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2014
Provider Manual
Coventry Health Care of Florida Inc.
June 2014
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Table of Contents
❶ Administration ................................................................................................................................... 7
Section 1 – Overview ................................................................................................................................ 7
Introduction .......................................................................................................................................... 7
History .................................................................................................................................................. 7
Purpose of this Manual ......................................................................................................................... 7
Protocols and Guidelines....................................................................................................................... 7
Coventry Provider Services.................................................................................................................... 8
Coventry National & First Health Network Contact Information ............................................................ 8
Key Contact Information ....................................................................................................................... 9
Products and Plan ................................................................................................................................. 9
Special Needs Plan ................................................................................................................................ 9
Provider Tools ..................................................................................................................................... 10
Translation Services ............................................................................................................................ 11
IVR (Integrated Voice Response System) ............................................................................................. 11
Forms & Reference Documents ........................................................................................................... 11
Designated Liaison .............................................................................................................................. 11
Member Responsibility ....................................................................................................................... 11
Direct Access and Cost-Sharing ........................................................................................................... 12
Marketing ........................................................................................................................................... 12
Compliance and Ethics Program .......................................................................................................... 12
Section 2 – Provider Programs and Responsibilities ............................................................................... 13
Provider Selection Criteria .................................................................................................................. 13
Changes to Provider Information or Status ......................................................................................... 13
Member Identification ........................................................................................................................ 14
Acceptance of Members ..................................................................................................................... 14
Verification of Eligibility ...................................................................................................................... 14
Managing the Member’s Health Care .................................................................................................. 15
Authorizing Treatment for Members................................................................................................... 15
Timeliness of Authorizations ............................................................................................................... 16
Access to Care and Service Standards ................................................................................................. 17
Section 3-Primary Care Physicians ......................................................................................................... 18
Membership Assigned to PCPs ............................................................................................................ 18
Hospitalist Program............................................................................................................................. 18
Section 4-Specialist Physicians ............................................................................................................... 19
Referrals for Specialist Services ........................................................................................................... 19
Follow-Up Care ................................................................................................................................... 19
Exceptions to Referral Requirement for Specialist Services ................................................................. 19
Prescriptions from OB/GYN: ................................................................................................................ 20
Obstetricians ....................................................................................................................................... 20
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Section 5-Hospitals ................................................................................................................................. 21
Hospital Emergency Services ............................................................................................................... 21
Follow-Up Care ................................................................................................................................... 21
Section 6-Medical Records Guidelines .................................................................................................... 22
Medical Records Requests .................................................................................................................. 22
Advance Directives .............................................................................................................................. 23
Medical Record Alteration or Falsification ........................................................................................... 24
Transfer of Medical Records upon Termination of the Agreement ...................................................... 24
Medical Records: Member Consent .................................................................................................... 24
Member’s Rights to Access Medical Records ....................................................................................... 24
Section 7-Utilization Management Program & Clinical Practice Guidelines........................................... 25
Care/Case Management ..................................................................................................................... 25
Medically Necessary or Medical Necessity .......................................................................................... 25
Behavioral Health................................................................................................................................ 26
Case Management .............................................................................................................................. 26
Obstetrical Case Management Program .............................................................................................. 26
Pediatric Case Management Program ................................................................................................. 26
Transplant Case Management Program .............................................................................................. 26
Ventilator Case Management Program ............................................................................................... 26
Disease Management Programs .......................................................................................................... 27
Chronic Care Improvement Program (CCIP)......................................................................................... 28
Clinical Practice Guidelines.................................................................................................................. 28
Diabetes Clinical Practice Guidelines ................................................................................................... 28
Asthma Clinical Practice Guidelines ..................................................................................................... 30
Congestive Heart Failure ..................................................................................................................... 32
Skilled Nursing Admissions .................................................................................................................. 32
Rehabilitation Admissions ................................................................................................................... 32
Discharge Planning .............................................................................................................................. 33
Second Opinions ................................................................................................................................. 33
New Medical Technologies ................................................................................................................. 33
Section 8- Quality Improvement............................................................................................................. 34
Quality Improvement .......................................................................................................................... 34
HEDIS™ ............................................................................................................................................... 34
Medical Quality Performance Measure ............................................................................................... 35
Risk Management Program ................................................................................................................. 57
Long Term Care Program .................................................................................................................... 58
Medicare Social Services Unit.............................................................................................................. 59
Medicare Provider Training & Education ............................................................................................. 59
Section 9 – Fee Schedule Maintenance & Reimbursement Determinations ........................................... 61
Medicare/Commercial HMO/POS/PPO/Individual Products ................................................................ 61
Medicaid/Healthy Kids/Individual Product .......................................................................................... 61
Laboratory and Pathology Services ..................................................................................................... 61
Section 10 – Claims, Billing, Capitation & Encounters ............................................................................ 63
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Coordination of Benefits ..................................................................................................................... 64
Claim Status ........................................................................................................................................ 64
How to Read Your Remittance Advice ................................................................................................. 65
Claim Detail......................................................................................................................................... 65
Editing Guidelines ............................................................................................................................... 66
High Dollar Claims (with expected payable amounts over $50,000) .................................................... 66
National Provider Identifier (NPI) ........................................................................................................ 67
Section 11 – EDI Claim & Encounter Submissions ................................................................................... 68
Monitoring Your EDI Reports .............................................................................................................. 69
Common Rejection Reason ................................................................................................................. 69
EDI Assistance ..................................................................................................................................... 70
Section 12 – Provider Administration Claims Review Process ................................................................ 71
Medical Necessity Reconsideration (Pre-Service) ................................................................................ 72
Important Information About Commercial Member Appeal Rights ..................................................... 72
Important Information About Medicare Member Appeal Rights ......................................................... 74
Important Information About Medicaid Member Appeal Rights ......................................................... 74
Section 13 – Overpayment Recovery ...................................................................................................... 77
Section 14 – Credentialing ...................................................................................................................... 78
Practitioners Rights: ............................................................................................................................ 78
Board Certification: ............................................................................................................................. 79
Re-Credentialing ................................................................................................................................. 79
Dual Specialties ................................................................................................................................... 79
Ongoing Monitoring ............................................................................................................................ 80
Credentialing Committee .................................................................................................................... 80
Section 15 - Provider Participating Status Dispute Resolution ............................................................... 81
Section 16 – Regulation and Accreditation ............................................................................................ 82
Disciplinary Action .............................................................................................................................. 82
Reporting to Regulatory Agencies ....................................................................................................... 84
Committee Activity ............................................................................................................................. 84
Treatment of Immediate Relatives and Self:........................................................................................ 84
Section 17- Pharmacy ............................................................................................................................. 85
Pharmacy Drug Formulary................................................................................................................... 85
Pharmaceutical Management Procedures ........................................................................................... 85
Generic Drug Policy ............................................................................................................................. 85
Prior Authorization and Step Therapy ................................................................................................. 86
Quantity Limits.................................................................................................................................... 86
Diabetic Supplies ................................................................................................................................. 86
Specialty Drugs and Self-Administered Injectables .............................................................................. 86
Pharmacy Network ............................................................................................................................. 87
Maintenance Drug Program ................................................................................................................ 87
Appeal Rights ...................................................................................................................................... 87
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Section 18- General Information ............................................................................................................ 88
Independent Contractor Relationship ................................................................................................. 88
Member Provider Reportable Diseases ............................................................................................... 88
❷ Medicaid .......................................................................................................................................... 90
Medicaid Program............................................................................................................................... 90
Florida Agency for Health Care Administration’s Medicaid Coverage and Limitations Handbook ........ 90
Medicaid Fraud and Abuse Complaint Form ........................................................................................ 90
Provider Subcontractor Responsibilities .............................................................................................. 90
Continuity of Care in Enrollment ......................................................................................................... 91
Emergency Service Responsibilities ..................................................................................................... 91
Requirements Regarding Background Screening ................................................................................. 92
Cultural Competency .......................................................................................................................... 92
Community outreach and marketing activities: ................................................................................... 94
Florida SHOTS/Healthy Kids ................................................................................................................ 95
Healthy Behaviors Program: ................................................................ Error! Bookmark not defined.6
Important Information for Medicaid Members ................................................................................... 96
Listing of Medicaid Covered Services .................................................................................................. 97
Enrollees Rights and Responsibilities: .................................................................................................. 104
❸Key Lists & List of Forms .................................................................................................................. 105
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❶ Administration
Section 1 – Overview
Introduction
Welcome to Coventry Health Care of Florida, Inc. and its affiliate companies including, but not limited to Coventry
Health Plan of Florida, Inc., Coventry Summit Health Plan and Coventry Health and Life Insurance Company
(hereinafter collectively referred to as “Coventry”). Coventry offers an array of products such as HMO, POS and
PPO for employer groups and individual policies (CoventryOne). Coventry also has policies that cover enrollees in
government programs such as Medicare, Medicaid and Florida Healthy Kids. We appreciate your participation in
our network and welcome and encourage your comments and questions.
History
Coventry Health Care of Florida Inc., Coventry Health Plan of Florida Inc., Coventry Summit Health Plan and
Coventry Health and Life Insurance Company are subsidiaries of Coventry Health Care, Inc. -- a national managed
health care company based in Bethesda, Maryland operating insurance companies, network rental and workers’
compensation services companies. Coventry offers a full range of risk and fee-based managed care products and
services including HMO, PPO and POS, Medicare Advantage, Medicaid, Healthy Kids, Workers’ Compensation and
network lease products to a broad cross-section of employer and government-funded groups, government
agencies, individuals and other insurance carriers and administrators in all 50 states, as well as, the District of
Columbia and Puerto Rico.
Purpose of this Manual
The purpose of this Provider Manual (this "Manual") is to provide your office with business guidelines and
requirements necessary to conduct business transactions with Coventry. This Manual supports all Coventry
Health and Life Agreements. This Manual is incorporated by reference into the terms and conditions of your
Agreement with Coventry. All capitalized terms not otherwise defined in this Manual shall have such meaning as
ascribed to them in the Agreement between Coventry and the particular Provider.
Periodically, it will become necessary to update this Manual. Updated versions of this Manual are available at
www.directProvider.com. Updates may also be delivered via fax, mailing or other electronic means for significant
changes and/or updates. Please retain updates with your Manual for future reference and guidance. Additional
reference material can be located at www.chcflorida.com.
Protocols and Guidelines
Provider acknowledges and agrees that (i) all decisions rendered by Coventry in its administration of the
Agreement, including, but not limited to, all decisions with respect to the determination of whether or not a
service is a covered service, are made solely to determine if payment of benefits under applicable Member
Contract is appropriate; and (ii) any and all decisions relating to the necessity of the provision or non-provision of
medical services or supplies shall be made solely by the Member and Provider in accordance with the usual
Provider patient relationship and Provider as applicable, shall have sole responsibility for the medical care and
treatment of Members under their care. Providers should encourage Members under their care to review their
Member Contract concerning benefits, procedures and exclusions or limitations prior to receiving treatment.
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Coventry Provider Services
Coventry offers Provider support and education services through a dedicated team of network management
associates. Provider relations representatives are available to answer your questions and assist you with
navigating Coventry’s operations, policies, procedures and business guidelines.
You may contact a Provider Relations Representative Provider by:
Phone: 800-470-3555
Fax:
866-874-4140
Email: chcflProviderrelations@cvty.com
Coventry National & First Health Network Contact Information
This Manual contains information related to Coventry’s Florida health plan products and networks. For
information related to Coventry’s national network, First Health network, or Workers' Comp network
please visit the sites below:
For any questions related to the status of receipt or payment of a claim call the payor-specific billing telephone
number listed on the M e m b e r ’s benefit card. For any questions regarding how a claim was paid according
to your Contract, please call Coventry National Provider Services at 1-800-937-6824.
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Key Contact Information
Products and Plan
Coventry offers a variety of products in its portfolio with several Provider networks to service the membership of
each product. Coventry’s products include:
-HMO
-PPO
-Medicare
-Healthy Kids
-POS
-ASO
-Medicaid
-Special Needs Plan for dual eligible members enrolled in a Coventry Medicare
Advantage benefit plan
Specific products are offered in select markets; your participating Provider Agreement will determine your
participation.
Special Needs Plan
The Special Needs Plan was approved by Congress in 2003 to provide improved services to Medicare beneficiaries
in three special needs populations, i.e.
•
•
•
Institutionalized Members;
Members with certain severe or disabling chronic conditions, and
“Dual Eligible” Medicare and Medicaid Members.
Coventry offers Dual Eligible Special Needs Plans (DE-SNP) in Dade, Broward, Palm Beach, St. Lucie, Hernando,
Hillsborough, Pinellas, Polk and Pasco counties. The DE-SNPs operate under the product names of Coventry Vista
Maximum Choice, Coventry Vista Maximum, Coventry Summit Maximum and Coventry Advantra Maximum.
The DE-SNP program is available to eligible Coventry Members residing within the program’s service area and
meeting dual eligibility status requirements. Dual eligibility qualification is determined by the Members’
participation in federally administered Medicare programs and the state administered Medicaid programs based
on low-income, assets and age or disability status.
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Coventry’s PCPs have partnered with the plan to identify eligible SNP Members and to assist in navigating through
the health care system. Participants in DE-SNPs are enrolled in Coventry’s Case Management program to:
•
•
•
•
•
•
Integrate and coordinate care across specialty, multi-setting care continuums through a central point of
contact;
Emphasize early intervention and education;
Improve access to care including medical, behavioral health and social services;
Provide seamless transitions across health care settings, care providers and health services;
Improve Member health outcomes through reducing hospitalizations and nursing home placement; and
Provide specialty support through management of specific diseases, e.g. CHF, diabetes, chronic renal disease,
hypertension and asthma/COPD.
Coventry developed and implemented a model of care to provide guidance for comprehensive care management
to Members enrolled in a DE-SNP. Providers are required to review, understand and utilize the guidelines set
forth in Coventry’s model of care. The Special Needs Program Physician Training and Model of Care are available
on CHCflorida.com at
http://chcflorida.coventryhealthcare.com/web/groups/public/@cvty_regional_chcfl/documents/webcontent/c07
4933.pdf
To support HEDIS initiatives it is very important that Providers submit encounter data for Care for Older Adults
(COA) measures and ensure that the supporting documentation for all SNP Members ages 65 and older in the
Member's chart.
Requirements:
-Advance Care Planning (CPTII: 1157F, 1158F)
-Medication Review (CPTII: 1160F)
-Functional Status Assessment: (CPTII: 1170F)
-Pain Screening (CPTII: 0521F, 1125F, 1126F)
For specific individualized care plans, PCPs may access and download the information at www.SNPCarePlans.com
or contact the Disease Care Management department directly at 1-800-422-7335 ext. 3359.
Information on these and other services may also be viewed in the news section at www.DirectProvider.com
Visit our website to download a copy of the training at www.chcflorida.com under the document library and
www.DirectProvider.com in the resource library.
Provider Tools
Coventry offers Providers easy access to a variety of functions, web-based tools, and resources at
www.DirectProvider.com. All participating Providers may use this resource to access business activity information
such as:
-Claim inquiries
-Authorization requirements and information
-Remittance advices
-Member eligibility
-Business forms
-Provider Manual
-Member benefit information
-Other business information or documentation
-Member health alerts
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DirectProvider.com Provider has a customer service center available to address questions regarding the web site
and services. You may contact a representative at 1-866-629-3975. Hours of operation are Monday through
Friday 8:00am to 6:00pm Eastern Time. Sign up is quick and easy at www.DirectProvider.com. Please have your
FTIN, Provider CPD and IDX numbers available.
Translation Services
If a language barrier prevents you from communicating effectively with our Members, we have translation
services available to assist. Our language line provides interpreter services at no cost. Please contact our customer
service center at 866-847-8235. Inform the customer service representative of your need of an interpreter and
the language. The connection will be made for you.
For individuals with hearing impairment, Coventry Health Care of Florida offers a 7-1-1 relay. For Members who
are hearing impaired, the health plan will utilize the 7-1-1 Telecommunications Relay Service (TRS). Members
should call 7-1-1 and a representative will contact our customer service number on their behalf.
As a Provider of services, you should be aware of Members who do not speak English or who have hearing
impairments. Under Title VI of the Civil Rights Act and the Federal Rehabilitation Act, interpreter services must be
available to ensure effective communication regarding treatment, medical history or health education. Coventry
Health Care of Florida will arrange and pay for trained professionals when technical, medical or treatment
information needs to be discussed with Members.
Providers must offer the Member access to interpreter services, even when the Member brings a friend or
family Member to interpret.
In this event, the Member must be offered interpreter services and be informed that the services are available at
no charge; the friend or family Member should not be used to interpret unless specifically requested by the
Member, after having been advised of the availability of free interpreter services.
IVR (Integrated Voice Response System)
Access to information such as eligibility, claim status and authorization are available by using our Integrated Voice
Response system (IVR) by calling customer service and following the appropriate prompts.
Forms & Reference Documents
Required forms and reference documents can be downloaded and printed from the resource library under the
downloadable forms section of Coventry Health Care of Florida’s Provider website at: www.DirectProvider.com.
Designated Liaison
Each Provider’s office shall designate an office manager or administrator to be the primary contact person for
Coventry’s Network Operations department.
Member Responsibility
Providers acknowledge and agree that Coventry shall have no financial or other liability with respect to a
Member’s failure to pay Providers amounts due the Providers for co-payment, co-insurance, or deductible as
required under the Member’s Contract or for non-covered services. Providers may not refuse to provide services
to an eligible Member solely because the Member fails to pay the applicable co-payment at the time services are
rendered.
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Direct Access and Cost-Sharing
Providers shall, as mandated by state or federal law, the applicable Member Contract and this Manual; (i) allow
Members direct access to certain specialist physicians; (ii) not inhibit Members’ self-referral for certain services,
including mammography screening and influenza vaccinations; and (iii) not impose cost-sharing on any Member
for influenza or pneumococcal vaccines. To the extent permitted by applicable law and benefit plan design (i.e.
open access), Members may self refer without a primary care physician ("PCP") referral for (a) mental and
behavioral health services, (b) gynecologists and obstetricians; (c) chiropractors; (d) podiatrists for routine care;
(e) dermatologists for five (5) visits per year; and (f) optometrists, if such services are covered for the Member, in
addition to any other services for which applicable law allows direct access.
Marketing
Any Provider marketing activities or materials for Coventry must be approved by Coventry in advance to ensure
compliance with CMS and AHCA guidelines. This mandatory review will include letters announcing affiliation with
Coventry, plan availability, events, health fairs, etc. Any gifts or promotional items must also follow guidelines
promulgated by CMS or AHCA. Contact the network operations representative for more information.
Providers may make available and/or distribute Coventry marketing materials and display posters or other
materials announcing Coventry Contractual relationships in accordance with and subject to Medicare marketing
materials guidelines. However, Providers may not make available, accept or distribute Coventry enrollment
applications or offer inducements to enroll in a specific plan. Providers shall not offer anything of value to induce
a prospective Member to select them as their Provider.
Compliance and Ethics Program
We are dedicated to conducting our business in accordance with the highest standards of ethical conduct. We are
committed to conducting business activities with uncompromising integrity and in full compliance with the
federal, state and local laws governing the health benefits industry. This commitment applies to relationships
with shareholders, customers (enrollees, federal Providers, state and local governments), vendors, competitors,
auditors and all public and government bodies. Most importantly, it applies to directors, officers, employees and
representatives of Coventry. Each Coventry employee is responsible for upholding the highest level of ethical
standards that exemplify professionalism and promote confidence in the organization.
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Section 2 – Provider Programs and
Responsibilities
A Provider must complete an application, Provider Agreement and be fully credentialed as outlined in Section 14,
in order to be approved for participation and treat any Coventry Members. Upon execution of the Agreement a
copy will be returned to the Provider for his/ her records along with a welcome letter advising of product
participation and effective dates.
Provider Selection Criteria
The Coventry network is open for application by a particular Provider/Provider specialty type if at least one of the
following criteria is met:
a. Access and availability standards are not being met in that area
b. There appears to be a need in the market place for a particular specialty due to referral patterns
c. Member, group or provider self nomination (Depending upon product and geography any provider requesting a
direct contract with Coventry, provider information will be shared with the specialty network for review and
consideration.)
d. A provider’s participation is in the best interest of the plan and meets the business needs of the plan
Once a determination has been made to add a Provider to the network and reimbursement has been mutually
agreed upon, the Provider must meet quality of care and quality of service standards as well as Coventry’s
minimum administrative requirements covered in Section 14 of this Manual.
Changes to Provider Information or Status
Please notify Coventry’s Network Operations department in writing within sixty (60) days or in accordance with
your Agreement of any additions, deletions or changes to the topics listed below. Failure to notify Coventry timely
could negatively impact claims processing.
•
•
•
•
•
•
•
•
Tax identification number (submission of W-9 required). Changing a tax identification number will require
a new Agreement with the new tax identification number
Office or billing address
Telephone or fax number
Specialty (may require additional credentialing)
New physician additions to the practice (please allow time for credentialing)
Licensure (DEA, state licensure or malpractice insurance)
Group affiliation
Hospital privileges
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If you have any changes, written notification is required as far in advance as possible to the Coventry’s Network
Operations department. By providing the information prior to the change, the following is ensured:
•
•
•
•
The practice address is properly listed in the Coventry Provider directory
All claim payments are properly reported to the IRS
There is no disruption in claims payments and claims are processed accordingly
Coventry Members are notified in a timely manner if a change to their PCP becomes necessary or if they
desire as a result of an address change or inability to continue participation with Coventry
Member Identification
All Coventry Members receive an identification (ID) card shortly after enrollment. Members must present their ID
card to their Provider at the time services are rendered. If the Member is a recent enrollee who has not yet
received a card, he/she must present a copy of the enrollment form. The ID card will list the Member’s name,
Member number, primary care physician (PCP) (if applicable), group name and number, the benefit plan type, as
well as copayments or coinsurance for office visits, prescriptions, outpatient and inpatient services. Benefits vary
among Coventry’s different products. Therefore, it is important to reference the Member ID card for the correct
copayment or coinsurance amount. The ID card will also contain important customer service phone numbers for
Coventry, the pharmacy vendor, and the mental health vendor.
Acceptance of Members
Provider shall accept as patients all Members that select or are assigned by Coventry to a Provider unless
otherwise agreed upon in writing by Coventry. Written approval is required by Coventry Health Care of Florida for
a Provider’s panel to be frozen preventing or refusing new Members. Upon Coventry’s approval, Provider’s panel
may remain open only to existing patients who are Members at the time the Provider’s panel is frozen (“Existing
Members”). In such case, if a Member desires to select a Provider with a panel open only to existing Members,
Coventry will contact the Provider to verify that the Member meets the criteria for an existing Member. If the
Provider confirms that this is an existing Member, Coventry will open the panel to allow that Member to select
the Provider. Upon a Provider’s acceptance of a Member, Provider may terminate the Member from its panel or
as its patient only upon satisfaction of applicable provisions of this Manual and applicable laws and regulations.
If a Member is non-compliant or does not comply with the Member rights and responsibilities as set forth herein,
the Provider may notify the Member of the situation in writing. However, the Provider may not terminate the
Member from their panel or services. Provider must request of Coventry, in writing, that a Member be removed
from their panel; provided, however, that no such request can be based on the Member’s medical condition,
which request shall be determined by Coventry in Coventry’s sole discretion. Such request must be sent to
Coventry Provider representative.
Verification of Eligibility
Prior to providing any services to a Member, Providers shall determine a Member’s eligibility by taking the
following steps:
1.
2.
3.
Ask the Member to present his/her Coventry Membership card.
If this is the Member’s first visit, ask the Member to present additional proof of personal
identification, preferably a photo ID.
Refer to www.directProvider.com for current Member eligibility list or call the telephone number
provided on the Membership card to determine eligibility and verification of the type of plan in
which the Member is enrolled.
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Coventry shall make reasonable efforts to confirm or deny eligibility using the most current information available
to Coventry; provided, however, that Providers' compliance with such verification procedures and/or Coventry’s
confirmation of a Member’s eligibility does not constitute a guarantee of such Members eligibility or Coventry’s
coverage of any services provided by Providers in reliance on such confirmation. Providers may verify eligibility by
contacting a Coventry customer service representative or www.directProvider.com.
Managing the Member’s Health Care
Under certain Member Contracts, a referral or pre-authorization define as authorization that must be
obtained from Coventry, or its designee, prior to the provision of certain covered services, as set forth in
this Manual and as required by the applicable coverage plan and the Agreement. These Providers are
listed on Coventry website. All pre authorizations using the (The CHCFL Prior Authorization Form) and referrals
can be done electronically via directProvider.com. If a paper version is needed it can be downloaded and printed
from the resource library under the downloadable forms section of Coventry’s Provider website at:
www.directProvider.com.
No PCP referral is required for any care listed under the direct access provision of this Manual. Except in the case
of emergency services, urgently needed services, as otherwise permitted under this Manual or applicable state or
federal law, upon the prior written approval of Coventry’s medical director or his/her designee, or as otherwise
permitted under the applicable Member Contract, all referrals shall be made and pre-authorizations obtained by
Providers in accordance with this Manual, the Agreement and the applicable Member Contract. Any laboratory
services provided to Members in Providers’ offices shall not be reimbursable covered services, unless otherwise
expressly provided in the Agreement.
PCP shall use his/her best efforts to provide Members with any necessary referrals or obtain any required preauthorization from Coventry while the Member is in PCP’s office.
Authorizing Treatment for Members
Authorization is not a guarantee of payment. All Providers must contact Coventry via www.directProvider.com,
telephone or fax to obtain a pre-authorization prior to scheduling a Member for any medical service subject to
pre-authorization. Coventry may require the submission of clinical information to support a pre-authorization
request. Hospitals shall notify Coventry of an admission occurring subsequent to the provision of emergency
services.
Emergency services do not require pre-authorization.
IMPORTANT: The following services may not be covered under all Member Contracts even though such services
are listed below. Members should refer to their summary of benefits or evidence/certificate of coverage for
information regarding their covered services. This applies to all Member Contracts.
-Drug Order for Home Use
-Chemotherapy Drug Replacement
-Physician Office Medications
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Timeliness of Authorizations
Coventry shall use its best efforts to provide requested pre-authorizations immediately upon a Provider’s request;
provided, however, that Providers agree to take a pending or tracking number with respect to a pre-authorization
request in the event Coventry requires further information in making the pre- authorization coverage decision.
Routine pre-authorization requests will be completed within four to fourteen (4-14) business days of Coventry’s
receipt of the request. Coventry’s determination will be communicated verbally to the requesting Provider at the
time the decision is made and will be followed by written notice. All medical denial determinations will be made
by a Florida licensed Coventry medical director. Denial letters will be sent to the Provider by fax or U.S. mail.
Members will receive a copy of the notice via U.S. mail.
Urgent pre-authorization requests will be processed within 72-hours of Coventry’s receipt of the request, unless
additional information is required. The determination, approval or denial, will be verbally communicated or faxed
to the requesting Provider and/or the Member at the time the decision is rendered followed by written notice to
the Provider and/or the Member within (2) business days.
Authorization status can be obtained by using Coventry website, www.directProvider.com
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Access to Care and Service Standards
Providers shall offer appointments and access to Members within the following guidelines:
•
Appointment availability shall be:
o
For routine care and physicals – 30 calendar days
o
For urgent care – same day
o
For emergent care - immediately
o
For sick care – within a calendar week
•
Member telephone calls to Provider offices shall be returned as follows:
o
Urgent – within 30 minutes
o
Emergent – immediately
o
Routine – within one business day
During site visits to the Provider office for credentialing, re-credentialing and Provider representative office visits,
Coventry will verify access standards by reviewing the Providers’ schedules of available appointments and may
conduct periodic audits of appointment availability, return telephone calls, and after hours coverage
arrangements. Network Operations will review and intervene, when appropriate, based on Member complaints
about access to care and services.
Site visits are required for initial and re-credentialing of Primary Care and OB/GYN providers as required by
regulatory guidelines. Coventry can also conduct site visits upon inquiry. The Health plan monitors and tracks
Provider visit data. Site visit assessments can include the following, but not limited to:
Site visits include assessments of:
• Physical accessibility for persons with disabilities
• Adequate space, supplies, proper sanitation, smoke-free facilities
• Evidence of proper fire and safety procedures
• Medical record keeping practices
• Posting of the Agency’s statewide consumer call center telephone number including the hours of
operation in the waiting room reception area.
• Posting of the Agency’s Summary of Florida’s Patient’s Bill of Rights and Responsibilities (please refer to
www.DirectProvider.com to review in entirety)
• The availability of a copy of the Florida Patient’s Bill of Rights and Responsibilities for enrollees who
request a copy of the document.
