply with the Americans with Disabilities Act, and the Rehabilitation Act of 1973 and all other applicable laws related to the same. See Title VI Civil Rights Act of 1964, www.usdoj.gov/crt/cor/coord/titlevi.htm; Discriminating against qualified individuals with disabilities for employment purposes; Discriminating against employees based on race, color, religion, sex, or national origin; Offering or paying or accepting remuneration to or from other providers for the referral of members for services provided under the Dental Program; Referring members directly or indirectly to or solicit from other providers for financial consideration; Referring members to an independent laboratory, pharmacy, radiology or other ancillary service in which the provider or professional corporation has an ownership interest; and, Billing, charging, or seeking compensation, remuneration, or reimbursement from any member other than for supplemental charges, copayments (example: in 2014, there are no copayments or fees for covered services). Please refer to Section 3.4 of the Provider Manual for additional information regarding provider responsibilities. 19.2.4 Member Appeals and Grievances Please refer to Section 2.10 of the Provider Manual. 19.2.5 Provider Appeals and Grievances Please refer to Section 2.12 of the Provider Manual. 19.3. Credentialing/Re-Credentialing 19.3.1 Initial Application Process To begin the application process and join Passport, first call Dental Provider Services at (866) 9091083. A provider application packet will be mailed and Avesis will work with the provider to Page 278 of 331 become credentialed and, if approved, contracted as a Passport dental provider. Avesis participates with the Council for Affordable Quality Healthcare (CAQH). Providers who are participating with this common credentialing application database should contact Dental Provider Services at (866) 909-1083 and include their CAQH Provider ID number with the documents submitted. New dental practitioner (hereafter referred to as practitioner) applicants are required to complete all residency and/or training programs prior to joining the network. Practitioners still completing a residency program are required to bill under the attending practitioner. Applicants must submit a completed application, which includes the following as applicable: • • • • • • • • • • • Two Participating Provider Agreements signed by the provider indicating their intent to join the network if approved after being credentialed. Completed Provider Application, either a CAQH (Council for Affordable Quality Healthcare universal credentialing application) or the most current version of KAPER1 (Kentucky Department for Medicaid Services application), including: o Additional copies of pages from the application (as needed); o Disclosure questions, as applicable, including but not limited to: Documentation of any malpractice suits or complaints. Documentation of any restrictions placed on practitioner by hospital, medical review board, licensing board, or other medical body or governing agency. Documentation of any conviction of a criminal offense within the last 10 years (excluding traffic violations).; and, o The attestation page (including the practitioner signature and current date). Original, complete, and signed MAP Forms, if a Kentucky Medicaid Provider Identification (MAID) number is needed per the Kentucky Department for Medicaid Services (DMS) provider enrollment web page. If the provider has a current Kentucky MAID number, the provider must include a completed MAP-347 form. Copy of current State License Registration Certificate. Copy of current Federal Drug Enforcement Agency Registration - if applicable. Curriculum vitae or a summary specifying month and year for work history, explaining any lapse in time exceeding six months. Copy of a completed, dated and signed W-9 in the name of the provider or facility/group, including the Tax Identification Number and mailing address for all tax information. Copy of claim history form for each malpractice activity within the past five years. Copy of current professional liability insurance Certificate of Coverage, including the name and address of the agent and the minimum amount, in accordance with existing Kentucky laws at the time of the application submission. A letter adding practitioner to each existing group contract, including group ID number(s), if applicable. Copy of social security card (if applicant has as social security card stating “valid for work only with DHS/INS Authorization,” please refer to additional requirements at Page 279 of 331 • http://www.chfs.ky.gov/dms/provenr/),if submitted MAP forms for Kentucky MAID numbers ECFMG (Education Council for Medical Graduates), if applicable. Failure to submit a complete application may result in a delay of the credentialing process. Practitioners may contact Dental Provider Services at (866) 909-1083 to check the status of their applications. 19.3.2 Credentialing Process Practitioner applicants are assessed through Passport Health Plan’s credentialing process. With the receipt of all of the application materials, primary source verification is conducted. Following the verification of credentials, the Chief Dental Officer/designated Dental Director or Credentialing Committee reviews each application for participation. A credentialing review will not be initiated until a completed and signed application with attachments has been received. The normal processing time is between thirty (30) and sixty (60) days from date of submission of a completed application. 19.3.3 Reimbursement and the Credentialing Process Providers will be considered participating Passport providers once they have met Passport credentialing requirements and have an executed agreement and a Kentucky MAID number. Providers will be notified when they have been credentialed. Providers applying for participation are excluded from the Provider Directory until the credentialing process has been completed in its entirety. Providers will be reimbursed at the participating provider rate, retroactive to the first of the month in which the application is received provided the provider has an active Kentucky Medicaid MAID number and has submitted the MAP 347 form to be linked to Passport Health Plan. Providers may begin submitting claims for services provided to Passport members once they have been notified of the receipt of their completed application and have been assigned a Kentucky MAID number. Providers are required to submit all claims within 180 days of service, but no payment is made until Passport Health Plan receives confirmation that the provider has been issued a Kentucky MAID number. Please note, claims submitted without a Kentucky MAID number will be denied. Providers will receive notification from DMS when a MAID number is assigned. Providers must notify Avesis of receipt of a MAID number assignment. 19.3.4 Providing Services Prior to Becoming a Credentialed Passport Provider If a provider determines a Passport member must be seen prior to the assignment of a KY MAID number, the provider should see the member and submit for reimbursement under the plan after receiving his/her KY MAID number. As stated previously, the provider will not be eligible for payment until he/she has an executed contract and a KY MAID number. If payment is denied because the provider is not participating or he/she does not have a Kentucky MAID number, the member cannot be held liable. Page 280 of 331 19.3.5 Re-credentialing and Ongoing Monitoring Process Passport re-credentials its providers, at a minimum, every 36 months. In addition, Passport conducts ongoing monitoring of Medicare and Medicaid sanctions and sanctions or limitations on licensure. Practitioners who become participating and subsequently have restrictions placed upon their license will be reviewed by the Credentialing Committee and evaluated on a case-by-case basis, based upon their ability to continue serving Passport members. Member complaints and adverse member outcomes are also monitored and Passport will implement actions as necessary to improve trends or address individual incidents. If efforts to improve practitioner performance are not successful, the practitioner may be referred to the Credentialing Committee for review prior to his/her normally scheduled review date. A re-credentialing application will be generated on all practitioners with current CAQH applications on file. Practitioners without a CAQH on file will be notified by letter to submit a re-credentialing application (most current version of the KAPER 1 or CAQH) with the following list of attachments: • Disclosure questions, as applicable, including but not limited to: o Documentation of any malpractice suits or complaints. o Documentation of any restrictions placed on practitioner by licensing board, or governing agency. o The attestation page (including the practitioner signature and current date). o Copy of current State License Registration Certificate. o Copy of current Federal Drug Enforcement Agency Registration - if applicable. o Copy of current professional liability insurance Certificate of Coverage, including the name and address of the agent and the minimum amount, in accordance with existing Kentucky laws at the time of the application submission. Failure to return documents in a timely fashion may result in a period of non-participation. The initial credentialing process will need to be completed in order to re-enroll as a participating provider. Practitioners may contact the Dental Provider Services at (866) 909-1083 to check the status of their re-credentialing application. Should Passport decide to deny or terminate a provider, the provider will receive notification of the decision. The notification will include the reasons for the denial or termination, the provider’s rights to appeal and request a hearing within thirty (30) days of the date of the denial notice, and a summary of the provider’s hearing rights. 19.4 Changes in Provider Information 19.4.1 Changes in Provider and Demographic Information Providers are required to provide a written notice to both the Provider Network Management department and the Department for Medicaid Services (DMS) of any changes in information regarding their practice. Such changes include: • • Address changes, including changes for satellite offices. Additions to a group. Page 281 of 331 • Changes in billing locations, telephone numbers, tax ID numbers. Reimbursement may be affected if changes are not reported in accordance with Passport Health Plan policy. Please note that providers are required by DMS to annually submit a copy of current license and annual disclosure of ownership. If these documents are not provided, the provider’s Kentucky Medicaid (MAID) number may be terminated. Your office will receive notice from the DMS when these documents are due for submission. Please respond timely to these requests. Untimely response to this requirement may result in claims denials and/or untimely claims payment. 19.5 Standards of Care for Dental Offices The Passport Dental Program has established standards that our provider offices are expected to fulfill. The following are summaries of these standards: 19.5.1 Appointment Scheduling Standards Dental care is a direct access benefit for Passport members. Dental services do not require a referral from the member’s PCP. Passport adheres to state and National Committee for Quality Assurance (NCQA) guidelines for access standards for member appointments. Contracted providers may only provide such dental services within the scope of their license and must adhere to the following appointment standards and after-hours requirements: Type of Care Emergency Care Urgent Care Routine Care Hygiene Appointments (cleaning & comprehensive exam) Routine Symptomatic (member requests a follow-up for a tooth extraction) Appointment Availability Within 24 hours Within 48 hours Within 21 days Within 6 weeks Within 2 weeks 19.5.2 Preventive Treatment Patients should be encouraged to return for a recall visit as frequently as indicated by their individual oral status and within Passport time parameters. It is important that each dental office has a recall procedure in place. The following should be accomplished at each recall visit: • • • • • Update medical history Review of oral hygiene practices and necessary instruction provided Complete prophylaxis and periodontal maintenance procedures Topical application of fluoride, if indicated Sealant application, if indicated. Page 282 of 331 19.5.3 Reminder, Follow-up and Outreach Call Policy and Procedures Each Passport provider office is required to maintain and document the following member recall policy and procedures for all eligible members: • • • • For members of record (under age 18), providers must attempt to make contact at least two (2) times per year. Members of record are those members who have been routinely treated at the provider’s office. For adult members of record (over age 18), providers must attempt to make contact at least one (1) time per year. Again, members of record are those members who have been routinely treated at the provider’s office. Have a functional recall system in place for notifying members of the need to schedule dental appointments. The recall system must include the following requirements for all enrolled members: o The system must include either written or verbal notification. o The system must have procedures for scheduling and notifying members of routine check-ups, follow up appointments and cleaning appointments. o The system must have procedures for the follow up and rescheduling of missed appointments. Passport encourages its providers to make efforts to decrease the number of “no shows.” It is suggested the provider contact the member prior to the appointment either by phone or in writing to remind him/her of the time and place of the appointment. Follow-up phone calls or written information should be provided - encouraging the member to reschedule the appointment in the event the appointment is missed. CMS comprehensive and preventive child health program for individuals under the age of twentyone (21) is called Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT). Based upon the requirements of the EPSDT program, each Passport provider office is required to maintain and document the following member recall policy and procedures for all eligible members: • For members of record (under age 21), providers must attempt to make contact at least two (2) times per year. The recall policy must be written and implemented upon the commencement of the Passport Dental Program. The office procedures may be determined by each dental office, but must include a written process of notification for members including: • • • Recall month for routine preventive care Date of a missed appointment(s) Date for follow up appointments Note: Follow up appointments must be scheduled within thirty (30) calendar days following the initial appointment and incrementally thereafter. This system may be audited during any office visit. A log must be kept notating when a “Reminder Notice” was sent to the member or a telephone attempt was made to the member prior to the appointment. Page 283 of 331 Documentation of contact attempts and results must be submitted on a quarterly basis, if requested. 