1. health and fitness

Provider Manual
New for 2014!
Soundpath Health now has a Provider Portal that allows contracted providers to check Eligibility
and the status of paid claims!
Email us for more information at: portal@soundpathhealth.com.
Soundpath Health Provider Manual v3.1.14
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Contents
Soundpath Health Mission Statement
Introduction
Your Role As a Soundpath Health Provider
Statement of Non-Discrimination
Non-interference with Patient/Provider Relationship
Directory of Services & Contact Information
Product Overview
List of Entities - SPH “POD” structure
Sample Member ID Card
Responsibilities of All Providers
Definitions
Changes in Provider Status
Discharging a Patient from Your Practice
Participating Provider Access Standards
Member Rights and Responsibilities
Advance Directives
Responsibilities of Soundpath Health
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Significant Health Risk Assessment Findings
Member Transfers Between PCPs
Involuntary Member Disenrollment
Change In Residence
Loss of Entitlement to Medicare Part A or Loss of Enrollment in Part B
Member is Deceased
Disruptive Behavior
Member Fraud and Abuse
Contract Termination
Medical Management Division
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Care Management
Pharmacy Services
Quality Improvement (QI)
Delegation Oversight
Provider Cooperation
Adverse Incident Reporting
Referrals and Prior Authorization Process
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Facility Admissions
Out of Area
Notice of Medicare Non-Coverage
Credentialing Process
Re-credentialing Process
Appeals and Grievances
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Provider Reconsideration and Dispute Processes
Provider Appealing on the Member’s Behalf
Expedited Appeal
Quality Improvement Organization
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Who are QIO Physicians?
Immediate Review of Hospital Discharges
Special expedited appeal, if missed QIO deadline
QIO complaints process
Grievance Procedures
Fraud, Waste, and Abuse
Billing and Claims Payment
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Electronic Claims Submission
Where To Send Paper Claims
HCCM
Claims Process & Payment
Timeframes for Submission
Provider Remittance
Member Eligibility and Retroactive Disenrollment
COB
Co-Payments and Coinsurance
Checking Claims Status
Denial of Claims
NPI
Compensation
Site of Service Payment Differential
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Medicare Part D
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Pharmacy Management
Examples of UM tools
P & T Committee
Pharmacy Benefits and Covered Drugs
What Is Coverage Determination?
Can the Formulary Change?
Drug Utilization Review
Medication Therapy Management Programs
Mail Order Pharmacy
Vendor Partners
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Behavioral Health
Routine Vision Care
Complementary Alternative Medicine rider (if purchased by member)
Routine Hearing Exams and Hearing Devices
SilverSneakersFitness Program & Network
Discount Programs
o NutriSystem
o QuickMedical
o Mayo Clinic
CMS Regulations
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Soundpath Health Mission Statement
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Be the local industry leader in supporting health care delivery
Promote our Members’ health through local Provider innovation
Be responsible stewards of health care resources
Be an active partner in improving the health of our communities
Introduction
Soundpath Health is a unique, independent local health plan founded by doctors who have taken
a fresh approach by forming a licensed Medicare Advantage (MA) Plan which assures a
partnership between patient, Provider and health plan. Our purpose is to promote the Memberphysician relationship, provide the highest level of treatment in the most appropriate setting, and
improve health and wellness through this partnership.
This Provider Manual is designed to assist you and your staff and to provide information
regarding Soundpath Health policies and procedures that encompass patient/Member needs,
Provider standards, and Soundpath Health reporting. This makes it possible to deliver
appropriate and cost-effective care using the full continuum of services, which includes services
through delegation to highly qualified Independent Physician Associations.
Your Role as a Soundpath Health Provider
As a Soundpath Health-contracted Provider, you have agreed to provide care to members of
Soundpath Health. We look forward to supporting you in providing accessible, quality health
care that meets the needs of your patients – our members.
Statement of Non-Discrimination
Soundpath Health agrees to adhere to the principles of affirmative action and equal opportunity.
Our Organization will not discriminate on the basis of age, ethnicity, national
origin, marital status, race, religion, sexual orientation, sex, mental or physical disability,
genetic information, or source of payment in the enrollment of Members, the delivery
of covered services or items, or the credentialing or contracting of Providers. This Organization
will not accept or disregard behavior demonstrated by employees or Providers that discriminate
and follows CMS regulations S422.200, S422.202, S422.204, S422.205.
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Non-interference with Patient/Provider relationship
Soundpath Health encourages a strong Provider-Member relationship, and therefore does not
interfere, prohibit, or otherwise restrict contracted Providers from freely communicating with or
advising Members concerning their health status, medical care or treatment options. Therefore,
Soundpath Health serves as an advocate on behalf of a Member regarding the care or treatment
options, regardless of benefit coverage limitations, including, any information that is determined
to be in the Member’s best interests concerning:
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Alternative treatments, medication options and any other medical care and treatment
options
The opportunity to decide among all relevant treatment options
The risks, benefits and consequences of treatment or non-treatment
The opportunity to refuse treatment and express preferences about future treatment
decisions
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Directory of Services & Soundpath Health Contact Information
Soundpath Health Headquarters
32129 Weyerhaeuser Way South, Suite 201
Federal Way, WA 98001
Phone: 1-253-779-8830
Toll Free: 1-866-789-7747
Fax:
1-253-779-8829
Member Services
Claims Information
Claims Submission
Eligibility
Hours of Operation:
8:00 A.M. – 8:00 P.M. Monday –Sunday. You
may receive a voicemail on weekends and
holidays from March 2 through October 14.
Please leave a message and your call will be
returned the next business day.
Submit electronic claims to:
Emdeon Claims Submission
Payer ID #42172.
Submit paper claims to:
Phone:
1-866-789-7747
TDD/TTY: 1-866-264-4141
Fax:
1-253-779-8829
Website: www.SoundpathHealth.com
Soundpath Health
Attn: Claims
P.O. Box 4537
Federal Way, WA 98063
Medical Affairs
Utilization Management – Prior Authorization
Case Management
Quality Improvement
Appeals and Grievances
Phone:
1-253-779-8830
Toll Free: 1-866-352-7086
Fax:
1-866-362-0627
Provider Relations
Phone:
1-253-517-4342
Toll Free: 1-866-789-7747
Fax:
1-253-345-5538
Sales & Marketing
Phone:
Fax:
Soundpath Health Provider Manual v3.1.14
1-866-789-7747
1-253-779-8829
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Language Assistance
Soundpath Health provides Member’s access to
interpretive services, if the Member does not
speak English. In such cases, the Provider may
call Member Services at 1-866-789-7747 on
behalf of the Member.
Product Overview
We feel the best healthcare is accomplished in partnership between the member, doctor and
health plan; because of this we are proud that our benefit designs are the result of input from our
contracted providers and members.
We provide plans that offer an array of benefits beyond Original Medicare. We offer various
plans to fit every budget; all of which provide comprehensive coverage, predictable costs, and
robust benefits. Find out more about these programs in the Evidence of Coverage (EOC) or on
our website, www.SoundPathHealth.com.
List of Entities – SPH “Pool of Doctor (POD)” structure
Pod
Physicians of SW Washington (“Pod 1”)
319 Seventh Avenue S.E., Suite 201
Olympia, WA 98501
Phone: (360) 943-4337
Fax: (360) 754-4324
Northwest Physicians Network (“Pod 2”)
PO Box 2117
Tacoma, WA 98401
Phone: (253) 573-1880
Fax: (253) 573-9511
Medical
Management
Claims
Processing
Credentialing
Delegated
Delegated
Delegated
NonDelegated
NonDelegated
Delegated
Pod 3 is not in use at this time.
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Physicians Care Network (“Pod 4”)
1401 Harvard Ave., Suite 300
Seattle, WA 98122
Phone: (206) 860-2220
Fax: (206) 860-2283
Delegated
Delegated
Delegated
Pod 5 is SPH’s directly-contracted providers.
All administrative functions performed by
SPH. All inquiries to SPH Customer Service:
1-866-789-7747.
Pod 6 is not in use at this time.
Central Washington Area – CWA (“Pod 7”)
including:
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Confluence Health
Independent providers throughout
Grant, Chelan, and Douglas counties
Family Care Network (“Pod 8”)
709 W Orchard Dr, #4
Bellingham, WA 98225
(360) 318-8065
Fidelis Senior Care (“Pod 9”)
1412 SW 34th ST Ste 315
Renton, WA 98056
Phone: (425) 272-4600
Fax: (425) 289-3103
Confluence
Health is
delegated for
credentialing
its employed
providers.
N/A
N/A
NonDelegated
NonDelegated
Delegated
Delegated
NonDelegated
NonDelegated
NonDelegated
NonDelegated
Delegated
Franciscan Medical Group (“Pod 10”)
All inquiries to SPH Customer Service: 1866-789-7747.
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Sample Member Identification Card
Responsibilities of All Providers
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To maintain current licensure in the State of Washington
To maintain participation in Medicare under Sections 1128 or 1128A of the Social Security
Act
To comply with Washington State Statute regarding maintaining malpractice insurance
deemed sufficient by Soundpath Health
To maintain the requirements for Continuing Medical Education (CME)
Provide notification if there are any changes to your licensure status, sanctions or business
information. (Tax ID number, address, etc.)
To maintain confidentiality with the Members’ records, correspondence, and discussions in
accordance with state and federal laws and regulations
To maintain Members’ medical records in a form that is consistent with the requirements of
state and federal laws and regulations
To provide coverage by a contracted Soundpath Health Physician and/or Mid-Level Provider
twenty-four (24) hours a day, seven (7) days a week
 Applicable to PCPs, to provide, coordinate, monitor, and supervise the delivery of health
care services for assigned-Members and to provide appropriate referrals to participating
specialists
 Applicable to specialists, to provide the Members’ PCP with a written report within 14
days of the date of service regarding the proposed plan of treatment, including any
proposed hospitalization or surgery. This report should also be provided to a member’s
PCP for self-referred services such as women’s health care services. Failure to provide
the PCP with this report may result in nonpayment for services and the Provider cannot
bill the member. With the exception of Urgent or Emergent Care, specialists should see
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members only upon a referral from the PCP (for services not on the current Prior
Authorization list). For services on the current Prior Authorization list, specialists should
only see members upon approval by Soundpath Health or its delegate.
 Applicable to acute facilities, to provide notification of all inpatient admissions as
described in this Manual and have inpatient and emergency services available 24 hours a
day, 7 days a week
Maintain active admitting privileges at an in-network hospital or designate coverage such as
an associate or hospitalist
To collect the appropriate co-payment in accordance with the Members benefit plan
To provide copies of medical records to the Member upon request at no cost consistent with
Revised Code of Washington (RCW) 70.02.080
To provide services in a manner consistent with standards of care
To encourage a Member to participate in their treatment planning and course of care
To provide clear and understandable information to the Member regarding treatment options,
including interpretive services for members who are hearing impaired or whose primary
language is not English
To provide Members with written information about advance directives and the right to make
anatomical gifts
To maintain an environmentally safe practice facility
To meet Safety Standards in accordance with the Occupational Safety Health Administration,
ADA, and regulatory requirements
To comply with Utilization Management/Quality Improvement activities, including but not
limited to, HEDIS, Medical Record reviews, Utilization Management Reviews, audits and
corrective action plans
To comply with the Plan’s Quality Improvement Plan
To comply with Plan’s audits, including but not limited to, retrospective Hierarchical
Condition Category audits at no cost to Plan
To ensure that Members are not discriminated against based on race, ethnicity, national
origin, religion, sex, sexual orientation, age, mental or physical disability, or source of
payment
To ensure that the hours of operation are convenient for Members so services may be
provided with reasonable promptness
To make an exception, as per written authorization from the Member, to allow their medical
records or medical condition(s) disclosed to others
To maintain safe storage of inactive medical records for a minimum of ten years (or the
extent required by federal regulations) and have them easily retrievable when needed
To allow Members to directly access screening mammography and influenza vaccination
services
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To provide female Members with direct access to a women’s health specialist for routine and
preventive health care services
You may not distribute marketing materials or forms to Members without CMS approval
You must ensure that any payment and incentive arrangements with subcontractors are
specified in writing, that such arrangements do not encourage reductions in medically
necessary services, and that any physician incentive plans comply with applicable CMS
standards
You must cooperate with our processes to disclose to CMS all information necessary for
CMS to administer and evaluate the Medicare Advantage Program, and all information
determined by CMS to be necessary to assist members in making an informed choice about
Medicare coverage
You must cooperate with our processes for notifying members of provider agreement
terminations
You must comply with our medical policies, quality improvement programs and medical
management procedures, including Participating Provider Access Standards
You must cooperate with Soundpath Health in fulfilling its responsibility to disclose to CMS
quality, performance and other indicators, as specified by CMS
You must cooperate with our procedures for handling grievances, appeals, and expedited
appeals
You must provide full disclosure to members before providing a health service if you feel
that such service will not be covered by a member’s benefit plan. The member may assume
additional financial responsibility in accordance with the member’s benefit plan and the
contract language. A document similar to the Medicare Advanced Beneficiary Notice (ABN)
must be signed by the member before liability for payment can be passed to the member. If
the service is performed and there is no signed advance notice on record, the claim will be
denied and you may not bill the member
You must abide by all State and Federal rules, regulations, and statutes