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Section 3-Primary Care Physicians
PCPs are responsible for coordinating and managing the health care of their assigned Members in accordance
with the applicable Member Contract, this Manual, and the Agreement. PCPs provide primary care services to all
their patients and coordinate all other covered services, including specialist services defined as those covered
services generally provided by specialist physicians in their respective fields of training and experience.
Membership Assigned to PCPs
Members may choose a PCP from Coventry’s Provider directory. Every month, PCPs receive a Coventry
Membership listing of the Members that have chosen them as their PCP. PCPs shall contact any new Medicare or
Medicaid Members in their panel to ask if they need any assistance or to schedule an office visit for continued
medical care.
Each PCP office shall designate an encounter/referral coordinator to ensure that encounters and referrals are
completed and submitted to Coventry and/or the Member. Encounters may be submitted electronically or on a
CMS1500 form.
Hospitalist Program
Under Coventry’s Hospitalist Program (the “Program”), PCP acknowledges and agrees that hospitalist physicians
provide primary care services which PCP is otherwise obligated to provide under the Agreement on behalf of
Members assigned to PCP (“PCP Members”) who present as observation or as inpatients to a hospital, including,
but not limited to (i) evaluation of PCP Members presenting to the hospital’s emergency room; (ii) conducting
daily hospital rounds of PCP Members; (iii) coordinating care of PCP Members and ensuring timely provision of
covered diagnostic tests and procedures; (iv) communicating regularly with PCP, PCP Members and the PCP
Members’ families, as appropriate; and (v) overseeing and coordinating discharge planning of PCP Members with
the PCP, Coventry and the hospital. PCPs who elect to participate in the program shall assign responsibility of PCP
Members to hospitalist physicians when PCP Members present to the emergency department or are inpatients of
a hospital.
In cases where a PCP elects not to participate in the program, the PCP shall continue to perform all other primary
care services with respect to PCP Members, including, but not limited to (i) resuming responsibility for all care,
including follow-up care, of a PCP Member immediately upon the PCP Member’s discharge from the hospital; (ii)
communicating all medical information/history to the hospitalist physician or other physician attending to a PCP
Member which is necessary to the PCP Member’s care and treatment in the hospital; and (iii) performing any and
all other requirements as requested by Coventry in connection with the PCP’s participation in the program.
Hospitals acknowledge and agree that if a PCP Member presents to the emergency department, the hospital shall
notify PCP Member’s PCP and/or hospitalist physician participating in Coventry hospitalist program.
18
Section 4-Specialist Physicians
The Member’s PCP is responsible for coordinating the provision of specialist services. The Specialist and the PCP
work together to coordinate medical care for the Member.
Referrals for Specialist Services
Except for (i) emergency services; (ii)urgently needed services; (iii) as otherwise permitted under this Manual, the
applicable Member Contract or applicable state or federal laws; or (iv) upon the prior written approval of
Coventry’s medical director or his/her designee, specialist shall not provide specialist services to Members who’s
Member Contract has a referral requirement unless the Member furnishes specialist with a completed referral
from the Member’s PCP.
Follow-Up Care
Specialist shall coordinate the provision of specialist services with the Member’s PCP in a prompt and efficient
manner and, except in the case of an emergency medical condition, shall not provide any follow-up or additional
specialist services to Members other than the covered services indicated on the applicable referral form provided
to specialist by Coventry or the PCP. Within ten (10) business days of providing specialist services to a Member,
specialist shall furnish the Member’s PCP with a written report regarding the Member’s medical condition in such
form and detail reasonably acceptable to the Member’s PCP and Coventry. Specialist shall at all times promptly
and openly communicate with the Member’s PCP regarding the Member’s medical condition, including, without
limitation obtaining the appropriate pre-authorization should a Member require additional or follow-up covered
services.
Except in the case of emergency services, Urgently Needed Services, as otherwise permitted under the applicable
Member Contract, applicable law or upon the prior written approval of Coventry’s Medical Director or his/her
designee, specialist shall refer Members back to the Member’s PCP in the event specialist determines the
Member requires the services of another specialist physician.
URGENTLY NEEDED SERVICES/URGENT CARE – Covered Services for conditions that (i) though not lifethreatening, could result in serious injury or disability to the Member unless medical attention is received or
(ii) substantially restrict a Member’s activity; and (iii) which are provided (a) when a Member is temporarily
absent from the service area or; (b) under unusual and extraordinary circumstances, when the Member is in
the service area but all participating Providers are temporarily unavailable or inaccessible when such covered
services are medically necessary (as defined under Medicaid) and immediately required (1) as a result of an
unforeseen illness, injury, or condition; and (2) it was not reasonable given the circumstances to obtain the
covered services through a participating Provider. Examples include, without limitation, high fever, animal
bites, fractures, severe pain, infectious illness, flu and respiratory ailments.
Exceptions to Referral Requirement for Specialist Services
Diagnostic Centers/Ambulatory Surgery Centers: For any Commercial HMO, POS, PPO, or Individual HMO or
Individual POS Member, specialists may issue a prescription for outpatient diagnostic testing at a participating
freestanding diagnostic center, or for covered services provided at a participating ambulatory surgery center
without pre-authorization from Coventry, as set forth on the table on the next page. If pre-authorization is
required for the requested service, the specialist and PCP, for PCP required products, will be required to
coordinate obtaining the proper authorization for Member.
19
Prescriptions from OB/GYN:
Commercial HMO, POS, PPO, Individual HMO or Individual POS, Medicaid and Healthy Kids Members: A
gynecologist or obstetrician may issue prescriptions for (i) covered services which do not otherwise require preauthorization in accordance with this Manual; and (ii) covered services provided by gynecological oncologists,
maternal and fetal medicine specialists, reproductive endocrinologists and uro-gynecologists. The gynecological
oncologist, maternal and fetal medicine specialist, reproductive endocrinologist or uro-gynecologist must contact
Coventry directly for pre-authorization prior to providing services to Members.
Medicare Members: A gynecologist or obstetrician may issue prescriptions for covered services provided by
gynecological oncologists, maternal and fetal medicine specialists, reproductive endocrinologists and urogynecologists. The gynecological oncologist, maternal and fetal medicine specialist, reproductive endocrinologist
or uro-gynecologist must contact Coventry directly for pre-authorization prior to providing services to Members.
OB/GYN’s may not issue prescriptions for any other services for Medicare Members.
HMO Open Access; Open Access plus point of service, PPO: Specialists may provide covered services to
Members enrolled in an HMO Open Access, Open Access Plus, and Point of Service (POS) plan or Preferred
Provider Organization (PPO) benefit plan without a referral from the Member’s PCP or a prescription from the
Member’s obstetrician/gynecologist.
See table below:
Provider Type
Format
PCP
Referral
Obstetrician
Gynecologist
Specialist
Coverage Plan
Medicare, Medicaid, Healthy Kids,
HMO, Individual HMO & POS,
Individual POS, PPO
Prescription Medicaid, Healthy Kids, HMO,
Individual HMO, POS, Individual POS,
PPO
Prescription HMO, Individuel HMO, POS, Individuel
or Referral
POS, PPO
For Services Not Requiring PreAuthorization
All
All
Outpatient diagnostic testing
(freestanding, par facility)
Ambulatory surgery center
(freestanding, par facility)
Obstetricians
The obstetrical notification form should be completed during a Members’ first prenatal visit. The form is located
in the resource library under the downloadable forms section of the Coventry website at
www.directProvider.com.
20
Section 5-Hospitals
Hospital Emergency Services
In the case of an emergency medical condition, hospitals are not required to obtain pre-authorization from
Coventry prior to providing emergency services to Members; provided, however, that upon admitting a Member
into hospital, hospital shall immediately notify the hospitalist physician participating in Coventry’s hospitalist
program or other designated Coventry Provider of such admission and obtain the required pre-authorization in
accordance with this Manual.
Except for emergency services, coverage of all services rendered to Members by hospital are subject to Coventry’s
sole determination of whether such service is a covered service under the applicable Member Contract. In the
event it is determined that an emergency medical condition does not exist with respect to a Member who
presented to the hospital, hospital must comply with all pre-authorization requirements as set forth in this
Manual prior to providing any non-emergency services to a Member.
Hospital’s failure to so obtain all required pre-authorizations for non-emergency services may, in Coventry’s sole
discretion, result in Coventry’s denial of payment for such services as set forth in the Agreement. Hospital shall
comply with this Manual and the Agreement in providing non-emergency services to Members. Hospital
acknowledges and agrees that Coventry has the right to review the admission of any Member for an emergency
medical condition for appropriateness of continued stay in accordance with the Manual.
Follow-Up Care
Hospital shall coordinate the provision of hospital services with the Member’s PCP in a prompt and efficient
manner and, except in the case of an emergency medical condition, as otherwise permitted under the Manual or
applicable state or federal law or upon the prior written approval of Coventry’s medical director or his/her
designees’, shall not provide any follow-up or additional hospital services to Members other than the covered
services in accordance with the pre-authorization for such services. Hospital shall at all times promptly and openly
communicate with the Member’s PCP regarding the Member’s medical condition, including, without limitation
obtaining the appropriate pre-authorization should a Member require additional or follow-up covered services.
21
Section 6-Medical Records Guidelines
The Managed Care Plan shall ensure maintenance of medical/case records for each enrollee in accordance with
this section and with 42 CFR 431 and 42 CFR 456. Medical/case records shall include the quality, quantity,
appropriateness and timeliness of services performed under the contract.
Providers shall prepare and maintain complete medical records for Members under their care in a manner that
complies with the following:
•
•
•
Applicable federal and state laws
Licensing, accreditation, and reimbursement rules and regulations applicable to Coventry, and
Accepted medical practice
In accordance with federal and state law and the Agreement, each Provider must protect the confidentiality of
Members’ patient records. To fulfill this obligation, Providers must designate a person to be in charge of the
Provider's medical records, and such person’s responsibilities include, but are not limited to, the following duties
in accordance with federal and state law and the Agreement:
•
•
•
Maintaining the confidentiality, security, and physical safety of patient records
Retrieving Member records in a timely manner upon the request of an authorized party, and
Supervising the collection, processing, maintenance, storage, retrieval, and distribution of records
In accordance with the Agreement and this Manual, the medical records must be available for utilization review,
risk management and peer review studies, customer service inquiries, grievance and appeals, and quality
improvement initiatives.
All records should be kept confidential and maintained for seven (7) years and in certain instances described in
the Medicare Advantage regulation, periods of up to ten (10) per 59A-12.005 and 64B14-7.002 of the Florida
administrative code. All Member information should be available to be transferred upon request by the Member,
or authorized representative, to any organization with which the Member may subsequently enroll, or to a
Provider to ensure continuity of care.
Providers must keep our members’ information confidential and stored securely. Providers must also ensure all
staff members receive periodic training on member information confidentiality. Only authorized personnel
should have access to medical records.
We use practitioner/provider performance data to improve the quality of service and clinical care our members
receive. Accrediting agencies require that providers let us use your performance data for this purpose.
Medical Records Requests
Providers must respond and submit requested medical records to Coventry’s Grievance and Appeals and/or
Quality Improvement departments promptly to enable Coventry to comply with federal and Florida laws
governing grievances and appeals and complaint investigation. Only those records for the time period designated
on the request should be sent. A copy of the request letter should be submitted with the copy of the record. The
submission should include test results, office notes, referrals, telephone logs and consultation reports.
22
Advance Directives
Providers shall document whether or not a Member executed an advance directive in a prominent part of the
Member’s medical record. Providers shall certify if he/she/it cannot implement an advance directive on grounds
of conscience as permitted by state law.
23
Medical Record Alteration or Falsification
Alteration or falsification of medical records is unethical conduct for any medical professional. Any incident
relating to unethical behavior regarding medical record documentation is subject to the following process:
1.
2.
3.
4.
All incidents of possible medical record falsification are reported to Coventry’s Peer Review
Committee and the Special Investigation Unit (SIU).
The Peer Review Committee reviews the records in question and allows the Provider to explain
the circumstances.
The Peer Review Committee makes the final decision regarding the allegations of unethical
conduct and takes appropriate actions.
Health professionals not subject to the peer review process (nurse, lab personnel, etc.) may be
reported to the appropriate agency and/or governing body.
Transfer of Medical Records upon Termination of the Agreement
Upon the effective date of termination of the Agreement (and the expiration of any period of any continuing care
obligation), or such earlier date as a Member may select or be assigned to another Provider regardless of whether
the Agreement then remains in effect, pursuant to a Member’s or Coventry’s request, Provider shall copy all such
Member’s medical records in Provider’s possession and forward such records, at no cost to Coventry or to the
Member, to (i) such other Provider as designated by Coventry; (ii) the Member; and (iii) Coventry, as requested by
Coventry or the Member.
Medical Records: Member Consent
Where required by law, Providers shall obtain specific written authorization from a Member prior to releasing
such Member’s medical records. Providers acknowledge and agree that the consent by a Member in the
applicable Member Contract enrollment form and/or Providers' standard consent form is hereby deemed
satisfactory Member consent for the release of Members’ records, to the extent required by applicable law.
Member’s Rights to Access Medical Records
Providers shall ensure timely access by Members to review, amend and obtain a copy of their medical records
upon request, to the extent required by applicable law.
24
Section 7-Utilization Management Program & Clinical
Practice Guidelines
Care/Case Management
As required by applicable law, Coventry has procedures to identify, assess and establish treatment plans for
persons with complex or serious medical conditions. With respect to individuals with complex or serious medical
conditions, Providers shall assist Coventry in (i) identifying such individuals; (ii) diagnosing, assessing and
monitoring such individuals; and (iii) establishing and implementing treatment plans for such individuals that (a)
are appropriate for their condition; (b) are time-specific; (c) are updated periodically; (d) ensure adequate
coordination of care among Providers; and (e) include an adequate number of direct access visits to Providers
consistent with the treatment plan. Coventry shall maintain written protocols for identifying, assessing and
implementing interventions for enrollees with complex medical issues, high service utilization, intensive health
care needs, or who consistently access services at the highest level of care.
Medically Necessary or Medical Necessity
Services provided in accordance with 42 C.F.R. 438.210 (a)(4) and as defined in Section 59G-1.010(166), F.A.C., to
include those medical or allied care, goods, or services furnished or ordered must:
a) Meet the following conditions:
1. Be necessary to protect life, prevent significant illness or significant disability, or to alleviate
severe pain;
2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness
or injury under treatment, and not in excess of the Member’s needs;
3. Be consistent with the generally accepted professional medical standards as determined by the
Medicaid program, and not experimental or investigational;
4. Be reflective of the level of service that can be safely furnished, and for which no equally
effective and more conservative or less costly treatment is available, statewide;
5. Be furnished in a manner not primarily intended for the convenience of the Member, the
member’s caretaker, or Provider;
6. For those services furnished in a hospital on an inpatient basis, medical necessity means that
appropriate medical care cannot be effectively furnished more economically on an outpatient
basis or in an inpatient facility of a different type
7. “Medically Necessary” or “Medical Necessity” for inpatient hospital services requires that
those services furnished in a hospital on an inpatient basis could not, consistent with the
provisions of appropriate medical care, be effectively furnished more economically on an
outpatient basis or in an inpatient facility of a different type.
b) The fact that Provider prescribed, recommended, or approved medical or allied goods, or services
does not, in itself, make such care, goods or services medically necessary, a medical necessity or a
Covered Service.
25
Behavioral Health
Coordination of care between the Primary Care Physician (PCP) and the Behavioral Health Practitioners (BHP) is
critical to the well being of the patient.
Coventry Health Care, Inc. uses a variety of mechanisms to monitor continuity and coordination of care between
behavioral health and medical care. Coventry works collaboratively with our Behavioral Health vendors for the
administration, management and monitoring the quality of behavioral health services for members.
Some of the indicators that Coventry may review on an annual basis are the exchange of information between
behavioral healthcare and primary care physicians; the appropriate diagnosis, treatment and referral of
behavioral health care disorders commonly seen in primary care; the appropriate use of psychopharmacological
medications; management of treatment access and follow-up of members with co-existing medical and behavioral
disorders; and primary or secondary preventive behavioral health care program implementation.
Case Management
Members may self-refer and Providers may refer Members to Coventry’s case management programs. Providers
may request assistance in the development of plans of treatment for Members with complex or serious medical
conditions. To make such a referral or to request assistance, please contact Case Management at (800) 422-7335,
extension 3405. To refer a Member to one of these programs, use the disease and case management referral
form in the forms section of this Manual. Fax the completed form to (877) 479-8545.
The case management nurse will work with the Provider, the Member and the Member’s family in an effort to
help decrease the risk of complications, support coordination of care and provide education. These nurses will
work with Providers to assess, plan and monitor options and services for Members with chronic illness or injury.
Case management services are also offered to Members upon discharge from the hospital, to help facilitate the
receipt of post-discharge services administered by their Provider.
Obstetrical Case Management Program
An obstetrical nurse works with Obstetricians and Perinatologists to help coordinate services during pregnancy for
Members with high-risk conditions. The case manager also monitors the mother and newborn progress through
the sixth week postpartum follow-up visit. To make a referral or get information on this program, call (800) 4227335, extension 3630.
Pediatric Case Management Program
Pediatric Members with catastrophic or chronic diseases are supported by a pediatric nurse who works with the
Member’s Providers and family, while the child is in the hospital or at home. The nurse works to identify
participating Providers, and resources in the area to meet the child’s needs as defined by the Providers. For more
information on this program, call (800) 422-7335, extension 3377.
Transplant Case Management Program
Transplant candidate Members should be referred to the transplant coordinator. Contact the transplant
coordinator at (800) 422-7335, extension 3322.
Ventilator Case Management Program
A case manager follows up with Members who are placed on a ventilator in an acute facility, and will work with
the Member’s attending physician, other case managers and the family to establish a discharge plan for the
26
Member. If the Member is discharged to a SNF, the concurrent review coordinator will continue to follow the
Member until the Member is weaned from the ventilator or placed in a custodial setting. For more information,
call (800) 422-7335, extension 3405.
To refer a Member to one of these programs, use the disease and case management referral form in the forms
section of this Manual. Fax the completed form to (877) 479-8545.
Disease Management Programs
Disease management programs are population-based programs designed to improve the health status of
Members with chronic diseases by actively intervening to assist Members and practitioners manage the disease.
Coventry provides bi-lingual staff to support Spanish-speaking Members. Coventry maintains five disease
programs: Congestive Heart Failure, Diabetes, Asthma, Hypertension and Renal Disease Management. The
programs are based on scientific literature and industry disease management standards. Separate program
descriptions are maintained for each program.
Members are identified using a clinical rules program which pulls claims data regarding diagnosis, medication,
laboratory testing and procedures. Based on analysis of the data extracted, those Members meeting selected
disease state criteria will be enrolled in one of the identified disease management programs. Members may also
be identified through any of the following processes:
•
•
•
•
Member completes a health risk assessment form after enrollment
Member admitted to acute care facility and reviewed by Coventry on-site nurse. Nurse makes referral to
disease management program, as appropriate
PCP may contact Coventry to refer a Member to a program by faxing a disease management referral form
to (877) 479-8545). See the forms section of this Manual for a sample form
Member self-refers through customer service
Once the Member is identified as eligible to participate in the program, he or she is stratified by disease severity
and placed in one of the following tiers:
Tier I - Low:
The Member is notified of the appropriate disease management program and provided
educational materials through mail. Members are encouraged to contact their disease
management nurse if they need assistance, guidance or have any questions regarding
their disease. Once a Member is identified as having a disease state, and literature has
been mailed, they are automatically enrolled in the disease management program.
Members who wish to disenroll in the program will be directed to contact their disease
management nurse or call the customer service department.
Tier II - Moderate:
All of the above interventions as well as a disease management nurse will contact the
Member to perform an assessment for their specific condition. Nurses also provide
focused education on disease, diet, exercise and medication and discuss the importance
of self-management. The nurse will communicate with the Member and their attending
physician to coordinate a treatment plan.
Tier III - High:
Members meeting the highest criteria with CHF, diabetes or asthma are enrolled in a Tier
III program. In addition to the components featured in Tier I and Tier II, these Members
also receive an in-home monitoring device that records, on a daily basis, clinical data
related to their condition. This information is relayed electronically to Coventry which is
reviewed by the disease management nurse. If the nurse receives data that indicates an
27
exacerbation or complication of the disease, the Member and physician will be called to
facilitate an intervention so the appropriate medical treatment can be provided to the
Member in a timely manner.
The Member may call a case manager at any time during normal business hours, Monday through Friday,
between 8:30 a.m. and 5:30 p.m. Once the Member is stable, communication will be less frequent; however, the
Member may contact the case manager at any time.
To speak with a disease case manager call (800) 422-7335 ext. 3405 or (954) 858-3405. You will be connected to
the appropriate disease case manager for the following conditions:
-Asthma
-CHF
-Diabetes
-Hypertension
-Chronic Renal Disease
Chronic Care Improvement Program (CCIP)
To support the PCP in managing the care of Members with CHF, diabetes, and chronic renal disease, Coventry
offers CCIP. Potential Members will be identified by Coventry. To be eligible, the Member must have been
enrolled with Coventry for at least six (6) continuous months.
Once the Members are identified, Coventry will contact the Member’s PCP to participate in the program. The
disease case manager will contact the Member to perform a comprehensive assessment. If indicated Coventry’s
licensed social worker will conduct a home visit Member. The disease case manager and the social worker will
contact the PCP to develop a care plan. The Member and Member’s family or caregiver will be contacted and
provided education on disease state, diet, medication and care plan.
Clinical Practice Guidelines
Coventry Health Care, Inc. (Coventry) employees make clinical decisions regarding members’ health based on the
most appropriate care and service available. Coventry makes these decisions based on appropriate clinical
criteria. The clinical guidelines and criteria used by the Health Services Departments are available to practitioners
on the health plan website or via access to www.Direct Provider.com.
A Member's participation in Coventry’s disease management programs is not a substitute for a physician's
medical advice or treatment. Coventry does not intend to exercise any control or direction over a physician's
medical judgment or clinical decisions, or to interfere with the physician/patient relationship between Providers
and their patients. The following clinical practice guidelines are intended to be educational and informational in
nature and are not meant to substitute for a Provider's medical judgment or advice.
Diabetes Clinical Practice Guidelines
Purpose
As part of our goal of providing quality care and improved health outcomes, as well as improving Provider
awareness, Coventry supports the use of evidence-based medicine to reduce unnecessary variations in care. For
diabetes management, Coventry has adopted the current recommendations from the American Diabetes
Association, a recognized, national, expert source on diabetes management. A summary of the standards may be
accessed at: http://care.diabetesjournals.org/content/33/Supplement_1/S4.full.pdf1
1
“Please note that not all health insurance and group health plans cover all recommended services. Please check the member’s benefit documents to
determine whether their health insurance or group health plan covers these services”
28
This is intended solely as a guide and information source. Coventry recognizes that any management plan should
be individualized and developed in coordination with the physician, health care team, patient and family, as
deemed necessary.
Diabetes is a chronic illness that requires continuing medical care and patient self-management education to
prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and
requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a
range of interventions to improve diabetes outcomes.
29
Guideline Components to be Monitored
• Hemoglobin A1C testing
• Percentage of Members with Hemoglobin A1c greater than 9% (poor control)
• Percentage of Members with Hemoglobin A1c less than 8% (good control)
• LDL screening rates
• LDL-C control (Less than 100 mg/dL)
• Diabetic nephropathy testing
• Diabetes – eye examinations
Interventions
• By evaluating claims data, Coventry will collect data to verify Provider and Member compliance with the
guideline recommendations for the above components
• Educational information and individual Provider feedback will be provided where compliance rates do not
meet benchmark goals
• All Members with diabetes will be assessed for participation in the diabetes disease management
program, to facilitate achievement of clinical outcome goals
Clinical Outcome Goals
Hemoglobin A1C level < 8.0%
Lipid control: LDL-C < 100 mg./dL
Annual eye examination
Urine albumin and serum creatinine testing annually
Asthma Clinical Practice Guidelines
Purpose
In its efforts to improve Provider and Member awareness of nationally established practice guidelines for
common disease states, Coventry supports the clinical practice guideline for asthma outlined in 2007 by the
National Asthma Education and Prevention Program of the National Institutes of Health. Members and Providers
may access the asthma clinical practice guideline in its entirety at:
http://www.nhbli.nih.gov/guidelines/asthma/index.htm
Physicians are encouraged to familiarize themselves with the guideline and to incorporate the guideline into their
daily patient management. As with all guidelines, it is intended to offer evidence-based guidance for treating this
disease, with the understanding that a physician’s treatment plan for any particular patient will be individualized.
It offers a consensus opinion on the standard of care, keeping in mind that variations from it are expected when a
patient’s particular clinical circumstances so require.
Coventry intends to select several standards from within the guideline each year for particular focus and will
monitor rates of adherence to those standards (referenced below as a “monitored standard”). Again, it is
understood that deviations from any particular standard may occur based on physician judgment. Nevertheless,
the overall rates of compliance will be instructive, and it is Coventry’s goal to improve overall compliance on those
standards for appropriate patients.
30
Definitions
Asthma severity is classified in persons 5 years of age and older by assessing the level of impairment. The severity
level is based on the child’s/caregiver’s recall of the 2-4 weeks just prior to the assessment.
•
•
•
•
Severe persistent - continual daytime symptoms, frequent nighttime symptoms, and extreme limitation of
normal activity
Moderate persistent – daily daytime symptoms or symptoms more than one night per week, and some
limitation of normal activity
Mild persistent – daytime symptoms more than twice per week but less than once a day or symptoms
more than two nights per month, and minor limitation of normal activity
Intermittent – daytime symptoms less than or equal to two days per week and less than or equal to two
nights per month, and no limitation of normal activity
Guideline Components To Be Monitored – Coventry will monitor:
• The use of inhaled corticosteroids in asthmatic Members age five and older with two or more emergency
department visits and/or one inpatient admission for asthma in the past year
• The use of long-acting bronchodilators in asthmatic Members age five and older with two or more
emergency department visits and/or one inpatient admission for asthma in the past year
• The number of asthma-related emergency department visits annually in Members age 5 and older
• The number of asthma-related inpatient admissions annually in Members age five and older
Data Tracking – Coventry will track all pharmacy claims for inhaled corticosteroids and inhaled long-acting beta
agonists and record the following specifics for each claim:
• Member name
• Provider name/ whether Provider is PCP or specialist
• Panel size of Provider
Coventry will track claims for the two pharmaceutical agents above and compare claims per 1000 Members
against established benchmarks for utilization of these two agents (allowing for mail order claims for up to 90
days of medication per claim).
Clinical Outcome Goals
• Increased use of inhaled corticosteroids in asthmatic Members
• Increased use of long-acting bronchodilators in asthmatic Members
• Reduction in number of asthma-related emergency department claims for Coventry Members
• Reduction in number of asthma-related inpatient claims for Members
31
Congestive Heart Failure
Purpose
Congestive Heart Failure (CHF) is a prevalent disease in Medicare Members and that prevalence is reflected in the
Coventry Membership.
In an effort to improve Provider and Member awareness of nationally established practice guidelines for common
disease states, Coventry encourages Providers and Members to use clinical practice guidelines as reference tools
for giving and receiving care. Providers are encouraged to familiarize themselves with applicable guidelines and to
refer to them in their daily patient management. Coventry recognizes the guideline for CHF management
developed by the American College of Cardiology (ACC). A complete copy of the guideline, may be found at:
http://content.onlinejacc.org/cgi/reprint/53/15/e1.pdf2
This is intended solely as a guide and information source. Coventry recognizes that any management plan should
be individualized, and developed in coordination with the physician, healthcare team, patient, and family, as
deemed necessary.
Guideline Components To Be Monitored
• Prescription fill rates of ACEI/ARB
• Prescription fill rates of beta blockers
• Annual lipid testing rates
Interventions
• By evaluating claims data, Coventry will collect data to verify Member and Provider compliance with
ACEI/ARB, beta blocker and lipid testing, as recommended by the guideline
• Educational information and individual Provider feedback will be provided where compliance rates do not
meet benchmark goals
• All Members with diabetes will be assessed for participation in the CHF disease management program to
facilitate achievement of clinical outcome goals
Clinical Outcome Goals
• Increased use of ACEI/ARB increased use beta blockers
• Appropriate lipid testing rates
Skilled Nursing Admissions
Skilled nursing facility admissions require pre-authorization. The concurrent review coordinator, as part of the
discharge planning process, usually performs pre-authorization of SNF admissions. Following the admission, the
concurrent review coordinator will review the stay via the telephone or onsite with the facility case manager (or
designated facility review staff).