19.5.3.1 Follow-up Procedure The dentist or specialist shall conduct an affirmative outreach whenever a member misses an appointment. This outreach should be documented in the medical/dental record. Such an effort shall be deemed to be reasonable if it includes the prescribed number of attempts to contact the member. Such attempts may include but are not limited to written attempts and telephone calls. At least one attempt must be a follow-up telephone call, whenever possible. 19.5.4 Dental Professional Standard of Care Each dentist and dental specialist within the Passport network is expected to practice within the standard of care for dentists within Passport. All providers are required to practice within the scope of dental practice as established by the State board of dentistry. Providers are expected to be aware of any applicable state and federal laws that impact their position as an employer, a business owner and a healthcare professional. 19.5.5 Parameters of Care Providers should be aware of the ADA parameters of care that can be found on the Internet at: http://www.ada.org/Members/prac/tools/parameters/index.asp. While only guidelines, Passport will look to these parameters as indicative of the appropriate care for the situations described. For the actual treatment that occurs, providers are expected to use all relevant training, knowledge and expertise to provide the best care for the member. 19.5.6 Office Standards Each dentist office must: • • • • • • • • Have a sign containing the names of all dentists practicing at the office. The office sign must be visible when the office is open. Have a mechanism for notifying members if a dental hygienist or other non- dentist dental professional may provide care. Be accessible to all patients, including but not limited to its entrance, parking and bathroom facilities. Have offices that are clean, presentable and have a professional appearance. Have clean and properly equipped patient toilet and hand-washing facilities. Have a waiting room that will accommodate at least (4) four patients. Have treatment rooms that are clean, properly equipped and contain functional, adequately supplied hand-washing facilities. Have at least one (1) staff person (in addition to the dentist) on duty during normal office hours. Page 284 of 331 • • • • • • • Provide a copy of current licenses and certificates for all dentists, dental hygienists and other non-dentist dental professionals practicing in the office, Including state professional licenses and certificates, Federal Drug Enforcement and State Controlled Drug Substance licenses and certification (where applicable). Keep a file and make available any state required practices and protocols or supervising agreements for dental hygienists and other non-dentist dental professionals practicing in the office. Have appropriate, safe x-ray equipment. Radiation protection devices, including, without limitation, lead aprons shall be available and used according to professionally recognized guidelines (e.g. Food and Drug Administration). Maintain the standards and techniques of safety and sterility in the dental office required by applicable federal, state and local laws and regulations including, but not limited to, those mandated by OSHA and as advocated by the American Dental Association (ADA) and state and local societies. Comply with all applicable federal, state and local laws and regulations regarding the handling of sharps and environmental waste, including the disposal of waste and solutions. Make appointments in an appointment book (or an electronic equivalent as acceptable to Passport). Appointments should be made in a manner that will prevent undue patient waiting time and in compliance with the access criteria listed in this manual. Upon request, provide patients with a copy of their rights and responsibilities as listed in this Provider Manual. 19.5.6 Standards for Member Records Each member shall have an individual record and an individual file kept at the dental office. In accordance with 201 KAR 8:540, the dentist must keep accurate, readily accessible, and complete records which include: • • • • • • • • • • • • • The patient’s name; The patient’s date of birth; The patient’s medical history and documentation of the physical exam of the oral and perioral tissues; The date of treatment; The tooth number, surfaces, or areas to be treated; The material used in treatment; Local or general anesthetic used, the type, and the amount; Sleep or sedation dentistry medications used, the type, and the amount; Diagnostic, therapeutic, and laboratory results, if any; The findings and recommendations of the dentist and a description of each evaluation or consultation, if any; Treatment objectives; All medications, including date, type, dosage, and quantity prescribed or dispensed; and, Any post treatment instructions. 19.5.6.1 Review Page 285 of 331 A Passport representative may visit your office to review the patient records of Passport members. The member’s record must: 1. Contain a signed consent to permit Passport access to patient records upon request. 2. Be retained by you for all covered services rendered for the greater of ten (10) years for adults and thirteen (13) years for minors or longer as required by state and federal law. 19.5.6.2 Access Providers are required to comply with Passport’s rules for reasonable access to patient records during the Agreement term and upon termination allowing: 1. The following parties may have access to the members’ records: Passport representatives or their delegates, the member’s subsequent physician(s), or any authorized third party including employees or agents of the Kentucky Department for Medicaid Services, CMS, and the Department of Insurance. 2. For a maintenance period of ten (10) years from the last Date of Service for adult patients and at least thirteen (13) years from date of last service for minors. 19.5.6.3 Copies Passport has the right to request copies of the member’s complete record. When medical records are required due to a claims appeal initiated by the provider or by the member, the provider may not charge a fee for the medical records. Please refer to Section 4.5 of the Provider Manual for complete details and requirements regarding medical record keeping and continuity and coordination of care standards. 19.5.7 Standards for Infection Control The dental office shall follow all appropriate state and federal guidelines including any from OSHA and the CDC that impact clinical dental practice. The office shall perform appropriate sterilization procedures on all instruments and dental hand pieces. Furthermore, appropriate disinfection procedures for all surfaces in the treatment areas shall be performed following each patient visit. Masks and gloves shall be worn for all member treatment. Protective eyewear shall be available for all dental staff. Members shall be protected from all chemical and biological hazards at all times. Office Standards: • • • • • All personnel should wash with bacterial soap before all oral procedures. New gloves should be worn for each patient. All instruments should be thoroughly scrubbed and debrided before sterilization. Light chair switches, hand pieces, cabinet working surfaces and water/air syringes and their tips, should be disinfected, using approved techniques, after each use. ADA approved sterilization solutions should be utilized. Page 286 of 331 • • All equipment should be monitored using process indicators with each load and spore testing on a weekly basis. Handling of all environmental waste, including the disposal of waste and solutions, must be in compliance with all applicable federal, state and local laws and regulations. 19.5.8 Medical Emergencies All office staff shall be prepared to deal with any medical emergency through the implementation of the following guidelines: • • • • The dentist and at least one other staff member must have current CPR training. The dental office must have a formal medical emergency plan and staff members must understand their individual responsibilities. The emergency plan must include documented emergency procedures, including procedures addressing treatment, evacuation and transportation plans to provide for the safety of members. All emergency numbers must be posted. Patients with medical risk shall be identified in advance. All dental offices must have a portable source of oxygen with a positive demand valve, blood pressure cuff and stethoscope. 19.5.9 Standards for Radiation Protection All staff required to use radiograph technology must be trained on the proper use of this technology prior to its use. The dental office shall have only radiograph machines that have been checked by the appropriate State authorities and were confirmed to be within the standards set down by statute or regulation. Members shall be given proper shielding for all radiographs and the processing shall be done according to manufacturer’s specifications. For digital radiographs, the computer system shall have the appropriate storage and back-up protection as described in the ADA parameters of care. Radiation badges to monitor the levels of radiation in the dental office shall also be worn by all personnel on a voluntary basis. 19.5.10 Standard for Member Contacts Each provider office shall maintain accurate contact information for each member and shall have appropriate contact numbers for parent(s) or legal guardian if the member is under the age of majority. Members shall be offered appointments within the period of time dictated by the State administration. Emergency coverage shall be in keeping with the requirements established in the Provider Agreement, by the State administration and as described within this Provider Manual. No charges shall be permitted for late or broken appointments as required by the Passport Dental program. 19.5.11 Standard for Member Appointments Each new member must have thorough medical and dental health histories completed before any treatment begins. Each new member must have a complete clinical examination and oral cancer screening. Each member must have appropriate radiographs for diagnosis and treatment based upon their age and dentition. Each member must have a written treatment plan in the member record that clearly explains all necessary treatment(s). 19.5.12 Standard for Treatment Planning Page 287 of 331 All treatment plans must be recorded and presented to the member and parent or legal guardian, if the member is a minor. The member must be given the opportunity to accept or reject the treatment recommendations and the member’s response must be recorded in the member’s record. 19.5.13 Standard for Services not covered under the Passport Dental Program The provider’s office should be aware of those dental services that are not covered under the Passport Dental Program. If the member is willing to have a provider provide any non-covered services and is willing and able to pay directly for those services, the provider must complete the enclosed Non-Covered Services Disclosure Form (Attachment B) or use a similar disclosure form that contains all of the elements on the Non-Covered Services Disclosure Form included herein. A copy of the completed form shall be maintained in the member’s record. The member must be advised in advance that the service(s) is not covered and how much it will cost. 19.5.14 Standards for Submitting Claims Claims must be submitted for all dental services within 180 days of the member’s appointment and with all of the necessary materials included for review. Failure to submit claims within 180 days will result in claims processing denials for untimely filing. 19.6 Dental Benefits 19.6.1 Dental Services Dental services are outlined in 907 KAR 1:026. Coverage shall be limited to services identified in 907 KAR 1:626, Section 3, in the following CDT categories: • • • • • • • • • • Diagnostic; Preventive; Restorative; Endodontics; Periodontics; Removable prosthodontics; Maxillofacial prosthetics; Oral and maxillofacial surgery; Orthodontics; and Adjunctive general services. Please see Attachment F - Covered Benefits Schedule for additional information on benefits. Information is also available on the Avesis website at www.avesis.com. In 2014, there are no copayments or fees for covered services. 19.6.2 Non - Covered Items or Services Passport will not pay providers for non-covered services. Providers will hold harmless Passport, Avesis and DMS for payment of non-covered dental services. Page 288 of 331 Non-covered services include investigational items and experimental drugs or procedures not recognized by the United States Food and Drug Administration, the United States Public Health Service, CMS, and the Avesis Chief Dental Officer and State Dental Director as universally accepted treatment, including but not limited to, positron emission tomography, dual photon absorptiometry, etc. The member may purchase additional services as non-covered procedure(s) or treatment(s) for an additional charge. Passport requires that the provider and the member complete the Non-Covered Services Disclosure Form (see Attachment B) or a similar form that contains all of the elements of the Passport Non-Covered Services Disclosure Form prior to rendering these services. If the member elects to receive the non-covered procedure(s) or treatment(s), the member would pay the provider’s usual and customary rate as payment in full for the agreed upon procedure(s) or treatment(s). The member is financially responsible for such services. If the member will be subject to collection action upon failure to make the required payment, the terms of the action must be kept in the member’s treatment record. Failure to comply with this procedure will subject the provider to sanctions up to and including termination. Members may not be billed for any service, with the exception of services in which a Passport NonCovered Services Disclosure Form has been signed, prior to the service being rendered. 19.6.3 Periodicity Schedule RECOMMENDATIONS FOR PREVENTIVE PEDIATRIC ORAL HEALTH CARE Periodicity and Anticipatory Guidance Recommendations Dental Health Guidelines – Ages 0-18 Years Recommendations for Preventive Pediatric Dental Care (AAPD Reference Manual 2002-2003) Age 6-12 months 12-24 months 2-6 years 6-12 years >12 years Clinical oral examination1 X X X X X Assess oral growth and development2 X X X X X Caries-risk assessment3 X X X X X Radiographic assessment4 X X X X X Prophylaxis & topical fluoride3,4 X X X X X Page 289 of 331 Age 6-12 months 12-24 months 2-6 years 6-12 years >12 years Fluoride supplementation5 X X X X X Anticipatory guidance/ counseling6 X X X X X Oral hygiene counseling7 Parent Parent Patient/Parent Patient/Parent Patient Dietary counseling8 X X X X X Injury prevention counseling9 X X X X X Counseling for nonnutritive habits10 X X X X X Counseling for speech/ language development X X X Substance abuse counseling X X Counseling for intraoral/ perioral piercing X X Assessment and treatment of developing malocclusion X X X Assessment for pit and fissure sealants11 X X X Assessment and/or removal of third molars X Transition to adult dental care X 1. First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child's risk status/susceptibility to disease. Includes assessment of pathology and injuries. 2. By clinical examination. Page 290 of 331 3. Must be repeated regularly and frequently to maximize effectiveness. 4. Timing, selection, and frequency determined by child's history, clinical findings, and susceptibility to oral disease. 5. Consider when systemic fluoride exposure is suboptimal. Up to at least 16 years. 6. Appropriate discussion and counseling should be an integral part of each visit for care. 7. Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child. 8. At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and childhood obesity. 9. Initially play objects, pacifiers, car seats; then when learning to walk, sports and routine playing, including the importance of mouth guards. 10. At first, discuss the need for additional sucking: digits vs. pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For 11. For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.. school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism. 19.7 Care Management and Utilization Management 19.7.1 CDT Codes for Dental Programs Detailed descriptions for CDT Codes including benefit limitations and attachments required for claims processing may be found on the Covered Benefits Schedule (Attachment F). Medically necessary dental services must be appropriate and consistent with the standard of care for local dental practices. Providers understand that the omission of appropriate services could adversely affect the member’s condition. The nature of the diagnosis and the severity of the symptoms must not be provided solely for the convenience of the dental professional or facility or other entity. However, there must be no other effective and more conservative or substantially less costly treatment available. Furthermore, for certain procedures requiring prior-authorization as set forth herein, the procedure should be dentally or medically necessary to prevent or minimize the recurrence and progression of periodontal disease in recipients who have been previously treated for periodontitis; prevent or reduce the incidence of tooth loss by monitoring the dentition and any prosthetic replacements of the natural teeth; and increase the probability of locating and treating, in a timely manner, other diseases or conditions found within the oral cavity. 19.7.2 Services Performed by the General/Pediatric Dentist The Passport Dental Program is intended to be a general/pediatric dentistry program. Passport considers the general/pediatric dentist to be the provider responsible for rendering all primary dental care to members. That dentist is responsible for the initial examination and basic radiographs necessary for any professional review. General/pediatric dentists should render the following services whenever possible: • • • Preliminary diagnostic and all preventive care. Simple forceps extractions (D7140). All anterior (D3310) and bicuspid (D3320) root canal therapies. Page 291 of 331 • • • Initial root planning, scaling (requires Prior Authorization) and follow-up evaluation for all periodontal cases. Endodontic treatment may require a request for Prior Authorization along with radiographs and is not considered for cases with rampant cavities or multiple missing teeth. Routine restorative dentistry. The above procedures should not be referred to a specialist unless they present with unusual complications or fall outside the scope of the general/pediatric dentist practice. Also, it is the responsibility of the general/pediatric dentist to provide a copy of diagnostic quality radiographs to any successor dental provider, whenever possible. Appropriate radiographs are clear, labeled to identify the area of the mouth and show the parts of the tooth or teeth to be treated. Digital radiographs must have a date stamp or some date identification. If radiographs cannot be obtained from the general/pediatric dentist, the successor dental provider shall contact Avesis. Avesis will notify the general/pediatric dentist, in writing, within thirty (30) calendar days or less, that the successor dental provider did not receive diagnostic quality radiographs. If necessary, Avesis will charge back the general/pediatric dentist for radiographs that the successor dental provider must retake for appropriate care if: • • The general/pediatric dentist has taken radiographs that were not of diagnostic quality as determined by clinical staff; and/or, Radiographs were not submitted to the successor dental provider within ten (10) business days following a request for said radiographs. For those providers requesting radiographs less than ten (10) days prior to a member being treated by the successor dental provider, Avesis will not charge back the general/pediatric dentist. If the specialist deems that radiographs do not need to be repeated, the specialist must include a narrative to clearly explain the dental conditions found upon examination. 19.7.3 Clinical Criteria Requests for approvals for treatment are evaluated using criteria as defined in the American Dental Association's most current CDT volume. Determinations are reached using generally accepted dental standards for authorization, such as radiographs, periodontal charting, treatment plans, or descriptive narratives. In some instances, the State legislature or other state or federal agency will define the requirements for dental procedures and medical necessity. These criteria and policies are designed as guidelines for dental service authorization and payment decisions and are not intended to be all-inclusive or absolute. Additional narrative information is appreciated when there may be a special situation. Passport recognizes that "local community standards of care" may vary from region to region and will continue our goal of incorporating generally accepted criteria that will be consistent with both the concept of local community standards and the current ADA concept of national community standards. Page 292 of 331 The following are general criteria. Services described may not be covered. There may be program specific criteria regarding authorization for specific services. Therefore, it is essential providers review the Covered Benefits Schedule (Attachment F) prior to providing any treatment. 19.7.3.1 Criteria for Dental Extractions • • • • The prophylactic removal of asymptomatic teeth (i.e. third molars) or other teeth exhibiting no overt clinical pathology (for orthodontics) may be covered, based on the clinical history provided. Symptoms should be present for approval of all third molar extractions. Those symptoms may include cysts, resorption of adjacent teeth, angulation causing inability for tooth to erupt and other clinical symptoms. Normal eruption pain is not considered a pathological symptom that would require an extraction, unless accompanied by another symptom. The removal of primary teeth whose exfoliation is imminent does not meet criteria, unless the tooth presented with any unusual complication(s). Alveoloplasty (Code 07310) in conjunction with three or more extractions in the same quadrant will be covered subject to consultant post-review. 19.7.3.2 Criteria for Cast Crowns • • • • In general, criteria for crowns will be met only for permanent teeth or primary teeth where no permanent successor is present or needing multi-surface restorations where other restorative materials have a poor prognosis. Permanent molar teeth must have pathologic destruction to the tooth by caries or trauma, and that destruction should involve four or more surfaces and two or more cusps. Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma, and that destruction should involve three or more surfaces and at least one cusp. Permanent anterior teeth must have pathologic destruction to the tooth by caries or trauma, and that destruction must involve four or more surfaces and at least 50% of the incisal edge. A request for a crown following endodontic therapy must meet the following criteria: • • • • • • • Request should include a dated post-endodontic radiograph. The endodontic treatment of the tooth should show a fill sufficiently close to the radiological apex to ensure that an apical seal is achieved, unless there is a curvature or calcification of the canal that limits the ability to fill the canal to the apex. The endodontic fill must be properly condensed or obturated. Endodontic filling material should not extend excessively beyond the apex. The crown must be opposed by a tooth or denture in the opposite arch or be an abutment for a partial denture. The tooth should demonstrate no probings greater than 5mm. The patient must be free from active and advanced periodontal disease. Authorizations for crowns will not meet criteria if: • • A lesser means of restoration is possible. Tooth has subosseous and/or furcation caries. Page 293 of 331 19.7.3.3 Criteria for Endodontics • • Tooth must be damaged as a result of trauma or carious exposure. Fill must be properly condensed/obturated. Filling material does not extend excessively beyond the apex. Authorizations for endodontic therapy will not meet criteria if: • • • • • • • • The endodontic treatment is for aesthetic reasons. Gross periapical or periodontal pathosis is demonstrated radiographically. Caries is demonstrated radiographically to be present belong the crestal bone or into the furcation, deeming the tooth non-restorable. The generally poor oral condition does not justify root canal therapy. Endodontic therapy is being requested for third molars, unless they are an abutment for a partial denture. The tooth has advanced periodontal disease and/or pocket depths greater than 5mm. Endodontic therapy is in anticipation of placement of an overdenture. An endodontic filling material not accepted by the Federal Food and Drug Administration is used. 19.7.3.4 Criteria for Removable Prosthodontics (Full and Partial Dentures) • • • • Prosthetic services must be intended to restore oral form and function due to premature loss of permanent teeth that would result in significant occlusal dysfunction. Requests for partial dentures will only be considered for recipients with good oral health and hygiene, good periodontal health (AAP Type I or II), and a favorable prognosis where continuous deterioration is not expected. Abutments should be adequately restored and not have advanced periodontal disease. Pre-existing removable prosthesis (includes partial and full dentures), must be at least 5 years old and unserviceable to qualify for replacement. Authorizations for a removable prosthesis will not meet criteria if: • • • • • • There is a pre-existing prosthesis which is not at least 5 years old and unserviceable. Good oral health and hygiene, good periodontal health, and a favorable prognosis are not present. There are untreated caries on or active periodontal disease around the abutment teeth. Less than 50% bone support is visible radiographically in abutment teeth. The recipient cannot accommodate and properly maintain the prosthesis (i.e. gag reflex, potential for swallowing the prosthesis, severely handicapped). The recipient has a history or an inability to wear a prosthesis due to psychological or physiological reasons. 