Rehabilitation Admissions
Admissions to rehabilitation facilities require pre-authorization, which is often performed by the concurrent
review coordinator as a part of discharge planning. Concurrent review may be performed telephonically or onsite.
2
“Please note that not all health insurance and group health plans cover all recommended services. Please check the member’s benefit documents to
determine whether their health insurance or group health plan covers these services”
32
Discharge Planning
The concurrent review coordinator will begin the discharge planning process at the time of an inpatient, skilled
nursing, or rehabilitative facility admission. The concurrent review coordinator will collaborate with the hospital
discharge planner and the Member’s physician to ensure that the Member receives all medically necessary
covered services available within the Member’s Member Contract at the time of discharge.
Second Opinions
Florida Statute 641.51 requires that Coventry provide Members with access to a second medical opinion in any
instance in which the Member disputes Coventry’s or the Provider’s opinion of the reasonableness or necessity of
surgical procedures or is subject to a serious illness or injury. If requested, the Member may select a Provider or a
non-participating Provider in the geographical service area of Coventry.
If the Member selects a participating Provider, PCPs may issue a referral for the second opinion. If the Member
selects a non-participating Provider, the PCP must request a pre-authorization from Coventry.
New Medical Technologies
Coventry Health Care evaluates benefit coverage for new medical technologies or new applications of existing
technologies on an ongoing basis. These technologies may include medical procedures, drugs and devices. The
following factors are considered when evaluating the proposed technology:
• Input from appropriate regulatory bodies.
• Scientific evidence that supports the technology’s positive effect on health outcomes.
• The technology’s effect on net health outcomes as it compares to current technology.
The evaluation process includes a review of the most current information obtained from a variety of authoritative
sources including medical and scientific journals, medical databases and publications from specialty medical
societies and the government.
33
Section 8- Quality Improvement
Quality Improvement
Coventry’s Quality Improvement department identifies high-volume, high-risk and problem prone areas of care
and service affecting Members. To the extent required by applicable law and regulations and requirements of
applicable accreditation organizations, Coventry’s Quality Improvement department also:
Undertakes quality improvement initiatives:
•
•
•
Audits medical records and provides feedback on the results of those audits to Providers
Conducts retrospective review and investigation of complaints regarding quality of care
Shares findings with other committees, such as the Credentialing Committee, Peer Review Committee and
Quality Improvement Committee
HEDIS™
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures
designed to ensure that the public has the information needed to reliably compare performance of managed
health care plans. Some frequently asked questions regarding HEDIS data collection are addressed below:
Why do health plans collect HEDIS data?
The collection and reporting of HEDIS data are required by the Centers for Medicare and Medicaid Services (CMS)
for Medicare Members. Accrediting bodies such as the National Committee for Quality Assurance (NCQA), and
many states also require that health plans report HEDIS data. The HEDIS measures are related to many significant
public health issues such as cancer, heart disease, asthma, diabetes and utilization of preventive health services.
This information is used to identify opportunities for quality improvement for the health plan and to measure the
effectiveness of those quality improvement efforts.
How are HEDIS measures generated?
HEDIS measures can be generated using three different data collection methodologies:
• Administrative (uses claims and encounter data)
• Hybrid (uses medical record review on a sample of Members along with claims and encounter data)
• Survey
Why does Coventry need to review medical records when it has claims data for each encounter?
Medical record review is an important part of the HEDIS data collection process. The medical record contains
information such as lab values, blood pressure readings and results of tests that may not be available in
claims/encounter data. Typically, a Coventry employee will call the physician’s office to schedule an appointment
for the chart review. If there are only a few charts to be reviewed, the plan may ask the Provider to fax or mail the
specific information.
How accurate is the HEDIS data reported by the plans?
HEDIS results are subjected to a rigorous review by certified HEDIS auditors. Auditors review a sample of all
medical record audits performed by the health plan, so the plan may ask for copies of records for audit purposes.
Coventry also monitors the quality and inter-rater reliability of their reviewers to ensure the reliability of the
information reported.
34
Is patient consent required to share HEDIS related data with Coventry?
The HIPAA privacy rule permits a Provider to disclose protected health information to a health plan for the quality
–related health care operations of the health plan, including HEDIS, provided that the health plan has or had a
relationship with the individual who is the subject of the information, and the protected health information
requested pertains to the relationship. See 45 CFR 164.506(c)(4). Thus, a Provider may disclose protected health
information to a health plan for the plan’s HEDIS purposes, so long as the period for which information is needed
overlaps with the period for which the individual is or was enrolled in the health plan.
May the Provider bill Coventry for providing copies of records for HEDIS?
According to the terms of a Provider’s Agreement, Providers may not bill either Coventry or the Member for
copies of medical records related to HEDIS.
How can Providers reduce the burden of the HEDIS data collection process?
We recognize that it is in the best interest of both the Provider and Coventry to collect HEDIS data in the most
efficient manner possible. Options for reducing this burden include providing Coventry remote access to Provider
electronic medical records (EMR) and setting up electronic data exchange from the Provider EMR to Coventry.
Please contact your Provider relations representative or Coventry’s Quality Improvement department for more
information.
How can Providers obtain the results of medical record reviews?
Coventry’s quality improvement department can share the results of the medical record reviews performed at
your office and show you how your results compare to that of Coventry overall. Please contact your Provider
relations representative or Coventry’s quality improvement department for more information.
Medical Quality Performance Measure
The technical specifications, measures, and score criteria listed below are subject to change at any time based
upon changes issued by HEDIS or NCQA. Coventry shall use best efforts to notify Physician of such changes prior
to their effective date; however such changes shall not be subject to the formal notice and amendment provisions
of the Agreement.
At all times, PHYSICIAN shall be evaluated based upon the then-current technical
specifications, measures, and score criteria in effect.
1.
Evidence Based Medicine Guidelines (EBM)
Goal:
Improve compliance to the following evidence based guidelines.
Bone & Joint Conditions
•
Osteoporosis management in women who have a fracture. -% of women with t fracture who have
either a DEXA of osteoporosis drug in subsequent 6 months (NCQA/HEDIS) - Current Year HEDIS
Technical Specifications.
Comprehensive Adult Diabetes Care
•
HbAlc testing - The percentage of members 18 to 75 years of age with diabetes (type 1 and type
2) who had Hemoglobin Alc (HbAlc) testing (NCQA/HEDIS) - Current Year HEDIS Technical
Specifications.
35
•
Eye exam (retinal) – The percentage of members 18 to 75 years of age with diabetes (type 1 and
2) who had an eye screening for diabetic retinal disease in the measurement year or negative
retinal exam in the year prior to the measurement year. (NCQA/HEDIS) - Current Year HEDIS
Technical Specifications.
•
LDL-C screening – The percentage of members 18 to 75 years of age with diabetes (type 1 and 2)
who had an LDL-C test performed during the measurement year as identified by claim/encounter
or automated laboratory data. (NCQA/HEDIS) - Current Year HEDIS Technical Specifications.
Annual Monitoring for Patients on Persistent Medication (on angiotensin converting enzyme (ACE)
inhibitors or angiotensin receptor blockers (ARB))
•
Annual monitoring for members on ACE/ARB -The percentage of members 18 years of age and
older who received at least 180 treatment days of ambulatory medication therapy for a select
therapeutic agent during the measurement year and at least one therapeutic monitoring event
for the therapeutic agent in the measurement year (NCQA/HEDIS) - Current Year HEDIS Technical
Specifications.
Antidepressant Medication Management
•
The percentage of members 18 years of age and older who were diagnosed with a new episode of
major depression, treated with antidepressant medication, and who remained on an
antidepressant medication treatment. Two rates are reported:
1. Effective Acute Phase Treatment. The percentage of newly diagnosed and treated members
who remained on an antidepressant medication for at least 84 days (12 weeks).
(NCQA/HEDIS) - Current Year HEDIS Technical Specifications.
2. Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated
members who remained on an antidepressant medication for at least 180 days (6 months).
(NCQA/HEDIS) - Current Year HEDIS Technical Specifications.
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (Measure starts in Year 2)
•
COPD Spirometry - The percentage of members 40 years of age and older with a new diagnosis or
newly active COPD who received appropriate spirometry testing to confirm the diagnosis. (NCQA/HEDIS) - Current Year HEDIS Technical Specifications.
Breast Cancer Screening
•
The percentage of women 42 to 69 years of age with one or more mammograms during the
measurement year or the year prior to the measurement year. (NCQA/HEDIS) – Current Year
HEDIS Technical Specifications.
36
Colorectal Cancer Screening
•
The percentage of members 50 to 75 years of age who had an appropriate screening for colon
cancer. - (NCQA/HEDIS) - Current Year HEDIS Technical Specifications
Glaucoma Screening in Older Adults
•
The percentage of members 67 years and older, without a prior diagnosis of glaucoma or
glaucoma suspect, who had one or more eye exams for glaucoma by an eye care professional. (NCQA/HEDIS) - Current Year HEDIS Technical Specifications
Cholesterol Screening for Patients with Heart Disease
•
The percentage of members with heart disease who had a test for LDL cholesterol in the past
year. - (NCQA/HEDIS) - Current Year HEDIS Technical Specifications
Heart Failure – ACE and Acceptable Alternatives
•
The percentage of members 18 years and older identified with congestive heart failure (CHF) and
filled a prescription for an ACE-inhibitor, Angiotensin II Receptor Antagonist, Hydralazine or
Nitrate medication during the last 120 days of the period through day 90 days after the end of the
report period. - (Ingenix custom measure)
Coronary Artery Disease (CAD) – ACE and ARB
•
2.
The percentage of members 18 years and older identified with coronary artery disease (CAD) and
filled a prescription for an ACE-inhibitor or Angiotensin II Receptor Antagonist, medication during
the last 120 days of the period through day 90 days after the end of the report period- (Ingenix
custom measure)
Rx Compliance
Goal:
Improve pharmacy compliance and performance for the following conditions and measures.
Acute MI
•
Beta blocker after heart attack -% of member’s age 35 or greater diagnosed with MI with a
prescription for a beta blocker during the measurement year (NCQA/HEDIS) - Current Year HEDIS
Technical Specifications.
Rate of Generic prescription
• Ratio of generics to brand
• Formulary compliance rate
37
3.
Avoidable ER
Goal:
Decrease avoidable emergency room visits for select diagnosis codes. This metric will be
measured based on a per 1000 utilization rate based on the total Members, Avoidable ER ICD9
diagnosis codes are:
ICD-9 Code
Short Description
ICD-9 Code
Short Description
8.8
OTHER ORGANISM, NEC
372.1
CHRONIC CONJUNCTIVITIS
79.99
VIRAL INFECTION NOS
372.14
CHR ALLERGIC CONJUNCTNEC
110
110.5
DERMATOPHYT SCALP/BEARD
DERMATOPHYTOSIS OF BODY
372.2
372.3
BLEPHAROCONJUNCTIVITIS
CONJUNCTIVITIS NOS
307
SPECIAL SYMPTOM NEC
372.39
CONJUNCTIVITIS NEC
307.2
TIC DISORDER NOS
372.51
PINGUECULA
307.23
GILLES TOURETTE DISORDER
372.71
HYPEREMIA OF CONJUNCTIVA
307.4
307.42
NONORGANIC SLEEP DISORD
PERSISTENT INSOMNIA
372.72
372.73
CONJUNCTIVAL HEMORRHAGE
CONJUNCTIVAL EDEMA
307.46
SOMNAMBULISM/NGHT TERROR
372.74
CONJUNCTIVA VASC ANOMALY
307.47
SLEEP STAGE DYSFUNCT NEC
372.89
OTHER DISORDERS OF CONJUNCTIVA
307.5
EATING DISORDERS NEC/NOS
372.9
CONJUNCTIVA DISORDER NOS
307.59
EATING DISORDER NEC
380
DISORDER OF EXTERNAL EAR
307.8
PSYCHOGENIC PAIN NOS
380.1
INFEC OTITIS EXTERNA NOS
307.81
TENSION HEADACHE
380.11
ACUTE INFECTION OF PINNA
307.9
SPECIAL SYMPTOM NEC/NOS
380.12
ACUTE SWIMMERS' EAR
311
346
DEPRESSIVE DISORDER NEC
MIGRAINE
MIGRAINE W/O AURA W/O
INTRACTABLE MIGRAINE W/O
STATUS MIGRAINOSUS
380.22
380.31
ACUTE OTITIS EXTERNA NEC
HEMATOMA AURICLE/PINNA
380.39
NONINFECT PBX PINNA NEC
380.4
IMPACTED CERUMEN
380.89
DISORD EXTERNAL EAR NEC
380.9
381
DISORD EXTERNAL EAR NOS
AC NONSUP OTITIS MEDIA
381.01
ACUTE SEROUS OTITIS MEDIA
381.02
AC MUCOID OTITIS MEDIA
381.1
381.6
CHR SEROUS OM SIMP/NOS
NONSUPPURATIVE OTITIS MEDIA,
NOT SPEC.AS ACUTE OR CHRONIC
ET OBSTRUCTION
381.81
DYSFUNCT EUSTACHIAN TUBE
382
AC SUPPUR OTITIS MEDIA
ACUTE SUPPURATIVE OTITIS W/EAR
DRUM RUPTURE
346.1
346.2
VARIANTS OF MIGRAINE
346.8
MIGRAINE NEC
MIGRAINE, UNSPEC, W/O
INTRACTABLE MIGRAINE W/O
STATUS MIGRAINOSUS
346.9
354
CARPAL TUNNEL SYNDROME
354.2
354.3
ULNAR NERVE LESION
RADIAL NERVE LESION
354.9
MONONEURITIS ARM NOS
372
ACUTE CONJUNCTIVITIS NOS
372.01
SEROUS CONJUNCTIVITIS
372.03
372.05
MUCOPURULENT CONJUNCTNEC
AC ATOPIC CONJUNCTIVITIS
381.4
382.01
38
ICD-9 Code
ICD-9 Code
Short Description
473.9
CHRONIC SINUSITIS NOS
477
ALLERGIC RHINITIS
477.1
ALLERGIC RHINITIS DUE TO FOOD
477.2
ALLERG RHINITIS DUE TO ANIM
477.8
ALLERGIC RHINITIS NEC
477.9
382.9
Short Description
CHRONIC TUBOTYMPANIC
SUPPURATAIVE OTITIS MEDIA
CHRONIC ATTICOANTRAL
SUPPURATIVE OTITIS MEDIA
UNSPEC CHRONIC SUPPURATIVE
OTITIS MEDIA
UNSPECIFIED SUPPURATIVE OTITIS
MEDIA
OTITIS MEDIA NOS
388.2
SUDDEN HEARING LOSS NOS
486
ALLERGIC RHINITIS NOS
OTHER DISEASE OF NASAL CAVITY
AND SINUSES
PNEUMONIA, ORGANISM NOS
388.3
TINNITUS NOS
490
BRONCHITIS NOS
388.4
388.6
OTH ABN AUDITORY PERCEP
OTORRHEA
491
388.69
OTORRHEA NEC
388.7
OTALGIA
388.71
OTOGENIC PAIN
491.21
491.22
CHRONIC BRONCHITIS
OBSTRUCTIVE CHRONIC BRONCHITIS,
W/O ACUTE EXACERBATION
OCB W ACUTE EXACERBATION
OBSTRUCT CHRON BRONCH W/ACUT
388.8
388.9
OTHER DISORDERS OF EAR
DISORDER OF EAR NOS
491.8
CHRONIC BRONCHITIS NEC
491.9
CHRONIC BRONCHITIS NOS
460
ACUTE NASOPHARYNGITIS
461
AC MAXILLARY SINUSITIS
493.9
493.92
ASTHMA W/O STATUS ASTH
ASTHMA,UNSPEC W ACUTE EXAC
461.1
AC FRONTAL SINUSITIS
520.6
TOOTH ERUPTION DISTURB
461.2
461.8
AC ETHMOIDAL SINUSITIS
OTHER ACUTE SINUSITIS
520.7
TEETHING SYNDROME
520.9
TOOTH DEVEL/ERUPT DISNOS
461.9
ACUTE SINUSITIS NOS
462
ACUTE PHARYNGITIS
521
522.5
HARD TISSUE DIS OF TEETH
PERIAPICAL ABSCESS W/O SINUS
463
ACUTE TONSILLITIS
525.9
464
ACUTE LARYNGITIS
464.1
AC TRACHEITIS NO OBSTR
464.2
AC LARYNGOTRACH NO OBSTR
465
AC URI MULT SITES/NOS
555.9
465.8
ACUTE URI MULT SITES NEC
465.9
ACUTE URI NOS
556.6
466
ACUTE BRONCHITIS
556.9
466.19
AC BRONCHIOLITIS ORG NEC
558.3
473
CHR MAXILLARY SINUSITIS
473.1
473.2
CHR FRONTAL SINUSITIS
CHR ETHMOIDAL SINUSITIS
558.9
564
DENTAL DISORDER NOS
REGIONAL ENTERITIS, SMALL
INTESTINE
REGIONAL ENTERITIS, LARGE
INTESTINE
REGIONAL ENTERITIS NOS
UNIVERSAL ULCERATIVE CHRONIC
COLITIS
ULCERATIVE COLITIS NOS
ALLERGIC GASTROENTERITIS AND
COLITIS
OTHER AND UNSPEC NONINFECTIOUS
GASTROENTERITIS AND COLITIS
FUNCT DIGESTIVE DIS NEC
473.3
CHR SPHENOIDAL SINUSITIS
564.01
SLOW TRANSIT CONSTIPATION
382.1
382.2
382.3
382.4
478.19
491.2
555
555.1
39
ICD-9 Code
Short Description
ICD-9 Code
Short Description
564.09
OTHER CONSTIPATION
690.12
SEBORRHEIC INFANTILE DERMATITIS
564.1
690.18
OTHER SEBORRHEIC DERMATITIS
691
564.9
IRRITABLE BOWEL SYNDROME
OTHER FUNCTIONAL DISORDERS OF
INTESTINE
FUNCT DISORD INTEST NOS
595
CYSTITIS
692
595.1
CHR INTERSTIT CYSTITIS
595.89
595.9
CYSTITIS NEC
CYSTITIS NOS
692.3
599
URIN TRACT INFECTION NOS
599.1
URETHRAL FISTULA
692.4
599.5
PROLAPSE URETHRAL MUCOSA
599.7
599.84
HEMATURIA, UNSPECIFIED
URETHRAL DISORDER NEC
692.5
599.9
URINARY TRACT DIS NOS
623.8
NONINFL DISORD VAG NEC
692.6
648.93
681
OTH CCE ANTEPARTUM
CELLULITIS OF FINGER
681.01
FELON
ONYCHIA AND PARONYCHIA OF
FINGER
CELLULITIS OF TOE
692.76
ATOPIC DERMATITIS
OTHER ATOPIC DERMATITIS AND
RELATED CONDITIONS
CONTACT DERMATITIS
CONTACT DERMA/ECZEMA, DUE TO
DRUGS/MEDICINES IN CONTACT
WITH SKIN
CONTACT DERMATITIS AND OTHER
ECZEMA, DUE TO OTHER CHEMICAL
PRODUCTS
CONTACT DERMATITIS AND OTHER
ECZEMA,DUE TO FOOD IN CONTACT
W/SKIN
CONTACT DERMATITIS AND OTHER
ECZEMA, DUE TO PLANTS(EXCEPT
FOOD)
SOLAR RADIATION DERM
CONTACT DERMATITIS AND OTHER
ECZEMA,DUE TO SUNBURN
SUNBURN OF SECOND DEGREE
692.81
COSMETIC DERMATITIS
564.89
681.02
681.1
691.8
692.7
692.71
692.82
RADIATION DERMATITIS NEC
692.83
DERMATITIS DUE TO METALS
DERMATITIS DUE TO ANIMAL
(CAT)(DOG) DANDER
DERMATITIS NEC
684
ONYCHIA AND PARONYCHIA OF TOE
CELLULITIS AND ABSCESS OF DIGIT
NOS
OTHER CELLULITIS AND ABSCESS,
UPPER ARM AND FOREARM
OTHER CELLULITIS AND ABSCESS,
BUTTOCK
OTHER CELLULITIS AND ABSCESS, LEG,
EXCEPT FOOT
OTHER CELLULITIS AND ABSCESS,
FOOT, EXCEPT TOES
OTHER CELLULITIS AND ABSCESS,
OTHER SPEC SITES
OTHER CELLULITIS AND ABSCESS,
UNSPECIFIED SITE
IMPETIGO
690.1
SEBORR DERMATITIS NOS
690.11
SEBORRHEA CAPITIS
681.11
681.9
682.3
682.5
682.6
682.7
682.8
682.9
692.84
692.89
692.9
700
DERMATITIS NOS
DERMATITIS DUE TO DRUGS AND
MEDICINES
DERMATITIS DUE TO FOOD
DERMATITIIS DUE TO UNSPEC
SUBSTANCE TAKEN INTERNALLY
CORNS AND CALLOSITIES
703
INGROWING NAIL
703.8
DISEASES OF NAIL NEC
704
ALOPECIA
704.01
ALOPECIA AREATA
704.8
HAIR DISEASES NEC
704.9
HAIR DISEASE NOS
693
693.1
693.9
40
ICD-9 Code
Short Description
ICD-9 Code
Short Description
705
DISORDERS OF SWEAT GLAND
726.65
PREPATELLAR BURSITIS
705.1
PRICKLY HEAT
726.69
ENTHESOPATHY OF KNEE NEC
705.81
DYSHIDROSIS
726.71
ACHILLES TENDINITIS
705.89
SWEAT GLAND DISORDER NEC
726.73
CALCANEAL SPUR
706.1
ACNE NEC
726.79
ANKLE ENTHESOPATHY NEC
706.2
SEBACEOUS CYST
726.9
ENTHESOPATHY, SITE NOS
706.3
706.8
SEBORRHEA
SEBACEOUS GLAND DIS NEC
729.1
729.2
MYALGIA AND MYOSITIS NOS
NEURALGIA/NEURITIS NOS
708.9
URTICARIA NOS
729.5
PAIN IN LIMB
719.41
JOINT PAIN SHOULD
729.81
SWELLING OF LIMB
719.46
JOINT PAIN L/LEG
729.82
CRAMP IN LIMB
719.47
723.1
JOINT PAIN ANKLE
CERVICALGIA
780.4
780.6
DIZZINESS AND GIDDINESS
FEVER
724
BACK DISORDER NEC NOS
780.8
HYPERHIDROSIS
724.1
PAIN IN THORACIC SPINE
780.96
GENERALIZED PAIN
724.2
724.3
LUMBAGO
SCIATICA
782
782.1
SKIN/OTH INTEGUMENT SX
NONSPECIF SKIN ERUPT NEC
724.4
LUMBOSACRAL NEURITIS NOS
782.2
LOCAL SUPERF SWELLNG
724.5
BACKACHE NOS
782.3
EDEMA
724.6
DISORDERS OF SACRUM
782.4
JAUNDICE NOS
724.79
724.8
DISORDER OF COCCYX NEC
OTHER BACK SYMPTOMS
782.62
782.7
FLUSHING
SPONTANEOUS ECCHYMOSES
724.9
BACK DISORDER NOS
782.8
CHANGES IN SKIN TEXTURE
726
ADHESIVE CAPS SHOULD
782.9
INTEGUMENT TISS SX NEC
726.1
ROTATOR CUFF SYND NOS
784
SX INVOLVING HEAD/NECK
726.11
726.12
CALCIF TENDINITIS SHOULD
BICIPITAL TENOSYNOVITIS
784.1
784.2
726.19
ROTATOR CUFF DISORD NEC
726.2
SHOULD REGION DISORD NEC
726.31
MEDIAL EPICONDYLITIS
784.5
THROAT PAIN
SWELLING IN HEAD & NECK
OTHER VOICE AND RESONANCE
DISORDERS
SPEECH DISTURBANCE NEC
726.32
726.33
LATERAL EPICONDYLITIS
OLECRANON BURSITIS
786
DYSPNEA/RESPIRATORY ABN
726.4
ENTHESOPATHY OF WRIST
786.01
786.02
HYPERVENTILATION
ORTHOPNEA
726.5
ENTHESOPATHY OF HIP
786.05
SHORTNESS OF BREATH
726.6
ENTHESOPATHY OF KNEE
786.06
TACHYPNEA
726.61
726.64
PES ANSERINUS TENDINITIS
PATELLAR TENDINITIS
786.07
WHEEZING
786.09
RESPIRATORY ABNORM NEC
784.49
41
ICD-9 Code
Short Description
ICD-9 Code
Short Description
786.2
COUGH
789.04
LLQ ABDOMINAL PAIN
786.3
HEMOPTYSIS
789.05
PERIUMBILIC ABD PAIN
786.51
PRECORDIAL PAIN
789.06
EPIGASTRIC ABD PAIN
786.52
PAINFUL RESPIRATION
789.07
GENERALIZED ABD PAIN
786.6
CHEST SWELLING/MASS/LUMP
789.09
ABDOMINAL PAIN SITE NEC
786.7
ABNORMAL CHEST SOUNDS
789.1
HEPATOMEGALY
786.8
786.9
HICCOUGH
RESP SYST/CHEST SX NEC
789.2
789.3
SPLENOMEGALY
ABD/PELVIC SWELLING NEC
787.01
NAUSEA WITH VOMITING
789.31
RUQ ABD/PELVIC SWELLING
787.02
NAUSEA ALONE
789.32
LUQ ABD/PELVIC SWELLING
787.03
VOMITING ALONE
789.33
RLQ ABD/PELVIC SWELLING
787.1
787.2
HEARTBURN
DYSPHAGIA
789.34
789.35
LLQ ABD/PELVIC SWELLING
PERIUMB ABD/PELV SWELLNG
787.3
FLATUL, ERUCT & GAS PAIN
789.36
EPIGASTRIC SWELLING
787.4
VISIBLE PERISTALSIS
789.39
ABD/PELV SWELL SITE NEC
787.6
787.7
INCONTINENCE OF FECES
ABNORMAL FECES
789.5
789.6
ASCITES
ABDOMINAL TENDERNESS
787.91
DIARRHEA
789.61
RUQ ABDOMINAL TENDERNESS
787.99
OTH GI SYSTEM SYMPTOMS
789.63
RLQ ABDOMINAL TENDERNESS
788
RENAL COLIC
789.64
LLQ ABDOMINAL TENDERNESS
788.1
788.21
789.65
789.66
PERIUMBILIC TENDERNESS
EPIGASTRIC TENDERNESS
789.67
GENERAL ABD TENDERNESS
788.36
DYSURIA
INCOMPL BLADDER EMPTYING
UNSPECIFIED URINARY
INCONTINENCE
NOCTURNAL ENURESIS
789.69
ABD TENDERNESS SITE NEC
788.39
URINARY INCONTINENCE NEC
789.9
ABDOMEN/PELVIS SX NEC
788.41
URINARY FREQUENCY
788.42
POLYURIA
799.2
799.89
NERVOUS
OTHER ILL DEFINED CONDITIONS
788.63
URGENCY OF URINATION
799.9
UNKN CAUSE MORB/MORT NEC
788.64
URINARY HESITANCY
826
FRACTURE PHALANGES, FOOT
788.69
URINATION ABNORMALTY NEC
840.8
SPRAIN SHOULDER/ARM NEC
788.7
URETHRAL DISCHARGE
788.9
URINARY SYS SYMPTOM NEC
840.9
842
SPRAIN SHOULDER/ARM NOS
SPRAIN OF WRIST
789
ABDOMINAL PAIN
842.1
SPRAIN OF HAND NOS
789.01
RUQ ABDOMINAL PAIN
844.9
SPRAIN OF KNEE & LEG NOS
789.02
LUQ ABDOMINAL PAIN
845
SPRAIN OF ANKLE NOS
789.03
RLQ ABDOMINAL PAIN
847
847.2
SPRAIN OF NECK
SPRAIN LUMBAR REGION
788.3
42
ICD-9 Code
Short Description
ICD-9 Code
Short Description
873
OTHER OPEN WOUND OF HEAD
924.2
CONTUSION ANKLE FOOT
873.4
OPEN WOUND OF FACE
931
FOREIGN BODY IN EAR
873.42
OPEN WOUND OF FOREHEAD
959.01
HEAD INJURY, UNSPECIFIED
873.43
OPEN WOUND OF LIP
959.9
INJURY OF FACE AND NECK
873.44
OPEN WOUND OF JAW
959.3
ELB/FOREARM/WR INJ NOS
882
OPEN WOUND HAND/S COMP
959.5
FINGER INJURY NOS
883
883.1
OPEN WOUND OF FINGER
OPEN WOUND FINGER COMP
959.7
959.9
LOWER LEG INJURY NOS
INJURY SITE NOS
891
OP WND LOW LEG /S COMP
995.3
ALLERGY, UNSPECIFIED
892
OPEN WOUND FOOT/S COMP
34
910
SUPERFICIAL INJURY HEAD
918.1
919.4
SUPERFICIAL INJ CORNEA
INSECT BITE NEC
920
CONTUSION FACE/SCALP/NCK
922.1
CONTUSION OF CHEST WALL
922.31
923.2
BACK CONTUSION
CONTUSION OF WRIST/HAND
923.3
CONTUSION OF FINGER
STREPTOCCOCAL SORE THROAT
ENCOUNTER FOR CHG OR REMOVAL
SURGICAL WOUND DRESSING
ENCOUNTER FOR REMOVAL OF
SUTURES
FOLLOW UP EXAM NEC
ISSUE REPEAT PRESCRIPT
OBSERVATION FOLLOWING OTHER
ACCIDENT
OTHER SPECIF SUSPECTED CONDIT
924.1
CONTUSION KNEE/LOWER LEG
924.11
CONTUSION OF KNEE
4.