19.7.3.5 Criteria for General Anesthesia and Intravenous (IV) Sedation The use of general anesthesia or IV sedation is considered acceptable for procedures covered by Passport, if appropriate criteria are met, including but not limited to any of the following: Page 294 of 331 • Extensive or complex oral surgical procedures such as: o o o o Impacted wisdom teeth. Surgical root recovery from maxillary antrum. Surgical exposure of impacted or unerupted cuspids. Radical excision of lesions in excess of 1.25 cm. and/or one of the following medical conditions: o Medical condition(s) which require monitoring (e.g. cardiac problems, severe hypertension). o Underlying hazardous medical condition (cerebral palsy, epilepsy, mental retardation, including Down syndrome) which would render patient noncompliant. o Documented failed sedation or a condition where severe periapical infection would render local anesthesia ineffective. o Patients 5 years old and younger with extensive procedures to be accomplished. 19.7.3.6 Criteria for Periodontal Treatment 19.7.3.6.1 Gingivectomy or Gingivoplasty Criteria for approval of gingivectomy or gingivoplasty includes evidence of one or more of the following: • • Comprehensive periodontal evaluation (i.e. description of periodontal tissues, pocket depth chart, tooth mobility, mucogingival relationships). Documentation of severe gingival hyperplasia restricting the ability to perform effective daily oral hygiene procedures (i.e. photos). 19.7.3.6.2 Periodontal Scaling and Root Planing Criteria for approval of periodontal scaling and root planing include evidence of one or more of the following: • • • • Radiographically demonstrated evidence of bone loss. 3-5mm pocket depths on at least 3 or more teeth in each quadrant with perio charting no more than a year old. Medication related gingival hyperplasia. Persistent inflammation characterized by generalized bleeding points on at least ½ of the remaining dentition per quadrant. 19.7.6.3 Orthodontic Coverage Criteria Members age 20 and under may qualify for orthodontic care under the program. KCHIP III members are not eligible for orthodontic benefits. Members must have a severe, dysfunctional, handicapping malocclusion. Page 295 of 331 Since a case must be dysfunctional to be accepted for treatment, members whose molars and bicuspids are in good occlusion seldom qualify. Crowding alone is not usually dysfunctional in spite of the aesthetic considerations. Minor tooth guidance, if a covered benefit, will be authorized on a selective basis to help prevent the future necessity for full-banded treatment. All appliance adjustments are incidental and included in the allowance for the tooth guidance appliance. With the exception of situations involving gingival stripping or other nonreversible damage, appliances for minor tooth guidance (codes D8010 through D8030) will be approved when they are the only treatment necessary. If treatment is not definitive, the movement will only be covered as part of a comprehensive orthodontic treatment plan. All orthodontic services require prior authorization. The member should present with a fully erupted set of permanent teeth. At least 1/2 to 3/4 of the clinical crown should be exposed, unless the tooth is impacted or congenitally missing. Diagnostic study models (trimmed) with wax bites or OrthoCad electronic equivalent, and treatment plan must be submitted with the request for prior authorization of services. Treatment should not begin prior to receiving notification indicating coverage or non-coverage for the proposed treatment plan. Dentists who begin treatment before receiving an approved or denied prior authorization are financially obligated to complete treatment at no charge to the member or face possible termination of their Provider Agreement. Providers cannot bill prior to services being performed. If the case is denied, the prior authorization will be returned to the provider indicating Passport will not cover the orthodontic treatment. However, an authorization will be issued for the payment of the pre-orthodontic visit (code D8660), which includes treatment plan, radiographs, and/or photos, records and diagnostic models, for full treatment cases only (Code D8080), at the provider's contracted rate. This payment will be automatically generated for any case denied for full treatment. 19.7.3.6.1 Cleft Palate Services Orthodontic care under the program will be evaluated based on medical necessity. All orthodontic services require prior authorization by a Dental Consultant. 19.7.3.6.2 General Billing Information for Orthodontics The start and billing date of orthodontic services is defined as the date when the bands, brackets, or appliances are placed in the member's mouth. The member must be eligible on the first date of service. Should the member lose eligibility during treatment, the full treatment will be covered/paid. To guarantee proper and prompt payment of orthodontic cases, please follow the steps below: Electronically file, fax or mail a copy of the completed ADA form with the date of service (banding date) filled in. Our fax number is (866) 653-5544. Page 296 of 331 19.7.3.6.3 Orthodontic Payment Information • • • • • Initial payments for orthodontics (code D8080) includes pre-orthodontic visit, radiographs, treatment plan, records, diagnostic models, initial banding, debanding, 1 set of retainers, and 12 months of retainer adjustments (If retainer fees are not separate). Once Avesis receives the banding date, the initial payment for code D8080 will be set to pay out. Providers must submit a claim for a periodic treatment visits (code D8670) after six months of treatment to receive the final payment for orthodontics. At the end of treatment, providers may bill for code D8680 for retention. The maximum case payment for orthodontic treatment will be one (1) initial payment (code D8080) and one (1) periodic orthodontic treatment visits (code D8670) six months after banding. Members may not be billed for broken, repaired, or replacement of brackets or wires. Payment of records for cases that are denied will be made automatically. There is no need to submit for the records payment (code D8660). Payment of records/exams (code D8660) will NOT be paid prior to the case being reviewed by the consultant. Please do not submit separate claims for these procedures. Please notify Avesis immediately should the member discontinue treatment for any reason. 19.7.3.6.4 Continuation of Orthodontic Treatment: The following information is required for possible payment of continuation of care cases: • • • The original banding date. A detailed paid-to-date history showing dollar amounts for initial banding and periodic orthodontic treatment fees. A copy of the member's prior approval including the total approved case fee, banding fee, and periodic orthodontic treatment fees. If the member started treatment under commercial insurance or fee for service, the ORIGINAL diagnostic models (or OrthoCad) must be provided, or radiographs (optional), banding date, and a detailed payment history. It is the provider’s and member's responsibility to get the required information. Cases cannot be set-up for possible payment without complete information. Payments for orthodontics (code D8080) include pre-orthodontic visit, radiographs, treatment plan, records, diagnostic models, initial banding, 1 set of retainers, and 12 months of retainer adjustments. The maximum case payment for orthodontic treatment will be 1 initial payment (code D8080), initial and final records (code D8660), o n e ( 1) payment for the 6 periodic orthodontic treatment visits (code D8670), and retention (code D8680). Members may not be billed for broken, repaired, or replacement of brackets or wires. Page 297 of 331 See Attachment D for Orthodontic Criteria Index Form. See Attachment E for Orthodontic Continuation of Care Form. 19.7.3.7 Post Treatment Review Routine Services While some dental services will be reviewed after the treatment is completed, payment will not be delayed for this review. Providers are responsible for submitting all necessary attachments. If these attachments are not received, payment and/or claims will be denied and additional information requested. If the Avesis State Dental Director or a member of the Dental Advisory Board determines the treatment was inappropriate or excessive based upon the status of the tooth on the radiograph, future claim payments may be reduced to recoup monies already paid for the service. If there are extenuating circumstances that are relevant, it is imperative that the dental provider include a written explanation with the claim. Dental service codes requiring post treatment review are provided below. CDT Code D3310 D3320 D3330 D3410 D3421 Description Root canal - Anterior (excluding final restoration) Root canal - Bicuspid (excluding final restoration) Root canal - Molar (excluding final restoration) Apicoectomy/periradicular surgery – anterior D3425 D3426 D4341 D4355 Apicoectomy/periradicular surgery - molar (first root) Apicoectomy/periradicular surgery (each additional root) Periodontal scaling and root planing, per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Apicoectomy/periradicular surgery - bicuspid (first root) All of these services will require copies of pre-treatment radiographs of the tooth or teeth to be included at the same time that the claim form is submitted. The claim form and pre-treatment radiographs may be submitted either electronically or on the current ADA claim form. Please note that no additional radiographs will be requested other than those necessary for proper diagnosis and treatment. 19.8 Authorization Procedures and Requirements Prior Authorization is a request made in advance for dental services to be performed by the Passport network general/pediatric dentist. 19.8.1 Prior Approval for Non-Emergency Situations Non-emergency treatment for services requiring prior approval started prior to the granting of prior authorization will be performed at the financial risk of the dental office. If authorization is denied, the dental office or treating provider may not bill the member, Passport, or Avesis. Receipt of authorization or denial of the request for prior approval will be provided within two (2) business days. Page 298 of 331 Services that require Prior Approval for non-emergency care include ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED YES / NO All Yes for members age 5 and under only D0330 Panoramic film All One per patient per dentist or dental group every 24 months. Part of D8660 for orthodontic patients. Authorization required for ages 0 - 5. D0340 Cephalometric Film All Part of D8660 D4210 Gingivectomy or gingivoplasty-four or more contiguous teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty- one to three contiguous teeth or bounded spaces per quadrant All One per 12 months. A minimum of four (4) teeth in the affected quadrant. Limited to patients with gingival overgrowth due to congenital, heredity or drug induced causes. Yes for members age 5 and under only All Yes--prepayment review All Yes--prepayment review All One per 12 months. One (1) to three (3) teeth in the affected quadrant. Limited to patients with gingival overgrowth due to congenital, heredity or drug induced causes. D4341 Periodontal scaling and root planing, per quadrant All One per 12 months. A minimum of three (3) teeth in the affected quadrant. Cannot bill in conjunction with D1110 or D1201. One per 3 months for patients diagnosed with AIDS. All Yes-post review since 10/1/12 and prior authorization effective ? D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis All Covered for pregnant women only. One per pregnancy. All Post review to confirm pregnancy D5820 Interim partial denture (maxillary) All One per 12 months per patient. 0-20 Yes D5821 Interim partial denture (mandibular) All One per 12 months per patient. 0-20 Yes D5913 Nasal prosthesis All Covered for Prosthodontists only. All Yes Page 299 of 331 ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED YES / NO D5914 Auricular prosthesis All Covered for Prosthodontists only. All Yes D5919 Facial prosthesis All Covered for Prosthodontists only. All Yes All Covered for Prosthodontists only. All Yes All Covered for Prosthodontists only. All Yes All Covered for Prosthodontists only. All Yes All Covered for Prosthodontists only. 0-13 Yes D5931 D5932 D5934 D5952 Obturator prosthesis, surgical Obturator prosthesis, definitive Mandibular resection prosthesis Speech aid pediatric (13 and under) D5953 Speech aid - adult (14 -20) All Covered for Prosthodontists only. 14-20 Yes D5954 Palatal augmentation prosthesis All Covered for Prosthodontists only. All Yes D5955 Palatal lift prosthesis All Covered for Prosthodontists only. All Yes D5988 Oral surgical splint All Covered for Prosthodontists only. All Yes All Covered for Prosthodontists only. All Yes 1-32 No Limitations 0-20 Yes-prepayment review D5999 D7280 Unlisted maxillofacial prosthetic procedure Surgical access of an unerupted tooth D7880 Occlusal orthotic device, by report All Once per lifetime. 0-20 Yes-prior authorization D8080 Comprehensive orthodontic treatment of the adolescent dentition All No Limitations 0-20 Yes D8210 Removable Appliance Therapy All 0-20 Yes D8220 Fixed Appliance Therapy All 0-20 Yes This appliance is not to be used to control harmful habits. Limit of two (D8210, or D8220) per 12 months. This appliance is not to be used to control harmful habits. Limit of two (D8210, or D8220) per 12 months. Page 300 of 331 ADA CODE D8660 D8670 D8680 D8999 DESCRIPTOR Pre-orthodontic treatment visit Periodic orthodontic treatment visit(as part of the contract) Orthodontic Retention(removal of appliances, construction and placement of retainer(s)) Unspecified orthodontic procedure, by report TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS All Used to pay for records. Final records will be paid only if member is age 20 and under and still eligible for benefits on date of service. Member cannot be billed for final records. AUTHORIZATION REQUIRED YES / NO 0-20 Yes All Quarterly Payment No limitations Yes All Final Payment No limitations Yes All Six month payment. 