V58.31
V58.32
V67.59
V68.1
V71.4
V71.89
Follow up Visit Within 2 Weeks after Inpatient Discharge
Goal:
Reduce unnecessary readmissions.
•
Measured by a Member follow up office visit to PCP, or a Cardiologist, Pulmonologist or
Endocrinology specialist 2 weeks after an inpatient admission for a Heart Failure, COPD,
Pneumonia, Atrial Fibrillation and/or Diabetes condition.
•
Follow up visits will be measured 2 weeks after the discharged date. Coventry will measure the
ratio of E&M CPT codes 992XX and 993XX from PCP, or a Cardiologist, Pulmonologist or
Endocrinology specialist to total discharge for the following inpatient discharge diagnosis:
Code
Code Description
Condition
427.3
ATRIAL FIB/FLUTTER
Atrial Fibrillation
427.31
427.32
ATRIAL FIBRILLATION
ATRIAL FLUTTER
Atrial Fibrillation
Atrial Fibrillation
398.91
RHEUMATIC HEART FAILURE (CONGESTIVE
CHF
402.01
Malignant hypertensive heart disease ; with heart failure
CHF
43
Code
Code Description
Condition
402.11
Benign hypertensive heart disease; with heart failure
CHF
402.91
Unspecified hypertensive heart disease; with heart failure
CHF
404.01
Malignant Hypertensive heart and chronic kidney disease; with heart
failure and with chronic kidney disease stage I through stage IV, or
unspecified
CHF
404.11
Benign Hypertensive heart and chronic kidney disease; with heart
failure and with chronic kidney disease stage I through stage IV, or
unspecified
CHF
404.91
Unspecified hypertensive heart disease; with heart failure and with
chronic kidney disease stage I through stage IV, or unspecified
CHF
425.4
Other primary cardiomyopathies; Cardiomyopathy not otherwise
specified includes congestive
CHF
428
428.1
Congestive heart failure, unspecified (code actually 428.0)
LEFT HEART FAILURE
CHF
CHF
428.2
UNSPECIFIED SYSTOLIC HEART FAILURE (code actually 428.20)
CHF
428.21
ACUTE SYSTOLIC HEART FAILURE
CHF
428.22
CHRONIC SYSTOLIC HEART FAILURE
CHF
428.23
428.3
Systolic heart failure: Acute on chronic
UNSPECIFIED DIASTOLIC HEART FAILURE (code actually 428.30
CHF
CHF
428.31
ACUTE DIASTOLIC HEART FAILURE
CHF
428.32
CHRONIC DIASTOLIC HEART FAILURE
CHF
428.33
428.4
Diastolic heart failure; acute on chronic
Unspecified; Combined systolic and diastolic heart failure
CHF
CHF
428.41
Acute; Combined systolic and diastolic heart failure
CHF
428.42
Chronic; Combined systolic and diastolic heart failure
CHF
428.43
Acute on Chronic: Combined systolic and diastolic heart failure
CHF
428.9
HEART FAILURE, UNSPEC
CHF
429.4
Heart failure following cardiac surgery or due to prosthesis
CHF
491
CHRONIC BRONCHITIS
COPD
491.1
MUCOPURUL CHR BRONCHITIS
COPD
491.2
OBSTR CHR BRONCHITIS
COPD
491.2
OCB NO EXACERBATION
COPD
491.21
OCB W ACUTE EXACERBATION
COPD
491.22
OBSTRUCT CHRON BRONCH W/ACUT
COPD
491.8
CHRONIC BRONCHITIS NEC
COPD
491.9
CHRONIC BRONCHITIS NOS
COPD
492
492
EMPHYSEMA
EMPHYSEMATOUS BLEB
COPD
COPD
44
Code
Code Description
Condition
492.8
EMPHYSEMA NEC
COPD
496
CHR AIRWAY OBSTR NEC
COPD
496
CHRONIC AIRWAY OBSTRUCTION NOS
COPD
250
DIABETES MELLITUS
Diabetes
250
DM2 UNCOMP NSU
Diabetes
250.01
DM1 UNCOMP NSU
Diabetes
250.02
250.03
DM2 UNCOMP UNC
DM1 UNCOMP UNC
Diabetes
Diabetes
250.1
DM2 W KETOACIDOSIS NSU
Diabetes
250.11
DM1 W KETOACIDOSIS NSU
Diabetes
250.12
DM2 W KETOACIDOSIS UNC
Diabetes
250.13
250.2
DM1 W KETOACIDOSIS UNC
DM2 HYPEROSMOLARITY NSU
Diabetes
Diabetes
250.21
DM1 HYPEROSMOLARITY NSU
Diabetes
250.22
DMII HYPEROSMOLARITY UNC
Diabetes
250.23
250.3
DM1 HYPEROSMOLARITY UNC
DM2 COMA NEC, NSU
Diabetes
Diabetes
250.31
DM1 COMA NEC, NSU
Diabetes
250.32
DM2 W COMA NEC, UNC
Diabetes
250.33
DM1 W COMA NEC, UNC
Diabetes
250.4
250.41
DM2 RENAL MANIFEST, NSU
DM1 RENAL MANIFEST, NSU
Diabetes
Diabetes
250.42
DM2 W RENAL MANFEST, UNC
Diabetes
250.43
DM1 W RENAL MANFEST, UNC
Diabetes
250.5
DM2 W EYE MANIFEST, NSU
Diabetes
250.51
250.52
DM1 W EYE MANIFEST, NSU
DM2 W EYE MANIFEST, UNC
Diabetes
Diabetes
250.53
DM1 W EYE MANIFEST, UNC
Diabetes
250.6
DM2 NEURO MANIFEST, NSU
Diabetes
250.61
DM1 NEURO MANIFEST NSU
Diabetes
250.62
250.63
DM2 W NEURO MANFEST UNC
DM1 W NEURO MANFEST UNC
Diabetes
Diabetes
250.7
DM2 W CIRC DISORD, NSU
Diabetes
250.71
DM1 W CIRC DISORD, NSU
Diabetes
250.72
DM2 W CIRC DISORD UNC
Diabetes
250.73
250.8
DM1 W CIRC DISORD UNC
DM2 W MANIFEST NEC, NSU
Diabetes
Diabetes
45
Code
Code Description
Condition
250.81
DM1 W MANIFEST NEC, NSU
Diabetes
250.82
DM2 W MANIFEST NEC, UNC
Diabetes
250.83
DM1 W MANIFEST NEC, UNC
Diabetes
250.9
DM2 W COMP NOS, NSU
Diabetes
250.91
DM1 W COMP NOS, NSU
Diabetes
250.92
DM2 W COMP NOS, UNC
Diabetes
250.93
357.2
DM1 W COMP NOS, UNC
NEUROPATHY IN DIABETES
Diabetes
Diabetes
362
RETINAL DISORDERS NEC
Diabetes
362.01
DIABETIC RETINOPATHY NOS
Diabetes
362.02
PROLIF DM RETINOPATHY
Diabetes
362.03
362.04
NONPROLIF DIABETIC RETINOPATHY
MILD NONPROLIF DIABETIC RETINO
Diabetes
Diabetes
362.05
MODERATE DIABETIC RETINOPATHY
Diabetes
362.06
SEVERE DIABETIC RETINOPATHY
Diabetes
362.07
366.41
DIABETIC MACULAR EDEMA
DIABETIC CATARACT
Diabetes
Diabetes
V58.67
LONG-TERM/CURRENT USE OF INSULIN
Diabetes
3.22
SALMONELLA PNEUMONIA
Pneumonia
11.6
TB PNEUMONIA (ANY FORM)
Pneumonia
11.6
11.61
TB PNEUMONIA (ANY FORM), UNSPEC EXAM
TB PNEUMONIA (ANY FORM), BACTERIO/HISTO NOT DONE
Pneumonia
Pneumonia
11.62
TB PNEUMONIA (ANY FORM), BACTERIO/HISTO RESULTS UNKNOWN
Pneumonia
11.63
TB PNEUMONIA (ANY FORM), BACILLI FOUND IN SPUTUM BY MICRO
Pneumonia
11.64
TB PNEUMONIA (ANY FORM), BACILLI NOT IN SPUTUM BY MICRO BUT
BY BACT CX
Pneumonia
11.65
TB PNEUMONIA (ANY FORM), BACILLI NOT BY BACTERIO EXAM BUT
HISTO
Pneumonia
11.66
TB PNEUMONIA (ANY FORM), BACILLI NOT BY BACTERIO/HISTO BUT
OTH METHOD
Pneumonia
41.3
KLEBSIELLA PNEUMONIAE
Pneumonia
55.1
POSTMEASLES PNEUMONIA
Pneumonia
73
ORNITHOSIS PNEUMONIA
Pneumonia
115.05
HISTOPLASMA CAPSULATUM PNEUMONIA
Pneumonia
115.15
H DUBOISII PNEUMONIA
Pneumonia
115.95
480
HISTOPLASMOSIS PNEUMONIA
VIRAL PNEUMONIA
Pneumonia
Pneumonia
46
Code
Code Description
Condition
480
ADENOVIRAL PNEUMONIA
Pneumonia
480.1
RSV PNEUMONIA
Pneumonia
480.3
SARS CORONAVIR PNEUMONIA
Pneumonia
480.8
VIRAL PNEUMONIA NEC
Pneumonia
480.9
VIRAL PNEUMONIA NOS
Pneumonia
481
PNEUMOCOCCAL PNEUMONIA
Pneumonia
482
482
OTH BACTERIAL PNEUMONIA
K. PNEUMONIAE PNEUMONIA
Pneumonia
Pneumonia
482.1
PSEUDOMONAL PNEUMONIA
Pneumonia
482.2
H.INFLUENZAE PNEUMONIA
Pneumonia
482.3
STREPTOCOCCAL PNEUMONIA
Pneumonia
482.3
482.31
STREPTOCOC PNEUMONIA NOS
GRP A STREP PNEUMONIA
Pneumonia
Pneumonia
482.32
GRP B STREP PNEUMONIA
Pneumonia
482.39
STREP PNEUMONIA NEC
Pneumonia
482.4
STAPHYLOCOCCAL PNEUMONIA
Pneumonia
482.41
METHICILLIN SUSCEPTIBLE PNEUMONIA DUE TO STAPHYLOCOCCUS
AUREUS
Pneumonia
482.42
METHICILLIN RESISTANT PNEUMONIA DUE TO STAPHYLOCOCCUS
AUREUS
Pneumonia
482.49
STRAPHYLOCOCCUS PNEUMONIA
Pneumonia
482.8
BACTERIAL PNEUMONIA NEC
Pneumonia
482.81
482.82
PNEUMONIA D/T ANAEROBES
E. COLI PNEUMONIA
Pneumonia
Pneumonia
482.83
GRAM NEG PNEUMONIA NEC
Pneumonia
482.89
BACTERIAL PNEUMONIA-NEC
Pneumonia
482.9
BACTERIAL PNEUMONIA NOS
Pneumonia
483
PNEUMONIA: ORGANISM NEC
Pneumonia
483
M.PNEUMONIAE PNEUMONIA
Pneumonia
483.1
CHLAMYDIAL PNEUMONIA
Pneumonia
483.8
PNEUMONIA-OTH SPEC ORG
Pneumonia
484.3
PNEUMONIA IN WHOOP COUGH
Pneumonia
484.5
485
PNEUMONIA IN ANTHRAX
BRONCHOPNEUMONIA ORG NOS
Pneumonia
Pneumonia
486
PNEUMONIA, ORGANISM NOS
Pneumonia
487
INFLUENZA WITH PNEUMONIA
Pneumonia
517.1
RHEUMATIC PNEUMONIA
Pneumonia
47
Code
Code Description
Condition
770
CONGENITAL PNEUMONIA
Pneumonia
997.31
VENTILATOR ASSOCIATED PNEUMONIA
Pneumonia
5.
Preventable IP Admissions
Goal:
Prevent unnecessary inpatient admissions.
Chronic Obstructive Pulmonary Disease Admission Rate. Numerator: All Member non-maternal
discharges of age 18 years and older with ICD-9-CM principal diagnosis code for COPD.
Include ICD-9-CM diagnosis codes:
Code
Code Description
Code
Code Description
466.0
AC BRONCHITIS*
494
BRONCHIECTASIS OCTOO491.9
CHRONIC BRONCHITIS NOS
491.20
OBS CHR BRNC WIO ACT EXA
490
BRONCHITIS NOS*
494.0
BRONCH IECTAS WIO AC EXAC OCTOO492.0
EMPHYSEMATOUS BLEB
491.21
OBS CHR BRNC W ACTEXA
491.0
SIMPLE CHR BRONCHITIS
494.1
BRONCHIECTASIS W AC EXAC OCTOO492.8
EMPHYSEMA NEC
491.8
CHRONIC BRONCHITIS NEC
491.1
MUCOPURUL CHR BRONCHITIS
496
CHR AIRWAY OBSTRUCT NEC
*Qualifies only if accompanied by secondary diagnosis of 491.xx, 492.x, 494.x or 496 (i.e., any other
code on this list).
Exclude cases:
• transfer from a hospital (different facility)
• transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
• transfer from another health care facility
• MDC 14 (pregnancy, childbirth, and puerperium)
Denominator: Member population, age 18 years and older
CHF Admission Rate. Numerator: All Member non-maternal discharges of age 18 years and older with
ICD-9-CM principal diagnosis code for CHF.
Include ICD-9-CM diagnosis codes:
Code
Code Description
398.91
RHEUMATIC HEART FAILURE
428.31
AC DIASTOLIC HRT FAILURE OCT02
428.0
CONGESTIVE HEART FAILURE
428.32
CHR DIASTOLIC HRT FAIL OCT02428.1
LEFT HEART FAILURE
428.33
AC ON CHR DIAST HRT FAIL OCT02428.20
SYSTOLIC HRT FAILURE NOS OCT02428.40
SYST/DIAST HRT FAIL NOS OCT02428.21
AC SYSTOLIC HRT FAILURE OCT02-
48
Code
428.41
428.22
428.42
428.23
42843
428.30
428.9
Code Description
AC SYSTIDIASTOL HRT FAIL OCT02
CHR SYSTOLIC HRT FAILURE OCT02CHR SYST/DIASTL HRT FAIL OCT02
AC ON CHR SYST HRT FAIL OCT02AC/CHR SYST/DIA HRT FAIL OCT02DIASTOLC HRT FAILURE NOS OCT02HEART FAILURE NOS
Exclude ICD-9·CM diagnosis codes:
Code
Description
402.01
MAL HYPERT HRT DIS W CHF
404.11
BEN HYPER HRT/REN W CHF
402.11
BENIGN HYP HRT DIS W CHF
404.13
BEN HYP HRT/REN W CHF/RF
402.91
HYPERTEN HEART DIS W CHF
404.91
HYPER HRT/REN NOS W CHF
404.01
MAL HYPER HRT/REN W CHF
404.93
HYP HT/REN NOS W CHF/RF
404.03
MAL HYP HRT/REN W CHF/RF
Exclude cases:
• transfer from a hospital (different facility)
• transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
• transfer from another health care facility
• MDC 14 (pregnancy, childbirth, and puerperium)
• with cardiac procedure codes in any field (see list of ICD-9 - CM below)
Exclude ICD-9-CM Cardiac procedure codes:
Code
005.0
005.1
005.7
005.2
005.3
006.6
350.0
005.4
350.1
005.6
350.2
350.3
361.2
350.4
361.3
351.0
3614
Code Description
IMPL CRT PACEMAKER SYS OCT02-0CT06IMPL CRT DEFIBRILLAT OCT02IMP/REP SUBCUE CARD DEV
IMP/REP LEAD LF VEN SYS OCT02- OCT06IMP/REP CRT PACEMKR GEN
PTCA OCT06-0CT02CLOSED VALVOTOMY NOS
IMP/REP CRT DEFIB GENAT OCT02CLOSED AORTIC VALVOTOMY
INS/REP IMPL SENSOR LEAD
CLOSED MITRAL VALVOTOMY
CLOSED PULMON VALVOTOMY
AORTOCOR BYPAS-2 COR ART
CLOSED TRICUSP VALVOTOMY
AORTOCOR BYPAS-3 COR ART
OPEN VALVULOPLASTY NOS
AORTCOR BYPAS-4+ COR ART
45
Code
351.1
361.51
351.2
361.62
351.3
361.7
351.4
361.9
352.0
362.
352.1
363
352.2
363.1
352.3
363.2
352.4
363.3
352.5
352.6
363.4
352.7
352.8
363.9
353.1
369.1
353.2
369.9
353.3
373.1
353.4
373.2
353.5
373.3
353.9
373.4
354.1
373.5
354.2
373.6
355.0
355.1
355.2
374.1
355.3
355.4
375.
Code Description
OPN AORTIC VALVULOPLASTY
INT MAM·COR ART BYPASS
OPN MITRAL VALVULOPLASTY
INT MAM·COR ART BYPASS
OPN PULMON VALVULOPLASTY
ABD·CORON ART BYPASS OCT96
OPN TRICUS VALVULOPLASTY
HRT REVAS BYPS ANAS NEC
REPLACE HEART VALVE NOS
ARTERIAL IMPLANT REVASC
REPLACE AORT VALV· TISSUE
OTH HEART REVASCULAR
REPLACE AORTIC VALVE NEC
OPEN CHESTTRANS REVASC
REPLACE MITR VALV·TISSUE
OTH TRANSMYO REVASCULAR
REPLACE MITRAL VALVE NEC
ENDO TRANSMYO REVASCULAR
REPLACE PULM VALV·TISSUE OCT06REPLACE PULMON VALVE NEC
PERC TRANSMYO REVASCULAR
REPLACE TRIC VALV· TISSUE
REPLACE TRICUSP VAL V NEC
OTH HEART REVASULAR
PAPILLARY MUSCLE OPS
CORON VESS ANEURYSM REP
CHORDAE TENDINEAE OPS
HEART VESSLE OP NEC
ANNULOPLASTY
PERICARDIECTOMY
INFUNDIBULECTOMY
HEART ANEURYSM EXCISION
TRABECUL CARNEAE CORD OP
EXC/DEST HRT LESION OPEN
TISS ADJ TO VAL V OPS NEC
EXC/DEST HRT LES OTHER
ENLARGE EXISTING SEP DEF
PARTIAL VENTRICULECTOMY
CREATE SEPTAL DEFECT
EXCISION OR DESTRUCTION OF
PROSTH REP HRT SEPTA NOS LEFT ATRIAL APPENDAGE (LAA)
PROS REP ATRIAL DEF·OPN OCT08PROS REPAIR ATRIA DEF·CL
IMPLANT PROSTH CARD SUPPORT
PROST REPAIR VENTRIC DEF DEV OCT06
PROS REP ENDOCAR CUSHION
HEART TRANSPLANTATION (NOT
46
Code
355.5
375.1
356.0
375.2
356.1
375.3
356.2
356.3
375.4
357.0
357.1
375.5
357.2
357.3
358.1
376.0
358.2
358.3
358.4
376.1
359.1
376.2
359.2
359.3
376.3
359.4
376.4
359.5
359.6
376.5
359.S
359.9
376.6
360.1
360.2
377.0
360.3
377.1
360.4
377.2
360.5
377.3
360.6
377.4
360.7
377.5
377.6
Code Description
PROS REP VENTRC DEF·CLOS VALID AFTER OCT 03) OCT06·
HEARTTRANPLANTATION OCT03
GRFT REPAIR HRT SEPT NOS
IMPLANT TOT REP HRT SYS OCT03·
GRAFT REPAIR ATRIAL DEF
REPUREP THORAC UNIT HRT
GRAFT REPAIR VENTRIC DEF OCT03GRFT REP ENDOCAR CUSHION
REPUREP OTH TOT HRT SYS
HEART SEPTA REPAIR NOS OCT03ATRIA SEPTA DEF REP NEC
REMOVAL OF INTERNAL
VENTR SEPTA DEF REP NEC BIVENTRICULAR HEART
ENDOCAR CUSH ION REP NEC REPLACEMENT SYSTEM OCTOSTOT REPAIR TETRAL FALLOT
IMPLANTATION OR INSERTION OF
TOTAL REPAIR OF TAPVC BIVENTRICULAR EXTERNAL HEART
TOT REP TRUNCUS ARTERIOS ASSIST SYSTEM OCT08TOT COR TRANSPOS GRT VES
IMPLANT OF PULSATION BALLOON
INTERATVEN RETRN TRANSP
INSERTION OF NON-IMPLANTABLE
CONDUIT RT VENT-PUL ART HEART ASSIST SYSTEM
CONDUIT LEFT VENTR-AORTA
REPAIR OF HEART ASSIST SYSTEM
CONDUIT ARTIUM-PULM ART
REMOVAL OF HEART ASSIST
HEART REPAIR REVISION SYSTEM
PERC HEART VALVULOPLASTY
IMPLANT OF EXTERNAL HEART
OTHER HEART SEPTA OPS ASSIST SYSTEM
OTHER HEART VALVE OPS
INSERTION OF IMPLANTABLE
PTCA-1 VESSEL WIO AGENT HEART ASSIST SYSTEM
PTCA-1 VESSEL WITH AGNT
INT INSERT PACEMAK LEAD
OPEN CORONRY ANGIOPLASTY
INT INSERT LEAD IN VENT
INTRCORONRY THROMB INFUS
INT INSERT LEAD A TRI-VENT
PTCA-MULTIPLE VESSEL
INT INSER LEAD IN ATRIUM
INSERT OF COR ART STENT OCT95INT OR REPL LEAD EPICAR
INS DRUG-ELUT CORONRY ST
REVISION OF LEAD OCT02REPL TV ATRI-VENT LEAD
47
Code
Code Description
360.9
REM OF COR ART OBSTR NEC
377.7
REMOVAL OF LEAD WIO REPL
361.0
AORTOCORONARY BYPASS NOS
377.S
INSER TEAM PACEMAKER SYS
361.1
AORTOCOR BYPAS-1 COR ART
377.9
REVIS OR RELOCATE POCKET
378.0
INT OR REPL PERM PACEMKR
378.9
REVISE OR REMOVE PACEMAK
378.1
INT INSERT i-CHAM, NON
379.4
IMPLT/REPL CARDDEFIB TOT
37S.2
INT INSERT i-CHAM, RATE
379.5
IMPLT CARDIODEFIB LEADS
378.3
INT INSERT DUAL-CHAM DEV
379.6
IMPLT CARDIODEFIB GENATR
378.5
REPL PACEM W i-CHAM, NON
379.7
REPL CARDIODEFIB LEADS
378.6
REPL PACEM 1-CHAM, RATE
379.8
REPL CARDIODEFIB GENRATR
378.7
REPL PACEM W DUAL-CHAM
Denominator: Member population.
Dehydration Admission Rate. Numerator: All Member non-maternal discharges of age 18 years and
older with ICD-9-CM principal diagnosis code for hypovolemic.
Include ICD-9-CM diagnosis code:
Code
Code Description
276.50
VOL DEPLETION, UNSPECIFIED OCT06276.52
HYPOVOLEMIA OCT06276.51
DEHYDRATION OCT06276.5
HYPOVOLEMIA
Exclude cases:
• transfer from a hospital (different facility)
• transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
• transfer from another health care facility
• MDC 14 (pregnancy, childbirth, and puerperium)
Denominator: Member population, age 18 years and older.
Bacterial Pneumonia Admission Rate. Numerator: All Member non-maternal discharges of age 18 years
and older with ICD-9-CM principal diagnosis code for bacterial pneumonia.