0-20 Yes All EPSDT Special Services (aka Expanded Services) require prior authorization. This list is also available at www.avesis.com. Form to use: ADA Claim Form for Pre-Treatment Estimates. Providers may submit a pre-treatment estimate in one of two ways: 1. Electronic submission, please go to www.avesis.com; or 2. Mail on an ADA claim form to: Avesis Third Party Administrators, Inc. P. O. Box 7777 Phoenix, Arizona 85011-7777 Attn: Dental Pre-Treatment Estimate ADA dental claim forms are not accepted via fax. Because all prior authorization requests for prior approval for non-emergency situations must be submitted electronically on our website or on an ADA dental claim form, the provider must either submit them on the website or mail in an ADA dental claim form with the appropriate box checked indicating the provider is submitting a request for a pre-treatment estimate. Prior authorization of dental services must be performed as a part of a complete dental treatment program and must be accompanied by a detailed treatment plan. The treatment plan must include all of the following: Page 301 of 331 • • • • • • • • • • • • • • pertinent dental history; pertinent medical history, if applicable; the strategic importance of the tooth; the condition of the remaining teeth; the existence of all pathological conditions; preparatory services performed and completion date(s); documentation of all missing teeth in the mouth; the general oral hygiene condition of the member; all proposed dental work; identification of existing crowns, periodontal services, etc. identification of the existence of full and/or partial denture(s), with the date of initial insertion, if known; the periodontal condition of the teeth, including pocket depth, mobility, osseous level, vitality and prognosis; identification of abutment teeth by number; periodontal services, include a comprehensive periodontal evaluation. For those situations where dental services are limited to services provided in an inpatient hospital, hospital short procedure unit or ambulatory surgical center, please include a statement identifying where the service will be provided. Please see Sections 19.8.4 and19.8.5 for information regarding referrals to hospitals and other facilities for dental treatment. 19.8.2 Emergency Care A dental emergency is a situation where the member has or believes there is a current, acute dental crisis that could be detrimental to his/her health if not treated promptly. In the event a dental emergency occurs after business hours and the provider cannot treat the member within twenty-four (24) hours, please refer the member to Avesis at 1-866-909-1037 for further assistance. Passport requires providers ensure sufficient access to help keep the member from having services rendered in a hospital emergency room. 19.8.2.1 Emergency Access and Authorizations All Passport provider offices are responsible for the effective response to, and treatment of, dental emergencies. In relation to dental emergencies, there are two types of members: 1) Members of record (i.e., members who are routinely treated by the provider); or 2) Members who have not been previously seen by the office. and two situations: 1) during regular office hours; or 2) after hours. Page 302 of 331 To confirm whether the situation is a true emergency, the dentist should speak with the member to determine the member’s problem and take the necessary actions. If it is determined by the provider and the member that it is a true dental emergency (that is: a situation that cannot be treated simply by medication and, that left untreated, could affect the member’s health or the stability of his/her dentition), then the provider may either: A) render services in the dental office to treat the emergency, or B) assist the patient in obtaining proper dental care from another dental provider or a hospital emergency room, if the condition warrants emergency room treatment. 19.8.2.2 Members of Record If the member telephones with an emergency before 12 noon, the provider must respond to the member the same business day, if possible. If the member telephones after 12 noon, the member must be responded to the same day if possible, but no later than the following business day. If the provider is not treating patients the following business day, then weekend requirements will apply. For a weekend, holiday, or other "off hour" dental emergency, the provider must make available an answering service or telephone number available for the member of record to contact. The responding dentist should assess the emergency request from the patient and make arrangements to provide appropriate follow-up care. If the situation is determined to be a true dental emergency (a situation that cannot be treated simply by medication and, that left untreated, could affect the member’s health or the stability of his/her dentition), the responding dentist must either: • • arrange for the member to come into the office to treat the emergency, or assist the member in obtaining proper dental care from another network dental provider. Passport is committed to providing effective emergency care for patients without the use of hospital emergency rooms, unless absolutely necessary. Members of record shall be required to see their dentist of choice prior to any hospital admission. The dentist must request prior approval from Passport (see Sections 19.8.4 and 5.1). 19.8.2.3 Members Not Previously Treated By Provider In the case of a Dental Emergency or Urgent dental condition, the provider must make every effort to see the member immediately or see the member on the next business day or sooner, if possible. For weekend Dental Emergencies, the provider must have an answering service or cell phone number available for contact. Passport will permit treatment of all dental services necessary to address the Dental Emergency for the member without prior authorization. However, elective dental services, not necessary for the relief of pain and/or prevention of immediate damage to dentition, fall under the standard Pre-Treatment/Prior Authorization estimate procedures. 19.8.2.4 Waiver of Pre-Treatment Estimate/Prior Approval for Emergencies Passport recognizes that in the case of emergency care, the provider may not be able to obtain a Pre-Treatment Estimate / Prior Authorization. In this situation, required documentation must be submitted after treatment along with the provider’s ADA claim form including radiographs, Page 303 of 331 narrative, and CDT codes within thirty (30) business days of the date of service. Claims sent without documentation will be denied and the member is not liable for payment. The minimum materials must include: • • • • • Narrative explaining the emergency and treatment rendered; Claim form complete with all applicable ADA-CDT codes or medical CPT codes; Radiograph(s) of tooth / teeth and any area of treatment, if appropriate; Hospital records, if admitted to hospital; and, Anesthesia records, if general anesthesia was administered. The clinical reviewer and/or the State Dental Director or Dental Advisory Board Member will review the claim along with the accompanying documentation submitted. If the claim is found to not be a qualified emergency, the payment may be reduced or denied. In the event the emergency occurs after business hours and the provider cannot treat the member within twenty-four (24) hours, the provider must contact Avesis at 1-866-909-1037 to allow for the arranging of timely emergency care. Although Passport requires dental providers ensure sufficient access so that the provider attempts to limit having services rendered in a hospital emergency room, the provider should refer members to a hospital emergency room when he/she cannot provide or arrange immediate care. Emergency services shall not include the following: • • • • Prophylaxis, fluoride and routine examinations. Routine restorations, including stainless steel and composite crowns. Dentures, partial dentures and denture relines and repair. Extraction of any asymptomatic teeth, including 3rd molars. 19.8.3 Specialty Referral Process A member requiring a referral to a dental specialist can be referred directly to any specialist contracted with Passport without authorization. The dental specialist is responsible for obtaining prior authorization for services. If the provider is unfamiliar with the Passport contracted specialty network or needs assistance locating a certain specialty, please contact the Provider Services department. In addition, members may self-refer to any network provider without authorization. Members have direct access to dental specialists. A referral is not necessary. 19.8.4 Hospital Referral Hospital referrals will be handled by Passport. If hospitalization of a member for dental services is necessary, the hospital must be authorized using the regular process for Passport. Please refer to Section 5.1 of the Provider Manual. 19.8.5 Participating Ambulatory Surgical Centers (ASC) and Hospitals for PreTreatment Estimate/Prior Approval Page 304 of 331 With Pre-Treatment Estimate/Prior Approval, providers may render services at Passport approved Ambulatory Surgical Centers (ASC), IV Sedation Clinics or hospitals when services are unable to be performed in the dental clinic setting. Please see the following link for a list of Passport ASCs, IV Sedation Clinics and hospitals: http://www.passporthealthplan.com/apps/provider-directory/index.asp 19.8.6 Second Opinion The dentist should discuss all aspects of the patient’s treatment plan prior to beginning treatment. Make sure all of the member’s concerns and questions have been answered. If the patient indicates he/she would like a second opinion, inform the member he/she may do so and that Passport will cover the cost of a second opinion if h e / s h e sees a dentist within the Passport network of participating dentists. The dentist must provide copies of the chart, radiographs and any other information to the dentist performing the second opinion upon request. 19.9 Quality Improvement Passport strongly encourages and supports providers in the use of outcome measurement tools for all members. Outcome data is used to identify and understand why there are areas of under-utilization. Annual analysis of HEDIS results along with quarterly statistical provider reviews facilitates our efforts and is complemented by on-site surveys and quarterly wait time reviews as described below. 19.9.1 Quarterly Statistical Provider Review At the end of each quarter, Avesis compiles and reviews total services rendered by all dental providers in the Passport Dental Program. The objective of the utilization review process is intended to provide feedback regarding the demand for dental services and appropriateness of care. Each code will be analyzed against the number of total Passport dental members being treated. The result will be an average frequency of services per 100 recipients treated in the Passport Dental Program. Providers’ per member cost will be calculated for the quarter. An average per member cost income will be the result. The following items formulate the basis of the utilization review: • Average Service Comparison – a summary of the statistical results by ADA code for each provider compared with the state average. An analysis will be performed only if the provider has treated a sufficient number of Passport dental members in that quarter. Providers that qualify must fall within a reasonable range of the state average. Those providers falling outside of the range will be reviewed for over or under-treatment patterns. • Relative Service Comparison – Certain dental services are typically performed with or after other services. A series of related dental services will be reviewed for appropriate care. Examples of such services are: o A root canal on a tooth, D3310 or D3320, followed by the placement of a stainless steel crown, D2930 o A fluoride treatment for a child being performed at the same appointment as their prophylaxis. These related services would be compared to the averages and to other similarly utilized providers to detect any over or under utilization. Page 305 of 331 • Total Quarterly Per Member Cost –A calculation of the per member cost for all Passport providers using the services rendered during each quarter. The results shall be compared to all other providers and to previous quarters. Providers may request a summary of their per member cost compared to the state average. • Accurate Claim Submission – This will be assessed via the following: o During the quarterly statistical review, Passport will look for any services that would be impossible due to a tooth being previously extracted or a service done on a tooth that would not require that service (i.e. placing an amalgam on a tooth that already had a stainless steel crown). o Compliance with processes. The goal in the utilization review process is to ensure provider satisfaction along with quality care for members. 19.9.2 On-Site Office Survey The office site survey has two components: prospective and ongoing for participating offices. Each review highlights essential areas of the office management and dental care delivery. During the site survey (which may or may not be scheduled), the following areas will be evaluated: • • • • • • • General Information – the name of the practice, address, name of principal owner and associates, license numbers, staffing information, office hours, list of foreign languages spoken in the office, availability of appointments and method of providing twenty-four (24) hour coverage (e.g. answering machine, answering services, etc.) the name of the covering dentist when the office is closed, such as on vacation. Practice History – the office provides information regarding malpractice suits, settlements and disciplinary actions, if applicable. Office Profile - indicates services they routinely perform. Facility Information – includes location, accessibility (including handicap accessibility) description of interior office such as the reception area, operatory and lab, type of infection control, equipment and radiographic equipment. Risk Management – includes review of personal protective equipment (such as gloves, masks, handling of waste disposal, sterilization and disinfection methods), training programs for staff, radiographic procedures and safety, occupational hazard control (regarding amalgam, nitrous oxide and hazardous chemicals), medical emergency preparedness training and equipment. Recall System – includes review of procedures for assuring patients are scheduled for recall examinations and follow-up treatment. Verification that all participating dental providers in a group practice are credentialed. 