Include ICD-9-CM diagnosis code:
Code
Description
481
PNEUMOCOCCAL PNEUMONIA
482.42
METHICILLIN RESISTANT PNEUMONIA
482.2
H.INFLUENZAE PNEUMONIA DUE TO STAPHYLOCOCCUS AUREUS
482.30
STREP PNEUMONIA UNSPEC OCT08482.31
GRP A STREP PNEUMONIA
482.9
BACTERIAL PNEUMONIA NOS
48
482.32
483.0
482.39
483.1
482.41
483.8
485
486
GRP B STREP PNEUMONIA
MYCOPLASMA PNEUMONIA
OTH STREP PNEUMON IA
CHLAMYDIA PNEUMONIA OCT96METHICILLIN SUSCEPTIBLE PNEUMONIA
OTH SPEC ORG PNEUMONIA DUE TO STAPHYLOCOCCUS AU REUS
BRONCOPNEUMONIA ORG NOS OCT08PNEUMONIA, ORGANISM NOS
Exclude cases:
• transfer from a hospital (different facility)
• transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
• transfer from another health care facility
• MDC 14 (pregnancy, childbirth, and puerperium)
• with any diagnosis of sickle cell anemia or HB-S disease (see ICD-9 CM list below)
• with any diagnosis or procedure code for immunocompromised state (see ICD-9 CM list below)
Exclude ICD-9-CM Sickle Cell or HB-S diagnosis codes:
Code
Code Description
282.41
THLASEMA HB-S W/O CRISIS OCT03282.63
SICKLE-CELUHB-C DISEASE
282.42
THLASSEMIA HB-S W CRISIS OCT03282.64
HB-S/HB-C DIS W CRISIS OCT03282.60
SICKLE-CELL ANEMIA NOS
282.68
HB-S DIS W/O CRISIS NEC OCT03282.61
HB-S DISEASE W/O CRISIS
282.69
SICKLE-CELL ANEMIA NEC
282.62
HB-S DISEASE WITH CRISIS
Exclude ICD-9-CM Immunocompromised States diagnosis codes:
Code
Code Description
042
HUMAN IMMUNODEFICIENCY VIRUS DISEASE
238.73
HI GRDE MYELODYS SYN LES OCT06238.76
MYELOFI W MYELO METAPLAS OCT06136.3
PNEUMOCYSTOSIS
238.77
NEOPLASM OF UNCERTAIN BEHAVIOR, POST-TRANSPLANT - LYMPHOPROLIFERATIVE
DISORDER
199.2
MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANTED ORGAN OCT08288.50
LEUKOCYTOPENIA NOS OCT06238.79
NEOPLASM OF UNCERTAIN BEHAVIOR,
288.51
LYMPHOCYTOPENIA OCT06288.59
DECREASED WBC COUNT NEC OCT06- HEMATOPOIETIC TISSUES OCT08
289.53
NEUTROPENIC SPLENOMEGALY OCT06260
KWASH IORKOR OCT05289.83
MYELOFIBROSIS OCT06261
NUTRITIONAL MARASMUS OCT05403.01
MAL HYP KIDNEY W CHR KID OCT06262
OTH SEVERE MALNUTRITION OCT05
49
Code
403.11
279.00
403.91
279.01
404.02
279.02
404.03
279.03
404.12
279.04
404.13
279.05
404.92
279.06
404.93
279.09
579.3 279.10
585
279.11
585.5
279.12
585.6
279.13
996.8
279.19
279.2
996.80
279.3
996.81
279.4
996.82
996.83
279.50
996.84
996.85
279.51
996.86
996.87
279.52
996.89
V42.0
279.53
V42.1
V42.6
279.8
V42.7
Code Description
BEN HYP KIDNEY W CHR KID OCT06HYPOGAMMAGLOBULINEM NOS
HYP KIDNEY NOS W CHR KID OCT06SELECTIVE IGA IMMUNODEF
MAL HY HRT/KID W CHR KID OCT06SELECTIVE IGM IMMUNODEF
MAL HYP HRT/KID W HF/KID OCT06SELECTIVE IG DEFIC NEC
BEN HYP HT/KID W CHR KID OCT06CONG HYPOGAMMAGLOBULINEM
BEN HYP HT/KID W HF/KID OCT06
IMMUNODEFIC W HYPER-IGM
HYP HT/KID NOS W CHR KID OCT06COMMON VARIABL IMMUNODEF
HYP HRT/KID NOS W HF/KID OCT06
HUMORAL IMMUNITY DEF NEC
NTEST POSTOP NONABSORB OCT06
IMMUNDEF T-CELL DEF NOS
CHRONIC KIDNEY DISEASE OCT05
DIGEORGES SYNDROME
CHRON KIDNEY DIS STAGE V OCT05WISKOTT-ALDRICH SYNDROME
END STAGE RENAL DISEASE OCT06NEZELOFS SYNDROME
COMPLICATIONS OF TRANSPLANTED
DEFIC CELL IMMUNITY NOS -ORGAN
COMBINED IMMUNITY DEFICIENCY
COMP ORGAN TRANSPLNT NOS
UNSPECIFIED IMMUNITY DEFICIENCY
COMPL KIDNEY TRANSPLANT
AUTOIMMUNE DISEASE, NOT
COMPL LIVER TRANSPLANT ELSEWHERE CLASSIFIED
COMPL HEART TRANSPLANT
GRAFT-VERSUS-HOST DISEASE
COMPL LUNG TRANSPLANT UNSPECIFIED OCT08COMPL MARROW TRANSPLANT
ACUTE GRAFT-VERSUS-HOST DISEASE
COMPL PANCREAS TRANSPLNT OCT08COMP INTESTINE TRANSPLNT
CHRONIC GRAFT-VERSUS-HOST
COMP OTH ORGAN TRANSPLNT DISEASE OCT08
KIDNEY REPLACED BY TRANSPLANT
ACUTE ON CHRONIC GRAFT-VERSUS
HEART REPLACED BY TRANSPLANT HOST DISEASE OCT08LUNG REPLACED BY TRANSPLANT
OTHER SPECIFIED DISORDERS
LIVER REPLACED BY TRANSPLANT INVOLVING
50
Code
V42.8
279.9
V42.81
284.09
V42.82
284.1
288.0
V42.83
288.00
28801
V42.84
288.02
V42.89
288.03
V45.1
288.09
V45.11
288.2
V56.0
2884
V56.1
V56.2
Code Description
OTHER SPECIFIED ORGAN OR TISSUE
UNSPECIFIED DISORDER OF IMMUNE
BONE MARROW SPECIFIED BY -TRANSPLANT
CONST APLASTC ANEMIA NEC OCT06PERIPHERAL STEM CELLS REPLACED
PANCYTOPEN IA OCT06- -BY TRANSPLANT
AGRANULOCYTOSIS OCT05PANCREAS REPLACED BY
NEUTROPENIA NOS OCT06- -TRANSPLANT
CONGENITAL NEUTROPENIA OCT06INTESTINES REPLACE BY TRANSPLANT
CYCLIC NEUTROPENIA OCT06OTHER REPLACED BY TRANSPLANT
DRUG INDUCED NEUTROPENIA OCT06RENAL DIALYSIS STATUS OCT06NEUTROPENIA NEC OCT06RENAL DIALYSIS STATUS OCT08GENETIC ANOMALY LEUKOCYT OCT06RENAL DIALYSIS ENCOUNTER OCT06HEMOPHAGOCYTIC SYNDROMES
FT/ADJ XTRCORP DIAL CATH OCT06- OCT06FIT/ADJ PERIT DIAL CATH OCT06
Exclude ICD-9-CM Immunocompromised States procedure codes:
Code
Code Description
001.8
INFUS IMMUNOSUP ANTIBODY OCT05410.1
AUTOLOGOUS BONE MARROW
335
LUNG TRANSPLANTATION
335.0
LUNG TRANSPLANTATION, NOS
410.2
ALLOGENEIC BONE MARROW
335.1
UNILATERAL LUNG TRANSPLANTATION
335.2
BILATERAL LUNG TRANSPLANTATION
410.3
ALLOGENEIC BONE MARROW
336
COMBINED HEART-LUNG TRANSPLANTATION
410.4
AUTOLOGOUS HEMATOPOIETIC STEM
375
HEART TRANSPLANTATION
375.1
HEART TRANSPLANTATION (OCT 03)
410.5
ALLOGENEIC HEMATOPOIETIC STEM
410
OPERATIONS ON BONE MARROW AND SPLEEN
410.6
CORD BLOOD STEM CELL TRANSPLANT
410.0
BONE MARROW TRANSPLANT, NOS
410.7
AUTOLOGOUS HEMATOPOIETIC STEM CELL TRANSPLANT WI PURGING
528.1
REIMPLANTATION OF PANCREATIC
410.8
ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANT WI PURGING
410.9
AUTOLOGOUS BONE MARROW
528.2
HOMOTRANSPLANT OF PANCREAS
51
Code
528.3
528.5
505.1
505.9
528.0
528.6
556.9
Code Description
HETEROTRANSPLANT OF PANCREAS
ALLOTRANSPLANTATION OF CELLS OF ISLETS OF LANGERHANS
AUXILIARY LIVER TRANSPLANT
LIVER TRANSPLANT, NEC
PANCREATIC TRANSPLANT, NOS
TRANSPLANTATION OF CELLS OF ISLETS OF LANGERHANS, NOS
OTHER KIDNEY TRANSPLANTATION
Denominator: Member population, age 18 years and older.
Urinary Tract Infection Admission Rate. Numerator: All Member non-maternal discharges of age 18
years and older with ICD-9-CM principal diagnosis code of urinary tract infection (see below).
Include ICD-9-CM diagnoses codes:
Code
Code Description
590.10
AC PYELONEPHRITIS NOS
590.81
PYELONEPHRIT IN OTH DIS
590.11
AC PYELONEPHR W MED NECR
590.9
INFECTION OF KIDNEY NOS
590.2
RENAL/PERIRENAL ABSCESS
595.0
ACUTE CYSTITIS
590.3
PYELOURETERITIS CYSTICA
595.9
CYSTITIS NOS
590.80
PYELONEPHRITIS NOS
599.0
URIN TRACT INFECTION NOS
Exclude cases:
• transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
• transfer from another health care facility
• MDC 14 (pregnancy, childbirth, and puerperium)
• with any diagnosis of kidney/urinary tract disorder (see ICD-9 CM list below)
• with any diagnosis or procedure code for immunocompromised state (see ICD-9 list below)
Exclude ICD-9-CM Kidney/Urinary Tract Disorder diagnosis codes:
Code
Code Description
590.00
CHR PYELONEPHRITIS NOS
753.16
MEDULLARY CYSTIC KIDNEY
590.01
CHR PYELONEPH W MED NECR
753.17
MEDULLARY SPONGE KIDNEY
593.70
VESCOURETRL RFLUX UNSPCF
753.19
CYSTIC KIDNEY DISEAS NEC
593.71
VESICOURETERAL REFLUX UNIL TRL
753.20
OBS DFCT REN PLV&URT NOS
593.72
VESICOURETERAL REFLUX NPHT
753.21
CONGEN OBST URTROPLV JNC BL TRL
753.22
CONG 08ST URETEROVES JNC
593.73
VESICOURETERAL REFLUX W NPHT
753.23
CONGENITAL URETEROCELE NOS
753.29
OBST DEF REN PLV&URT NEC
52
Code
753.0
753.3
753.10
753.4
753.11
753.5
753.12
753.6
753.13
753.14
753.8
753.15
753.9
Code Description
RENAL AGENESIS
KIDNEY ANOMALY NEC
CYSTIC KIDNEY DISEAS NOS
URETERAL ANOMALY NEC
CONGENITAL RENAL CYST
EXSTROPHY OF URNIARY BLADDER
POLYCYSTIC KIDNEY NOS
ATRESIA AND STENOSIS OF URETHRA
POLYCYST KID-AUTOSOM DOM AND BLADDER NECK
POL YCYST KID-AUTOSOM REC
CYSTOURETHRAL ANOM NEC
RENAL DYSPLASIA
URINARY ANOMALY NOS
Exclude ICD-9-CM Immunocompromised States diagnosis codes:
Code
042
288.03
288.09
136.3
288.2
199.2
288.4
238.73
288.50
238.76
288.51
238.77
288.59
289.53
289.83
403.01
238.79
403.11
403.91
404.02
260
404.03
261
404.12
262
404.13
279.00
404.92
279.Q1
404.93
Code Description
HUMAN IMMUNODEFICIENCY VIRUS
DRUG INDUCED NEUTROPENIA OCT06- DISEASE
NEUTROPENIA NEC OCT06PNEUMOCYSTOSIS
GENETIC ANOMALY LEUKOCYT OCT06MALIGNANT NEOPLASM ASSOCIATED
HEMOPHAGOCYTIC SYNDROMES
HI GRDE MYELODYS SYN LES OCT06LEUKOCYTOPENIA NOS OCT06MYELOFI W MYELO METAPLAS OCT06LYMPHOCYTOPENIA OCT06NEOPLASM OF UNCERTAIN BEHAVIOR,
DECREASED WBC COUNT NEC OCT06NEUTROPENIC SPLENOMEGALY OCT06MYELOFIBROSIS OCT06MAL HYP KIDNEY W CHR KID OCT06NEOPLASM OF UNCERTAIN BEHAVIOR,
BEN HYP KIDNEY W CHR KID OCT06HYP KIDNEY NOS W CHR KID OCT06MAL HY HRT/KID W CHR KID OCT06KWASHIORKOR OCT05MAL HYP HRT/KID W HF/KID OCT06NUTRITIONAL MARASMUS OCT05BEN HYP HT/KID W CHR KID OCT06OTH SEVERE MALNUTRITION OCT05
BEN HYP HT/KID W HF/KID OCT06
HYPOGAMMAGLOBULINEM NOS
HYP HT/KID NOS W CHR KID OCT06SELECTIVE IGA IMMUNODEF
HYP HRT/KID NOS W HF/KID OCT06
53
Code
279.02
579.3
279.03
585.
279.04
585.5
279.05
585.6
279.06
996.8
279.09
279.10
996.80
279.11
996.81
279.12
996.82
279.13
996.83
279.19
996.84
279.2
996.85
279.3
996.86
279.4
996.87
996.89
279.50
V42.0
V42.1
27951
V42.6
V42.7
279.52
V42.8
V42.81
279.53
V42.82
279.8
V42.83
279.9
V42.84
28409
V42.89
284.1
V45.1
Code Description
SELECTIVE IGM IMMUNODEF
INTEST POSTOP NONABSORB OCT06
SELECTIVE IG DEFIC NEC
CHRONIC KIDNEY DISEASE OCT05
CONG HYPOGAMMAGLOBULINEM
CHRON KIDNEY DIS STAGE V OCT05IMMUNODEFIC W HYPER-IGM
END STAGE RENAL DISEASE OCT06COMMON VARIABL IMMUNODEF
COMPLICATIONS OF TRANSPLANTED
HUMORAL IMMUNITY DEF NEC
IMMUNDEF T-CELL DEF NOS
COMP ORGAN TRANSPLNT NOS
DIGEORGES SYNDROME
COMPL KIDNEY TRANSPLANT
WISKOTT-ALDRICH SYNDROME
COMPL LIVER TRANSPLANT
NEZELOFS SYNDROME
COMPL HEART TRANSPLANT
DEFIC CELL IMMUNITY NOS
COMPL LUNG TRANSPLANT
COMBINED IMMUNITY DEFICIENCY
COMPL MARROW TRANSPLANT
UNSPECIFIED IMMUNITY DEFICIENCY
COMPL PANCREAS TRANSPLNT
AUTOIMMUNE DISEASE, NOT
COMP INTESTINE TRANSPLNT
COMP OTH ORGAN TRANSPLNT
GRAFT-VERSUS-HOST DISEASE
KIDNEY REPLACED BY TRANSPLANT
HEART REPLACED BY TRANSPLANT
ACUTE GRAFT-VERSUS-HOST DISEASE
LUNG REPLACED BY TRANSPLANT
LIVER REPLACED BYTRANSPLANT
CHRONIC GRAFT-VERSUS-HOST
OTHER SPECIFIED ORGAN OR TISSUE
BONE MARROW SPECIFIED BY
ACUTE ON CHRONIC GRAFT-VERSUS
PERIPHERAL STEM CELLS REPLACED
OTHER SPECIFIED DISORDERS
PANCREAS REPLACED BY
UNSPECIFIED DISORDER OF IMMUNE
INTESTINES REPLACE BY TRANSPLANT
CONST APLASTC ANEMIA NEC OCT06·
OTHER REPLACED BY TRANSPLANT
PANCYTOPENIA OCT06·
RENAL DIALYSIS STATUS OCT06-
54
Code
288.0
V45.11
288.00
V56.0
288.01
V56.1
288.02
V56.2
Code Description
AGRANULOCYTOSIS OCT05·
RENAL DIALYSIS STATUS OCT08·
NEUTROPENIA NOS OCT06·
RENAL DIALYSIS ENCOUNTER OCT06·
CONGENITAL NEUTROPENIA OCT06·
FT/ADJ XTRCORP DIAL CATH OCT06·
CYCLIC NEUTROPENIA OCT06FITIADJ PERIT DIAL CATH OCT
Exclude ICD-9-CM Immunocompromised States procedure codes:
Code
Code Description
001.8
INFUS IMMUNOSUP ANTIBODY OCT05·
336
COMBINED HEART·LUNG TRANSPLANTATION
335
LUNG TRANSPLANTATION
335.
LUNG TRANSPLANTATION, NOS
375
HEARTTRANSPLANTATION
335.1
UNILATERAL LUNG TRANSPLANTATION
375.1
HEART TRANSPLANTATION (OCT 03)
335.2
BILATERAL LUNG TRANSPLANTATION
410
OPERATIONS ON BONE MARROW AND Spleen
410.8
ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANT WI PURGING
410.0
BONE MARROW TRANSPLANT, NOS
410.1
AUTOLOGOUS BONE MARROW
410.9
AUTOLOGOUS BONE MARROW
505.1
AUXILIARY LIVER TRANSPLANT
410.2
ALLOGENEIC BONE MARROW
410.3
ALLOGENEIC BONE MARROW
505.9
LIVER TRANSPLANT, NEC
528.0
PANCREATIC TRANSPLANT, NOS
528.1
REIMPLANTATION OF PANCREATIC
410.4
AUTOLOGOUS HEMATOPOIETIC STEM
410.5
ALLOGENEIC HEMATOPOIETIC STEM
528.2
HOMOTRANSPLANT OF PANCREAS
528.3
HETEROTRANSPLANT OF PANCREAS
528.5
ALLOTRANSPLANTATION OF CELLS OF ISLETS OF LANGERHANS
410.6
CORD BLOOD STEM CELL TRANSPLANT
410.7
AUTOLOGOUS HEMATOPOIETIC STEM
528.6
TRANSPLANTATION OF CELLS OF ISLETS OF LANGERHANS, NOS
556.9
OTHER KIDNEYTRANSPLANTATION
Denominator: Member population, age 18 years and older
Adult Asthma Admission Rate. Numerator: All Member non-maternal discharges of age 18 years and
older with ICD-9-CM principal diagnosis code of asthma.
55
Include ICD-9-CM diagnosis codes:
Code
Code Description
493.00
EXT ASTHMA WIO STAT ASTH
493.21
CH OB ASTHMA W STAT ASTH
493.01
EXT ASTHMA W STATUS ASTH
493.22
CH OBS ASTH W ACUTE EXAC OCTOO
493.02
EXT ASTHMA W ACUTE EXAC OCTOO493.81
EXERCSE IND BRONCHOSPASM OCT03493.10
INT ASTHMA WIO STAT ASTH
493.82
COUGH VARIANT ASTHMA OCT03493.11
INT ASTHMAW STATUS ASTH
493.90
ASTHMA WIO STATUS ASTHM
493.12
INT ASTHMA W ACUTE EXAC OCTOO493.91
ASTHMA W STATUS ASTHMAT
493.20
CH OB ASTH WIO STAT ASTH
493.92
ASTHMA W ACUTE EXACERBTN OCTOO
Exclude cases:
• transfer from a hospital (different facility)
• transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
• transfer from another health care facility
• MDC 14 (pregnancy, childbirth, and puerperium)
• with any diagnosis code of cystic fibrosis and anomalies of the respiratory system (see list of ICD-9 CM
below)
Exclude ICD-9-CM diagnosis codes of cystic fibrosis and anomalies of the respiratory system:
Code
277.00
748.60
277.01
748.61
277.02
748.69
277.03
748.8
277.09
748.9
747.21
750.3
748.3
759.3
748.4
770.7
748.5
Code Description
CYSTIC FIBROS WIO ILEUS
LUNG ANOMALY NOS
CYSTIC FIBROS W ILEUS
CONGEN BRONCHIECTASIS
CYSTIC FIBROS W PUL MAN
LUNG ANOMALY NEC
CYSTIC FIBROSIS W GI MAN
RESPIRATORY ANOMALY NEC
CYSTIC FIBROSIS NEC
RESPIRATORY ANOMALY NOS
ANOMALIES OF AORTIC ARCH
CONG ESOPH FISTOLAfATRES
LARYNGOTRACH ANOMALY NEC
SITUS INVERSUS
CONGENITAL CYSTIC LUNG
PERINATAL CHR RESP DIS
AGENESIS OF LUNG
Denominator: Member population, age 18 years and older
56
Risk Management Program
Providers shall participate in and cooperate with Coventry’s risk management program. The Managed Care Plan
shall require participating and direct service provider to report adverse incidents to the Managed Care Plans within
twenty-four (24) hours of the incident. The Managed Care Plan must ensure that all participating and direct service
providers are required to report adverse incidents to the Agency immediately but not more than twenty-four (24)
hours of the incident. Reporting will include information including the enrollee’s identity, description of the
incident and outcomes including current status of the enrollee. Coventry developed and implemented an incident
reporting system to minimize injury/incidents to Members, employees and visitors. The risk management program
and incident reporting policy and procedures comply with §59A-12.012, Florida Administrative Code (Internal Risk
Management Program for HMOs) and §641.55, Florida Statute. (Internal risk management program for HMOs).
ADVERSE or UNTOWARD INCIDENT – an event, as defined in Chapter 395.0197(5) of the Florida statutes, over
which Provider could exercise control which is more probably associated, in whole or in part, with the medical
intervention rather than the medical condition for which such medical intervention occurred and which results in
one of the following:
a. Death;
b. Brain or spinal damage;
c. Permanent disfigurement;
d. Fracture or dislocation of bones or joints;
e. A resulting limitation of neurological, physical, or sensory function which continues after discharge from
the facility;
f.
Any condition that required specialized medical attention or surgical intervention resulting from nonemergency medical intervention, other than an emergency medical condition, to which the Member has
not given his/her informed consent; or
g. Any condition that required the transfer of the Member, within or outside the facility, to a unit providing a
more acute level of care due to the adverse incident, rather than the Member’s condition prior to the
adverse incident, including:
1.
2.
3.
4.
The performance of a surgical procedure on the wrong patient, a wrong surgical procedure or wrongsite surgical procedure, or a surgical procedure otherwise unrelated to the Member’s diagnosis or
medical condition;
Required surgical repair of damage resulting to a Member from a planned surgical procedure where
the damage was not a recognized specific risk, as disclosed to the Member and documented through
the informed-consent process;
A procedure to remove unplanned foreign objects remaining from a surgical procedure; or
Any complaint or allegation of sexual misconduct and abuse, or contact by Provider employee or
agent of Provider.
57
If an adverse or untoward incident occurs to a Member, Provider shall report the adverse or untoward incident (as
defined under Florida law) to Coventry’s risk manager within twenty-four (24) hours after its occurrence. Provider
shall (i) participate in and cooperate with Coventry’s risk management program; (ii) provide such medical and other
records without charge within ten (10) days of receipt of written notice; (iii) share such investigation reports and
other information as may be required or requested by Coventry’s risk manager to determine if an adverse or
untoward incident is reportable as a “Code 15” to AHCA; and (iv) in all other respects comply with and abide by this
Manual. A Provider’s failure to comply with these requirements may be deemed a material breach of the
Agreement, at Coventry’s sole discretion.
When an incident occurs:
• Complete the incident report (located in the forms section) form immediately when becoming aware of an
adverse or untoward incident
• Fill each blank on the form, using N/A when not applicable to the particular occurrence
• Write legibly or type the information on the form
• Describe the incident carefully. Be brief, but include important information, including who, what, where,
when and how
• Indicate the body part injured, the location and extent of injury and document fully, including lack of injury
• Report any pertinent action taken in response to the occurrence
• Obtain the name and location information for any witnesses, including employees
• Sign and date the report. Include title/designation and contact phone number
• Fax to Coventry’s risk manager at: (877) 479-8564
For assistance in completing the incident report form, contact Coventry’s risk manager at (954) 858-3246.
Incident reports are part of risk management files only and copies of incident reports must be maintained
separately from Member’s medical records.
All incident reports will be reviewed and date stamped upon receipt. Appropriate action will be initiated when
indicated. Incident reports will not be used to penalize Providers; however, failure to report an adverse or
untoward incident may result in further action by Coventry.
Long Term Care Program
Coventry offers a special program for Members in Broward, Miami-Dade and Palm Beach counties who are both
Medicare and Medicaid eligible. The program is designed to keep these Members living in their own homes or in a
long-term care facility rather than in a nursing home. Eligible Members will need some assistance with the skills
required for daily living.
The PCP may refer a potential long term care Member to the CARES (Comprehensive Assessment Review and
Evaluation for Long-Term Care services) Unit of the Department of Elder Affairs of the State of Florida by calling:
Broward:
Miami-Dade – Central and North area:
Miami-Dade – South area:
Palm Beach:
(954) 746-1773
(786) 336-1400
(305) 671-7200
(561) 840-3150
58
Medicare Social Services Unit
Coventry has a social services unit to facilitate Members’ access to government programs known as
Medicare savings programs and other social services programs. Eligibility for such programs is determined by the
Florida Department of Children and Families. Such programs include:
•
•
•
•
•
Qualified Medicare Beneficiary (QMB)
Specified Low Income Medicare Beneficiary (SLMB)
Qualified Individual -1 (QI-1)
Qualified Disabled Working Individuals (QDWI)
Medicaid
If the Member’s income and assets meet the guidelines for these programs, Member may qualify for assistance. To
contact Coventry’s Social Services Unit for an in-service visit call (800) 297-6217, then press 1.
Medicare Provider Training & Education
Coventry is pleased to have the opportunity to work with you as a Provider or Provider organization in delivering
high value services to our Members. Our association, particularly in relation to our Medicare product lines, relies
on a Contracted relationship that establishes your entity as a first tier3 or related entity4. As a first tier or related
entity, there are several requirements imposed upon you, some by federal law, some by federal regulations as
promulgated by the Centers for Medicare & Medicaid Services (“CMS”), and other requirements in light of your
Contracted relationship with Coventry. As a result, you, your entity, any downstream entities5 and/or related
entities under your direction, and in several cases your individual employees who are assigned to work on
Coventry’s Medicare business, must complete a number of requirements.
The requirements are summarized below and are applicable to your organization, as well as any of your
downstream and/or related entity arrangements.
1. General Compliance and Fraud, Waste and Abuse (“FWA”) Training
You and/or your organization must complete general compliance training. In addition, you must complete
the FWA portion of the training unless you are deemed to have met the FWA certification requirements
through enrollment into Parts A or B of the Medicare program or through accreditation as a supplier of
DMEPOS.
You must provide general compliance training to all of your employees, downstream, and related entity
arrangements who are assigned to work on Coventry Medicare business initially upon hire and annually
thereafter. You must also provide FWA training, initially upon hire and annually thereafter, to all your
employees, downstream and related entity arrangements who are assigned to work on Coventry Medicare
business unless these individuals are deemed to have met FWA certification requirements as described
above. In addition, your organization must provide either Coventry’s Code of Conduct (“COC”) or your own
3
A first tier entity is defined as any party that enters into a written arrangement acceptable to CMS with a Sponsor (i.e., Coventry) to provide
administrative or health care services for a Medicare eligible individual under Part C or Part D.
4
A related entity is defined as any entity that is related to the Sponsor by common ownership or control and a) performs some of the
Sponsor’s management functions under Contract or delegation; b) furnishes services to Medicare enrollees under an oral or written
Agreement, or c) leases real property or sells materials to the Sponsor at a cost of more than $2500 during a Contract period. 42 CFR
423.501
5
A downstream entity is defined as any party that enters into a written arrangement, acceptable to CMS, below the level of the arrangement
between the Sponsor and the first tier entity. These written arrangements continue down to the level of Provider of both health and
administrative services.
59
equivalent COC to all of your employees, downstream, and related entities who are assigned to work on
Coventry Medicare business initially upon hire or Contract commencement and annually thereafter.
2. Reporting Mechanisms
You and/or your organization must report compliance concerns and suspected or actual misconduct to
Coventry.
3. Exclusion/Debarment
You and/or your organization must ensure that none of its employees or downstream and/or related
entities that service Coventry Medicare businesses is on any of the following excluded persons, sanction
and debarment lists: HHS Office of Inspector General (OIG); General Services Administration (GSA).
4. Downstream and Related Entity Oversight
You and/or your organization must ensure that compliance is maintained by you and/or your organization
as well as any of your Contracted downstream and/or related entities that service Coventry Medicare
business.
5. Offshore Operations
You and/or your organization must ensure that you do not engage in offshore operations for Coventryrelated Medicare business without the express consent of an authorized Coventry representative. Offshore
operations are usually Contractually prohibited by Coventry.
Any Coventry-approved offshore
arrangements are subject to reporting requirements to alert CMS of these activities and therefore must be
reported to Coventry before utilization.
You must access the training and compliance materials mentioned above, along with additional information
concerning these requirements, available for you on the Coventry Medicare FDR Training and Education Portal
under Provider and Provider Group FDRs.
This portal can be accessed through the following URL link:
www.CoventryMedicareFDRs.com.
Further, if you and/or your organization utilizes downstream and/or related entities to perform Coventry Medicare
work or serve Coventry Medicare Members, that entity is also responsible for satisfaction of all of the above
requirements. Due to the unique nature of the relationship between you and your downstream and/or related
entities, Coventry expects that you ensure that they receive these requirements.
You and/or your organization are responsible to ensure that evidence of the effectuation for all of the
requirements is developed and maintained. This evidence may be in the form of attestations, training logs, or
other means determined by you to best represent fulfillment of your obligations. Please be reminded that
Coventry and CMS require records to be retained for a period of ten (10) years, and that your records must be
available to Coventry and/or CMS upon request.
Coventry takes these responsibilities very seriously. If you have any questions or concerns regarding this
requirement or if you have difficulty accessing the Coventry Medicare FDR Training and Education Portal, please
contact Coventry’s FDR Governance personnel at corpcompliance@cvty.com.
60
Section 9 – Fee Schedule Maintenance &
Reimbursement Determinations
The Coventry schedule of allowances represents the maximum reimbursement amount for each covered service that
corresponds to any given medical service code. The basis of determining valid medical service codes are from Current
Procedural Terminology (CPT), HCFA Common Procedural Coding System (HCPCS), or National Drug Codes (NDC). For
covered services represented by a single code, the maximum reimbursement amount is the allowance amount
determined by Coventry or the Provider’s usual charge for the service, whichever is less. In many cases, Coventry
allowances are based upon measures of relative value such as Average Wholesale Price (AWP), the Federal Resource
Based Relative Value Scale (RBRVS), American Society of Anesthesiologists (ASA) units and Medicare laboratory and
Durable Medical Equipment (DME) rates. Your Contract will outline the specific fee schedule methodology used to
determine your rates.
Medicare/Commercial HMO/POS/PPO/Individual Products
Coventry will make best efforts to have all CMS based fee schedules for Contracted Medicare products updated in a
timely matter in accordance with CMS’s publication of new codes and reimbursement schedules issues.
• All Provider Agreements with prevailing year schedules will be updated according to CMS published rates
and effective dates
• All Provider Agreement with fixed year schedules will only be updated with NEW codes with the assigned
reimbursement published by CMS
Any schedule updates that are retrospectively updated CHC FL will request discrepancy reports be pulled and all
claims be reviewed and over and underpayments will be handled accordingly with Providers.
Medicaid/Healthy Kids/Individual Product
Coventry updates all Medicaid based fee schedules as published by Medicaid and in accordance with Medicaid
effective dates assigned to codes and reimbursement.