19.9.3 Quarterly Wait Time Review In lieu of requiring providers to submit a report of average wait times on a quarterly basis, random and anonymous surveys are performed of provider practices to inquire whether scheduling wait Page 306 of 331 times as well as office wait times are excessive. Providers found to have excessive wait times will be required to implement a corrective action plan. 1. If a member complains to Passport, DMS, CMS or other state or federal agency that wait times in a provider’s office were excessive, it is required for us to contact the provider to advise there was a complaint filed against their office. Once the provider is notified, Passport will work with the provider to formulate a written corrective action plan and follow up to ensure the action has been implemented. 2. If a member complains to Passport, DMS, CMS, or other state or federal agency that it was difficult to make an appointment for routine care, Passport is required to contact the provider’s office to advise the provider there was a complaint filed against their office. Once the provider is notified, a written corrective action plan will be formulated and follow up to ensure the action has been implemented. It is important to note that providers who do not implement a corrective action plan upon request may be subject to termination from the network. 19.9.4 Dental Committees Passport welcomes involvement from the dentists who participate in the Passport Dental Program. There are currently three active committees that are staffed with dentists who participate in the Passport Dental Program. These committees provide opportunities for feedback from our local dental communities. The Credentialing Committee helps to ensure the acceptability of new dentists before their entry into the Passport network as well as upon re-credentialing. The committee credentials new network providers and reviews the credentials upon re-credentialing every thirty-six (36) months. In addition, this committee reviews disciplinary information received during the continuous credentialing process on a monthly basis and conducts review of any appeals from dentists who have been sanctioned. Meetings are held every other week. The Quality Assurance Committee is a multi-disciplinary committee whose critical focus is the review of the statistical summary data to determine the primary areas to focus on for improvement. Committee members review planned efforts toward continuous quality improvement, establish standards for quality review of the Dental Program and provide input toward Passport planning for future planned improvements. Meetings are held on a quarterly basis. The Complaint Resolution /Peer Review Committee includes the Chief Dental Officer, Advisory Board and up to (3) dentists from the Passport provider network. Its critical focus includes reviewing the complaints received from members and dental network providers to determine the validity of the complaints and the appropriate response to the party bringing the complaint. The committee addresses decisions concerning the appropriate settlement of clinical disputes between providers and patients. Meetings are held quarterly. The State Dental Director is an employee or contractor with Avesis who serves as the provider’s local contact as a dental professional. The State Dental Director represents Avesis at meetings of the Page 307 of 331 local Dental Association and its component societies and at meetings with Passport. The State Dental Director is available for discussion and consultation concerning issues of importance to Passport’s dental network providers. Providers may contact Provider Services at (866) 909-1083 to speak with the State Dental Director. All of Passport Dental Program committees include the Chief Dental Officer as either an active member or as an attendee. 19.10 Dental Provider Billing Manual All claims submitted will be processed and paid according to the Passport Covered Benefits Schedule. Passport follows the American Dental Association (ADA) Current Dental Terminology (CDT) guidelines. Each claim must include the appropriate line item with the provider’s usual charge, current CDT Code, and tooth number, when applicable. Claims must be received within one hundred eighty (180) days from the date of service to meet timely filing requirements. Claims received after the one hundred eighty (180) days will be denied. Claims may be submitted in one of the following three formats: • • • Through EDI (arrangements must be made with the Avesis IT Department prior to submission); On our website at: www.avesis.com; or On paper, submit ADA claim form to: Avesis Third Party Administrators, Inc. Attn: Dental Claims P.O. Box 7777 Phoenix, Arizona 85011-7777 19.10.1 Electronic Claims Submission via Clearinghouses Providers may submit claims using Emdeon or EHG clearinghouses that can convert paper claims into a HIPAA Compliant Electronic Data Interchange (EDI) format. The Avesis payer identification number is 86098. If you have any questions regarding Emdeon, please contact Emdeon directly at (877) 469-3263. If you have any questions regarding EHG, please contact EHG directly at (800) 576-6412. 19.10.1.1 Electronic Attachments Providers may submit images, charting, and notes directly to Avesis at no charge on our website at www.avesis.com. Avesis also accepts electronic attachments via FastAttach™, a National Electronic Attachment, LLC (NEA) company, for Prior Authorizations requests requiring these documents. This program allows transmissions via secure internet lines. For more information, contact FastAttach™ at: www.fast.nea.com or NEA at: (800) 782-5150. Page 308 of 331 19.10.2 Claim Follow -Up The provider has a right to correct information submitted by another party or to correct his/her own information submitted incorrectly. Changes must be made in writing and directed to the attention of the Claims Manager within the appropriate time frame. When calling or writing to follow up on a claim(s), please have the following information available: 1. 2. 3. 4. 5. 6. 8. Patient’s Name Date of Service Patient’s Date of Birth Member’s Name Member’s KY Medicaid ID Number CDT Codes Claim Number, if the claim has been paid Providers are encouraged to follow-up on any and all claims not paid within thirty (30) days of the date that the claim was filed. Do not wait more than thirty (30) days after claim submission before notifying of a claim that has not been adjudicated. We are required to strictly adhere to the timely filing guideline of one hundred eighty (180) days. There will be no exceptions. Claims received after the filing deadline will be denied. Note: Members cannot be balanced billed for any charges or penalties incurred as a result of late or incorrect submissions. 19.10.3 To Resubmit Claims Resubmitted claims must be submitted within ninety (90) days of the initial submission and include the original claim number. If submitting them on an ADA claim form, please write CORRECTED at the top of the form to ensure proper handling of the claim in the Processing Department. 19.10.4 Summary of Claim A summarization of the claim payment will be included with the provider’s claim check. A summarization of previously submitted claims for underpayments and/or overpayments may also be included. Summarizations of claim payments are available after submission of a claim on Avesis' website. In addition, providers may view remittance advices within one business day of payment on the website at www.avesis.com. 19.10.5 Payment Passport complies with all applicable prompt payment laws regarding the processing and payment of clean claims. Check runs are routinely done on a weekly basis. A “CLEAN” claim contains the following correct and true information: 1. Member’s Name 2. Member’s Date of Birth 3. Member’s KY Medicaid Identification Number Page 309 of 331 4. 5. 6. 7. Acceptable CDT Code Approval Number, if applicable Provider information including NPI number and State Medicaid number, if applicable Provider’s signature Missing or incorrect information will cause delays in payment or the claim may be returned to the provider unpaid. If payment is not received in a timely manner, it may be due to: 1. Claim not received 2. Eligibility verification 3. Claim was returned to the provider for missing information Do not wait more than thirty (30) calendar days after claim submission before notifying of a claim that has not been adjudicated. Note: Members cannot be balance billed for any charges or penalties incurred as a result of late or incorrect submissions Claims being investigated for fraud or abuse or pending medical necessity review are not Clean Claims. 19.10.6 EPSDT Claims Early and Periodic Screening, Diagnosis and Treatment (EPSDT) is a federally mandated program developed to ensure that the Medicaid population younger than the age of 21 is monitored for preventable and treatable conditions. EPSDT Special Services (aka Expanded Services) are available to some Passport members younger than 21 years of age depending on the category of aid. These are services required to treat conditions detected during an encounter with a health professional and are eligible for payment under the federal Medicaid program but not currently recognized under the state plan. KCHIP III members are not eligible for EPSDT Expanded Services. (Note this pertains to KCHIP III members only - not KCHIP I and II). Please refer to Section 8.0 for detailed information on EPSDT. All EPSDT Special Services require pre-authorization. Indicate “EPSDT” on the pre-authorization form and submit with X-rays and/or charting. Requests for pre-authorization must be made on an ADA form with supporting documentation explaining the rationale for treatment. Requests for EPSDT Special Services pre-authorization may be submitted electronically via the website or mailed to our office at: Avesis PO Box 7777 Phoenix, AZ 85011-7777 Page 310 of 331 19.10.7 Coordination of Benefits Primary vs. Secondary Insurance Passport is the payer of last resort for members. All claims must be filed with commercial insurance companies or third party administrators prior to filing claims with Passport for reimbursement for services rendered to Passport members. If it is later determined that the member had other insurance coverage, you will be notified and will be required to either reimburse Passport for the amounts paid to the provider or the money will be recouped from future payments. If Passport is not the primary payer, you must bill the primary payer first. If the claim is initially filed with Avesis, the claim will be denied. If the primary payer pays less than the agreed upon fee, you may bill for the balance. You must enclose the Remittance Advice from the primary payer. The claim must be received within 180 days after receiving the Remittance Advice. Remaining charges will be reimbursed up to the maximum Passport allowed amount. However, Passport agrees to pay all clean claims for EPSDT services to children. Cost avoidance of these claims is prohibited. 19.10.8 Payment Passport complies with the federal and Commonwealth of Kentucky prompt pay law requiring that all eligible clean claims be processed within 30 business days. Passport will pay eligible clean dental claims on a weekly basis. Providers submit a clean claim form or file electronically after services and materials have been provided. Should the provider’s clean claim not be processed within thirty (30) business days, Passport will pay interest in accordance with state and federal requirements. Providers are eligible to receive payments via Electronic Funds Transfer thereby enabling dental practices to maintain a positive cash flow. Providers may access their remittance advice electronically within twenty-four (24) hours of the payments being deposited (Please see Attachment C for Electronic Funds Transfer Agreement). The remittance advice will still be mailed to the address of record in the provider file once weekly as well. All claims should be submitted on an ADA claim form. The claim form must include the following information: • • • • • • • • • Member name Member KY Medicaid Identification number Member and/or Guardian Signature (or Signature on File) Member date of birth Description of services rendered Dentist Individual NPI, group NPI if applicable, taxonomy code, group taxonomy code if applicable and Medicaid number (included with electronic or online submissions) Dentist name, state license number and signature (included with electronic or online submissions) Dentist address, office ID# and phone number (included with electronic or online submissions) Proper CDT coding with tooth numbers, surfaces, quadrants and arch when applicable Page 311 of 331 • Full mouth x-ray series, bitewings and/or periapical x-rays when needed Explanations of Benefits (EOBs) will be available online for all offices. • • • • For offices receiving Electronic Funds Transfer (EFT) payments, the EOB will only be available online. For offices receiving a paper check, the EOB will be included in the envelope. Offices that receive EFT payments have the option to request a paper. EOB be sent at the time of payment. 19.11 Fraud, Waste and Abuse Passport is committed to preventing, detecting and reporting possible fraud, waste and abuse. Providers are required to cooperate with the investigation of suspected fraud, waste and abuse. If you suspect fraud, waste or abuse by a Passport member or provider, it is your responsibility to report this information immediately. Please contact: Passport Health Plan Compliance Hotline: (855) 512-8500 Please refer to Section 3.4.6 of the Provider Manual for detailed information on Fraud and Abuse. 19.12 Cultural Competency Please refer to Section 2.11 of the Provider Manual for important information regarding Title VI Requirements including but not limited to translator and interpreter services as well as training and resources available to providers. Page 312 of 331 Attachment A Avesis Eligibility Verification Fax Form Provider Name: __________________________________________ Provider PIN#: _________________________________________ Provider Tax ID #: ________________________________________ Fax Number: Member ID #: ________________________________________ Member Name Member DOB Date of Service Active Coverage: Yes No Member eligible for: D0120 D1110 D0220 D0230 Restorations Instructions: Complete the appropriate fields indicated above (one line per Member) and fax to Avesis’ secure fax line at: (866) 332-1632. You will receive a reply by fax within one (1) business day. Page 313 of 331 Attachment B Non - Covered Services Disclosure Form To be completed by Dentist Rendering Care I am recommending that _____________________________________ receive Member Name and Identification Number services that are not covered by the Passport Health Plan Covered Benefits Schedule. I am willing to accept my Usual and Customary Fee as payment in full. The following procedure codes are recommended: CODE DESCRIPTION FEES The total amount due for service(s) to be rendered is $___________ Provider’s Signature Date To be completed by Member I ________________________________________________, have been told Print Your Name that I require services or have requested services that are not covered by the Covered Benefits Schedule. Read the question and check either YES or NO Passport Health Plan YES NO My doctor has assured me that there are no other covered benefits. I am willing to receive services not covered by the dental program. I am aware that I am financially responsible for paying for these services. I am aware that Passport Health Plan is not paying for these services. As agreed to with the dentist, I agree to pay $_________. If I fail to make the agreed upon payment(s) I may be subject to collection action. Member’s Signature if over eighteen (18) or Parent / Guardian Date Page 314 of 331 Attachment C Electronic Funds Transfer Agreement ACCOUNT REGISTRATION INFORMATION Name Tax ID Number Address City, State, Zip Code BANK INFORMATION Bank Name Checking Savings Other ____________ Address City, State, Zip Code Routing # Account # I, ____________________________________, as the authorized party, allow Avesis to deposit funds into my Bank Account using Electronic Funds Transfer. A voided check is included with this agreement to facilitate this process. This transfer is for my convenience. All claims filed are in accordance with the terms of the executed Passport Agreement and the Passport Provider Manual. All funds shall be deposited into my bank account at the banking institution shown above. The bank shall provide to Avesis your most current address upon request. I understand that: 1. The origination of electronic credits to my account must comply with the provisions of United States law. 2. Avesis and the Bank will share with each other limited account and contract information as necessary to affect these credits. 3. By signing this document, I agree to accept the terms of the Electronic Funds Transfer. 4. This form must processed by Avesis before funds will be transferred into my Bank Account. Page 315 of 331 Printed Name of Account Holder Signature of Account Holder Date Printed Name of Joint Account Holder Signature of Joint Account Holder Date Telephone Number: Please mail to: Avesis Third Party Administrators, Inc. Attention: Finance PO Box 782 Owings Mills, Maryland 21117 Page 316 of 331 Attachment D First Review ____ Second Review ____ Models ____ Orthocad ____ Ceph Films ____ X-Rays ____ Photos ____ Narrative ____ ORTHODONTIC CRITERIA INDEX FORM - COMPREHENSIVE D8080 Patient Name: ____________________________________ DOB: ___________________ ABBREVIATIONS CRITERIA YES DO Deep impinging overbite that shows palatal impingement of the majority of lower incisors AO True anterior open bite. (Not including one or two teeth slightly out of occlusion or where the incisors are not fully erupted). AP Demonstrates a large anterior-posterior discrepancy. (Class II and Class III malocclusions that are virtually a full tooth Class II or Class III) AX Anterior crossbite. (Involves more than two teeth in crossbite or in cases where gingival stripping from the crossbite is demonstrated). PX Posterior transverse discrepancies. (Involves several posterior teeth in crossbite, one of which must be a molar AND must also contribute to a handicapping malocclusion i.e.: “functional shift, facial asymmetry, complete buccal or lingual crossbite (scissor bite) or speech concern. PO Significant posterior open bites. (Not involving partially erupted teeth or one or two teeth slightly out of occlusion). IMP Impacted teeth (one or more) that will not erupt into the arches without orthodontic or surgical intervention. (Does not include 3rd molars or cases where teeth are going to erupt ectopically). OJ Has extreme overjet in excess of eight (8) to nine (9) millimeters AND one (1) of the skeletal conditions specified above (DO, AO, AP, PX, or PO). Overjet alone is not sufficient for approval. TR Has trauma or injury resulting in severe misalignment of the teeth or alveolar structures, and does not include simple loss of teeth with no other affects. CDD Dentition exhibits a profound impact from a congenital or developmental disorder. FAS Significant facial asymmetry requiring a combination of orthodontics and orthognathic surgery for correction. ANO Has developmental anodontia in which several congenitally missing teeth result in a handicapping malocclusion or arch deformation. Approved Page 317 of 331 NO Attachment E ORTHODONTIC CONTINUATION OF CARE FORM Member ID Number: ____________________________________________________ Member Name (Last/First): Date of Birth: _______________________________________________ _________________________________________________________ Name of Previous Vendor that issued original approval: _____________________________________________________________________ Banding Date: ________________________________________________________ Case Rate Approved By Previous Vendor: ___________________________________ Amount Paid for Dates of Service That Occurred Prior to Avesis: Amount Owed for Dates of Service That Occurred Prior to Avesis: Balance Expected for Future Dates of Service: Number of Adjustments Remaining: Additional information required: • • • _________________ ________________ _______________________________ ________________________________________ ___________________________________________ Completed ADA claim form listing services to be rendered. If the Member is transferring from an existing Medical Assistance program: A copy of the original orthodontic approval. If the Member is private payer transferring from a commercial insurance program, please enclose the original diagnostic models (or OrthoCad equivalent). Radiographs are optional. Mail to: Avesis 2300 Lake Park Drive, Suite 400 Smyrna, Georgia 30080 Attn: Utilization Management Page 318 of 331 Attachment F Covered Benefits Schedule ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED? ATTACHMENTS REQUIRED D0140 Limited Oral EvaluationProblem Focused All All No Requires a prepayment review D0120 Periodic Oral Evaluation - established patient All All No None D0150 Comprehensive Oral Evaluation All All No None D0210 Intraoral - complete series (including bitewings) Intraoral - periapical first view All All No None All No None D0230 Intraoral - periapical each additional film All All No None D0270 Bitewing - single film All All No None D0272 Bitewing - two film All All No None D0274 Bitewing - four films All All No None D0330 Panoramic film All Not reimbursable on the same day as D0120 and D0150. Trauma related injuries only. May only be billed in conjunction with D0220, D0230, D0270, D0272, D0274, D0330, D2330, D2331, D2332, D2335, D7140, D7130, D7250, D7530, D7910 and D9240. Only one exam (D0120 or D0150) every 6 months per patient per dentist or dental group. One comprehensive exam (D0150) per patient per dentist or dental group every 12 months. Only one exam (D0120 or D0150) every 6 months per patient per dentist or dental group. Cannot be billed on the same day as D0120, D0140, D1510, D1515, D1520, D1525. One per patient per dentist or dental group every 12 months. Total of 14 (D0220 and D0230) per patient per dentist or dental group every 12 months. Not to be billed in the same 12 months as a D0210. Total of 14 (D0220 and D0230) per patient per dentist or dental group every 12 months. Not to be billed in the same 12 months as a D0210. Total of 4 bitewing x-rays per patient per dentist or dental group every 12 months. Not to be billed in the same 12 months as a D0210. Total of 4 bitewing x-rays per patient per dentist or dental group every 12 months. Not to be billed in the same 12 months as a D0210. Total of 4 bitewing x-rays per patient per dentist or dental group every 12 months. Not to be billed in the same 12 months as a D0210. One per patient per dentist or dental group every 24 months. Part of D8660 for orthodontic patients. Authorization required for ages 0 - 5. All Yes for members age 5 and under only None D0220 All Page 319 of 331 ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED? ATTACHMENTS REQUIRED D0340 Cephalometric Film All Part of D8660 Yes for members age 5 and under only None D1110 Prophylaxis - Adult All One per 12 months. D1120 Prophylaxis - Child (Age 0 to 13) All Two per 12 months. 21 and older No None 0-20 No None D1208 Topical application of fluoride - Child (prophylaxis not included) All Two per 12 months. Fluoride must be applied separately from prophylaxis paste. 0-20 No None D1351 Sealant - per tooth All 0-20 No None 0-20 No None 0-20 No None 0-20 No None 0-20 No None All One per 48 months. Maximum of 3 times. Occlusal surfaces only. Teeth must be caries free. Sealant will not be covered when placed over restorations. Repair, replacement or reapplication of the sealant within the four year period is the responsibility Limit of 2 (D1510, D1515, D1520 or D1525) per 12 months. Limit of 2 (D1510, D1515, D1520 or D1525) per 12 months. Limit of 2 (D1510, D1515, D1520 or D1525) per 12 months. Limit of 2 (D1510, D1515, D1520 or D1525) per 12 months. No Limitations D1510 Space maintainer-fixedunilateral All D1515 Space maintainer-fixedbilateral All D1520 Space maintainerremovable-unilateral All D1525 Space maintainerremovable-bilateral All D2140 Amalgam-one surface, permanent/primary All No None D2150 Amalgam-two surfaces, permanent/primary All No Limitations All No None D2160 Amalgam-three surfaces, permanent/primary All No Limitations All No None D2161 Amalgam-four surfaces or more, permanent/primary All No Limitations All No None D2330 Resin-based composite one surface, anterior Anterior Teeth only No Limitations All No None D2331 Resin-based composite two surfaces, anterior Anterior Teeth only No Limitations All No None D2332 Resin-based composite three surfaces, anterior Anterior Teeth only No Limitations All No None D2335 Resin-based composite four or more surfaces, anterior Anterior Teeth only No Limitations All No None D2391 Resin-based composite, 1 surface-posterior primary/permanent Posterior Teeth only No Limitations All No None D2392 Resin-based composite, 2 surfaces-posterior primary/permanent Posterior Teeth only No Limitations All No None Page 320 of 331 ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED? ATTACHMENTS REQUIRED D2393 Resin-based composite, 3 surfaces-posterior primary/permanent Posterior Teeth only No Limitations All No None D2394 Resin-based composite, 4+ surfaces-posterior primary/permanent Posterior Teeth only No Limitations 0-11 No None D2930 Prefabricated stainless steel - primary tooth No Limitations 0-20 No None D2931 Prefabricated stainless steel - permanent tooth No Limitations 0-20 No None D2932 Prefabricated Resin crown No Limitations 0-20 No None D2934 Prefabricated esthetic coated stainless steel crown - primary tooth (Stainless steel primary crown with exterior esthetic coating) Primary Teeth only (A-T) Permanent Teeth only (1-32) Only Anterior teeth 6-11, 22-27, c-h, m-r Anterior Primary Teeth only(ch,m-r) 2 per anterior tooth, per member, per lifetime. Anterior primary teeth only (C, D, E, F, G, H, M, N, O, P, Q, R). 0-11 No None D2951 Pin retention - per tooth, in addition to restoration Only for Permanent Molars(13,14-16,1719,30-32) 0-20 No None D3110 Pulp cap - direct (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament. All Limited to permanent molars; used in conjunction with D2160, D2161, D2931, or D2932. Lifetime maximum of two per molar. Limit of one per tooth per date of service. No Limitations 0-20 No None 1-32, A-T Shall not be billed in conjunction with D3310, D3320, or D3330 on the same day. 0-20 No None D3310 Root canal - Anterior (excluding final restoration) Only for teeth 6-11 and 22-27 Once per lifetime. 0-20 Post review Pre and Post treatment radiographs showing endodontic fill D3320 Root canal - Bicuspid (excluding final restoration) Only for teeth 4, 5, 12, 13, 20, 21, 28, 29 Once per lifetime. 0-20 Post review Pre and Post treatment radiographs showing endodontic fill D3330 Root canal - Molar (excluding final restoration) Only for teeth 1-3, 1419, 30-32 Once per lifetime. 