Upon publication of codes previously not valued by Medicaid, Coventry will update Medicaid based schedules
accordingly. Coventry will request code specific discrepancy reports be pulled; claims will be reviewed and over
and underpayments will be handled accordingly with Providers.
Coventry will reprocess any Provider claims affected by new codes upon Provider’s written request.
Laboratory and Pathology Services
Laboratory and pathology services must be performed by a Coventry participating laboratory. Coventry maintains a
Contract with LabCorp to provide outpatient lab services for Members. LabCorp provides all necessary supplies; request
forms; specimen pick-up; accurate and prompt test results.
Laboratory and pathology services provided by an outside or reference lab that is not the applicable Contracted
laboratory Provider (LabCorp) will not be reimbursed to the Provider of service by Coventry. Laboratory and pathology
services include but are not limited to clinical labs, nonclinical labs, pathology, and dermatology. If services are
performed in office, the Provider may not bill the Member/patient or Coventry for the laboratory/pathology services.
Quest Diagnostics is available ONLY for commercial PPO Members. LabCorp must be used for all other Coventry
Commercial, Medicare, Medicaid, and Healthy Kids Members.
61
Although Coventry maintains a Contract with LabCorp to provide lab and path services, we recognize the need
for urgent lab work to make a diagnosis, or to treat the patient while in the Provider’s office. When this situation
occurs, some lab procedures listed below can be billed to Coventry and the Provider will be reimbursed according to
the schedule below:
CPT
Code Description
Allowable
Rate
Provider Type
36410
36415
81000
81001
81002
81003
81005
82247
82947
82948
84520
85002
85007
85008
85013
85018
85025
85027
85610
Non-routine Blood draw > 3 yrs
Routine venipuncture
Urinalysis manual
Urinalysis automated
Urinalysis non automated w/o microscopy
Urinalysis automated w/o microscopy
Urinalysis
Bilirubin
Glucose; quantitative
Glucose blood; reagent strip
BUN - Assay of urea nitrogen (HEDIS Code)
Bleeding time test
B1 smear w/diff w/bc count
B1 smear w/o diff w/bc count
Blood count; spun micro hematocrit
Hemoglobin
CBC
Hemogram and platelet count automated
Prothrombin time
$ 3.00
$ 3.00
$ 2.00
$ 2.00
$ 3.00
$ 3.00
$ 3.00
$ 10.00
$ 3.00
$ 3.00
$ 8.00
$ 4.00
$ 4.00
$ 4.00
$ 2.00
$ 2.00
$ 6.00
$ 6.00
$
4.00
86580
86580
87081
Skin Test, Tuberculosis, Intradermal
Skin Test, Tuberculosis, Intradermal
Culture, presumptive, pathogenic organisms,
screening
Influenza Immunoassay
Influenza Immunoassay
Streptococcus group A with direct optical
observation
$
$
7.00
3.20
ALL
ALL
ALL
ALL
ALL
ALL
Urology Providers Only
ALL
ALL
ALL
ALL
Hematology/Oncology Providers Only
Hematology/Oncology Providers Only
ALL
ALL
ALL
ALL
ALL
Hematology/Oncology/Cardiovascular
Disease Physicians Only
ALL
Medicaid/Healthy Kids
$
5.00
ALL
87804
87804
87880
$ 11.50
$ 16.88
Medicaid/Healthy Kids
Commercial/Medicare
$
ALL
5.00
All preadmission laboratory testing should be performed by a Coventry Contracted lab. For Members scheduled for
elective admission, all preadmission diagnostic work-ups including lab, radiology, and supporting specialty consultations,
must be referred to free-standing Contracted Providers. If needed, lab services may be performed at that facility
within seven (7) days of the event. Any laboratory service required prior to the seven (7) days must be performed
as described above.
CLIA Certification
Physician office laboratories must hold either a CLIA certificate or a CLIA waiver to perform laboratory tests for
Coventry Members. When billing for laboratory services, please be sure to include your CLIA number on the claim
form.
62
Section 10 – Claims, Billing, Capitation &
Encounters
Providers shall submit claims in accordance with applicable state and federal laws. Untimely claims will
be denied when they are submitted past the timely filing deadline. Unless otherwise stated in the
Provider Agreement, the following guidelines apply:
Timely Filing & Prompt Pay Guidelines Grid
Provider / Claim Type
Commercial participating and non-participating
Providers
Medicare participating and non-participating
Providers
Medicaid participating and non-participating
Providers
Late charges/corrected claim (corrected coding, NDC,
type of submission indicator)
Guideline
Provider shall submit bills within one hundred eighty (180)
days or as set forth in applicable law, whichever is less, of
the date of discharge/service unless coordination of benefit
issues exist as defined in F.S. 641.3155.
Provider shall be paid in accordance with the payment
terms set forth in each product attachment. In accordance
with the law in the state of Florida, payments to physician
shall be made within twenty (20) days of receipt of an
electronic clean claim and within forty (40) days of receipt
of a non-electronic clean claim. When Florida law does not
apply, payment to physician shall be made within forty-five
(45) days of receipt of a clean claim
In accordance with CMS 42 CFR 422.520(a)(1), Coventry
shall make best efforts to pay clean claims submitted by
hospital for covered services provided to Medicare
Advantage Members within thirty (30) calendar days of
receipt.
For purposes of this product, the term “clean claim” shall
have the meaning assigned in 42 CFR 422.500. Coventry
shall pay interest on clean claims that are not paid within
thirty (30) calendar days in accordance with 42 CFR
422.520(a)(2).
Provider shall mail or electronically transfer (submit) the
claim within six (6) months after the date of service or
discharge from an inpatient setting or the date that the
provider was furnished with the correct name and address
of the Managed Care Plan.
When the Managed Care Plan is the secondary payer, the
provider must submit the claim within ninety (90) calendar
days after the final determination of the primary payer.
Provider shall have the opportunity to correct any billing or
coding error within thirty-five (35) days of denial related to
any such claim submission
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Return of requested additional information (itemized
bill, ER records, med records, attachments)
A Provider must submit any additional information or
documentation as specified, within thirty-five (35) days
after receipt of the notification. Additional information is
considered received on the date it is electronically
transferred or mailed. Coventry cannot request duplicate
documents. (F.S. 641.3155(2)(c)(2)
Coordination of Benefits
Coordination of Benefits (“COB”) provision applies when a Member has health care coverage under more than one
plan. In the event that Coventry is the secondary payer, coordination of benefit claims must be submitted within
ninety (90) days after final determination by the primary organization as evidenced by the primary carrier’s
Explanation of Payment (EOP) or Explanation of Benefits (EOB) as required under applicable law and regulation.
(See Florida statute 641.3155(2)). All explanations of payment or denials from the Member’s primary carrier must
be provided with the claim. Information should be sent to:
Attn: Commercial
Coventry
ACS
P.O. Box 7807
London, Kentucky 40742
Attn: Medicare
Coventry
ACS
P.O. Box 7808
London, Kentucky 40742
Attn: Medicaid & Healthy Kids
Coventry
ACS
P.O. Box 7803
London, Kentucky 40742
Claim Status
You may use the Coventry website at www.directProvider.com to check the status of claims with dates of service
within the last year (365 days).
64
How to Read Your Remittance Advice
Here are detailed explanations of the fields on the remittance advice to aid you in reading your remittance
advice.
Claim Detail
•
•
•
•
•
•
•
•
•
•
•
Patient Name – The name of the Member receiving the services
Account # -- Patient account number taken from the claim submission
Place of Service – Identifies the type of facility where the services were provided,
e.g., outpatient, hospital, office, etc.
Member # -- Coventry identification number for the Member receiving services
Date Received- The date the claim was received by Coventry
Processed Date – The date the claim was processed in Coventry's system
Claim # -- A unique number assigned during the claim imaging process. Please provide this number
when making claim inquiries as it speeds specific claim retrieval
Auth # -- The number that Coventry assigns to the referral associated with the claim, if applicable.
Claim Provider – Identifies the name of the Provider in the HIPAA compliant format, who performed and
billed the service
Carrier – The information in this field may vary by product and account. It indicates the entity
responsible for funding the claim, including the employer group if a self-funded arrangement is
applicable
Network/Division – Division of referring physician, if a referral is applicable. May also signify network
accessed
65
•
•
•
•
•
•
•
•
•
•
•
Product- Indicates which one of the Coventry products applies to the coverage for the Member, e.g., HMOCommercial, PPO, etc.
Service Dates – Dates of service corresponding to each procedure code. From first date the Member
received the service from the Provider (from date) through the last date the Member received the service
from the Provider (to date)
Procedure Code – Code pertaining to the procedure performed and billed by the Provider on the
corresponding service date(s)
Mod Cd – Indicates the modifier for the procedure code and procedure description, if applicable
DRG/APC- Reflects the specific DRG or APC used to process the claim, if applicable
Procedure Description – Describes the procedure performed for the procedure code indicated
CAP Y=Yes, Indicates the claim line was adjudicated as a result of a capitated Agreement.
CAP N=No, indicates the claim line was adjudicated as a result of a fee for service Agreement
Total Charges – The amount billed for the procedure(s) performed on the corresponding service
dates(s)
Allowed Amount – Amount of billed charges less any ineligible amounts
Ineligible Amount – Amount that is not covered or is in excess of the Provider’s Contracted rate
and for which the Member or Provider is responsible
Editing Guidelines
Coventry uses multiple editing systems to process claims through its practice management application. These
systems are configured to comply with applicable state and federal regulations, with respect to timely filing, coding
combinations, maximum units, place of service and other editing guidelines. Claim denials resulting from editing
that conflict with Contractual obligations will be reviewed by our Clinical Editing Review Committee and a payment
determination will be made based on the Provider’s Agreement and correct coding initiatives.
A reduction in payment as a result of claims policies and/or editing procedures is not an indication that the service
is a non-covered service.
Note: Claims processed after the implementation date, regardless of date of service, will process according to the
most recent version. No retrospective claim payment changes are made for processing changes that are a result of
new editing rules.
High Dollar Claims (with expected payable amounts over $50,000)
All claims submitted to Coventry with an expected payable amount of over $50,000 (“high dollar”) require the
accompaniment of an itemized statement. High dollar claims not accompanied by itemization are subject to denial.
If a hospital Provider receives such a denial, the claim should be marked as an “appeal” and resubmitted with the
itemization for processing.
The purpose of the review is to identify items billed under routine services in an inpatient setting that are not
separately billable. Such items include but are not limited to:
• Minor medical and surgical supplies such as Band-Aids, cotton balls, Q-tips, swab sticks, drapes, saline
solutions irrigation/flush, syringes, gloves, drapes, bed linen, gowns.
• Other identified nursing charges.
• IV nursing care, procedural charges for an IV flush and or administration is considered a routine cost.
• Equipment permanently stored or housed in a room such as cardiac/heart monitor in ICU/CCU, BP monitor,
resp. ETCO2 equipment.
• Continuous pulse ox monitoring in critical care or step down units.
• Personal items such as slippers, lotions, powders, deodorant, admission kits (except MD), tooth
brushes, denture care kits, under pads.
66
National Provider Identifier (NPI)
NPI is the standard unique health identifier for health care Providers adopted by the Secretary of Health and
Human Services under the Health Insurance Portability and Accountability Act of 1996. You may apply for an NPI
number online at https://nppes.cms.hhs.gov.
67
Section 11 – EDI Claim & Encounter Submissions
An encounter or a claim is an interaction between a patient and provider (MCO, HMO, rendering physician,
pharmacy, lab, etc.) who delivers services or is professionally responsible for services delivered to a patient.
Encounters can be reimbursed to the provider for fee for service or capitation by the health plan.
In support of Health Insurance Portability and Accountability Act (HIPAA) and its goal of administrative
simplification, Coventry encourages physicians and medical Providers to submit claims electronically. Electronic
claims submission can have a significant, positive impact on the productivity and cash flow for your practice.
Electronic claim submission to the Coventry payers is easy to establish. Contact your practice management system
vendor or clearinghouse to initiate the process. Electronic claim submissions will be routed through Emdeon who
will review and validate the claims for HIPAA compliance and forward them directly to Coventry.
Providers can also submit directly to Emdeon. Emdeon will provide the electronic requirements and set-up
instructions. Providers should call (800) 215-4730 or go to www.emdeon.com for information on direct submission
to Emdeon.
EDI claim submitters should review the electronic claim submission requirements below:
1. EDI Specifications: The 837 claim transaction is utilized for electronic professional and institutional claims and
encounters. Coventry uses the ASC X12N 837 Professional Health Care Claim and the ASC X12N 837 Institutional
Health Care Claim implementation guides. The official implementation guides for claim transactions are available
electronically from the Washington Publishing Company website at www.wpc-edi.com.
This Coventry document contains clarifications and payer specific requirements related to data usage and content
with submitting an EDI claims to Coventry. Please note that this document is intended to list only those elements
where payer specific requirements or clarifications apply.
2. Coventry Specific Payer Edits at Emdeon: All EDI claims submitted through Emdeon will be subject to these
Coventry specific payer edits (unless indicated for one transaction only) that are in place at Emdeon. Submitters
will receive these types of rejections on their level 1 payer rejection reports.
•
The insured id must be at least two characters in length or the claim will reject
•
To allow zero dollar line charges and zero dollar claim charges
•
The billing Provider id may not contain a value of 999999999 or the claim will reject
•
If the procedure code begins with 0, then anesthesia minutes are required or the claim will reject.
Excluding procedure code is 01995 or 01996 then service units are required and the anesthesia minutes
should contain 00 or the claim will reject. If the procedure code begins with a 0 and ends with T, then
service units are required and the anesthesia minutes should contain 00 or the claim will reject.
68
•
If the procedure code does not begin with a 0, then service units are required and the anesthesia minutes
should contain 00 or the claim will reject.
•
The discharge hour must contain a numeric value of 00-23 or 99 if the batch type contains an inpatient
value of x10, x11x14 or x17 and the statement period from date is equal to the statement period thru date.
3. EDI Acknowledgement and Reject Reports: For every claim filed electronically, the Provider should monitor
whether or not that claim has been rejected by reviewing EDI acknowledgement and reject reports on a regular
basis. The following reports should be monitored regularly:
•
•
•
Initial reject report (Emdeon report Rpt 05 or equivalent vendor report) - This is a report that shows
claims rejected by Emdeon that were not forwarded to Mail Handlers Benefit Plan. These claims should be
corrected and re-submitted electronically
Initial accept report (Emdeon Envoy Report Rpt 04 or equivalent vendor report) - This is a report that
shows Emdeon accepted the EDI claim and forwarded it to Coventry for processing
Payer rejects report (Emdeon Report Rpt 11 or equivalent vendor report) - This report states why
Coventry rejected the claim. These claims should be corrected and re-submitted electronically
Monitoring Your EDI Reports
Please note that claims appearing on the initial reject report have not met the initial clearinghouse criteria
approved by Coventry and have not been sent to Coventry for adjudication. Any claims appearing on this report
must be corrected and re-submitted electronically as soon as possible to avoid timely filing issues.
It is also important to note that a claim can pass the clearinghouse edits and be displayed on the initial accept
report, but still be rejected by Coventry. Claims rejected by Coventry payors will appear on the payer reject report.
Any claims appearing on this report should be corrected and re-submitted electronically as soon as possible to
avoid timely filing issues.
Timely Filing-Coventry must accept a claim within its timely filing limit or it will be denied for untimely filing. If you
are not receiving the described clearinghouse and payer reports on a regular basis, please contact your
clearinghouse or Emdeon. A Provider can avoid timely filing issues through understanding and regular monitoring
of EDI Reports. This process will help to ensure all rejected claims are re-filed timely and electronically.
Common Rejection Reason
Review the following tips for assistance with resolving the most common rejections received by Providers. The
most common claim reject reason for Coventry is “Member not found.” Use the Coventry secure Provider portal,
directProvider.com, Emdeon, or an integrated solution through your vendor or clearinghouse to verify/validate
Member’s eligibility prior to submitting claims.
•
Member Identification Number- Submit the 10 or 11 digit number as displayed on the patient's ID card.
•
Patient Date of Birth-Submit a valid date of birth for the patient.
- Do not send "00" for the month or date
- Do not send dummy dates such as "17760704"
- Do not send a date of birth greater than the date of service
69
•
A claim will be rejected if a valid date of birth does not match the date of birth on file in the Coventry
system. If this is the case, please verify the patient date of birth with the patient or policyholder.
•
Date Format -Submit all dates in the following format CCYYMMDD unless otherwise specified.
- Submit valid dates of service
- Do not submit future dates of service
•
Monetary Amount Format -Include the decimal point in all monetary amounts unless otherwise specified.
- Do not submit negative dollar amounts
•
Coding Detail-Consider the following when verifying service codes and/or modifiers that have been
rejected.
- Submit service codes and modifiers appropriate to the age and gender of the patient
- Submit service codes and modifiers appropriate to the date of service
- Submit service codes to their greatest level of specificity
EDI Assistance
Your Clearinghouse - typically, your first point of contact for resolving an EDI issue is your practice's specific
clearinghouse or vendor.
Emdeon - The Emdeon customer service center can track all EDI submissions received by them. Emdeon also
maintains the status message returned on an EDI claim from the health plan. This information is readily available
for forty-five (45) days after the submission. Information on older submissions is also available but will require
being forwarded to their research division for follow-up. Emdeon customer support can be reached at (877) 4693263. Additionally, Emdeon has a new web-based application, Vision for Claim Management that compiles claim
information received and generated during claim filing and processing. It is in an easy to use application for tracking
EDI claim submissions. For more information and registration for Vision for Claim Management, go
to http://transact.emdeon.com/editrx_services.php
Coventry staff is available to assist you with electronic filling concerns as they relate to our submission
requirements. Please contact us at (302) 283-6570 or via email at EDIClaims@cvty.com.
70
Section 12 – Provider Administration Claims
Review Process
Provider administration review process is a request by the Provider for consideration of a Coventry issued denial
for services rendered.
The review process outlined below applies to all Providers and does not replace the separate and distinct Member
appeal process wherein a Provider may appeal on behalf of a Member as the Member’s authorized representative.
Coventry’s benefit determinations are never intended to limit, restrict, or interfere with the physician’s judgment.
In all cases, decisions regarding treatment continuation or termination, treatment alternatives, or the provision of
medical services are between the physician and the patient.
Coventry recognizes that Providers may occasionally encounter situations in which the operation of Coventry does
not meet their expectations. When this occurs, the Provider is encouraged to call customer service to bring the
matter to Coventry’s attention.
Provider Administrative Review for the Medicaid line of business:
Level 1:
The review will be first handled by the customer service organizations (CSO) who are the dedicated staff for
the providers to contact via telephone, electronic mail, regular mail to ask questions, file a complaint,
including complaints about claims issues. The customer service organization (CSO) has the authority to
review and resolve provider complaints and claim issues. Allow providers forty-five (45) calendar days to file
a written complaint for issues that are not about claims. Within three (3 ) business days of receipt of the
complaint, the plan will notify the provider (verbally or in writing) that the complaint has been received and
the expected date of resolution.
The plan will investigate each provider complaint according to applicable guidelines and provider contractual
provisions, collecting all pertinent facts from all parties involved.
The plan will document why a complaint is unresolved after fifteen (15) calendar days of receipt and provide
written notice of the disposition and the basis of the resolution to the provider within three (3) business days
of the resolution and; Ensure that the plan executives with the authority to require corrective action are
involved in the provider complaint process.
Provider Administrative Review for the Commercial and Medicare lines of business:
The review will be handled by the Customer Service Organization (“CSO”) within 24-48 hours or the Provider
will be contacted in that time frame to confirm that we have received it and it is under review according to
the guidelines defined by Coventry for level 1 disputes. If the Provider still disagrees, a Level 2 review can be
requested.
Level 2:
A written review (see form) must be sent to the below corresponding CSO P. O. Box. The CSO will log the
request for review, research and bring the review to the Provider Administrative Review Committee on a
weekly basis for committee review and direction. Written notification via e-mail, fax or mail will be sent to
the Provider within 60 days of the written dispute request.
71
Types of Administrative Reviews (but not limited to):
• Timely Filing
• Administration (No authorization on file)
• Fee Schedule Disputes
• Claim Payment Disputes
• COB - disputing the way Coventry processed their claims when other insurance is primary
• Contract Allowance
• Editing Software
• Itemized Bills
• Network Accessibility
All Providers' requests for administrative reviews must be received by Coventry within 12 months from the date of
denial or date of remittance/EOP.
Attn: Commercial
Attn: Medicare
Attn: Medicaid & Healthy Kids
Coventry
Coventry
Coventry
ACS
ACS
ACS
P.O. Box 7807
P.O. Box 7808
P.O. Box 7403
London, Kentucky 40742
London, Kentucky 40742
London, Kentucky 40742
Medical Necessity Reconsideration (Pre-Service)
Coventry is not obligated to pay for unauthorized services. If the Provider does not agree with the determination
and the matter cannot be resolved informally, Coventry maintains a pre-service appeals process through which all
Providers (physician, facility, or ancillary) may appeal, on behalf of a Member, a medical management issue or
benefit determination. This process also includes provisions for an urgent review process in which the Provider can
expect a determination within 72 hours of initiating the request.
If a Provider does not agree with a denial for lack of medical necessity, he/she may request a reconsideration of the
decision. This may be done by providing additional information in one of two ways.
•
•
A peer to peer review with the medical director who made the decision may be requested by calling the
Health Services Department at (800) 292-4470 within 24 hours or one working day of the denial, or;
A request for reconsideration may be made by providing additional information by phone at (800) 2924470, by fax at (888) 399-1831, or mail to:
Coventry Health Care
Attn: Health Services/Appeals Unit
1340 Concord Terrace
Sunrise, FL 33323
Important Information About Commercial Member Appeal Rights
The Right to Appeal
If the Member is dissatisfied with our decision, the Member, or their authorized representative, can file for an
appeal through Coventry’s internal process. The Member has 180 calendar days from the date of the adverse
determination to file an appeal.
72
Need help understanding the denial? The Member, or their authorized representative, can contact Coventry at 1866-847-8235 if assistance is needed to understand the denial notice or Coventry’s decision to deny a service or
coverage.
What if the Member does not agree with this decision? The Member has a right to appeal any decision not to
provide or pay for an item or service (in whole or in part).
How to file an appeal? An appeal can be mailed or faxed to the address below:
Coventry – Florida
Attn: Member Appeals Department
1340 Concord Terrace, Sunrise FL 33323
Fax: 954-858-3437
What if the situation is urgent? If the situation meets the definition of urgent under the law, the review will be
conducted on an expedited basis. Generally, an urgent situation is one in which the Members health may be in
serious jeopardy or, in the opinion of the physician, the Member may experience pain that cannot be adequately
controlled while they wait for a decision on the appeal. If you believe the situation is urgent, you may request an
expedited appeal by calling us at 1-866-847-8235, or send your request via fax at 954-858-3437.
Who may file an appeal? The Member or someone they name to act on their behalf (authorized representative)
may file an appeal.
Can additional information be provided regarding a claim? Yes. Additional information can be sent by mail or fax
to the contact information listed under the section titled “How do I file an appeal?”
What happens next? If an appeal is filed, Coventry will review the decision and provide a written determination. If
the decision is to deny the payment, coverage, or service requested or a decision is not made timely, the Member
may be able to request an external review of the claim by an independent third party, who will review the denial
and issue a final decision.
Pre-Service Appeal - If the appeal involves services that have not yet been provided, the Appeals department will
notify you of a decision within 15 calendar days after receipt of the appeal request.
Urgent Care Services (Expedited) Appeal. If the requested services involve urgent care, as defined by federal ERISA
law, a decision will be made no later than 72 hours after Coventry receives the appeal request. The Appeals
department will notify you if your request does not qualify as urgent.
Post Service Appeal. If the appeal involves services that have already been provided, Coventry will notify you of our
decision within 30 calendar days after the receipt of an appeal.
Appealing a Medical Necessity Decision
A medical necessity appeal is an appeal involving Coventry’s decision that a service does not meet medical
necessity criteria or is considered to be experimental or investigational.
A level one medical necessity appeal will be reviewed by a physician with the same or similar credentials as would
usually treat the condition which is being appealed. The physician reviewing the level one medical necessity appeal
has no involvement in the initial denial.
[Employer Group Plans Only] A level two medical necessity appeal is available if the decision is not favorable.
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Important Information About Medicare Member Appeal Rights
There are two kinds of appeals:
Standard (30 days) – Coventry must issue a decision no later than thirty (30) days after receipt of the appeal. (This
may be extended by up to fourteen (14) days if an extension is requested, or if Coventry needs additional
information and the extension benefits the Medicare Member.)
Fast (72 hour review) – A fast appeal can be requested if the Medicare Member’s health could be seriously harmed
by waiting up to 30 days for a decision. Coventry must decide on a fast appeal no later than 72 hours after receipt
of the appeal. (This may be extended by up to fourteen (14) days if requested or if Coventry needs additional
information and the extension benefits the Medicare Member.)
•
•
If any Provider asks for a fast appeal by indicating that waiting for 30 days could seriously harm the Medicare
Member’s health, Coventry will process the appeal as a fast request.
If the Medicare Member requests a fast appeal without support from a Provider, Coventry will decide if the
Member’s health requires a fast appeal. Coventry will notify the Medicare Member if we do not issue a fast
appeal, and we will decide the appeal within 30 days.
What should be included with an appeal?
A written request should include: your name, address, Medicare Member number, reasons for appealing, and any
evidence you wish to attach. You may send in supporting medical records, doctor’s letters, or other information
that explains why Coventry should provide the service.
How Do I File An Appeal?
For a Standard Appeal: Mail or deliver the written appeal to the address below:
Coventry Health Care of Florida
Attn: Member Appeals Department
P.O. Box 7776
London KY 40742
For a Fast Appeal: Contact us by telephone or fax:
Telephone: 1-866-707-9781
Fax: 1-855-788-3994
What Happens Next?
After Coventry’s review, if any of the requested services are still denied, Medicare will provide the Medicare
Member with a new and impartial review of the case by a reviewer outside of Coventry.
Important Information About Medicaid Member Appeal Rights
A Medicaid Member may file a Medicaid grievance, or a Provider acting on the Medicaid Members behalf with
written authorization, may file a Medicaid grievance. Medicaid grievances can be filed either orally or in writing
and must be filed within one (1) year after the date of occurrence that initiated the grievance. The address and
telephone number to contact the Grievance and Appeals department is:
Coventry Health Care of Florida, Inc.
Attention: Appeals and Grievance
1340 Concord Terrace, Sunrise FL 33323, (800) 441-5501 (toll free)
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You can contact the Coventry customer service department to file a grievance and request the form by calling (800441-5501) Monday through Friday 8:00 a.m. – 7:00 p.m. Eastern Time. Coventry and/or the Provider must give the
Medicaid Member reasonable assistance in completing the forms and other steps, including but not limited to
providing interpreter services and interpreter capability.
The grievance coordinator will send an acknowledgement letter within three (3) business days of the receipt of the
Medicaid grievance. The Medicaid grievance will be reviewed as expeditiously as the Medicaid Member’s health
requires, or in a reasonable length of time not to exceed ninety (90) days from initial filing by the Medicaid
Member, or Provider acting on their behalf. If an extension is necessary, Coventry will notify the Medicaid Member
of the delay, which is not to exceed fourteen (14) calendar days.
Information about the Beneficiary Assistance Program (BAP) process, including an explanation that a review by the
BAP must be requested within one (1) year after the date of the occurrence that initiated the appeal, how to
initiate a review by the BAP and the BAP address and telephone number:
Agency for Health Care Administration Beneficiary Assistance Program
Building 1, MS #26 2727 Mahan Drive, Tallahassee, FL 32308
(850) 412-4502
(888) 419-3456 (toll-free)
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Request for a Reconsideration (Appeal) for Medicaid Members
A Medicaid Member may file an appeal, or a review of a Medicaid action (denial in whole or part of a requested
service). The Medicaid Member, or Provider acting on their behalf, may file an appeal within thirty (30) calendar
days of the date of the action. If Coventry did not issue a written notice of action, the Medicaid Member may file
an appeal within one (1) year of the action. Any oral requests to appeal a Medicaid action are treated as appeals
and Coventry will confirm the appeal in writing, unless the Medicaid Member or Provider requests an expedited
resolution.
For decisions that involve an appeal of a denial that is based on medical necessity, a Medicaid grievance regarding
the denial of an expedited resolution of an appeal, or a grievance/appeal that involves clinical issues, the decision
maker will be someone other than the person involved in making the initial determination, and who has the clinical
expertise in the Medicaid Members condition or disease.
The Medicaid Member or their representative will have an opportunity to review the case file, including medical
records and any other documents and records.
Expedited Reconsideration (Expedited Appeal) for Medicaid Members
Coventry has an expedited review process for appeals when Coventry determines, or the Provider indicates that
taking the time for a standard resolution could seriously jeopardize the Medicaid Member’s life or health or ability
to attain, maintain, or regain maximum function.
The Medicaid Member or Provider may file an expedited appeal either orally or in writing. No additional Medicaid
Member follow-up is required.
Further Rights for Review/Medicaid Fair Hearing for Medicaid Members
Coventry’s grievance and appeal processes state that the Medicaid Member has the right to request a Medicaid fair
hearing in additional to pursuing Coventry’s grievance process. A Provider acting on behalf of the Medicaid
Member and with the Medicaid Member’s written consent may request a Medicaid fair hearing. A Medicaid
grievance taken to the Medicaid fair hearing process will not be considered by the subscriber assistance program.
The Medicaid Member or Provider may request a Medicaid fair hearing within ninety (90) days of the date of the
notice of action (or denial of service). To request a Medicaid fair hearing, the Medicaid Member or Provider must
contact:
Office of Public Assistance Appeals Hearings
1317 Winewood Boulevard, Building 5, Room 255
Tallahassee, FL 32399-0700
Coventry is required to continue the Medicaid Member’s benefits while a Medicaid fair hearing is pending if:
(a) The Medicaid fair hearing is filed timely, meaning on or before the latter of the following:
(i) within ten (10) days of the date on the notice of action;
(ii) the intended effective date of Coventry’s proposed action;
(b) The Medicaid fair hearing involves the termination, suspension, or reduction of a previously authorized
course of treatment;
(c) The services were ordered by an authorized Provider;
(d) The authorization period has not expired; and
(e) The Medicaid Member requests an extension of benefits.
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Section 13 – Overpayment Recovery
If a claim is overpaid, the Provider will receive a letter via U.S. mail from Coventry requesting the return of monies
paid in error in accordance with Florida statute.
Providers are able to access and track their overpayment recovery detail through our website at
www.directProvider.com under the “Providers’ section.” If there are any questions about the information in the
notice, on the website or concerns about an explanation of payment entry for a negative amount, please email
Coventry’s Financial Recovery department at Financial.RecoverySF@cvty.com or via mail to:
Recovery Operations
P.O. Box 7247-7427
Philadelphia, PA 19170-7427
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Section 14 – Credentialing
The Coventry’s Credentials Verification Center (CVC) has responsibility for the centralized credentialing of Providers
Contracted with Coventry. Credentialing activities follow the guidelines defined by various accrediting
organizations, CMS as well as state and federal regulations.
Provider categories requiring full credentialing based on these stated guidelines include:
• Physicians (MD,DO)
• Dentists (Oral Maxillofacial – DDS/DMD)
• Chiropractors (DC)
• Podiatrists (DPM)
• Physical Therapists/Occupational Therapists/Speech Therapists (ONLY if individually contacted and listing in
the Provider directories)
• Various allied health and behavior health Providers, as defined by Coventry, and
• Additional Providers who hold independent relationships or Contracts with Coventry and/or are listed in
Provider directories, or as required by a specific state statute.
Providers may complete the Coventry Provider application. Use of The Council for Affordable Quality Healthcare,
Inc. (CAQH) universal application, which is free to the Provider and available statewide, is encouraged to support
electronic submission. Providers may access www.caqh.org to register directly.
The requirements for Provider credentialing are:
• Complete executed appropriate application
• Verification of current licensure in the state(s) where the Provider has a practice location and/or hospital
privileges/affiliation
• Evidence of good standing with state regulatory bodies
• Absence of federal and state sanctions verified through the EPLS and NPDB
• OIG Form – Ownership & Controlling Interest Worksheet
• Absence of sanctions verified through OIG/LEIE
• DEA or state controlled substance license (CDS/BNDD) in every state in which a Provider sees Coventry
Members as defined by practice location and hospital affiliation
• Liability insurance (by attestation or by a copy of liability insurance policy declaration sheet, or as required
by Florida statute 458.320)
• Verification of education, either by board certification or education verification
• Current hospital affiliation
• At least a 5-year uninterrupted work history (or period of time required by state statute)
• Completion of survey questions with explanations for any “yes” answers
• Current signed attestation/release; and
• Site visit (PCPs and OB/GYNs)
Practitioners Rights:
Practitioners have a right to correct erroneous information submitted by another source. Information that differs
substantially from that submitted by provider will require staff to notify provider for clarification/correction,
including variations from Provider reported information on malpractice history, licensure actions or board
certification status.
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Practitioners may review information submitted to support their credentialing application, including any
information received from outside sources, with the exception of references, recommendations or other peer
review protected information.
Practitioners may receive the status of their credentialing or recredentialing application, upon request
Board Certification:
Board certification is not a requirement for network participation. However, Providers may be ineligible for
participation in specific regulated products which require the Provider to be board certified, e.g. Florida Healthy
Kids.
Facilities are credentialed by license, not by TIN and must utilize a Coventry facility application. Urgent Care
Centers are subject to credentialing at the facility level only; Providers in these centers are not individually
credentialed. Additional categories may be added based on state requirements, regulations and/or accreditation
standards. All facilities require evidence of one of the following; accreditation from a recognized approved entity,
results of a survey done by the state, CMS audit or CMS Certification.
Facility categories requiring full credentialing based on these stated guidelines include:
• Hospitals
• Laboratories
• Free standing ambulatory surgery centers
• Nursing Homes
• Home Health Agencies
• Skilled Nursing Facilities
• Home IV/Infusion Services
• Urgent Care Centers
• Retail Clinics (“Minute Clinics”)
• Hospices
• Behavioral health Facilities including in-patient,
• End Stage Renal Disease Facilities
residential and /or ambulatory
(ESRDs)
• Physical Therapy/Occupational Therapy/Speech
• Comprehensive Outpatient
Language Therapy
Rehabilitation Facilities
The requirements for facility credentialing are:
o Complete executed application
o Verification of current licensure in the state where the facility treats Coventry Members
o Evidence that the facility is in good standing with state regulatory bodies
o Absence of federal and state sanctions verified through the OIG/LEIE
o Liability insurance
o Current signed attestation/release; and
o Copy of W-9
Re-Credentialing
Providers and facilities are subject to re-credentialing every three years or as applicable based on state standards.
Initiated by the CVC within 180 days of the current expiration date, the process follows the same as initial
credentialing with the exception of primary source verification of education and work history. Providers and
facilities non-compliant with the re-credentialing requirements may be terminated from Coventry’s network.
Dual Specialties
Participation in two or more specialties may be granted based on Coventry’s business need and supported by
verifiable training in the specialties requested.
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Ongoing Monitoring
Coventry routinely monitors Providers and facilities ensuring any changes in licensure status, sanctions or other
adverse actions are reviewed by the credentialing committee. Providers or facilities with a license suspension or
revocation are subject to termination from Coventry’s network.
Credentialing Committee
Coventry’s credentialing committee renders decisions on whether to grant or deny credentialing to the Provider.
Credentialing is generally granted for a three year period; however, the committee may choose to grant
credentialing for a lesser time frame. The credentialing committee meeting minutes and discussions are
confidential. Committee decisions are communicated to all applicants in writing. Coventry maintains credentialing
files on each Provider and supporting electronic systems in a confidential manner. All information collected is
solely utilized for the purpose of credentialing.
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Section 15 - Provider Participating Status
Dispute Resolution
Coventry has a process for participating Providers to resolve issues between the participating Provider and
Coventry that may result in a change in network status of the Provider, as such network status change relates to
Coventry’s review of the Providers professional competency and/or conduct or clinical quality. A Provider may be
denied continued participation status for quality concerns based on the competence or professional conduct of a
Provider, which affects or could affect the health or welfare of a patient or patients.
Examples of such quality concerns include but are not limited to:
•
•
•
•
•
•
Evidence of substandard treatment rendered to patients
Malpractice judgments/settlements
In any instance where corrective action will be required to be reported to the National Provider Data Bank
In any instance where a Provider’s Contract with Coventry is terminated for cause under the terms of the
Contract
Current Medicare or Medicaid sanctions
Loss of accreditation or certification status if a facility or ancillary Provider
Prior to taking any final action to deny continued participation status to a Provider for quality concerns, the
Provider will be entitled to pursue the appeal process.
If the credentialing committee has made the determination to not renew a Providers reappointment for
reasons based on quality concerns, the Provider shall be notified in writing by the medical director of the decision
and the reasons for it. The Provider may request an appeal, within thirty (30) days of receipt of the decision letter.
The Provider must make this request to the medical director in writing.
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Section 16 – Regulation and Accreditation
Providers shall comply with the applicable provisions of this Manual and cooperate with and participate in all
internal and external QIO review process; independent quality review and improvement organizations’ activities;
utilization management, including patient assessment and disease management programs, credentialing and recredentialing, quality assurance and management and other administrative activities, including site medical audit
reviews and medical record charting and compliance audits, financial audits and post audit interviews by Coventry
personnel or internal or external financial or other audit programs; performance improvement projects; *HEDIS™
reporting requirements and performance measurement and reporting activities, in each case consistent with
applicable law as may be established or implemented by Coventry or its designees from time to time, including but
not limited to Coventry nurse reviewers.
Coventry is authorized to take whatever steps necessary to ensure that the Provider is recognized by the state
Medicaid program, including its choice counseling/enrollment broker contractor(s) as a participating provider of
the health plan and that the Provider’s submission of encounter data is accepted by the Florida MMIS and/or the
state’s encounter data warehouse.
Providers shall comply with all final determinations rendered by Coventry in connection with any of the foregoing.
Providers shall cooperate and participate in any program required for Coventry’s compliance with the Medicare
and Medicaid programs and any other federal or state laws and regulations or the rules and regulations of
accreditation organizations.
Providers shall grant Coventry, AHCA, CMS, OIR, any accreditation organization, any QIO and any other agency with
governing or accreditation authority over Coventry access to its facilities and records on reasonable notice during
ordinary business hours for the purpose of conducting any reviews, audits or site visits in connection with the
foregoing in accordance with the Agreement and this Manual.
To the extent permitted by applicable law, Providers shall provide such medical and other records or data required
by Coventry or any regulatory agencies governing Coventry in connection with the foregoing within ten (10) days of
written notice to the Provider without cost to Coventry or such sooner time as requested by Coventry in order for
Coventry to comply with applicable law and regulations and in accordance with Contract terms.
Disciplinary Action
As required by applicable law and regulations, and accreditation organization requirements, all quality complaints
relating to the care and services rendered by Providers are investigated according to Coventry’s defined Adverse
Incident/Quality Complaint Investigation policy and procedure. All aspects of the peer review process including
investigation, conclusions, recommendations, actions taken and results of corrective actions are privileged and
confidential. All related documents are maintained securely and confidentially in the Quality Improvement
department pursuant to F.S. 766.101 (5).
Depending upon the nature of the issue the investigation may include, but not limited to:
• Internal fact finding from internal records (customer complaints, enrollment status, medical management
activities, claims history and status)
• Outreach to the Member and/or Member representative
• A letter of inquiry to the involved Provider summarizing the currently understood facts and a request for
response to the issue
• A request for medical records when necessary
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When a case is referred to the Peer Review Committee, the committee evaluates the facts of the case and
determines if the care and service meets the standard of care and makes one or more of the following
determination(s):
•
•
Assigns a severity level – (See Attachment B). and
Recommend a follow up activity which may include but is not limited to:
o Track and trend for patterns
o Provider education/orientation
o Request additional information
o Focused review – The committee recommends completing a focused review of additional
practitioner’s clinical records.
o Corrective action plan – The committee may request a corrective action plan from the Provider.
o Provider termination for failure to follow the Contract – The committee may make a
recommendation to issue a termination notice for failure to fulfill obligations of their Contract
o Reduction, suspension or termination for quality of care issues. This situation occurs when the
committee finds serious substandard quality issues.
o Referral to Provider relations department for follow up
o Letter of warning
This determination strictly follows the due process of appeals as outlined by the Health Care Quality Improvement
Act of 1986.
The Quality Improvement department notifies Providers in writing within five business days of the Committee’s
decision. The letter summarizes the following:
•
•
•
•
•
•
•
A summary of the facts of the case
The review of the case by the Peer Review Committee
The committee’s determination
The disposition of the case
Specific actions the Provider must take to correct the issue/problem and prevent recurrence, if any
A description of the process used to evaluate the effectiveness of the intervention
The Providers appeal and hearing rights
The Provider may disagree with the determination of Coventry’s Peer Review Committee, and decide to file an
appeal in accordance with the process define in Section 15 of this Manual.
Upon imposition of a corrective action plan, the Peer Review Committee evaluates the effectiveness of the
intervention. The committee makes one of the following determinations:
•
The intervention was effective. A letter is prepared and sent to the Provider stating that the quality
concerns were addressed.
•
The intervention was not fully effective. The Committee may recommend additional actions. A
notification letter is sent to the Provider.
•
The intervention was not effective. The committee may suspend the Provider, terminate the Provider,
freeze or move the Provider’s Membership.
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Issues that may be brought to the committee that are not related to clinical competency include:
•
Failure to respond to notice of defects in medical records
•
Failure to participate in quality management or peer review activities
•
Failure to meet other Contractual requirements not related to clinical competency
•
Evidence of illegal use of narcotics or other intoxicants
•
Unethical conduct
•
Failure to cooperate with Coventry’s quality improvement program
•
Failure to cooperate with Coventry’s utilization management program
•
Failure to respond to an investigational request
•
Failure to respond to a corrective action plan
•
Failure to comply with quality management or risk management guidelines
•
Insubordinate activity by Provider, including but not limited to lack of cooperation with Coventry, failure
to comply with the terms of this Manual or other business reasons.
Any of these failures may result in corrective action by the Peer Review committee, including but not limited to
termination.
Information gathered in the quality management and peer review process shall be shared with the credentialing
committee.
Reporting to Regulatory Agencies
Coventry will report any decision to reduce, suspend or terminate a Provider’s participation in Coventry network as
required by applicable law and regulations.
Committee Activity
Coventry values physician input and views it as an important element of the management structure of Coventry.
From time to time, you may be asked to participate in a variety of professional committees. Your participation in
these committees will be greatly appreciated.
Treatment of Immediate Relatives and Self:
Providers shall not treat themselves or immediate family Members, except in the case of an emergency medical
condition only when another physician is not readily available. For the purpose of this Manual “Immediate
Relatives” means any of the following but is not limited to:
1.
2.
3.
4.
5.
6.
husband or wife
natural or adoptive parent, child or sibling
stepparent, stepchild, stepbrother or stepsister
father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law or sister-in-law
grandparent or grandchild; and
spouse of grandparent or grandchild
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Section 17- Pharmacy
Pharmacy Drug Formulary
Coventry Health Care of Florida maintains a drug Formulary for each line of business: Commercial (HMO, POS, and
PPO), Medicaid (includes Florida Healthy Kids) and Medicare. These formularies are developed by the appropriate
Coventry Health Care Pharmacy and Therapeutics (P&T) Committee for that line of business to assist physicians in
prescribing cost-effective, quality drug therapy. The appropriate Formulary should be used when prescribing for
Coventry Health Care of Florida Members. The formularies contain convenient cost comparison guides for several
drugs within therapeutic categories. When writing a prescription for a Coventry Health Care of Florida Member,
please consider those medications that are covered under the appropriate Formulary. Products are accessible in a
tiered copayment arrangement and the Members copayments may vary depending on the product tier. Coventry
Health Care of Florida formularies and other prescription benefit documents are accessible at
http://www.chcflorida.com, or you may contact your Provider relations representative for a copy.
Pharmaceutical Management Procedures
The National Pharmacy and Therapeutics (P&T) Committee, with recommendations from Regional P&T Committees
(where applicable), will be responsible for the development and ongoing management of CHC Formularies. In
adhering to our principle of “embracing generics” we’ve developed a mechanism to add generic medications to the
Formularies without waiting for the National P&T Committee to meet. This will result in an increased number of
generic medications available on our Formulary, and decreased administrative hassles for our Members, and their
prescribing Practitioners.
The CHC Pharmacy Department will communicate Formulary changes that adversely affect Members and their
prescribing Practitioners via letter at least one (1) month in advance. Annually and after updates, changes to
pharmaceutical management procedures (i.e. Formulary, prior authorization, step-therapy, etc.) will also be
communicated to Members and participating Practitioners in writing.
The Coventry Health Care Pharmacy Department uses a number of processes to promote safe, cost-effective
medication use. One of these processes is prompt written notification of Members and prescribing Practitioners
regarding Class I and II medication recalls. We also monitor individual and aggregate patterns of medication use in
order to identify opportunities to promote safe and effective therapy. These efforts are supported contractually by
concurrent drug utilization review activities between CHC and the Pharmacy Benefits Manager (PBM).
Generic Drug Policy
Generic substitution is mandatory if the FDA has determined the generic to be therapeutically equivalent to the
brand product. These medications are noted in the commercial and Medicaid Formulary with an (*) asterisk and
the generic name is italicized in the Medicare formulary. These drugs are covered at a generic reimbursement level
and Maximum Allowable Cost (MAC) limits of reimbursement have been defined. When a physician indicates
“Dispense as Written” or if a Member insists on the brand-name when a generic is available, the Member may
incur the cost difference between the brand-name product and the MAC amount in addition to their copayment.
There are six (6) Florida negative Formulary drugs (narrow therapeutic window) that are exempt from automatic
generic substitution. These include: Digitoxin, Conjugated Estrogens, Dicumarol, Chlorpromazine (solid oral dosage
forms), Theophylline (controlled release) and Pancrelipase (oral dosage forms).
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Prior Authorization and Step Therapy
To promote appropriate utilization of Formulary generics and preferred brand name drugs, certain medications
may require prior authorization to be eligible for coverage under the Member’s prescription benefit. These
medications include all specialty drugs, along with high risk and/or high cost medications and select non-preferred
drugs. These drugs are designated in the Formulary by “Prior Authorization” or “Step Therapy”. Prior authorization
and step therapy criteria have been established by the different Coventry P&T Committees for each line of
business.
For a Commercial or Medicaid Member to receive coverage for a medication requiring prior authorization, the
physician or pharmacist can call the pharmacy department at 1-866-847-8279 to request authorization or fax your
request to 1-877-548-7648 for commercial members and 1-855-799-2554 for Medicaid members using a prior
authorization request form. In order for a Medicare Member to receive coverage for a medication requiring prior
authorization, the physician or pharmacist can call 1-800-551-2694 for or fax the request to 1-800-639-9158.
If your request does not have a specific form, please use the form that states Formulary exception and fill in the
medication that you are requesting. These forms may be duplicated as often as necessary. To view and access the
most current prior authorization and step therapy criteria and forms, visit the Coventry Health Care of Florida
website at http://www.chcflorida.com
Quantity Limits
Quantity Limits (QL) on medications are established for different reasons. Limits are set because some medications
have either a maximum limit recommended by the FDA or a maximum dose suggested by the medical literature.
Many commonly used once daily drugs have limits since these drugs are proven to be safe and effective when
taken once daily. In addition, taking two pills daily instead of one pill of equal strength may double the cost of
therapy without necessarily improving the benefit. Other drugs are on the list as a safeguard to make sure that
Members do not receive a prescription for a quantity that exceeds recommended dosage limits. The updated QL
list can be found on Coventry Health Care of Florida website at http://www.chcflorida.com.
Diabetic Supplies
Diabetic blood glucose test strips and supplies are covered if the employer purchases this benefit. For those
Members, only LifeScan One Touch Ultra®, One Touch FastTake®, One Touch SureStep® and One Touch Test Strips®
are available as the preferred formulary product. Insulin is a covered benefit through their prescription benefit.
Specialty Drugs and Self-Administered Injectables
Specialty drugs and Self Administered Injectables (SAI) are covered under the pharmacy benefit. Specialty drugs are
designated on the formulary with a SP applies to all Coventry Health Care of Florida Members. Members can
receive Specialty and SAI drugs through their Coventry Health Care of Florida pharmacy benefit after prior
authorization has been requested and approved. Depending on the Member’s pharmacy benefit, copayments will
be assessed at that time. Accredo specialty pharmacy is the preferred pharmacy vendor.
All specialty and SAI drugs require prior authorization by the Pharmacy department rather than the Coventry
Health Care of Florida precertification line. To request prior authorization for a Commercial or Medicaid Member,
Providers may call the Pharmacy department at 1-866-847-8279 or fax your request using a prior authorization
request forms to 1-877-548-7648 for commercial members and 1-855-799-2554 for Medicaid members using a
prior authorization request form. In order for a Medicare Member to receive coverage for a medication requiring
prior authorization, the physician or pharmacist can call 1-800-551-2694 for or fax the request to 1-800-639-9158.
Forms can be found on Coventry Health Care of Florida website at http://www.chcflorida.com.
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Pharmacy Network
Coventry Health Care of Florida Members have access to a national network of over 60,000 participating
pharmacists. Please refer your Coventry Health Care of Florida Members to the Coventry Health Care of Florida
website at http://www.chcflorida.com for a comprehensive list of participating pharmacies.
You can access the following pharmacy information at www.chcflorida.com
•
A list of preferred pharmaceuticals, including any restrictions and/or preferences;
•
A list of medications which require prior authorization, and applicable coverage criteria;
•
A list of medications which require step-therapy, including the medications which must be tried/failed prior
to coverage;
•
A list and explanation of medications which have limits or quotas;
•
Copayment and coinsurance requirements, and the medications or classes to which they apply;
•
Procedures for step-therapy, prior authorization, generic substitution, preferred-brand interchange, and
therapeutic interchange;
•
Information on the use of pharmaceutical management procedures;
•
Criteria used during the evaluation of new medications for inclusion on the formulary, and
•
A description of the process for requesting a medication coverage exception.
Maintenance Drug Program
Coventry Health Care of Florida Members may obtain maintenance medications through pharmacies that are
specifically Contracted with Coventry Health Care of Florida to provide up to a ninety (90) day supply. Express
Scripts mail order pharmacy is our Contracted pharmacy for 90 day supplies. For more mail order information, visit
the Coventry Health Care of Florida website at http://www.chcflorida.com
Appeal Rights
The fact that a Coventry Health Care of Florida participating Provider prescribes, recommends or orders a
medication does not make such a medicine a covered benefit. Whether or not a Member obtains a medication that
is not covered is a decision between the Provider and Member. A request for coverage of a medication that was
denied only indicates that Coventry Health Care of Florida will not be responsible for charges incurred.
If a medication request has been denied, with the consent of the commercial or Medicaid Member, you may
request reconsideration of a decision on behalf of the Member if you believe this decision was made in error. All
requests should be made by calling the pharmacy customer services department at 1-866-847-8279, Monday
through Friday from 8 a.m. to 7 p.m.
For Medicare Members, you have sixty (60) days from the notice of denial of Medicare prescription drug coverage
to ask for a redetermination (appeal) of our decision. This can be done by phone at 1-800-536-6767, fax 1-800-5354047 on through the website at http://coventry-medicare.coventryhealthcare.com/ grievances-and-appeals.
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Section 18- General Information
Independent Contractor Relationship
Coventry, in consideration of monthly premium payments made to Coventry on behalf of Members, agrees to
arrange for the delivery of health care services in accordance with and subject to the terms and conditions of the
applicable Member Contract entered into between the Members, or on the Member’s behalf, and Coventry.
Provider agrees Coventry, in so arranging for the delivery of health care services and supplies to Members, provides
such services or supplies through independently Contracted Providers.
In accordance with the Agreement, Provider and Coventry are independent Contractors. Coventry shall not be
liable for any negligent act or omission committed by a Provider or any Provider staff or hospital vendor who may
from time to time, furnish services or supplies to Members. Provider acknowledges and agrees that any decisions
made by Coventry concerning appropriateness of setting or whether any service is covered are made solely for
purposes of determining whether benefits are due under the applicable Member Contract, and not for purposes of
recommending any medical treatment or non-treatment.
Member Provider Reportable Diseases
Section 381.0031(1,2) of the Florida statutes provides that “Any practitioner, licensed in Florida to practice
medicine, osteopathic medicine, chiropractic, naturopathy, or veterinary medicine, who diagnoses or suspects the
existence of a disease of public health significance shall immediately report the fact to the Department of Health.”
The county health departments serve as the Florida Department of Health’s representatives to receive these
reports. To report a case of a reportable disease, report an outbreak, or get consultation on a public health
disease control problem, please call your County Health department or call the Bureau of Epidemiology at (850)
245-4401 (24/7/365 accessibility). You will find a list of the county health departments in all sixty seven (67)
Florida counties on the Coventry Provider website at. www.chcflorida.coventryhealthcare.com
Chapter 64D-3 of the Florida Administrative Code identifies three major categories for reporting timeframes:
1. Suspect Immediately: Report on initial suspicion or laboratory test order (24 hours a day, 7 days a
week by phone).
2. Immediately: Report immediately upon diagnosis confirmed clinically or by laboratory results (24 hours
a day, 7 days a week by phone).
3. Next Business Day (previously within seventy two (72) hours): Report next business day upon
diagnosis confirmed clinically or by laboratory results.
New diseases or conditions include:
• Reportable by practitioners: HIV exposed infants or newborns and conjunctivitis in neonates less than or
equal to fourteen (14) days old
• Reportable by laboratories: CD-4 counts, viral load and STARHS
• Reportable by both practitioners and laboratories:
o HPV cancer associated strains
o abnormal cervical cytologies / histologies
o novel or pandemic human influenza strains
o influenza associated pediatric mortality
o SARS
o California serogroup viruses
o hepatitis D, E and G
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o
o
o
o
varicella
varicella mortality
epidemic typhus fever
cancer, including benign and borderline intracranial and central nervous system tumors
Routine testing is required during pregnancy for chlamydia, gonorrhea, hepatitis Bm HIV, and syphilis with an optout approach. All blood tests must be electronically reported by laboratories.
Please be advised that Coventry will periodically monitor Member charts to assure compliance of Providers with
this Florida statute.
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❷ Medicaid
Medicaid Program
Florida Medicaid is the medical assistance program that provides access to health care for low-income families and
individuals. The Florida Medicaid program is responsible for policies, procedures, and programs to promote access
to quality acute and long-term medical, behavioral, therapeutic, and transportation services for Medicaid
beneficiaries. Medicaid also assists the elderly and people with disabilities with the costs of nursing facility care and
other medical expenses. Eligibility for Medicaid is usually based on the families or individual’s income and assets.
Statewide Medicaid Managed Care Program
Florida has offered Medicaid services since 1970. Medicaid provides health care coverage for eligible children,
seniors, disabled adults and pregnant women. It is funded by both the state and federal governments. The 2011
Florida Legislature passed House Bill 7107 (creating part IV of Chapter 409, F.S.) to establish the Florida Medicaid
program as a statewide, integrated managed care program for all covered services, including long-term care
services. This program is referred to as statewide Medicaid managed care (SMMC) and includes two programs: one
for medical assistance (MMA) and one for long-term care (LTC).
Florida Agency for Health Care Administration’s Medicaid Coverage and Limitations
Handbook
Providers may access the Florida Agency for Health Care Administration’s Medicaid Coverage and Limitations
Handbook on the state’s website at www.fdhc.state.fl.us or handbooks may be obtained from AHCA. The
handbooks provide more detail on the medical care, treatment and rights of Medicaid Members.
Coventry Health Care of Florida (CHCFL) and Providers shall comply with applicable AHCA handbooks and shall not
be more restrictive than the limitations and exclusions in such handbooks.
Medicaid Fraud and Abuse Complaint Form
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer complaint Hotline toll free at 1-888419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at:
https://apps.ahca.Myflorida.com/inspectorGeneral/fraud_complaintform.aspx
If you report suspected fraud and your report results in a fine, penalty, or forfeiture of property from a doctor or
health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (tollfree 1-866-866-7226 or 850-414-3990). The reward may be up to 25 percent of the amount recovered, or a
maximum of $500,000 per case (Florida Statutes Chapter 409.9203). You can talk to the Attorney General’s Office
about keeping your identity confidential and protected.
Provider Subcontractor Responsibilities
The Managed Care Plan shall be responsible for all work performed under this Contract, but may, with the prior
written approval of the Agency, enter into subcontracts for the performance of work required under this Contract.
All subcontracts must comply with 42 CFR 438.230, 42 CFR 455.104, 42 CFR 455.105 and 42 CFR 455.106
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Continuity of Care in Enrollment
Coventry shall be responsible for coordination of care for new enrollees transitioning into the Managed Care Plan.