0-20 Post review Pre and Post treatment radiographs showing endodontic fill D3410 Apicoectomy/periradicul ar surgery - anterior Only for teeth 6-11, 22-27 Once per lifetime. All Post review 1) Pre and PostTreatment radiographs showing endodontic fill of tooth (teeth) involved. 2) Complete treatment plan. D3220 Page 321 of 331 ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED? ATTACHMENTS REQUIRED D3421 Apicoectomy/periradicul ar surgery - bicuspid (first root) Only for teeth 4, 5, 12, 13, 20, 21, 28, 29 Once per lifetime. All Post review 1) Pre and PostTreatment radiographs showing endodontic fill of tooth (teeth) involved. 2) Complete treatment plan. D3425 Apicoectomy/periradicul ar surgery - molar (first root) Only for teeth 1-3, 1419, 30-32 Once per lifetime. All Post review 1) Pre and PostTreatment radiographs showing endodontic fill of tooth (teeth) involved. 2) Complete treatment plan. D3426 Apicoectomy/periradicul ar surgery (each additional root) Only for teeth 1-5, 1221, 28-32 Once per lifetime. All Post review 1) Pre and PostTreatment radiographs showing endodontic fill of tooth (teeth) involved. 2) Complete treatment plan. D4210 Gingivectomy or gingivoplasty-four or more contiguous teeth or bounded teeth spaces per quadrant All One per 12 months. A minimum of four (4) teeth in the affected quadrant. Limited to patients with gingival overgrowth due to congenital, heredity or drug induced causes. All Yes--prepayment review 1) Comprehensive periodontal evaluation documentation. 2) Narrative documenting necessity. 3) Pre-treatment radiographs 4)Periodontal charting D4211 Gingivectomy or gingivoplasty- one to three contiguous teeth or bounded spaces per quadrant All One per 12 months. One (1) to three (3) teeth in the affected quadrant. Limited to patients with gingival overgrowth due to congenital, heredity or drug induced causes. All Yes--prepayment review 1) Comprehensive periodontal evaluation documentation. 2) Narrative documenting necessity. 3) Pre-treatment radiographs 4)Periodontal charting D4341 Periodontal scaling and root planing, per quadrant All One per 12 months. A minimum of three (3) teeth in the affected quadrant. Cannot bill in conjunction with D1110 or D1201. One per 3 months for patients diagnosed with AIDS. All Yes-post review since 10/1/12 and prior authorization effective? 1) Periodontal charting. 2) Narrative documenting necessity. 3) Pre-Treatment radiographs. 4) List number of quadrants required on Pre-Treatment/ Prior Approval estimate. D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis All Covered for pregnant women only. One per pregnancy. All Post review to confirm pregnancy None D5520 Replace missing or broken teeth - complete denture (each tooth) All One per 12 months per denture per patient. 0-20 No None D5610 Repair resin denture base All Three per 12 months per patient. 0-20 No None D5620 Repair cast framework All Three per 12 months per patient. 0-20 No None Page 322 of 331 ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED? ATTACHMENTS REQUIRED D5640 Replace broken teeth per tooth All One per 12 months per patient per dentist. 0-20 No None D5750 Reline complete maxillary denture (laboratory) All 0-20 No None D5751 Reline complete mandibular denture (laboratory) All 0-20 No None D5820 Interim partial denture (maxillary) Interim partial denture (mandibular) All One per 12 months per denture per patient. Not covered within 6 months of placement. One per 12 months per denture per patient. Not covered within 6 months of placement. One per 12 months per patient. One per 12 months per patient. 0-20 Yes Narrative 0-20 Yes Narrative D5913 Nasal prosthesis All All Yes Narrative D5914 Auricular prosthesis All All Yes Narrative D5919 Facial prosthesis All All Yes Narrative D5931 Obturator prosthesis, surgical All Covered for Prosthodontists only. Covered for Prosthodontists only. Covered for Prosthodontists only. Covered for Prosthodontists only. All Yes Narrative D5932 Obturator prosthesis, definitive All Covered for Prosthodontists only. All Yes Narrative D5934 Mandibular resection prosthesis All Covered for Prosthodontists only. All Yes Narrative D5952 Speech aid - pediatric (13 and under) All Covered for Prosthodontists only. 0-13 Yes Narrative D5953 Speech aid - adult (14 20) Palatal augmentation prosthesis All Covered for Prosthodontists only. Covered for Prosthodontists only. 14-20 Yes Narrative All Yes Narrative D5955 Palatal lift prosthesis All All Yes Narrative D5988 Oral surgical splint All All Yes Narrative D5999 Unlisted maxillofacial prosthetic procedure All Covered for Prosthodontists only. Covered for Prosthodontists only. Covered for Prosthodontists only. All Yes Narrative D7111 Coronal Remnants Deciduous tooth A-T No Limitations All No None D7140 Extraction, erupted tooth or exposed root No Limitations All No None D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth 1 - 32, 51 82, A-T, ASTS 1-32, 5 -82, A-T, AS-TS Includes cutting of gingiva and bone, removal of tooth structure and closure. All No None D7220 Removal of impacted tooth - soft tissue 1-32, 51-82 No Limitations All No None D7230 Removal of impacted tooth - partially bony 1-32, 51-82 No Limitations All No None D7240 Removal of tooth completely bony Removal of impacted tooth - completely bony, with unusual surgical complications 1-32, 51-82 No Limitations All No None 1-32, 51-82 Unusual complications such as nerve dissection, separate closure of the maxillary sinus, or aberrant tooth position. All No None Surgical removal of residual tooth roots cutting procedure 1-32, 51-82, A-T, AS-TS Will not be paid to the dentists or group that removed the tooth. All No None D5821 D5954 D7241 D7250 All All Page 323 of 331 ADA CODE D7260 D7280 D7310 D7320 DESCRIPTOR Oroantral fistula closure Surgical access of an unerupted tooth Alveoloplasty in conjunction with extractions - per quadrant Alveoloplasty not in conjunction with extractions per quadrant D7410 Radical excision - lesion diameter up to 1.25 cm D7472 Removal of torus palatinus Removal of torus mandibularis D7473 TEETH COVERED All 1-32 BENEFIT LIMITATIONS No Limitations No Limitations AGE LIMITATIONS All 0-20 AUTHORIZATION REQUIRED? No Yes-prepayment review Per quadrant - 10 (UR), 20 (UL), 30 (LL), 40 (LR) Per quadrant - 10 (UR), 20 (UL), 30 (LL), 40 (LR) Per quadrant - 10 (UR), 20 (UL), 30 (LL), 40 (LR) Upper Arch (01, UA) Lower Arch (02, LA) Once per lifetime. Minimum of three extractions in the affected quadrant. Usually in preparation for a prosthesis. Once per lifetime. No extractions performed in an edentulous area. All No ATTACHMENTS REQUIRED None Approved orthodontic plan None All No None No Limitations All No None Once per lifetime. All No None Once per lifetime. All No None D7510 Incision and drainage of abscess (intraoral) All No Limitations All No None D7520 Incision and drainage of abscess (extraoral) All No Limitations All No None D7530 Removal of foreign body All All No None D7880 Occlusal orthotic device, by report Suture of recent small wounds up to 5 cm All Shall not pertain to removal of stitches (sutures) or teeth. Once per lifetime. 0-20 Yes-prior authorization Narrative All No None D7960 Frenulectomy All Shall not be billed in conjunction with any other surgical procedure. It shall not pertain to repair of surgically induced wounds. Once per lifetime. Limited to one per date of service. All No None D8080 Comprehensive orthodontic treatment of the adolescent dentition All No Limitations 0-20 Yes 1)Cephalometric image with tracing 2)Panoramic or full mouth image 3)Intraoral and extraoral facial frontal and profile pictures 4)Occluded and trimmed models or digital images of models 5)Initial payment is made when treatment is started D8210 Removable Appliance Therapy All 0-20 Yes Arch or quadrant must be indicated on the claim D8220 Fixed Appliance Therapy All 0-20 Yes Arch or quadrant must be indicated on the claim D8660 Pre-orthodontic treatment visit All This appliance is not to be used to control harmful habits. Limit of two (D8210, or D8220) per 12 months. This appliance is not to be used to control harmful habits. Limit of two (D8210, or D8220) per 12 months. Used to pay for records. Final records will be paid only if member is age 20 and under and still eligible for benefits on date of service. Member cannot be billed for final records. 0-20 Yes 1)Cephalometric image with tracing 2)Panoramic or full mouth image 3)Intraoral and extraoral facial frontal and profile pictures 4)Occluded and trimmed models or digital images of models 5)Initial payment is made when treatment is started D7910 All Page 324 of 331 ADA CODE DESCRIPTOR TEETH COVERED BENEFIT LIMITATIONS AGE LIMITATIONS AUTHORIZATION REQUIRED? ATTACHMENTS REQUIRED D8670 Periodic orthodontic treatment visit(as part of the contract) All Quarterly Payment No limitations Yes Approved orthodontic treatment D8680 Orthodontic Retention(removal of appliances, construction and placement of retainer(s)) All Final Payment No limitations Yes Beginning and final records D8999 Unspecified orthodontic procedure, by report All Six month payment. 0-20 Yes 1) Complete narrative describing Member's condition, compliance with and need for treatment, estimated treatment period 2) Study models 3) Radiographs D9110 Palliative (emergency treatment of dental pain minor procedure) (Not payable in conjunction with other dental services except radiographs.) All Not allowed with any other services other than radiographs. One per patient per dentist or dental group per date of service. All No None D9241 Intravenous sedation/analgesia - first 30 minutes All "This procedure code shall not be used for billing local anesthesia or nitrous oxide." (Kentucky State Dental Manual page 4.11). 0-20 No 1) Narrative detailing medical necessity and dental treatment done or to be done. 2) The person responsible for the administration must have a current valid permit from the Kentucky State Board of Dentistry to do so. D9420 Hospital call (Requires 24 hour notification after services rendered.) All No other procedures may be billed in conjunction with D9420. Not applicable for nursing home visits (D0150 or D9110). One per patient per dentist or dental group per date of service. Cannot bill conjunctively. All Yes Narrative Page 325 of 331 Provider Manual Section 20.0 Acronyms Table of Contents Acronym - Definitions Page 326 of 331 20.0 Acronyms Acronym Definition AAP American Academy of Pediatrics ABMS American Board of Medical Specialties ACOG American College of Obstetricians & Gynecologists ADA American Dental Association ADA American Diabetes Association AFDC Aid to Families with Dependent Children AHFS American Hospital Formulary System AIS Alternative Intermediate Services AMA American Medical Association APRN Advanced Practice Registered Nurse CAQH Council for Affordable Quality Healthcare CHFS Cabinet for Health and Family Services CLAS Culturally and Linguistically Appropriate Standards CLIA Clinical Laboratory Improvement Amendments COA Category of Aid COE Category of Eligibility CMS Center for Medicare and Medicaid Services DCBS Department for Community Based Services DD Developmental Disabilities DEA Drug Enforcement Agency Page 327 of 331 Acronym Definition DME Durable Medical Equipment DMS Department for Medicaid Services DOS Date of Service DRA Deficit Reduction Act DRE Dilated Retinal Exam DRG Diagnosis Related Group EDI Electronic Data Interchange EFT Electronic Funds Transfer EOB Explanation of Benefits EPSDT Early Periodic, Screening, Diagnosis and Treatment ER Emergency Room ERA Electronic Remittance Advice FDA U.S. Food and Drug Administration FFS Fee-for-Service FFSEs Fee-for-Service Equivalents FQHC Federally Qualified Health Centers GHAA Group Health Association of America HANDS Health Access Nurturing Developing Services HEDIS® Healthcare Effectiveness Data and Information Set HHS Health and Human Services Department HIPAA Health Information Portability and Accountability Act IBNRs Incurred But Not Reported Claims ID Identification Card Page 328 of 331 Acronym Definition ICF Intermediate Care Facility IVR Interactive Voice Response System KCHIP Kentucky Children’s Health Insurance Program KHC Kentucky Health Choices (a.k.a. Ky Health Choices) KTAP Child and Family Related Medical Cases LEP Limited-English Proficiency LOS Length of Stay LPCC Licensed Primary Care Center MAID Kentucky Medicaid Identification Number NCCI National Correct Coding Initiative NCQA National Committee for Quality Assurance NDC National Drug Code NHLBI National Heart, Lung and Blood Institute NIH National Institute of Health NPDB National Practitioner Data Bank NPI National Provider Identifier OTC Over-the-Counter PA Prior Authorization PBM Pharmacy Benefits Manager PCC Primary Care Center PCP Primary Care Provider/Practitioner PCS Patient Clinical Summary PCSU Provider Claims Service Unit Page 329 of 331 Acronym Definition PE Presumptive Eligibility PHI Protected Health Information PASSPORT Passport Health Plan PIC Program Integrity Coordinator PMPM Per Member Per Month POIS Passport Online Information Service PRP Provider Recognition Program PRTF Psychiatric Residential Treatment Facility QAPI Quality Assessment Program Improvement QDWIs Qualified Disabled Working Individuals QI Quality Improvement QMBs Qualified Medicare Beneficiaries RBRVS Resource Based Relative Value Scale RHC Rural Health Center RN Registered Nurse SCMBs Specified Low Income Medicare Beneficiaries SOBRA Sixth Omnibus Budget Reconciliation Act SNF Skilled Nursing Facility SSI Supplemental Security Income TANF Temporary Assistance to Needy Families TIN Tax Identification Number TPA Third Party Administrator TPL Third Party Liability Page 330 of 331 Acronym Definition UHC University Health Care, Inc. UM Utilization Management UPL Upper Payment Limit USP United States Pharmacopeia USPDI United States Pharmacopeia Dispensing Information VFC Vaccines for Children WIC Women, Infants, and Children Page 331 of 331
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