In the event a new enrollee is receiving prior authorized ongoing course of treatment with any provider, the
Managed Care Plan shall be responsible for the costs of continuation of such course of treatment, without any form
of authorization and without regard to whether such services are being provided by participating or nonparticipating providers.
LTC Managed Care Plans shall provide continuation of LTC services until the enrollee receives an assessment, a plan
of care is developed and services are arranged and authorized as required to address the long-term care needs of
the enrollee, which shall be no more than sixty (60) calendar days after the effective date of enrollment.
MMA Managed Care Plans shall provide continuation of MMA services until the enrollee’s PCP or behavioral health
provider (as applicable to medical or behavioral health services, respectively) reviews the enrollee’s treatment
plan, which shall be no more than sixty (60) calendar days after the effective date of enrollment.
Comprehensive LTC Managed Care Plans shall provide continuation of LTC services for enrollees with LTC benefits
and MMA services for enrollees with MMA benefits as indicated above.
Emergency Service Responsibilities
The Managed Care Plan shall provide pre-hospital and hospital-based trauma services and emergency services and
care to enrollees. See ss. 395.1041, 395.4045 and 401.45, F.S.
a.
When an enrollee presents at a hospital seeking emergency services and care, the determination that
an emergency medical condition exists shall be made, for the purposes of treatment, by a physician of
the hospital or, to the extent permitted by applicable law, by other appropriate personnel under the
supervision of a hospital physician. See ss. 409.9128, 409.901, F.S. and 641.513, F.S.
b.
The physician, or the appropriate personnel, shall indicate on the enrollee's chart the results of all
screenings, examinations and evaluations.
c.
The Managed Care Plan shall cover all screenings, evaluations and examinations that are reasonably
calculated to assist the provider in arriving at the determination as to whether the enrollee's condition
is an emergency medical condition.
d.
If the provider determines that an emergency medical condition does not exist, the Managed Care Plan
is not required to cover services rendered subsequent to the provider's determination unless
authorized by the Managed Care Plan.
e.
If the provider determines that an emergency medical condition exists, and the enrollee notifies the
hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee
of the Managed Care Plan, the hospital must make a reasonable attempt to notify:
- The enrollee's PCP, if known, or
- The Managed Care Plan, if the Managed Care Plan has previously requested in
writing that it be notified directly of the existence of the emergency medical
condition.
f.
If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to
contact the PCP, the hospital must:
g.
Notify the Managed Care Plan as soon as possible before discharging the enrollee from the emergency
care area; or
h.
Notify the Managed Care Plan within twenty-four (24) hours or on the next business day after the
enrollee’s inpatient admission.
i.
If the hospital is unable to notify the Managed Care Plan, the hospital must document its attempts to
notify the Managed Care Plan, or the circumstances that precluded the hospital's attempts to notify
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j.
k.
the Managed Care Plan. The Managed Care Plan shall not deny coverage for emergency services and
care based on a hospital's failure to comply with the notification requirements of this section.
If the enrollee's PCP responds to the hospital's notification, and the hospital physician and the PCP
discuss the appropriate care and treatment of the enrollee, the Managed Care Plan may have a
member of the hospital staff with whom it has a participating provider contract participate in the
treatment of the enrollee within the scope of the physician's hospital staff privileges.
The Managed Care Plan shall advise all enrollees of the provisions governing emergency services and
care. The Managed Care Plan shall not deny claims for emergency services and care received at a
hospital due to lack of parental consent. In addition, the Managed Care Plan shall not deny payment for
treatment obtained when a representative of the Managed Care Plan instructs the enrollee to seek
emergency services and care in accordance with s. 743.064, F.S.
Requirements Regarding Background Screening
Physicians and subcontractors shall be subject to background checks. Coventry shall consider the nature of the
work Physician, subcontractors or agents performs in determining the level and scope of background checks for all
treating providers not currently enrolled in Medicaid’s fee-for-service program, in accordance with the following:
Coventry shall ensure providers not currently enrolled in Medicaid’s fee-for-service program submit fingerprints
electronically following the process described on the Agency’s Background Screening website. Coventry shall verify
Medicaid eligibility through the background screening system;
Coventry shall not contract with any provider who has a record of illegal conduct; i.e., found guilty of, regardless of
adjudication, or who entered a plea of nolo contendere or guilty to any of the offenses listed in s. 435.04, F.S.;
Individuals already screened as Medicaid providers or screened within the past twelve (12) months by another
Florida agency or department using the same criteria as the Agency are not required to submit fingerprints
electronically but shall document the results of the previous screening; and
Individuals listed in s. 409.907(8)(a), F.S., for whom criminal history background screening cannot be documented
must provide fingerprints electronically following the process described on the Agency’s background screening
website.
Cultural Competency
Introduction
Coventry Health Care and its Florida affiliates recognize that a person’s cultural norms, values and beliefs
shape how they approach and utilize health care services. Numerous cultural variables including, but not
limited to, ethnicity, race, gender, age, socio-economic status, primary language, English proficiency,
spirituality, religion and literacy level influence the way in which a person seeks and utilizes health services
and the manner in which a person approaches and manages recovery.
The Cultural Competency Plan (CCP) has been developed to outline the methods used by Coventry Health
Care of Florida, Inc., serving Medicaid enrollees located in Miami-Dade County, hereafter referred to as
“the Health Plan”. The plan is developed to ensure that members receive care that is delivered in a
culturally and linguistically sensitive manner. The CCP is comprehensive and incorporates all members,
employees and providers. The Health Plan recognizes that respecting the diversity of our members has a
significant and positive effect on outcomes of care and have adopted the Culturally and Linguistically
Appropriate Services (CLAS) Standards, as developed by the Department of Health and Human Services,
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Office of Minority Health, as guidelines for providing culturally and linguistically competent services. These
15 standards are organized by themes:
•
•
•
•
Principle Standard (Standard 1)
Governance, Leadership, and Workforce (Standards 2-4)
Communication and Language Assistance (Standards 5-8)
Engagement, Continuous Improvement and Accountability (Standards 9-15)
The standards are intended to be inclusive of all cultures and not limited to any particular population group
or sets of groups; however, they are especially designed to address the needs of racial, ethnic, and
linguistic population groups that may experience unequal access to health services.
Cultural Competence Definition:
Cultural and linguistic competence is a set of coinciding behaviors, knowledge, attitudes, and policies that
come together in a system, organization, or among professionals that enables effective work in crosscultural situations. “Culture” refers to integrated patterns of human behavior that include the language,
thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups.
“Competence” implies having the capacity to function effectively as an individual or an organization within
the context of the cultural beliefs, practices, and needs presented by patients and their communities (Rural
Assistance Center, 2008).
Stated more simply, cultural competence is the integration and transformation of knowledge about
individuals and groups of people into specific standards, policies, practices, and attitudes used in
appropriate cultural settings to increase the quality of services; thereby producing better outcomes.
Also, cultural competence can be defined as services that are sensitive and responsive to cultural
differences whereby caregivers are aware of the impact of culture and possess the skills to help provide
services that respond appropriately to a person's unique cultural differences, including race and ethnicity,
national origin, religion, age, gender, sexual orientation or physical disability.
Goals of the Cultural Competency Plan
The purpose of the Health Plans’ Cultural Competency Plan is to implement enterprise-wide methodologies
and processes that measure and improve clinical care and services that are mindful of the language and
cultural needs of the plans’ members
The Health Plans have implemented procedures to assist their staff and Providers to develop awareness
and appreciation of cultural customs, values and beliefs, and provide educational information and
references to facilitate their incorporation into the assessment of, treatment of, and interaction with our
members. The Health Plans encourage their staff to share and utilize their own cultural diversity to
enhance the services provided to our members.
The Company is committed to providing competent health care that is culturally and linguistically sensitive
to members. The Health plans will achieve this by:
Program Activities
a. Cultural Competency Workgroups
Cultural Competency Workgroups are formed on an ad hoc basis to support the health plan in
implementing portions of the CLAS project plan. An annual Cultural Competency Work plan/Project
Plan (CCP) is developed to guide the activities of the health plan and the Company’s affected
functional areas. The CCP Annual Evaluation is used to assess the progress of initiatives and make
93
recommendations to the Quality Improvement Committee and executive leadership, when barriers
are identified.
b. Member Outreach
The Health Plan requests voluntary information on race and language from members and utilize
this information to improve linguistic and cultural services.
The Health Plan supports activities promoting Health Literacy and ensures member
communications are in Plain Language.
c. Member Satisfaction Assessment
Member satisfaction survey data is reviewed annually, paying special attention to those who
identify themselves with limited English proficiency, in order to determine any identifiable clinical
care and service gaps.
d. Member and Provider Education
Cultural Competency articles are posted on the Provider, Member and Employee web portals or via
the health plans approved communication venues. Provider and Employee Surveys are conducted
in order to determine how best to assist the providers and employees in meeting the cultural
needs of the population we serve. The Health Plan monitors complaints on a monthly basis from
providers and subcontractors to ensure complaints regarding cultural and linguistically services are
identified and resolved in a timely manner.
Program Evaluation and Assessment
Annually, the health plans conduct an evaluation of the Cultural Competency Plan to assess overall
effectiveness and to determine future directions. The evaluation serves as the foundation for planning the
upcoming year’s plan and activities relating to elevating cultural awareness. If you have any questions or
would like to request a free copy of the Health Plan’s Cultural Competency Plan please call the Quality
Department at 1-800-422-7335 extension 308-3576.
Providers and subcontractors are required to comply with the plan’s Cultural Competency Plan.
Community outreach and marketing activities:
Provider may not:
1. Offer marketing/appointment forms, make phone calls or direct, urge or attempt to persuade recipients to
enroll in the Coventry Health Care of Florida based on financial or any other interests of the provider.
2. Mail marketing materials on behalf of the Coventry Health Care of Florida.
3. Offer anything of value to induce recipients/enrollees to select them as their provider.
4. Offer inducements to persuade recipients to enroll in the Coventry Health Care of Florida.
5. Conduct health screening as a marketing activity.
6. Accept compensation directly or indirectly from the Managed Care Plan for marketing activities.
7. Distribute marketing materials within an exam room setting.
8. Furnish to the Managed Care Plan lists of their Medicaid patients or the membership of any Managed Care
Plan. For a complete list of Community outreach and marketing activities, refer to www.directprovider.com
Abuse, Neglect and Exploitation
1. Suspected cases of abuse, neglect and/or exploitation must be reported to the state’s Adult Protective
Services Unit. The Florida Adult Protective Services has the responsibility for investigating allegations of
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abuse and neglect of elders and individuals with disabilities. If the investigation required the enrollee to
move from his/her current locations, the Managed Care Plan will coordinate with the investigator to find a
safe living environment or another participating ALF of the enrollee’s choice.
2. The Managed Care Plan must ensure that all staff and providers are required to report adverse incidents to
the Agency immediately but not more than twenty-four (24) hours of the incident. Reporting will include
information including the enrollee’s identity, description of the incident and outcomes including current
status of the enrollee. If the event involves a health and safety issue, the Managed Care Plan and case
manager will arrange for the enrollee to move from his/her current location or change providers to
accommodate a safe environment and provider of the enrollee’s choice.
3. Documentation related to the suspected abuse, neglect or exploitation, including the reporting of such,
must be kept in a file, separate from the enrollee’s case file, that is designated as confidential. Such file
shall be made available to the Agency upon request.
4. Enrollee quality of care issues must be reported to and a resolution coordinated with the Managed Care
Plan’s Quality Management Department.
Florida SHOTS/Healthy Kids
All PCPs that are participating with Florida Healthy Kids must enroll in Florida SHOTS, Florida’s statewide online
immunization registry at the following link: http://www.flshots.com/
Florida SHOTS is a statewide immunization registry developed by the Florida Department of Health (DOH). Florida
SHOTS is designed to access and utilize a statewide immunization database. The registry is part of DOH's initiative
to increase vaccination coverage for children across Florida.
Immunization registries are confidential, computerized information systems that track childhood immunization
data. Children are entered into a registry either at birth, through a linkage with electronic birth records from Vital
Statistics, or by health care providers. As childhood immunizations are given, the information is entered so that
health care professionals know if immunizations are necessary or redundant.
Florida SHOTS receives vaccination information for children from across the state, including input from County
Health Departments, private providers, the Bureau of Vital Statistics, and eventually from Women Infant and
Children (WIC) clinics, and Medicaid. This immunization information will soon be available to schools, and childcare
centers.
Immunization registries are essential for maintaining high immunization coverage levels. This is true particularly
since disease levels are at record lows and outbreaks of preventable illnesses are becoming less common.
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Important Information for Medicaid Members
All Medicaid PCP’s are required to post a copy of the Florida Patients Bill of Rights and Responsibilities in the open
and conspicuous view of Medicaid Members. PCP’s are also required to post the Florida HMO Hotline number,
(888) 419-3456, in the open and conspicuous view of all Medicaid Members. To view the enrollee’s rights and
responsibilities, please see page 103.
If copayments are waived as an expanded benefit, the provider must not charge enrollees copayments for covered
services; and if copayments are not waived as an expanded benefit, that the amount paid to providers shall be the
contracted amount or for FFS Managed Care Plans, the Medicaid fee schedule amount, less any applicable
copayments.
Healthy Behaviors Program:
We will offer programs to our members who want to stop smoking, lose weight, or address any drug abuse
problems. We will reward members who join and meet certain goals. These programs will be ready October 1,
2014. Additional information will be provided related to these programs at a later time.
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Listing of Medicaid Covered Services
See table below for the Covered Services:
COVERED SERVICES
CY 2012 – 2013
9/1/12 – 8/31/15
Ambulance Services
Emergency service to hospital/$0 Copay
Behavioral Health Services
(Inpatient, outpatient, physician services, community mental
health, targeted case management for children & adults,
intensive targeted case management for adults)
PsychCare
Toll Free: 800-221-5487
Fax: 800-370-1116
Medical, social & educational resources
Services must be recommended by primary care physician or
psychiatrist
Substance abuse
$0 Copay
Child Health Check-Up Services
Health screening evaluation that shall consist of:
comprehensive health and developmental history (including
assessment of past medical history, developmental history
and behavioral health status); comprehensive unclothed
physical exam; developmental assessment; nutritional
assessment; appropriate immunizations; laboratory testing
(including blood lead testing); health education (including
anticipatory guidance); dental screening (including a direct
referral to a dentist for enrollees beginning at age three or
earlier as indicated); vision screening including objective
testing as required; diagnosis and treatment; and referral and
follow-up as appropriate.
Chiropractic Services
Up to 24 visits per year
Circumcision
Dental Services – Children (under age 21)
Dental Services – Adult (age 21 & over)
Dialysis Services
•
In-center hemodialysis, in-center administration of
injectable medication & home peritoneal dialysis
•
Routine lab tests, dialysis-related supplies &
ancillary/parenteral items
Diabetic Supplies
Up to age 20
MediKids - age 1-4
$0 Copay
$0 Copay
See expanded benefits below
MCNA - Dade
Dental Quest (Formerly ADI) – Dade
Toll Free: 800-964-7811
Fax: 305-443-2622
Broward – 1-866-875-9131
Hendry – 1-800-226-6735
NFL - 850 412-4002 1-800-248-2243
* Emergency & Denture Services: -SFL: (305) 499-2100
N FL (850) 921-8474
$0 Copay
$0 Copay
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Durable Medical Equipment & Medical Supplies – (DME)
•
Medical or surgical items that are consumable,
expendable, disposable or non-durable & are appropriate
for use in the patient’s home
•
Must have prescription, plan if care or hospital discharge
plan
•
Documentation must be signed by/dated by physician
with specific term, duration & diagnosis
•
Prior-authorized wheelchairs
•
Some services for under 21 years of age
Family Planning Services
(Member has access to par & non-par Providers)
•
Restrictions for enrollees under the age of 18 based on
marital status, parental consent and pregnancy or in the
opinion of the physician, the enrollee may suffer health
hazards if the services are not provided.
•
Not covered: Infertility or elective abortion
Flu Shots
•
Covered for up to 18 years of age under the Vaccine for
Children (VFC) program
•
State provides immunizations directly to the Provider
•
For ages 19-20, CHCFL covers the flu shot and the
Provider should bill CHCFL if administered
•
Not covered for ages 21 & older
Hearing Services
•
$0 Copay
$0 Copay
$0 Copay
Hearing exam and/or hearing aid (limited number and /or
selection of hearing aid) if medically necessary
Home Health Services
(Home visit services provided by RN/LPN, home health aide, private
duty nurse or therapist)
Private duty nursing, personal care, personal care, therapy services,
limited to children under age 21 who are medically complex
•
60 visits per lifetime
•
2 to 24 hours private nursing per day
•
2 to 24 hours personal care by health aid per day
Immunizations (including those provided by county health
departments)
•
Based on the recommended childhood immunization
schedule for the U.S. and established by the Advisory
Committee on Immunization Practices (ACIP)
•
Up to age 20
Inpatient Hospital Services – Adult
•
$0 Copay
$0 Copay
$0 Copay
$0 Copay
Coverage up to 45 days per fiscal year (7/1 to 6/30)
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Laboratory Services & X-ray Services
•
Outpatient Hospital Services
Covered outpatient hospital services included medical
supplies, nursing care, therapeutic services and drugs. Some
outpatient hospital services are limited to $1,500 for adults
age 21 and older. There is no limitation for children 20 years
of age or younger.
Physician Services - Primary
Physician Services - Specialist
(Including, but not limited to)
Allergy, anesthesiology, cardiology, chiropractic services,
dermatology, endocrinology, gastroenterology, general
surgery, gynecology, infectious diseases, nephrology,
neurology, obstetrics, oncology, ophthalmology, oral surgery,
orthopedics, pathology, podiatry, psychiatry, pulmonology,
radiology, therapy, urology
Podiatry Services
•
$0 Copay
Blood, urinalysis, freestanding facility, MRI, CAT scan
$0 Copay
•
Primary care Provider (PCP), psychiatrist, registered
nurse practitioner, physicians assistant, ambulatory
surgical center, rural health clinic, federally qualified
health center, birthing center and county health
department clinic
•
$0 Copay
Some services may require a referral from your primary care
physician
$0 Copay
$0 Copay
Up to 4 visits per year without authorization
Prescription Drug Services
Medicaid Formulary
• Unlimited Generic Drugs
Therapy Services – Adults (age 21 & over)
Physical, Respiratory
Therapy Services – Children (under age 21)
Physical, Respiratory, Speech/Language, Occupational
Translation Services
(Oral translations for non-English speakers)
Transplant Services
(Evaluation, bone marrow; cornea, intestinal/multivisceral,
kidney, pancreas, pre- and post transplant care including
transplants not covered by Medicaid)
Transportation Services
(Non-emergency)
$0 Copay
Vision Services
•
Contact lenses available only for unilateral or bilateral
aphakia
•
Adult eyeglass frames and
$0 Copay
$0 Copay
$0 Copay
$0 Copay
Some limitations to services may apply
SFL Logistic Care : 866-726-1457
Broward: 1-866-867-0729
Gadsden: 850-627-9958
Hendry: 239-768-2900
Jefferson: 850-997-1323
Leon: 850-891-5199
Liberty: 850-643-2524
Madison: 850-973-4418
Wakulla: 850-926-7145
Primary Plus aka CompBenefits
Toll Free 1-800-393-2873 / Option 3
Fax 1-800-329-6030
Eye Management, Inc. - Hillsborough
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•
Eyeglasses (frames are limited to 1 pair every 2 years per
recipient; lenses limited to 1 every 365 days based on
medical necessity)
•
All special eyeglasses and contact lenses must be prior
authorized
QUALITY BENEFIT ENHANCEMENTS
Smoking cessation
$0 Copay
Substance abuse
$0 Copay
Domestic violence
$0 Copay
Pregnancy prevention
$0 Copay
Pre-natal/postpartum pregnancy
Children’s programs
Disease management programs
diabetes, asthma, heart disease, hypertension, congestive
heart failure, chronic obstructive pulmonary disease, high
risk obesity, chronic kidney disease, dialysis, wound care,
pediatrics, neonatal intensive care, end of life
Physician
Surgical
EXPANDED BENEFITS/SERVICES
Circumcision
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay (Up to 12 weeks)
Chiropractic Services
Up to 24 visits per year
$0 Copay
Circumcision
See expanded benefits below
Dental Services – Children (under age 21)
Dental Quest (Formerly ADI) – Dade
Toll Free: 800-964-7811
Fax: 305-443-2622
Broward – 1-866-875-9131
Hendry – 1-800-226-6735
NFL - 850 412-4002
Dental Services – Adult (age 21 & over)
Dialysis Services
•
In-center hemodialysis, in-center administration of
injectable medication & home peritoneal dialysis
•
Routine lab tests, dialysis-related supplies &
ancillary/parenteral items
Diabetic Supplies
* Emergency & Denture Services: -SFL: (305) 499-2100
N FL (850) 921-8474
$0 Copay
$0 Copay
100
Durable Medical Equipment & Medical Supplies – (DME)
•
Medical or surgical items that are consumable,
expendable, disposable or non-durable & are appropriate
for use in the patient’s home
•
Must have prescription, plan if care or hospital discharge
plan
•
Documentation must be signed by/dated by physician
with specific term, duration & diagnosis
•
Prior-authorized wheelchairs
•
Some services for under 21 years of age
Family Planning Services
(Member has access to par & non-par Providers)
•
Restrictions for enrollees under the age of 18 based on
marital status, parental consent and pregnancy or in the
opinion of the physician, the enrollee may suffer health
hazards if the services are not provided.
•
Not covered: Infertility or elective abortion
Flu Shots
•
Covered for up to 18 years of age under the Vaccine for
Children (VFC) program
•
State provides immunizations directly to the Provider
•
For ages 19-20, CHCFL covers the flu shot and the
Provider should bill CHCFL if administered
•
Not covered for ages 21 & older
Hearing Services
•
$0 Copay
$0 Copay
$0 Copay
Hearing exam and/or hearing aid (limited number and /or
selection of hearing aid) if medically necessary
Home Health Services
(Home visit services provided by RN/LPN, home health aide, private
duty nurse or therapist)
Private duty nursing, personal care, personal care, therapy services,
limited to children under age 21 who are medically complex
•
60 visits per lifetime
•
2 to 24 hours private nursing per day
•
2 to 24 hours personal care by health aid per day
Immunizations (including those provided by county health
departments)
•
Based on the recommended childhood immunization
schedule for the U.S. and established by the Advisory
Committee on Immunization Practices (ACIP)
•
Up to age 20
Inpatient Hospital Services – Adult
•
$0 Copay
$0 Copay
$0 Copay
$0 Copay
Coverage up to 45 days per fiscal year (7/1 to 6/30)
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Laboratory Services & X-ray Services
•
$0 Copay
Blood, urinalysis, freestanding facility, MRI, CAT scan
Outpatient Hospital Services
Covered outpatient hospital services included medical
supplies, nursing care, therapeutic services and drugs. Some
outpatient hospital services are limited to $1,500 for adults
age 21 and older. There is no limitation for children 20 years
of age or younger.
$0 Copay
Physician Services - Primary
•
Primary care Provider (PCP), psychiatrist, registered
nurse practitioner, physicians assistant, ambulatory
surgical center, rural health clinic, federally qualified
health center, birthing center and county health
department clinic
•
$0 Copay
Physician Services - Specialist
(Including, but not limited to)
Allergy, anesthesiology, cardiology, chiropractic services,
dermatology, endocrinology, gastroenterology, general
surgery, gynecology, infectious diseases, nephrology,
neurology, obstetrics, oncology, ophthalmology, oral surgery,
orthopedics, pathology, podiatry, psychiatry, pulmonology,
radiology, therapy, urology
Podiatry Services
•
Some services may require a referral from your primary care
physician
$0 Copay
$0 Copay
Up to 4 visits per year without authorization
Prescription Drug Services
Medicaid Formulary
$0 Copay
Therapy Services – Adults (age 21 & over)
Physical, Respiratory
Therapy Services – Children (under age 21)
Physical, Respiratory, Speech/Language, Occupational
Translation Services
(Oral translations for non-English speakers)
Transplant Services
(Evaluation, bone marrow; cornea, intestinal/multivisceral,
kidney, pancreas, pre- and post transplant care including
transplants not covered by Medicaid)
Transportation Services
(Non-emergency)
$0 Copay
$0 Copay
$0 Copay
$0 Copay
Some limitations to services may apply
SFL Logistic Care : 866-726-1457
Broward: 1-866-867-0729
Gadsden: 850-627-9958
Hendry: 239-768-2900
Jefferson: 850-9971323
Leon: 850-891-5199
Liberty: 850-643-2524
Madison: 850-973-4418
Wakulla: 850-926-7145
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Vision Services
•
Contact lenses available only for unilateral or bilateral
aphakia
•
Adult eyeglass frames and
•
Eyeglasses (frames are limited to 1 pair every 2 years per
recipient; lenses limited to 1 every 365 days based on
medical necessity)
•
All special eyeglasses and contact lenses must be prior
authorized
Primary Plus aka CompBenefits
Toll Free 1-800-393-2873 / Option 3
Fax 1-800-329-6030
QUALITY BENEFIT ENHANCEMENTS
Smoking cessation
$0 Copay
Substance abuse
$0 Copay
Domestic violence
$0 Copay
Pregnancy prevention
$0 Copay
Pre-natal/postpartum pregnancy
Children’s programs
Disease management programs
diabetes, asthma, heart disease, hypertension, HIV/AIDS
Physician
$0 Copay
$0 Copay
$0 Copay
$0 Copay
Surgical
$0 Copay
EXPANDED BENEFITS/SERVICES
Circumcision
$0 Copay (Up to 12 weeks)
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Enrollees Rights and Responsibilities:
RIGHTS
Enrollees have the right to have your privacy protected
Enrollees have the right to a response to questions and requests
Enrollees have the right to know who is providing services to you
Enrollees have the right to know the services that are available, including an interpreter if you don’t speak English
Enrollees have the right to know the rules and regulations about your conduct
Enrollees have the right to be given information about your health
Enrollees have the right to get service from out-of-network providers
Enrollees have the right to get family planning services from any participating Medicaid provider without prior
authorization
Enrollees have the right to be given information and counseling on the financial resources for your care
Enrollees have the right to know if the provider or facility accepts the assignment rate
Enrollees have the right to receive an estimate of charges for your care
Enrollees have the right to receive a bill and to have the charges explained
Enrollees have the right to be treated regardless of race, national origin, religion, handicap, or source of payment
Enrollees have the right to be treated in an emergency
Enrollees have the right to participate in experimental research
Enrollees have the right to file a grievance if you think your rights have been violated
Enrollees have the right to information about our doctors
Enrollees have the right to be treated with respect and with due consideration for your dignity and privacy
Enrollees have the right to receive information on available treatment options and alternatives, presented in a
manner appropriate to your condition and ability to understand
Enrollees have the right to participate in decisions regarding your health care, including the right to refuse
treatment
Enrollees have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation
Enrollees have the right to request and receive a copy of your medical records and request that they be amended
or corrected
Enrollees have the right to be provided health care services in accordance with federal and state regulations
Enrollees are free to exercise your rights, and the exercise of those rights does not adversely affect the way the
health plan and its providers or the State agency treat you
Enrollees have the right to make a complaint or appeal about the health plan or the care it provides.
Enrollees have the right to make a recommendation regarding the health plan’s member rights and responsibilities
RESPONSIBILITIES
Enrollees should provide accurate and complete information about your health
Enrollees should report unexpected changes in your condition
Enrollees should report that you understand your care and what is expected of you
Enrollees should follow the treatment plan recommended
Enrollees should keep appointments
Enrollees should follow your doctor’s instructions
Enrollees should make sure your health care bills are paid
Enrollees should follow health care facility rules and regulations
Enrollees should understand your health problems and participate in starting equally agreed-upon treatment goals
104
❸Key Lists & List of Forms
Required forms and reference documents can be downloaded and printed from the Resource Library under the
Downloadable Forms section of Coventry’s Provider Website at: www.directProvider.com and include but is not
limited to the list of forms below. This list as well as any forms or documents found on www.directProvider.com is
subject to change at Coventry Health Care of Florida’s discretion.
Forms/Reports/Bulletins/Newsletters
2014 Annual Mandatory Provider Trainings
Provider Newsletter Notification
Clinical Practice Guidelines
Provider Satisfaction Survey – Re-send
Financial Compensation
Federal Reimbursement Guidelines
Duplicate Claim Submission Update
Prior Authorization Updates
Triad Notification
Provider Satisfaction Survey 2013
Referral/Hospital Admissions Notification
Standards For Medical Records Documentation
Provider Newsletter
Carelink Notification
Oncology Specialist Care Management Program Notification
105