You must abide by all provisions of your Participant Agreement with Soundpath Health
You are required to refer all services to a participating provider in our network, except as
otherwise authorized by Soundpath Health
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Definitions:
Soundpath Health provides Emergency Services as required by law and in accordance with the
enrollee’s benefits, limitations, and exclusions based on our contract with Centers for Medicare
and Medicaid Services. Soundpath Health ensures that enrollees have the right to access
emergency health care services, consistent with the enrollee’s determination of the need for such
services as a prudent layperson without prior authorization.
Pursuant to the member’s Evidence of Coverage, a “medical emergency” is when the member, or
any other prudent layperson with an average knowledge of health and medicine, believes that they have
medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss
of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical
condition that is quickly getting worse.
Emergency Services and Care means medical screening, examination, and evaluation by a
physician or, to the extent permitted by applicable law, by other appropriate personnel under the
supervision of a physician. It is to determine if an emergency medical condition exists, and if it
does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or
eliminate the emergency medical condition within the service capability of a hospital.
No Plan referral or prior authorization request is necessary for emergency care services.
Members have been instructed to call 911 or go to the nearest emergency room for emergency
care services. In addition, the Member should inform the PCP about the emergency care so the
PCP may coordinate any follow-up care and services.
Urgent Care
Urgent care is when the Member requires medical attention right away for an unforeseen illness
or injury; however the health of the Member is not in serious danger. The main difference
between an urgent need for care and a medical emergency is in the danger to the Member’s
health.
The Members should consider contacting the Primary Care Physician (PCP) if they have sudden
illness or injury that is not a medical emergency. They may seek services without a referral, but
are advised to remain in the Network. Please refer to the EOC for additional information.
Changes in Provider Status
All Soundpath Health providers are responsible for giving notice at least 30 days in advance of
provider changes such as Tax ID, billing address, and practice locations. This ensures time for
Soundpath Health to update its systems, notify members, and prevent payment delay.
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PCPs are also responsible for notifying Soundpath Health when their practice reaches capacity
and they can no longer accept new patients. This notice should be in writing and will be effective
the first day of the month following 30 days from receipt of notice.
Discharging a Patient from your Practice
Occasionally, you may encounter patients who you no longer wish to treat. Reasons for ending
the physician-patient relationship may include chronic non-compliance, rudeness to office staff,
or non-payment of bills. While these patient behaviors can affect the interactive care-giving
process, they may also identify patients with a propensity to file a claim against you. To help
reduce the risk of a future claim, a physician may terminate or discharge a patient from the
practice. There are, however, certain exceptions that apply to terminating a patient:
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You may not terminate your professional relationship for any discriminatory purpose
Or in violation of any laws or rules prohibiting discrimination such as the Americans with
Disabilities Act.
You also are not permitted to terminate a patient where you know, or reasonably should
know, that no other healthcare provider is currently able to provide the patient the type of
care or services that you are providing to the patient.
 Reduce the Risk of Abandonment for the patient:
Abandonment occurs when a physician suddenly terminates a patient relationship without giving
the patient sufficient time to locate another practitioner.
A patient, however, may withdraw from a physician’s care at any time without notifying the
physician.
 To reduce the risk of allegations of abandonment, it is recommended that you discuss
with the patient, in-person, the difficulties in the physician-patient relationship and your
intention to discharge the patient from the practice.
 Be sure to document the discussion fully in the patient’s medical record, also noting the
presence of any witnesses such as a patient’s family member or a member of your office
staff.
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 Write a Formal Discharge Letter to the patient:
You are required to notify the patient and Soundpath Health, in writing, of the termination. The
letter must state that you will no longer provide care to the patient as of a date certain. The date
must be at least 30 days from the date of the letter. You must also state in the letter that you will
be available to provide emergency care or services, including provision of necessary
prescriptions, during the 30-day notice period.
The discharge letter should also include:
 A description of any urgent medical problems the patient may have,
 An offer to forward copies of the patient’s medical records to the subsequent treating
Physician.
 Soundpath Health’s Member Services contact information to assist the patient in locating
a physician who is accepting new patients.
The care of a patient is a mutual agreement and is in many ways a team between you, the
provider, and the patient, but when that relationship is strained and you can no longer feel that
you are able to provide quality care to the patient, at that point it is time to end that patientprovider interaction. Make sure you have attempted all you can do to help and when you realize
there is no more to do, discharging the patient may be the only course of action.
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Participating Provider Access Standards:
New & Established Patients (not seeking Behavioral Health Care)
Routine, Wellness & Physical
Appointment within 30 days of request
Routine, Primary Care
Appointment within 7 days of request
Urgent Care
Same day appointment or within 24 hours
Emergency Care
24 hour availability of appropriate triage
Waiting time for scheduled appt
Should not exceed 30 minutes
Patients Seeking Behavioral Health (BH) Care
Urgent
Appointment with BH provider within 6
hours
Appointment with BH provider within 48
hours
Emergency
24 hour availability of appropriate triage
Routine Office Visit
Appointment with BH provider within 10
business days
Waiting time for scheduled appt
Should not exceed 30 minutes
Care for non-life threatening emergency
Behavioral Health Telephone Access Standards
Triage calls
Answered by a live voice within 30 seconds
Triage abandonment rate
Within 5%
Preventative Care: No symptomatic clinical concerns, complete physicals or other preventative
services, i.e. flu inoculations.
Routine Primary Care: Stable conditions that require a visit but are not considered urgent.
Urgent Care: Conditions that require medical intervention on the same day or within 24 hours to
prevent serious deterioration in health.
Emergency Care: Conditions that require emergent, possibly lifesaving, intervention that must be
referred immediately for medical intervention.
After-Hours Care: Care required after the provider’s scheduled closing time and before their
scheduled opening time or on a day the clinic is closed.
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Office Waiting Time: Amount of time between the time a patient checks in and the time they see a
provider, starting no earlier than their scheduled appointment time.
Member Rights and Responsibilities
Below are Member rights and responsibilities in accordance with CMS requirements. The
following is in the Member Handbook:
AS A SOUNDPATH HEALTH MEMBER, YOU HAVE A RIGHT TO:
 Receive information about the organization, its services, its practitioners and Providers
and Member rights and responsibilities
 Be treated with respect and recognition of your dignity and right to privacy
 Participate with practitioners in making decisions about your health care
 A candid discussion of appropriate or medically necessary treatment option(s) for your
condition, regardless of cost or benefit coverage
 Voice complaints or appeals about the organization or the care it provides
 Make recommendations regarding the organization’s Member rights and responsibilities
policy
 Supply information (to the extent possible) that the organization and its practitioners and
Providers need in order to provide care
 Understand your health problems and participate in developing mutually agreed-upon
treatment goals to the degree possible
AS THE MOST IMPORTANT MEMBER OF YOUR HEALTH CARE TEAM, IT IS YOUR
RESPONSIBILITY TO:
 Provide complete and correct facts about your health history, current health status, and
changes in your symptoms
 Make informed decisions about treatments and procedures before they are performed
 Follow the treatment plan that you and your Provider agree on
 Tell your Provider if you do not understand your treatment plan, or if you believe you
cannot follow through with it
 Accept the risks of refusing treatment
 Treat health care professionals, staff, other Members, and their property in a kind and
respectful manner
 Seek medical services only through your PCP, except in a life threatening emergency
 Make and keep appointments. Tell your PCP if you are going to be late or need to cancel
an appointment
 Request a referral from your PCP before going to a specialist
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Call Soundpath Health if you do not understand how your health plan works
Tell us about your suggestions for improvements, concerns and complaints
Use emergency room services only for injury or illness that, in the judgment of a
reasonable person, requires immediate treatment to avoid jeopardy to life or health
Pay any necessary copayment at the time you receive treatment
Protect against the wrongful use of your ID card by another person
Verify that the physician or health care professional you receive services from is
participating in the Soundpath Health network.
Notify Soundpath Health of any change in address.
Identify yourself as a Member of Soundpath Health when you seek care and carry your
identification card with you
Notify Soundpath Health if you are injured as a result of actions of a third party and are
entitled to recovery from the third party as a result of your injury for medical expenses.
As such, you are obligated to reimburse Soundpath Health for the value of the medical
services paid on your behalf by Soundpath Health.
Let us know if you have a living will, durable power of attorney for health care, or other
advance directives.
Advance Directives
Soundpath Health is required to provide members with information regarding their health care
rights under Washington law. Washington State law recognizes a member’s right to accept or
refuse health care by using documents called Advance Directives. If a patient is no longer able to
make medical decisions, the Advance Directive takes effect when the provider determines the
patient’s medical condition is terminal. The Directive may also go into effect if the patient’s
provider and another provider agree that the patient is in a permanently unconscious state.
Health Care Directives (also known as Living Wills) and Durable Power of Attorney for Health
Care are the two types of Advance Directives that can be used to set forth in writing one’s wishes
regarding medical treatment in the event of the inability to clearly communicate due to
incapacitating injury or illness.
Federal law requires hospitals to ask patients if they have Advance Directives when they are
admitted. Other health care providers should document Advance Directives in the patient’s
medical record. Hospitals and providers must also inform patients of their own policies regarding
Advance Directives and end-of-life treatment, as well as any conflict between the patient’s
Directive and their own policies. If there is a conflict, a written plan of action must be agreed
upon and included in the patient’s medical record.
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All hospital and primary care providers are required to provide adult members with written
information about Advance Directives and the right to make anatomical gifts. Specialists must
inform members of these rights when deemed appropriate based on the treatment or care they are
providing. In addition, a member has the right to be informed and educated about the opportunity
to express his/her wishes concerning future care, including choosing a person to make medical
decisions on the patients behalf if the patient is unable to do so.
Responsibilities of Soundpath Health
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To offer a Provider Network that provides care and services to enrollees
To supply the Provider and the office staff with any revisions to Policy/Procedure in
accordance with Regulatory and applicable Accreditation Agencies
To offer training and support to the Provider and their staff
To ensure that Member Health Risk Assessments received will be forwarded to the
Member’s PCP
To offer support in the provision of language services
To ensure that the Provider Relations staff will be available for the Providers
To supply the Provider with any changes, revisions, additions, deletions and other
modifications to the Provider agreement
To conduct Oversight Reviews in compliance with state and federal regulatory
requirements
To conduct reviews to assess content, legibility, organization and completeness of the
enrollee’s records as well as assess compliance concerning confidentiality of medical and
health information
To ensure the compliance of Providers for Site Audits, Medical Record Review, Access
Audits, QI Reviews, and other requirements as determined by Soundpath Health
Publicly acknowledge Providers with high positive satisfaction scores and address
Providers with low scores
To maintain and provide access to accurate Provider Directory information
To maintain current Membership records for Providers
To ensure non-discriminatory practices for prospective and current enrollees or to
enrollees with physical, mental disability and/ or chronic illnesses
To conduct Member satisfaction surveys regarding the Provider’s services and share the
reports with the Provider
Soundpath Health will send each Member a Health Risk Assessment within the first 30
days after selection of a Primary Care Physician. The objectives of the assessment tools
are:
To proactively identify conditions that requires attention by a health care Provider
To promote continuity and coordination of care
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To identify conditions that may qualify for disease management programs or case
management
To provide Members with appropriate educational materials
Significant Health Risk Assessment Findings
New members will be offered a Health Risk Assessment (HRA) tool to complete and return to
the health plan. In response to the HRA, members that indicate they are depressed and need help
will be connected on an urgent basis with their Primary Care Provider. This is done by faxing a
copy of the HRA to the PCP with a letter encouraging them to see their patient at the earliest
availability. Referrals are made Case Management from as appropriate. Plan may intervene on
behalf of the Member to facilitate appointments, education, and assistance with resources
available through the Plan and/or the community.
Member Transfer Between Soundpath Health-contracted PCPs
The following guidelines apply to the transfer of a Soundpath Health Member, upon his/her
request, from one PCP to another:




The Member’s decision to transfer should be strictly voluntary.
The Member must not have been directly recruited by phone or in person by anyone involved
with either primary care office.
The Member must not have been influenced to transfer PCP due to improper or incorrect
information, or for medical reasons.
Upon a Member’s request, the primary care office must send his/her medical records to the
newly selected primary care office.
Any Provider who violates these guidelines is subject to corrective action.
Involuntary Member Disenrollment
A beneficiary may be involuntarily disenrolled from a Medicare Advantage Plan under the
following circumstances:





Change in residence outside the plan’s service area or temporary absence for more than 6
consecutive months
Loss of entitlement to Medicare Part A or loss of enrollment in Part B
Member is deceased
Disruptive behavior
Member fraud and abuse
Soundpath Health Provider Manual v3.1.14
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
Contract termination
 Change in residence outside the plan’s service area or temporary absence for more than 6
consecutive months
The Eligibility Coordinator (EC) will document receipt of a verbal request for disenrollment and
will document and stamp the date of receipt of written requests.
When a member or legal representative contacts Soundpath Health with an address change that is
outside the service area, the EC will determine the effective date of disenrollment and mail the
member a Disenrollment Due to Permanent Move letter. The EC will notify CMS of this action.
When Soundpath Health receives a member’s address change from a source other than the
member or the member’s representative, the EC cannot disenroll until the member or member’s
representative has confirmed that this out-of-area move is permanent or that six consecutive
months have passed. The EC will attempt to call the member to verify the address change.
If the EC cannot contact the member via telephone, the EC will mail the member a Verification
of Change in Address letter. If the EC does not receive a response by the beginning of the sixth
month after sending the letter, the EC will mail an Upcoming Disenrollment Due to Out of Area
Six Months letter. The EC will determine the disenrollment effective date and send a
Disenrollment Transaction to CMS. Upon receipt by CMS, a Final Confirmation of
Disenrollment Due to Out of Area Six Months letter will be sent to the member.
 Loss of Entitlement to Medicare Part A or Loss of Enrollment in Part B
When the EC receives a CMS Reply Listing that indicates a member has lost Medicare Part A or
Part B benefits, the EC will mail to the member a Disenrollment Due to Loss of Part A or Part B
Coverage letter. If a member subsequently contacts Soundpath Health regarding an erroneous
disenrollment, the EC will use the Enrollment Reinstatement procedure.
 Member is Deceased
When the EC receives a CMS Reply Listing that indicates a member is deceased, the EC will
mail a Disenrollment Due to Death letter to the estate of the member. If a member subsequently
contacts Soundpath Health regarding an erroneous disenrollment, the EC will use the Enrollment
Reinstatement procedure.
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 Disruptive Behavior
This language is from the MA Regulations: 42 CFR 422.74 Disenrollment by the MA
organization regarding disruptive behavior.
(i) Definition of disruptive behavior. An MA plan enrollee is disruptive if his or her behavior
substantially impairs the plan's ability to arrange for or provide services to the individual or other
plan Members. An individual cannot be considered disruptive if such behavior is related to the
use of medical services or compliance (or noncompliance) with medical advice or treatment. (ii)
Basis of disenrollment for disruptive behavior. An organization may disenroll an individual
whose behavior is disruptive as defined in 422.74(d)(2)(i) only after it meets the requirements
described in this section and CMS has reviewed and approved the request. (iii) Effort to resolve
the problem. The MA organization must make a serious effort to resolve the problems presented
by the individual, including providing reasonable accommodations, as determined by CMS, for
individuals with mental or cognitive conditions, including mental illness and developmental
disabilities. In addition, the MA organization must inform the individual of the right to use the
organization's grievance procedures. The beneficiary has a right to submit any information or
explanation that he or she may wish to the MA organization. (iv) Documentation. The MA
organization must document the enrollee's behavior, its own efforts to resolve any problems, as
described in paragraph (iii), and any extenuating circumstances. The MA organization may
request from CMS the ability to decline future enrollment by the individual. The MA
organization must submit this information and any documentation received by the beneficiary to
CMS. (v) Effective date of disenrollment. If CMS permits an MA organization to disenroll an
individual for disruptive behavior, the termination is effective the first day of the calendar month
after the month in which the MA organization gives the individual notice of the disenrollment
that meets the requirements set forth in paragraph (c) of this section, unless otherwise determined
by CMS.
 Member fraud and abuse
Examples include:


When a member submits fraudulent information on an enrollment form.
When a member allows another person to use his/her enrollment card to obtain services
or a prescription drug.
When Soundpath Health receives information that a member has committed fraud and abuse, the
EC will call CMS to discuss the issue with the CMS Plan Manager. If the CMS Plan Manager
advises Soundpath Health to disenroll the member, the EC will determine the effective date of
disenrollment and send a Disenrollment for Fraud and Abuse letter to the member. The EC will
Soundpath Health Provider Manual v3.1.14
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then send a Disenrollment Transaction to CMS as well as send all supporting documentation to
the Inspector General in the CMS Regional Office.
 Contract Termination
If Soundpath Health determines not to renew its contract with CMS, the EC will mail to the
member a Contract Non-Renewal Notification letter at least 90 calendar days before the effective
date of the non-renewal.
If Soundpath Health receives a contract termination notice from CMS, the EC will mail to the
member a Contract Termination by CMS Notification Letter at least 30 calendar days before the
effective date of the termination.
If Soundpath Health terminates the contract with CMS due to CMS substantially not carrying out
the terms of its contract, members will be sent the Contract Termination by Soundpath Health
Notification 60 days prior to the effective date of the termination.
Soundpath Health’s Medical Management Division
Medical Management is designed to assure and deliver consistent, high quality, cost-effective,
medically necessary care and services for all members. Medical Management promotes
evidence-based, efficient and effective care and drug utilization and effective oversight of all
delegated entities. All care and services delivered to the members will be compliant with CMS
regulatory requirements and evidence-based criteria. The Board of Directors has delegated the
ongoing oversight and administration of the Medical Management program to the Quality
Improvement Committee (QIC). The Medical Advisory Committee, an advisory subcommittee
to the QIC, provides community physician input into the Medical Management program.
The Medical Management Division provides:

Care Management
o Utilization Management
o Case Management
o Population Health/Chronic Disease Management



Pharmacy Services
Quality Improvement
Delegation Oversight
Soundpath Health Provider Manual v3.1.14
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Care Management
Care Management is the set of processes that manages utilization of medical services, promotes
equal access for members to their benefits, and promotes cost effective, high quality care across
the continuum.
The Care Management Program has two key areas:


Utilization Management
Population Health/Case Management
Key functions of Care Management include, but are not limited to:













Pre-Service Authorization and management for services on the Prior Authorization
List and for all services provided by a non-contracted provider (The Prior
Authorization List is available in the member’s Evidence of Coverage document
and on the Plan’s website.)
Concurrent Review
Retrospective or Post-Service Review
Home Health/Ambulatory Review
Out of Area Review and management
Referral management between contracted PCPs and contracted specialists
Discharge Planning
Appeals and Operations Interface
Coordination and oversight of Delegated Care Management/Utilization Management
Entities
Case Management
Population Health/Chronic Disease Management
Transplant Coordination
Behavioral Health Coordination
Pharmacy Services
Pharmacy Services provides drug utilization and quality oversight. In partnership with the
Pharmacy Benefit Manager (PBM) partner, Pharmacy Services assures member access to Part D
benefits, promotes evidenced-based management of the drug formulary, assures regular review
of therapeutic classes of drugs, and promotes cost-effective drug utilization. Working with the
delegated Pharmacy Benefits Management Company, the Chief Medical Officer and the Quality
Soundpath Health Provider Manual v3.1.14
Page 24
Improvement Committee, Pharmacy Services has the accountability to assure that this process is
performing at expected standards and costs.
The Medication Therapy Management Program is a program of Drug Management managed by
the PBM that identifies at-risk members with defined chronic diseases. The interventions are
focused on compliance with evidence-based guidelines for medication use. The MTM Program
works with the member and their PCP to assure compliance and cost effective drug use.
Quality Improvement (QI)
Under the oversight of the QIC, the QI Department identifies opportunities for improvement in
service and clinical care, while promoting the evidence-based clinical practices. QI develops
appropriate metrics for Quality Improvement initiatives, facilitates HEDIS reporting, and tracks
and directs initiatives to improve Star Rating measures. Performance measurement is
fundamental to Quality Improvement and is a critical tool that guides improvement.
The QI program:







Establishes the criteria for all activities related to care and services in accordance with
state and federal regulatory requirements.
Ensures that improvements initiated are of value to the members and are implemented
and sustained through ongoing monitoring.
Develops specific, measurable Quality Improvement goals and timelines in alignment
with RiverLink Health’s strategic goals.
Collaborates with delegated groups and partners to improve clinical and service
quality that results in improvement of processes and outcomes.
Focuses on identifying opportunities for improvement through systematic internal
quality processes and working with the providers to develop appropriate action plans,
when indicated.
Identifies studies that address meaningful, relevant clinical issues that are relevant to
the population served and uses them to develop improvement initiatives.
Promotes physician use of nationally recognized practice guidelines to improve the
process and outcome of chronic and acute disease management.
The intent of the QI department is to continuously improve the quality of care provided to
members with the intent of optimizing their health outcomes. QI activities and initiatives include
but are not limited to - Medicare Star Rating Improvement; Healthcare Effectiveness and Data
Information Set (HEDIS) Reporting; HEDIS Compliance Audit; Consumer Assessment of
Healthcare Providers and Systems (CAHPS), Health Outcomes Survey (HOS), Health Risk
Assessments (HRA), Chronic Care Improvement Program (CCIP), Quality Improvement
Soundpath Health Provider Manual v3.1.14
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Program (QIP), Data Analytics and Physician Engagement – Actionable Reports and Closing
Gaps in Care.
Delegation Oversight
Delegation oversight is the process to assure that all delegated entities are performing at the
expected and contracted level; that performance is consistent with the policies and procedures of
Soundpath Health; and that all members have equal access to their benefits across the service
areas.
Soundpath Health can delegate the performance of specific services, such as care
management/utilization management, behavioral health, drug management and claims
management, to outside entities. To assure the highest level of service and satisfaction to all
members, it is necessary to monitor and audit the performance of delegated services. Policies
and procedures are established to assess the initial and ongoing compliance of delegated
functions with Soundpath Health standards. Soundpath Health will perform an initial or PreDelegation Audit to ensure the Medical Groups/IPA/PHO complies with Soundpath Health
standards for delegation of Care Management. At least annually thereafter, Soundpath Health
will audit the Medical Groups/IPA/PHO to ensure continued compliance. Soundpath Health may
initiate a focused audit based on specific activities at the Medical Groups/IPA/PHO that warrants
such an audit. The Medical Groups/IPA/PHO is required to provide specific documents/evidence
to the auditor as applicable. Pre-Delegation, Annual Audit, corrective action plans, and Dedelegation may occur with any delegated responsibilities from Soundpath Health to the entity.
The Medical Management goals are to:






Facilitate medical care and services based on contractual agreement with CMS for
assigned eligible Medicare Advantage Members
Provide equitable and fair access to care and timeliness of care demonstrated through
audits, reporting and evaluation of quality
Improve coordination of care by facilitating communication
Improve quality of healthcare services through the identification and communication
of quality indicators
Identify Members considered to be high-risk for complicated, long-term continuous
care in order to assure appropriate coordination of care and case management
intervention
Identify and monitor key indicators for tracking potential over-and-under utilization
of specific healthcare services and report findings to the QIC for corrective action
Soundpath Health Provider Manual v3.1.14
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Care Management uses the following industry and nationally-recognized criteria in assisting
decision-making:
Guidelines

Function
Review of medical necessity, priorauthorization, preadmission review,
concurrent review, discharge planning,

InterQual and/or other nationally
recognized medical necessity criteria
CMS Coverage Determinations and
Manual Guidelines

Independent and peer medical reviews Medical necessity reviews.
Provider Cooperation
In support of Soundpath Health’s care management program and quality initiatives, including but
not limited to, Healthcare Effectiveness Data and Information Set (HEDIS), quality improvement
projects, prior-authorization requirements, concurrent review activities, providers and facilities
are required to give access to: (1) facilities, including the emergency room; (2) our members and
their medical records; and (3) hospital and medical staff for purposes of obtaining necessary
clinical information regarding our member’s condition or treatment plan. In addition, providers
and facilities are expected to participate in discharge planning activities. This protocol also
applies when providing continued care to our members following termination of a provider
agreement.
Adverse Incident Reporting
Serious Reportable Adverse Events (SRAEs)
Soundpath Health adopts the most current version of the Serious Reportable Adverse Events
(SRAEs), as published by the National Quality Forum (www.qualityforum.org). SRAEs are
serious patient safety incidents that, by definition, should never happen and include events such
as surgery on the wrong part of the body or surgical instruments left in the body after an
operation.
This Incident Reporting System is one of the components of Soundpath Health’s Risk
Management Program. All employees, agents and Providers of Soundpath Health are required to
report to Soundpath Health’s Director of Quality Improvement any “adverse” or “sentinel”
incident involving a Member.
Soundpath Health Provider Manual v3.1.14
Page 27
An “adverse” or “sentinel” incident means any incident that:







Is associated, in whole or in part, with any action of any health care facility or
personnel in the provision of health care to a Member (referred to as a “medical
intervention”) rather than the condition for which such intervention occurred.
Is not consistent with or expected to be a consequence of such medical intervention.
Occurs as a result of medical intervention to which the Member has not given his
informed consent.
Occurs as a result of any other action or lack thereof on the part of the facility or
personnel of the facility.
Results in a surgical procedure being performed on the wrong Member.
Results in a surgical procedure unrelated to the Member’s diagnosis or medical needs
being performed on any Member (including the surgical repair of injuries or damage
resulting from the planned surgical procedure, wrong site or wrong procedure
surgeries and procedures to remove foreign objects remaining from surgical
procedures); and causes injury to a Member.
Per Medicare guidelines, if a SRAE occurs on a Soundpath Health patient, the
provider, hospital or healthcare facility must immediately report it to Soundpath
Health’s Director of Quality and Care Management at 1-866-352-7086.
Soundpath Health Provider Manual v3.1.14
Page 28
Referrals & Prior Authorizations Process
Soundpath Health Care Management is responsible for managing Plan level referrals to noncontracted providers and services on the Prior Authorizations list.
The Prior Authorization List is available in the member’s Evidence of Coverage document
and on the Plan’s website.
The PCP is responsible for initiating and submitting requests for authorization to the Care
Management Department of Soundpath Health or the Delegated Entity, where appropriate.
Services performed without authorization are subject to review and denial of payment. Member
eligibility and benefits must be checked prior to authorizing services.
Coverage for medical services is subject to the limits and conditions of the Member benefit plan.
Members and their Providers should consult the Members Summary of Benefits and/or Evidence
of Coverage or contact a Customer Service representative to determine whether there are any
applicable benefit limitations.
While the current Prior Authorization list can be located at www.SoundpathHealth.com,
Soundpath Health will provide its contracted providers with the most current Prior Authorization
list upon return of the initial contract signature and/or as it is updated by the Soundpath Health
Utilization Management Department. The Prior Authorization list is subject to change.
When a Plan Referral or Authorization request is received, Soundpath Health determines the
level of urgency and follows Medicare Part C turnaround time requirements, as follows. These
are the Plan’s minimum standards:
Soundpath Health Provider Manual v3.1.14
Page 29
Service Type
Decision Timeframe
Notification Timeframes
(approvals & denials)
Extensions Allowed
(Pending status)
Standard Pre-Service
(non urgent)
Up to 14 calendar
days from date of
receipt
Written notification 14
calendar days from date
of receipt
Up to 14 calendar days
Expedited PreService (urgent)
72 hours from date of
receipt of request
(including weekends
and holidays)
VERBAL Notification
within 72 HOURS
FROM receipt of
request.
Up to 48 hours
WRITTEN Notification
required within 3 days
of verbal notification
Concurrent
Decision &
notification within 24
hours of receiving all
the necessary
information to make
a determination.
Extension for decision
Decision & notification
is NOT Allowed
(verbal) within 24 hours of
receiving the request. Written
notification will follow.
PostService/Retrospective
(Pre Claim)
30 calendar days
from date of receipt
Written notification within Up to 14 calendar days
30 calendar days of receipt of
request, with adverse
determination notification
within business 5 days
Soundpath Health Provider Manual v3.1.14
Page 30




Pre-Service Non-Urgent (Standard) received without adequate information to make a medical
necessity determination will be placed on requested status and a Lack of Documentation
(LOD) letter will be sent to the Provider and Member which initiates a fourteen (14) day
extension process.
Review will be pended until necessary information is received. If the information is not
received within the required timeframe, an administrative denial will be issued in accordance
with Medicare Part C requirements.
Requested information will be documented and forwarded for medical review within the
Medicare Part C turnaround time requirements.
When a determination is made, the data will be entered into our system and the specialist,
Provider or Member (if the service has not been approved) will be notified via fax, or mail.
For an Expedited Request, all parties will be notified via telephone in addition to a letter sent
via electric transmission and/or mail to the PCP, Specialist and, if denied, to the Member.
Delegated Entities will follow the referral process as approved by Soundpath Health.
Facility Admissions
All Member Acute Hospital and Skilled Nursing Facility Admissions must be approved by the
Prior Authorization Request Process. The Care Management Department telephone number is 1866-352-7086 and the fax is 1-866-362-0627.
Pertinent medical records and supporting documentation will be required on a periodic basis and
may involve on-site review at the hospital or Skilled Nursing Facility (SNF) by the Chief
Medical Officer, Medical Director, or CM Nurse. The request will be reviewed against the
designated medical review criteria. Requests not meeting the medical review criteria will be
reviewed by the Chief Medical Officer and / or Medical Director for final decision.



Emergency Admissions/Admissions after ER Visit require notification to Soundpath
Health within 24 hours of the admission.
Pre-scheduled acute and SNF admissions must be pre-certified and approved.
Concurrent review is performed by the Utilization Management Nurse who will monitor
the necessary services in Member related cases as well as any discharge planning
services.
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Out of Area (OOA)
Soundpath Health provides coverage for emergent services for Members worldwide. For
purposes of CMS compliance, Soundpath Health defines out of area services as being those
services received by an Enrollee outside the approved service area. Soundpath Health Care
Management requires notification of all out-of-area Inpatient admissions if PCP is made aware
of such admission. The Care Management staff will conduct concurrent review and assist in
discharge planning. Soundpath Health staff will assist in coordination of the Member
discharge/transfer with the appropriate delegated group when necessary.
Currently, only the Apex+Rx plan, available to residents of Thurston and Lewis counties, offers
a supplemental benefit visitor/traveler program outside of the Plan’s service area, but within the
continental United State and its territories. Under this benefit plan, member’s may receive all
plan covered services at in-network cost sharing. Members are still required to select a local PCP
and obtain the necessary referrals and prior authorizations, as required. Members should contact
the Plan for assistance in locating a provider who accepts original Medicare when using the
visitor/traveler benefit. As with all plans, members can stay enrolled while out of the service area
for up to 6 months. Members who have not returned to the plan’s service area within 6 months
will be disenrolled from the Plan.
Notice of Medicare Non-Coverage (NOMNC)
A written Notice of Medicare Non-Coverage/Generic Notice is given to all beneficiaries whose
skilled services are being terminated by:




Home Health Agencies (HHA’s)
Skilled Nursing Facilities (SNF’s)
Comprehensive Outpatient Rehabilitation Facilities (CORF’s)
Hospice
Copies of all letters issued by the SNF, HHA or CORF to a Member or Member’s
representatives will be sent to Soundpath Health, or delegated medical group.
Soundpath Health Provider Manual v3.1.14
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Credentialing Process
This section represents the Soundpath Health process for Credentialing and Recredentialing.
Please read through all the criteria as listed.
1. Established criteria for practitioners will be maintained and required in order to
participate in the Soundpath Health Provider network. Any exceptions are at the
discretion of the Board of Directors.
2. The health care practitioner must be registered with Provider Source through One Health
Port pursuant to Washington State Senate Bill 5346. Senate Bill 5346 requires a statewide
data collection process be setup for all credentialing and privileging data to reduce
hassles for the provider community and simplify access to data for health plans and
hospitals. The service is free for practitioners inputting data.
3. The health care practitioner must possess a current, valid, and unrestricted license to
practice in the state where he or she provides services to Soundpath Health’s Members.
4. The health care practitioner must have clinical privileges and be in good standing at a
hospital participating in the Provider network of Soundpath Health. If the health care
practitioner is a primary care physician, he or she must have admitting privileges and be
in good standing at a hospital participating in the Provider network of Soundpath Health.
Exceptions may be granted if:
A. The health care practitioner’s practice does not require admitting or clinical
privileges at a hospital participating in the Provider network of Soundpath
Health. This type of practice may include, but is not limited to: anesthesiology,
dentistry, chiropractic, pathology, occupational medicine, optometry, physical
therapy, and podiatry.
B. The health care practitioner’s practice is exclusively office-based and the
health care practitioner provides documentation that another practitioner or
hospitalist will provide inpatient services for the health care practitioner’s patients
at a hospital participating in the network of Soundpath Health.
5. The health care practitioner must provide all information regarding any current or past
limitations, restrictions, terminations or other disciplinary actions taken with respect to
his or her medical staff appointment or clinical or admitting privileges. The health care
practitioner must never have had his or her medical staff appointment or clinical or
admitting privileges denied, revoked or terminated by any hospital or other health care
facility. Exceptions may be granted if Soundpath Health has identified an access,
adequacy or other need in the practice area in which the health care practitioner practices,
and the health care practitioner’s history and present circumstances do not indicate a
Soundpath Health Provider Manual v3.1.14
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probable future substandard practitioner performance or competency concern in the
opinion of Soundpath Health’s Chief Medical Officer or Credentialing Committee.
6. The health care practitioner must never have been convicted of, pled guilty to or no
contest to, or have been sanctioned for, any offense or action involving Medicare,
Medicaid or other governmental or private third party payor fraud or program abuse, and
must not be listed on the Office of Inspector General (OIG) “Sanction List”.
7. The health care practitioner must never have been sanctioned, debarred, excluded or
precluded from participation in Medicare or Medicaid programs.
8. The health care practitioner must possess and maintain, in the proposed practicing
contracted specialty, Board Certification; completion of an approved and accredited
residency-training program, awaiting certification results; or equivalent training and/or
experience acceptable to the Soundpath Health Chief Medical Officer or Credentialing
Committee.
9. The health care practitioner must provide a minimum of five (5) years of malpractice
history. If the health care practitioner has a history of liability suits, claims, arbitration or
settlements, this history must not demonstrate probable future substandard practitioner
performance as determined by the Soundpath Health Chief Medical Officer or
Credentialing Committee.
10. The health care practitioner must provide evidence of and maintain practitioner liability
insurance coverage in such minimum amounts as are required by Soundpath Health from
to time. Currently, the health care practitioner must maintain practitioner liability
insurance coverage, on occurrence basis, in the amount of at least $1,000,000 million
dollars per occurrence and $3,000,000 million dollars in the aggregate.
11. The health care practitioner must never have been indicted or convicted of, pled guilty to
or no contest to, a felony, any offense involving moral turpitude or fraud, or any offense
related to the practice of healing arts, other health care related matters, third-party
reimbursement, controlled substances violations, child or adult abuse, or any other matter
that in the opinion of Soundpath Health’s Chief Medical Officer or the Credentialing
Committee, would adversely affect the ability of the applicant to participate. Exceptions
may be granted if Soundpath Health has identified an access, adequacy or other need in
the practice area in which the health care practitioner practices and the health care
practitioner’s history and present circumstances do not indicate a probable future
substandard practitioner performance in the opinion of Soundpath Health’s Chief Medical
Officer or Credentialing Committee.
12. The health care practitioner must possess a valid, current and unrestricted state and
federal Drug Enforcement Agency Certificate (DEA number) applicable to his or her
specialty. Exceptions may be granted if the health care practitioner does not need to
prescribe narcotics or other controlled substances in his or her practice (e.g., pathologist
Soundpath Health Provider Manual v3.1.14
Page 34
or non-invasive radiologist) in the opinion of Soundpath Health’s Chief Medical Officer
or Credentialing Committee.
13. The health care practitioner must permit Soundpath Health representatives to conduct onsite office reviews and the results of such review must not demonstrate a probable
substandard practitioner performance in the opinion of Soundpath Health’s Chief Medical
Officer or Credentialing Committee.
14. The health care practitioner must have no current abuse of illegal substances or chemical
dependency.
15. The health care practitioner must not be experiencing physical or mental health
problem(s), which impair the health care practitioner’s ability to practice within the scope
of his or her license. Proof of ability will be based upon the nature of the impairment and
other information obtained.
16. The health care practitioner’s financial and legal status history must not demonstrate
probable future substandard practitioner performance or lack of financial capability and
must demonstrate that the practitioner has authority to provide health care services to
Soundpath Health’s Members.
17. The health care practitioner must not be restricted from participating in the Provider
network of Soundpath Health by an exclusive or other arrangement with any person or
entity other than Soundpath Health.
18. In certain geographic areas, the health care practitioner must participate in the Provider
network of Soundpath Health through an intermediary with whom Soundpath Health has
an exclusive or other restrictive arrangement.
19. The health care practitioner must execute, and enter into with Soundpath Health (or any
required intermediary), the then current template of Soundpath Health’s written
practitioner agreement, and must abide by and comply with all terms and conditions of
the practitioner agreement and fulfill all obligations imposed on the health care
practitioner under such practitioner agreement.
20. The number of existing practitioners who participate in Soundpath Health’s Provider
network in the practice area of the health care practitioner must not exceed the
number determined necessary by Soundpath Health’s Chief Medical Officer or
Credentialing Committee to meet the needs of Soundpath Health’s Members.
Soundpath Health Provider Manual v3.1.14
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Re-Credentialing Process
Practitioners are re-credentialed at a minimum every three (3) years. Approximately 120 days
before the re-credentialing date, Soundpath Health will review the provider’s Provider Source
record.
The Provider Source record must be up-to-date and include:






Reason for any inability to perform the essential functions of the position, with or
without accommodation
Lack of present illegal drug use
History of loss of license and felony convictions
History of loss or limitation of privileges or disciplinary action
Current malpractice insurance coverage
The correctness and completeness of the application
If the Provider Source record is not up-to-date, the provider will be notified in writing and
requested to update his/her information. 3 attempts will be made to obtain up-to-date
information. If the provider is unresponsive it may be cause for suspension or termination of
Network participation. Incomplete re-credentialing may also result in Network suspension or
termination as determined by the Chief Medical Officer and in accordance with the established
Network Agreement and participation criteria.
Soundpath Health may also elect to obtain updated copies of those practitioner and Provider
documents that expire. This includes but is not limited to the state license, business license,
professional liability coverage, DEA certificate if applicable, board certification and
accreditation.
Soundpath Health Provider Manual v3.1.14
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Appeals and Grievances
Provider Claim Reconsideration and Provider Claim Dispute Processes
1st Level: Provider Reconsideration
If you believe an item or service was denied in error by Soundpath Health, the first step in
addressing your concern is to request a Claim Reconsideration. You may submit a Claim
Reconsideration request via fax or mail.
Mail to:
Soundpath Health
Attn: Provider Reconsiderations
PO Box 4397
Federal Way, WA 98063
Fax to:
(253) 517-4364
Your reconsideration request must be submitted to us within twelve (12) months from the date of
the organization determination on the Explanation of Benefits (EOB) or Provider Remittance
Advice (PRA) and should include any supporting documentation.
Please identify the specific claim(s) in “paid” or “denied” status which you believe should be
adjusted, including any necessary supporting documentation.
If you are submitting a Claim Reconsideration Request for a claim which was denied due to
untimely filing:
1. Electronic claims – include confirmation that Soundpath Health or one of our delegated
groups received and accepted your claim.
2. Paper claims – include a copy of a screen print from your accounting software to show the
date you submitted the claim to Soundpath Health or one of our delegated groups.
Note: All proof of timely filing must also include documentation that the claim is for the correct
patient and the correct visit.
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2nd Level: Provider Dispute
If you believe you were underpaid or feel an item or service was denied in error by us, the first
step in resolving your concern is to submit a Claim Reconsideration as described above.
If you do not agree with the outcome of the Claim Reconsideration decision made at the 1st level
review, you may submit a formal dispute.
Mail to:
Soundpath Health
Attn: Provider Reconsiderations
PO Box 4397
Federal Way, WA 98063
Fax to:
(253) 517-4364
Your dispute must be submitted to us within sixty (60) days from the date of the reconsideration
decision shown on the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA).
Attach all supporting materials such as member specific treatment plans or clinical records to the
formal dispute letter, based on the reason for the request. Include information which supplements
your previous reconsideration submission that you wish to have included in the dispute review.
Our decision will be rendered based on the materials available at the time of the formal dispute
review.
If you are disputing a claim that was denied because filing was not timely:
1. Electronic claims – include confirmation that Soundpath Health or one of our delegated
groups received and accepted your claim.
2. Paper claims – include a copy of a screen print from your accounting software to show the
date you submitted the claim to Soundpath Health or one of our delegated groups.
Note: All proof of timely filing must also include documentation that the claim is for the correct
patient and the correct visit.
Soundpath Health will provide a response to your dispute in writing within thirty (30) calendar
days for pre-service disputes and sixty (60) calendar days for post-service disputes.
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Note: The second level dispute decision rendered is final and not subject to further appeal.
If you are disputing a refund request, please send your letter of appeal to the address noted on the
refund request letter. Your appeal must be received within thirty (30) calendar days of the date of
the refund request letter, or as required by law or your participation agreement, in order to allow
sufficient time for processing the appeal, and to avoid possible offset of the overpayment against
future claim payments to you. When submitting the appeal, please attach a copy of the refund
request letter and a detailed explanation of why you believe we have made the refund request in
error.
Send Reconsiderations and Provider Disputes to:
Soundpath Health
Attn: Provider Reconsiderations
PO Box 4397
Federal Way, WA 98063
Fax to:
(253) 517-4364
For assistance, please call the Member Services Department seven days a week, from
8:00 a.m. to 8:00 p.m. from October 1 through March 1. Monday through Friday from 8:00 a.m.
to 5:00 p.m. from March 2 through September 30.
Toll free: 1-866-789-7747 or for TTY users: 1-866-264-4141
Provider Appealing on the Member’s behalf
In the event that a member has authorized you to appeal a clinical or coverage determination on
his/her behalf, such an appeal will follow the process governing member appeals as outlined in
the member’s Evidence of Coverage (EOC) benefit handbook.
Expedited Appeal
Expedited appeal – for organizational determinations that resulted in a denial
The Provider may request that the appeal be expedited if he/she believes the service or the
discontinued service is a medically necessary covered service and is time-sensitive. As per the
Member’s request, the Provider may submit a seventy-two (72) hour appeal on the Member’s
behalf. Soundpath Health will make a decision on an expedited appeal within twenty-four (24)
hours to determine the need for expedition. Requests for expedition will be considered when a
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standard resolution could seriously jeopardize the Member’s life, health, or the ability to attain,
maintain, or regain maximum function. Soundpath Health must make a decision as expeditiously
as the health of the Member requires, but no later than the end of any extension period of
fourteen (14) calendar days.
The following are samples of expedited appeals that the Provider may believe are time-sensitive:



Member is being discharged from a Hospital early and the Provider has missed the
deadline for a Peer Review Organization (PRO) review.
Member is being discharged from a Skilled Nursing Facility early.
Member’s Home Health care is being discontinued early.
How to request an expedited seventy-two (72) hour appeal
Call, write, fax or visit the Soundpath Health Corporate Office at 32129 Weyerhaeuser Way
South, Suite 201, Federal Way, WA 98001.
The Provider needs to specify that this is an expedited appeal or urgent appeal.
Mail to:
Soundpath Health
Attn: Appeals Department
PO Box 4397
Federal Way, WA 98063
Phone: (253) 779-8830 or toll-free: (866) 789-7747
Fax to:
(253) 517-4364
The following are possible dispositions for the Provider to request an expedited
determination/appeal:


The request to expedite our determination/appeal decision is approved, Soundpath Health
will make a decision in seventy-two (72) hours and notify the Provider that Soundpath
Health will provide or continue the service.
The request to expedite our determination/appeal decision is not approved, and
Soundpath Health informs the Provider that the request will be handled under the
standard fourteen (14) day determination/appeal process. If the Provider does not hear
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back from Soundpath Health within 72 hours of the request, please call the Utilization
Management department or request a copy of the expedited determination/appeal
decision.
Quality Improvement Organization (QIO)
The Provider has the right to provide all the Hospital or Skilled Nursing care necessary for the
proper diagnosis and treatment of the Member’s illness or injury. The Member’s discharge date
must be determined solely by medical needs as per the Federal law. The Provider and Members
will receive a written notice of explanation called a “Detailed Notice of Discharge” or “Notice of
Medicare Non-Coverage” when discharging a Member from the hospital or skilled nursing
facility. This document outlines the Member’s rights. Soundpath Health or the Hospital is
required to issue this notice to the Provider.
Who are QIO Physicians?
QIOs are groups of doctors who are paid by the Federal Government to review Medical
Necessity, appropriateness and quality of Hospital treatment furnished to Medicare patients,
including those enrolled in a managed care plan such as Soundpath Health. There is a QIO in
every state. QIOs have different names, depending on which state they are in.
The QIO in Washington State is called Qualis Health. You may contact Qualis Health toll free at
1-877-290-4346 or write to:
Qualis Health
P.O. Box 33400
Seattle, WA 98133-0400
Immediate Review of Hospital Discharges
The Provider will be entitled to this process instead of the standard appeals process if the
Provider asks for immediate review by the QIO by noon on the workday following a Detailed
Notice of Discharge/Notice of Medicare Non-Coverage. Before the QIO makes its decision, the
Provider will be protected from liability for hospital services the Member received. The Provider
may appeal the Detailed Notice of Discharge/Notice of Medicare Non-Coverage as previously
discussed by requesting that Soundpath Health reconsider the decision instead of a QIO review.
If the Provider requests the review on time, the advantage of the QIO review is that the Provider
will get the results within three working days. During the QIO review process, the Member will
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not be financially liable for hospital charges incurred. This same protection for the Member does
not apply in the case of Soundpath Health’s reconsideration process.
Special expedited appeal, if missed QIO deadline
If the Provider has missed the deadline for requesting the QIO review, they may only file an oral
or written request for an expedited seventy-two (72) hour Soundpath Health appeal. If the
original determination to discharge the Member is not approved through the appeal process and
the Provider does not seek QIO review, however seeks an expedited reconsideration of the
Organization Determination, the Member will be financially responsible for the hospital costs
incurred from the date the Detailed Notice of Discharge/Detailed Explanation of Non-Coverage
is issued.
QIO complaints process
The Provider or Member may file a complaint with the QIO in their local area if they are
concerned about the quality of care provided to a Member.
Grievance Procedures
A “Complaint” is an Informal Grievance that is any expression of dissatisfaction with the
administration, claim practices, or provision of services relating to quality of care and services
provided. The Provider should use Soundpath Health’s Grievance Procedure for complaints that
do not involve coverage decisions. Please call Member Services if you have a question about
what type of complaint process to use.
The Provider has the right to file a complaint/grievance about problems the Member and/or
Provider may observe or experience.
The Provider may file a grievance (a written complaint) submitted on behalf of the Member. The
following are some examples of a grievance: complaints regarding Member issues, adequacy of
facilities, or other similar Providers; quality of care; claims payment, handling, or reimbursement
for health care services; or any matter pertaining to the contractual relationship between you and
Soundpath Health. If the Provider feels the standard of time frame for our decision could
seriously jeopardize the life or health of the enrollee or regain maximum function, he or she may
request an expedited seventy-two (72) hour review.
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Who to call for a complaint?
Soundpath Health will attempt to resolve any complaints and encourages the informal resolution
of complaints since some of the complaints may arise from misinformation, misunderstanding or
lack of information. By calling Soundpath Health, the Provider may utilize the informal
resolution of the complaint process.
Formal grievance
For issues involving quality of care and services, the formal grievance procedure is the
submission of the Provider’s issue in writing to Soundpath Health within 45 days of the incident.
To use the formal grievance procedure, submit your grievance in writing to:
Soundpath Health
Attn: Appeals Department
PO Box 4397
Federal Way, WA 98063
Fax to:
(253) 517-4364
If Soundpath Health requires additional time to address the concern, Soundpath Health may have
a 30-calendar day extension. Soundpath Health shall resolve a grievance within sixty (60) days
after receipt of the grievance, or within a maximum of ninety (90) days if the grievance involves
the collection of information outside the service area.
Fraud, Waste, and Abuse
Definitions:


Fraud is knowingly and willfully executing, or attempting to execute, a scheme or
artifice to defraud any health care benefit program or to obtain (by means of false or
fraudulent pretenses, representations or promises) any of the money or property
owned by, or under the custody or control of, any health care benefit program. (18
U.S.C. § 1347)
Waste is over-utilization of services or other practices that, directly or indirectly,
result in unnecessary costs to the Medicare program. Waste is generally not
considered to be caused by criminally negligent actions but rather misuse of
resources.
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
Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to
the Medicare Program, improper payment, payment for services that fail to meet
professionally recognized standards of care, or services that are medically
unnecessary. (Abuse involves payment for items or services when there is no legal
entitlement to that payment and the provider has not knowingly and/or intentionally
misrepresented facts to obtain payment. Abuse cannot be differentiated categorically
from fraud, because the distinction between “fraud” and “abuse” depends on specific
facts and circumstances, intent and prior knowledge, and available evidence, among
other factors.)
Pertinent Laws and Regulations:
False Claims Act
The Federal False Claims Act creates liability for the submission of a claim for payment to the
government that is known to be false – in whole or in part. Several states have enacted false
claims laws as well.



A “claim” is broadly defined to include any submissions that results, or could
result, in payment.
Under the False Claims Act, ‘knowing’ or ‘known’ means that a person:
 Has actual knowledge
 Acts in deliberate ignorance of truth or falsity or Acts in reckless
disregard of truth or falsity
(Proof of specific intent to defraud is not required to fall within the definition of
“knowing” or “known.”)
Claims submitted to the government include claims submitted to intermediaries
such as state agencies, managed care organizations and other subcontractors under
contract with the government to administer health care benefits.
Liability can also be created by improper retention of an overpayment.

The Affordable Care Act of 2010 (ACA) expanded a provision of the False
Claims Act referred to as a reverse false claim.
 Overpayments or any funds received or retained under Medicare or
Medicaid that a person or organization is not entitled to must be reported
and returned within sixty (60) days of identification.
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Whistleblower and Whistleblower Protections:


The False Claims Act and some state false claims laws permit private
citizens with knowledge of fraud against the U.S. or state governments to
file suit on behalf of the government against the person or business that
committed the fraud.
Individuals who file such suits are known as ‘whistleblowers’. The federal
False Claims Act and some state false claims acts prohibit retaliation
against individuals for investigating, filing or participating in a
whistleblower action.
Soundpath Health expressly prohibits retaliation against employees – including employees of
first tier, downstream and related entities – who, in good faith, report or participate in the
investigation of compliance concerns.
Examples of FWA include:



A physician who submits a bill to Medicare for medical services not provided.
A government contractor who submits records that he/she knows (or should
know) are false and that indicate compliance with certain contractual or
regulatory requirements.
An agent who submits a forged or falsified enrollment application to receive
compensation from a Medicare Plan Sponsor.
Anti-Kickback Statute
The Anti-Kickback law makes it a crime for individuals or entities to knowingly and willfully
offer, pay, solicit or receive something of value to induce or reward business referrals under
Federal health care programs.
The Anti-Kickback law is intended to ensure that referrals for health care services are based on
medical need and not financial or other types of incentives to individuals or groups.
The Affordable Care Act (sometimes referred to as the Health Care Reform law) has added a
provision to the Anti-Kickback statute where “knowingly and willfully” does not mean the
individual had the intent to specifically violate the statute. In addition, violations of the AntiKickback statute can now be considered a false and fraudulent claim under the False Claims Act.
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Examples include:


A frequent flyer campaign in which a physician may be given airline
frequent flier mileage rewards for questionnaires completed for new
patients put on a drug company's product.
Free laboratory testing offered to health care providers, their families and
their employees to induce referrals.
In addition to criminal penalties, violation of the Federal Anti-Kickback statute could result in
civil monetary penalties and exclusion from federal health care programs, including the
Medicare and Medicaid programs.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA contains provisions and rules related to protecting the privacy and security of protected
health information (PHI) as well as provisions related to prevention of health care fraud and
abuse.
HIPAA Privacy
 The Privacy Rule outlines specific protections for use and
disclosure of PHI. It also grants rights to members.
HIPAA Security
 The Security Rule outlines specific protections and
safeguards for electronic PHI.
If you become aware of a potential breach or inappropriate disclosure of protected information,
you must comply with the security breach and disclosure provisions under HIPAA and, if
applicable, with any business associate agreement.
Examples of HIPAA provisions related to the prevention of health care fraud and abuse:



Creation of the Fraud Abuse and Control Program for coordination of state and
federal health care fraud investigation and enforcement activities.
Expansion of the exclusion authority so that any health care fraud conviction,
even if the fraud is not related to Medicare or Medicaid, results in mandatory
exclusion from participation in the Medicare or Medicaid programs.
Creation of a new series of federal crimes, together referred to as “health care
fraud,” which make it a federal crime to defraud health care benefit programs –
any benefit program, not just Medicare or Medicaid.
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Criminal Health Care Fraud Statute
The Criminal Health Care Fraud statute (18 U.S.C. Section 1347) prohibits knowingly and
willfully executing, or attempting to execute, a scheme or artifice:


To defraud any health care benefit program; or
To obtain (by means of false or fraudulent pretenses, representations or promises)
any of the money or property owned by, or under the custody or control of, any
health care benefit program in connection with the delivery of or payment for
health care benefits, items or services.
Proof of actual knowledge or specific intent to violate the law is not required. Penalties for
violating the Criminal Health Care Fraud statute may include fines, imprisonment, or both.
Examples of Member Fraud, Waste and Abuse:



Doctor Shopping – Consumer or other individual consults with a number of
doctors for the purpose of inappropriately obtaining multiple prescriptions for
narcotic painkillers or other drugs. Doctor shopping might be indicative of an
underlying scheme, such as stockpiling or resale.
Prescription Diversion and Inappropriate Use – Consumers obtain prescription
drugs from a provider, possibly for a condition from which they do not suffer, and
give or sell this medication to someone else. Also can include the inappropriate
consumption or distribution of a consumer’s medications by a caregiver or anyone
else.
Identity Theft or Medical Identity Theft – A person uses another person’s
Medicare card to obtain services or prescriptions – OR – another person’s
information is used to bill for procedures never done or for supplies never
received.
Examples of Pharmacy Fraud, Waste and Abuse:


Prescription Drug Switching – The pharmacy or pharmacy benefit manager
(PBM) receives a payment to switch a consumer from one drug to another or
influences the prescriber to switch the patient to a different drug.
Prescription Drug Shorting or Splitting – A pharmacy or PBM’s mail order
pharmacy intentionally provides less than the prescribed quantity and does not
inform the patient or make arrangements to provide the balance, but bills for the
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fully-prescribed amount. The pharmacy splits the original prescription to receive
additional dispensing fees.

Inappropriate billing practices such as:
 Billing for brand when generics are dispensed.
 Billing for non-covered prescriptions as covered items.
 Billing for prescriptions that are never picked up.
 Prescriber Fraud, Waste and Abuse:
 Script Mills – Provider writes prescriptions for drugs that are not
medically necessary, often in mass quantities, and often for patients that
are not theirs. These scripts are usually written, but not always, for
controlled drugs for sale and might include improper payments to the
provider.
 Illegal Remuneration Schemes – Prescriber is offered, paid, solicits or
receives unlawful remuneration (payment or items of value) to induce or
reward the prescriber to write prescriptions for drugs or products.
 Prescription Drug Switching – Drug switching involves offers of cash
payments or other benefits to a prescriber to induce them to prescribe
certain medications rather than others.
Examples of Sales Agent Fraud, Waste and Abuse:

Marketing Schemes
 Enrollment of a consumer in a Medicare Plan without the consumer’s
knowledge or consent.
 Offering consumers a cash payment or other reward as encouragement to
enroll in a Medicare, Medicaid, or health care benefit plan.
 Selling or marketing insurance without a license.
 Using consumer information supplied through a third-party (another agent,
friend, etc.) to market Medicare plans.
 Agents splitting commissions or agent referral fees.
 Misrepresenting themselves as a representative of the government
(Medicare/Social Security/Federal Government).
If you identify or are made aware of potential misconduct or a suspected fraud, waste or abuse
situation, it is your right and responsibility to report it. Please call our Compliance/Fraud, Waste
and Abuse Hotline at 253-779-8830.
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State and the federal government regulations have very clear guidelines on the mandatory
reporting of claims that are suspicious. In addition Soundpath Health policy states that any
person who knowingly and with intent to defraud or deceive any insurer files a statement of
claim or application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
As a result of our legal obligations, Soundpath Health has established an anti-fraud program. We
routinely audit, and when necessary, investigate claims submitted to us for payment of services.
Common errors in billing include:




Billing for non-chargeable or non-covered services.
Reciprocal billing – billing for services rendered for another Provider.
Submitting duplicate claims for services rendered.
Any other unsound fiscal practices, i.e., up-coding, unbundling.
Upon investigation, it may be necessary to elicit your cooperation in an effort to resolve
questions regarding suspicious claims. While it is important to follow policies and procedures
and internal controls to prevent fraud and abuse, Soundpath Health is committed to balancing
prompt claims processing adjudication with effective claims control at all times.
Healthcare fraud, waste and abuse affects us all and causes an increase in health care costs. If
you suspect any person, provider or company of defrauding or attempting to defraud Soundpath ,
please call us at (253) 779-8830. All calls are confidential and you may report your suspicions
anonymously via our toll free hotline. For more information about health care fraud, visit
http://www.stopmedicarefraud.gov/.
Resources:
CMS’ Prescription Drug Benefit Manual – Chapter 9
CMS’ Medicare Managed Care Manual – Chapter 21
http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/Chapter9.pdf
CMS’ Prescription Drug Benefit Manual http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/PartDManuals.html
CMS’ Medicare Managed Care Manual http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html
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Code of Federal Regulations (see 42 CFR 422.503 and 42 CFR 423.504)
http://www.gpo.gov/fdsys/browse/collectionCfr.action?collectionCode=CFR
Office of the Inspector General – Fraud Information http://oig.hhs.gov/fraud/
Medicare Learning Network (MLN) Fraud & Abuse Job Aid http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/Fraud_and_Abuse.pdf
Billing and Claims Payment
Electronic Claims Submission
Soundpath Health strongly prefers electronic claims submission for a variety of reasons: less
manual work means less human error resulting in faster payment with minimal rework.
Soundpath Health uses Emdeon as the primary clearinghouse for claims. The clearinghouse’s
use of specific system edits ensures the accuracy of all claims forwarded. If you are a physician,
other health care professional or facility you may use electronic transactions.
Please use the Emdeon Claims Submission payer ID #42172.
Where to Send Paper Claims
If you are not currently set up to bill Soundpath Health electronically, paper claims need to be
submitted on the appropriate claim form (CMS-1500 for professional claims and the UB-04 for
facility claims). Please send claims to:
Soundpath Health
Attn: Claims
PO Box 4537
Federal Way, WA 98063-9346
Hierarchical Condition Category Model (HCCM)
Documentation must support the diagnosis and coding of the highest specificity. Medicare
payment to Soundpath Health is based on the most severe manifestation of disease when less
severe manifestation is present. Soundpath Health will not accept any claims that do not have a
5-digit code.
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Claims Process & Payment
Soundpath Health standard is to process 95% of clean claims from non-contracted Providers
within thirty (30) days of receipt and will pay interest on claims that do not meet this standard.
95% of unclean claims from non-contracted Providers will be paid in sixty (60) days.
Reimbursement to non-contracted Providers will be the amount the Provider would have
received under original Medicare.
A clean claim an uncontested, complete, accurate, and valid claim, submitted on a CMS 1500 or
UB92 or successors as appropriate, which has all mandatory entries and truthfully represents
Medically Necessary services provided to a Member as documented in the Members medical
record and which complies with standards established by Soundpath Health. It is also defined as
a claim that has no defect or impropriety, including lack of required substantiating
documentation for non-contracting Providers and suppliers, or particular circumstances requiring
special treatment that prevents timely payment for being made on the claim. 95% of claims from
contracted Providers will be paid in sixty (60) days or as required by the Participant Agreement.



All facility claims must be submitted on a UB-04 Form
All ancillary services claims must be submitted on a CMS 1500 Form
All coding must conform to National Coding Standards (HIPAA)
The “UNIT” submitted will vary according to the type of service authorized. All “UNITS” must
be submitted as whole numbers. Decimal numbers are not acceptable. The following are
examples of UNITS:





A day
A visit
An hour
A dose of medication
A piece of equipment
Soundpath Health does not count the day of discharge as a covered day for purposes of
reimbursement.
Claims for services that have not been authorized by Soundpath Health or the appropriate
delegate will be denied.
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An Explanation of Benefits/Remittance Advice will be provided for each claim line that is
denied.
Claims received with missing and/or invalid codes or with the use of any corrective material will
be denied and returned to the Provider for re-submission.
An Explanation of Benefits/Remittance Advice will accompany the claim.
Timeframes for Submission
Providers shall make best efforts to submit claims within thirty (30) days of the date of
authorized service. Under no circumstances will claims be paid for services billed more than 365
days from the date of service. Soundpath Health will make payment within the timeframes
required by the Participant Agreement, or the State and /or Federal mandate and the timeframe
for payment is based on the receipt of a complete, “clean” claim.
Provider Remittance (Explanation of Benefits)
All claim payments are sent with a Provider Remittance that includes the claims payment
calculations and benefit codes that explain why a service was paid, modified, or denied.
Member Eligibility and Retroactive Disenrollment
Soundpath Health verifies Member eligibility and benefit availability at the time services are
requested, at the time the claims are adjudicated, and when notified by CMS of a retroactive
disenrollment.
Payments will be made only when the Member is eligible on the dates the service is provided.
Occasionally, Soundpath Health is notified of a retroactive disenrollment by CMS after a claim
has been paid. In this event, Soundpath Health will notify the Provider of the overpayment, and
will request an immediate refund. If such monies are not received, the overpayment will be
deducted from the Provider’s next remittance. Soundpath Health will assist the Provider in
identifying the Member’s other coverage.
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Coordination of Benefits (COB)
Soundpath Health adheres to CMS regulations to determine primary insurance carrier and
appropriate reimbursement process.
The Soundpath Health Provider is responsible for identifying all insurance coverage held by the
Member by obtaining a copy of the Member’s identification card at the time of admission or
service initiation. Any coverage information obtained (in excess of that provided by Soundpath
Health at the time of service authorization) should be forwarded immediately to Soundpath
Health. This information will help expedite payment.
If the additional coverage is “primary,” the claim first must be submitted to that carrier for
payment. Soundpath Health will review the admission record or intake form to identify possible
COB, and will relay such information to the Soundpath Health Claims Department. If other
coverage is determined to be primary, Soundpath Health will deny payment and return the claim
to the Provider.
If Soundpath Health is the secondary payor an EOB from the primary carrier must be submitted
to Soundpath Health in order for Soundpath Health to process any secondary coverage payment.
All COB claims over $25,000 will be reviewed for case management.
Co-Payments and Coinsurance
Soundpath Health Providers are responsible for collection of all co-payments and co-insurance.
Such co-payments and co-insurance are generally reflected on the Member’s Soundpath Health
identification card. To obtain or verify the information, please contact Soundpath Health
Member Services at 1-866-789-7747.
Checking Claims Status
Soundpath Health Providers may contact the Member Services to check the status of a claim at
1- 866-789-7747. Contracted providers who have enrolled in the Soundpath Health Provider
Portal can look up certain claims payments online. More info at portal@soundpathhealth.com.
Providers must have the following information available:
 Member Identification number
 Member name
 Date of service
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Denial of Claims
Soundpath Health will deny a claim for the following reasons:









Member is not eligible on dates of service
Non-covered services or services which exceed benefit limits
No prior authorization (if service requires prior authorization)
Services billed are in excess of services authorized
Non-timely filing of claim
COB review determines that primary liability is not with Soundpath Health contracted
payor but rather with other health Insurance
Incomplete claim
Alteration of claim with corrective material (whiteout /corrective tape, etc
Duplicate claim
National Provider Identification (NPI)
The Health Insurance Portability and Accountability Act (HIPAA), federal Medicare regulations,
and many state Medicaid agencies mandate the adoption and use of a standardized National
Provider Identifier (NPI) for all health care professionals. In compliance with HIPAA, all
covered health care providers and organizations must obtain an NPI for identification purposes in
standard electronic transactions. HIPAA defines a covered health care provider as any provider
who transmits health information in electronic form in connection with a transaction for which
standards have been adopted. These covered health care providers must obtain an NPI and use
this number in all HIPAA transactions.
To avoid payment delays or denials, Soundpath Health requires a valid Billing NPI and
Taxonomy Code(s) be submitted on both paper and electronic claims. Please continue to submit
your Tax Identification Number (TIN) as well.
Compensation
Additional fees: You may not charge members fees for covered services beyond copayments,
coinsurance or deductibles as described in the Member’s benefit plans. You may not charge
members retainer, membership, or administrative fees, voluntary or otherwise. This includes, but
is not limited to, concierge/boutique practice fees, as well as fees to cover increases in
malpractice insurance and office overhead, any taxes, or fees for services you provide that are
denied or otherwise not paid due to your failure to notify us, to file a timely claim, to submit a
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complete claim, to respond to our request for information, or based on our reimbursement
policies or methodologies. Please note that CMS does not allow a provider to charge for “missed
appointments” unless the provider has previously disclosed that policy, in writing, to the
member.
Charges for non-covered services: A Notice of Denial of Medical Coverage must be provided to
the Member advising them when a service is not covered. You should know or have reason to
know that a service may not be covered if 1) we have provided general notice through an article
in a newsletter or bulletin, or information provided on our website (www.SoundpathHealth.com),
including clinical protocols, medical and drug policies, either that we will not cover a particular
service or that a particular service will be covered only under certain circumstances not present
with the member, or we have made a determination that planned services are not covered
services and have communicated that determination to you on this or a previous occasion.
Financial incentives: Soundpath Health notifies its members that the treatment decisions are
made between physicians and members and coverage decisions on health care services are based
on the member’s benefit contract. Therefore, 1) coverage decisions are made based on the
existence of coverage as defined with the Member’s benefit contract, 2) The staff of Soundpath
Health, its delegates, and the physicians and other health care professionals making these
decisions are not rewarded for issuing non-coverage decisions, and 3) Soundpath Health and its
delegates do not offer incentives to physicians or other health care professionals to encourage
underutilization of care or services.
Medicare Advantage risk adjustment data: The risk adjustment data you submit to Soundpath
Health must be accurate and complete. Note that 1) risk adjustment is based on ICD-9-CM (or its
successor) diagnosis codes, not CPT codes. Thus it is critical for your office to refer to an ICD-9CM (or its successor) coding manual and code accurately, specifically and completely when
submitting claims to Soundpath Health, 2) diagnosis codes must be supported by the medical
record. If it is not documented in the medical record, the Soundpath Health will not recognize it
as occurring. Medical records must be clear and complete, 3) be sure to distinguish between
acute vs. chronic conditions in the medical record and in coding. Only choose diagnosis code(s)
that fully describe the member’s condition and pertinent history at the time of the visit, 4) always
carry the diagnosis code all the way through to the correct digit for specificity. For example, do
not use a 3-digit code if a 5-digit code more accurately describes the Member’s condition, 5) be
sure that the diagnosis code is appropriate for the Member’s gender.
You shall cooperate with any Soundpath Health audits and/or external audits mandated by
federal or state law or regulations, and shall make all records available to appropriate federal and
state authorities, subject to applicable federal and state laws and regulations relating to the
privacy of an individual’s health care information. You will allow and fully cooperate with
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inspection, audit and duplication by Soundpath Health of any and all data and other records
maintained on Soundpath Health’s Members which relate to the Provider Agreement to the
extent necessary to perform the audit or inspection. Such data and other records include, but are
not limited to, billing, payment, assignment, utilization review, medical and medical abstract
records maintained on Members pursuant to this Agreement, and charge and reimbursement data
maintained by you related to charges made and payments received by you from other payors.
Such inspection, audit verification and duplication will be allowed upon reasonable notice during
regular business hours.
In addition, you shall make such data and other records available to appropriate state and federal
authorities involved in assessing the quality of care or investigating the grievances or complaints
of Members, subject to applicable state and federal laws related to the confidentiality of medical
records. Plan, the Secretary of Health and Human Services (the “Secretary”), the Comptroller
General or their designees shall have the right to audit, evaluate, inspect and copy any books,
contracts, medical records, patient care documentation and other records that pertain to: (1) the
services performed under the Provider Agreement; (2) reconciliation of benefit liabilities
(3) determination of amounts payable; or (4) other relevant matters as such person conducting
the audit, evaluation or inspection deems necessary.
The right described above shall extend through 10 years from the final date of the applicable
Plan Contract period or completion of audit, whichever is later; provided, however, that such
access may be required for a longer time period if: (1) CMS determines that there is a special
need to retain a particular record or group of records for a longer period and CMS provides
notice at least 30 days before the normal disposition date; (2) CMS determines that there has
been a termination, dispute, fraud or similar fault, in which case the retention may be extended to
10 years from the date of any resulting final resolution of the matter; or (3) CMS determines that
there is a reasonable possibility of fraud, in which case it may perform the inspection, evaluation
or audit at any time. (42 CFR §§ 422.504(e)(2); 422.504(e)(3); 422.504(i)(2)(i) and (ii);
422.504(e)(4)).
For the purpose of conducting the above activities, you shall make available their premises,
physical facilities and equipment, records relating to Soundpath Health Members, and any
additional relevant information that CMS may require.
Site of Service Payment Differential
The site of service differential is based on CMS‘s payment policy. Soundpath Health will pay
professional services at the RBRVS rates for facility and non-facility settings based on where the
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service was performed. It is important to include a valid 2-digit place of service code on your
bill.
Professional services will be paid at the RBRVS rate for facility settings when Soundpath Health
also makes a payment to a facility. The following codes will be paid at the rate for facility
settings:
Place of Service Code
Place of Service Description
05
Indian health service free-standing facility
06
Indian health service provider-based facility
07
Tribal 638 free-standing facility
08
Tribal 638 provider-based facility
21
Inpatient hospital
22
Outpatient hospital
23
Emergency room-hospital
24
Ambulatory surgery center
25
Birthing center
26
Military treatment facility
31
Skilled nursing facility
34
Hospice
41
Ambulance (land)
42
Ambulance (air or water)
51
Inpatient psychiatric facility
52
Psychiatric facility partial hospitalization
56
Psychiatric residential treatment center
61
Comprehensive inpatient rehabilitation facility
62
Comprehensive outpatient rehabilitation facility
99
Other unlisted facility
(none)
(Place of service code not supplied)
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When services are provided in non-facility settings, the professional provider typically bears the
costs of labor, medical supplies and medical equipment. These costs are included in the RBRVS
rate for non-facility settings. Professional services will be paid at the RBRVS rate for nonfacility settings when Soundpath Health does not make a separate payment to a facility. The
following place of service codes will be paid at the rate for non-facility settings:
Place of Service Code
Place of Service Description
01
Pharmacy
03
School
04
Homeless shelter
09
Correctional facility
11
Office
12
Home
13
Assisted living facility
14
Group home
15
Mobile unit
16
Temporary lodging
17
Walk-in retail health clinic
20
Urgent care facility
32
Nursing facility
33
Custodial care facility
49
Independent clinic
50
Federally qualified health center
53
Community mental health center
54
Intermediate care facility/mentally retarded
55
Residential substance abuse treatment center
57
Nonresidential substance abuse treatment center
60
Mass immunization center
65
End stage renal disease treatment facility
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71
State or local public health clinic
72
Rural health clinic
81
Independent laboratory
Facilities will be paid at the RBRVS rate for non-facility settings when Soundpath Health does
not make a separate payment directly to the provider of the service.
Medicare Part D
Soundpath Health is an approved Medicare Advantage Prescription Drug Plan (MAPD); and
therefore, as an approved Part D contracted Provider, have met specific guidelines that apply to
drug formulary and network development, drug management programs, and benefits design. By
law, certain types of drugs or categories of drugs are not covered by Medicare Drug Plans. These
include, but are not limited to:







Most non-prescription drugs
Drugs used for anorexia, weight loss, or weight gain
Drugs used to promote fertility
Drugs used to treat erectile dysfunction
Drugs used for cosmetic purposes or hair growth
Drugs used for the symptomatic relief of cough or colds
Prescription vitamins (with the exception of pre-natal vitamins) and mineral
products
Pharmacy Management
For certain prescription drugs, we have additional requirements which may include requirements
for “step therapy,” quantity limits, or limits on our coverage. These requirements and limits
ensure that our Members use these drugs in the most effective way and also help us control drug
plan costs. The Pharmacy and Therapeutic (P&T) Committee developed these requirements and
limits for Soundpath Health to help to provide cost effective coverage to our Members.
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Examples of utilization management tools are described below:



Prior Authorization: Soundpath Health requires Providers to get prior authorization
for certain drugs. This means that the Member, the physician, or pharmacist will need
to get approval from Soundpath Health before the prescription is filled. The
formulary identifies which drugs require prior authorization and quantity limits. The
Formulary Exception Request Form is available on the website as a PDF file (in
progress, contact Member Services for the form).
Quantity Limits: For certain drugs, Soundpath Health limits the amount of the drug
that is covered per prescription or for a defined period of time.
Generic Substitution: When there is a generic version of a brand-name drug available,
Soundpath Health network pharmacies will automatically give the Member the
generic version, unless the Provider has informed Soundpath Health that a brandname drug should be dispensed.
Pharmacy & Therapeutics (P&T) Committee
Soundpath Health benefits from MedImpact’s, our Pharmacy Benefit Manager partner’s, P&T
Committee. This committee meets regularly and its Members include primary care and specialty
physicians, pharmacists and pharmaceutical consultants. Responsibilities include but are not
limited to review and analysis of the covered drug list, the pharmacy benefits, requests for new
technologies and therapeutics, development of drug safety studies, and potential quality issues
regarding medications. Physicians are encouraged to participate in the process. The physicians
and pharmacists who serve on the Pharmacy and Therapeutics Committee are responsible for
reviewing all medications as they come to market. They consider whether each medication
should be covered under the prescription benefit. When making a recommendation, the P&T
Committee focuses on the medication’s overall health benefit as well as the cost. They consider
FDA recommendations, manufacturer package labeling instructions, and published clinical
recommendations.
Pharmacy Benefits and Covered Drugs
Pharmacy benefits are filed with CMS (Center for Medicare and Medicaid Services) on an
annual basis. The benefits include a list of covered drugs and corresponding co-payments,
dispensing limits, and other restrictions. For additional information regarding pharmacy benefits
please refer to the Soundpath Health member’s Evidence of Coverage or contact Customer
Services at 1-866-789-7747.
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What is a Coverage Determination?
The coverage determination made by Soundpath Health is the starting point for dealing with
requests Members may have about exceptions to cover or pay for a Part D prescription drug.
The following are examples of coverage determinations:
 Members may ask us to pay for a prescription drug they have already received. This
is a request for a coverage determination about payment
 Members may ask for a Part D drug that is not on the plan's list of covered drugs
("formulary"). This is a request for a formulary exception.
 Members may ask for an exception to our plan’s utilization management tools - such
as step therapy requirements, dosage limits, or quantity limits. Requesting an
exception to a utilization management tool is a type of formulary exception.
 Members may ask for a non-preferred Part D drug at the preferred cost-sharing level.
This is a request for a tier exception.
Generally, Soundpath Health will only approve a request for an exception if the alternative drug
included on the plan’s formulary or the low-tiered drug would not be as effective in treating the
Member’s condition and/or would cause the Member to experience adverse medical effects.
Can the formulary change?
Soundpath Health and the PBM will add or remove drugs from the formulary during the year.
Changes in the formulary may affect which drugs are covered and how much Members will have
to pay when filling a prescription.
If drugs are removed from the formulary, a tier change occurs, prior authorizations are added,
and/or quantity limits change on a drug, Soundpath Health will notify Members and Providers of
the change at least sixty (60) days before the date that the change becomes effective.
However, if a drug is removed from our formulary because the drug has been recalled from the
market, Soundpath Health will not give sixty (60) days notice before removing the drug from the
formulary. Instead, Soundpath Health will remove the drug from our formulary immediately and
notify Members and Providers about the change as soon as possible.
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Drug Utilization Review
Soundpath Health and the PBM conduct drug utilization reviews for all Members to make sure
that they are getting safe and appropriate care. These reviews are especially important for
Members who have more than one doctor who prescribe their medications. If we identify a
problem during the drug utilization review, we will work with the physician(s) to correct the
problem.
These reviews serve to look for problems such as:




Possible prescription drug errors
Duplicate drugs that are unnecessary because another drug is prescribed to treat the
same medical condition
Drugs which are inappropriate because of age or gender or possible harmful
interactions between drugs
Drug allergies and drug dosage errors
Medication Therapy Management Programs
Soundpath Health and the PBM offer medication therapy management programs at no additional
cost for Members who have multiple medical conditions, are taking many prescription drugs, or
have high drug costs. In compliance with the Centers for Medicaid and Medicare (CMS), the
MTMP program is outlined below, and the purpose of the program is to ensure appropriate
utilization of drugs, reduce the potential for adverse effects, and improve the opportunities for
optimal Member outcomes. Members will be designated for participation based on meeting all
three of the following criteria if they choose to Opt In to the MTMP Program:
Chronic Diseases: (two chronic conditions from the following list): diabetes, asthma,
hypertension, chronic obstructive pulmonary disease, hyperlipidemia, or congestive heart failure.
Multiple Covered Part D Drugs: more than two.
Total incurred cost: covered Part D drugs, if the Member is likely to incur annual costs of at least
$3,017 for all covered Part D drugs.
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Interventions and programs by the PBM and Soundpath Health for those Members who Opt-In
include: targeted quarterly mailings and educational materials to Members who are determined to
be non-adherent to prescribed medication therapy for identified disease states; targeted quarterly
mailings and educational materials to Members determined to be users of medications that are
potentially inappropriate for use in an elderly population due to the high potential for adverse
effects.
Mail Order Pharmacy Service
This program is provided through MedImpact and is a great convenience for Members. Please
refer to the website at www.SouthpathHealth.com for a program description and order forms.
MedImpact: (800) 788-2949
Vendor Partners
Behavioral Health
Soundpath Health has partnered with Reliant Behavioral Health (RBH) for the provision of
behavioral health and substance abuse services, including treatment review and payment
authorization for Members receiving behavioral health treatment.
RBH offers clients over 10 years of experience as an independent, regional, managed behavioral
healthcare organization (MBHO). Fully accredited by the National Committee for Quality
Assurance (NCQA), RBH offers reliable, quality care management. Their goal is to direct
members to the right care at the right time to ensure individuals receive appropriate care for their
unique needs at the greatest possible savings for the plan and/or employer.
Please note, the PCP must refer the member for non-emergent BH services.
Phone:
1-866-750-1327
Fax:
1 -877- 730-5113
www.MyRBH.com
1221 S.W. Yamhill St., Suite 200
Portland, Oregon 97205
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Routine Vision Care*
Access to routine vision services is an important benefit to most people on Medicare. In support
of this, Soundpath Health has partnered with Vision Service Plan (VSP) to provide access to
routine vision care for our Members. VSP is dedicated to offering affordable, high-quality eye
care plans that promote visual wellness and improve Members’ quality of life. As the nation’s
largest provider of eye care coverage, thousands of companies rely on them to provide a range of
vision plans to meet overall eye health and wellness. For our Members with a hardware (lenses,
frames, and/or contact lenses) benefit, they may elect to access this benefit through the VSP
network or out-of-network and is payable up to the benefit limit. Out-of-network benefits
require the Member to pay upfront and submit a receipt for reimbursement.
Vision Service Plan
1-800-877-7195
Complementary Alternative Medicine rider (if purchased by member)*
Soundpath Health is pleased to offer a unique benefit of chiropractic and acupuncture services to
Members. These services are provided through American Specialty Health (ASH). ASH is one of
the nation’s leading complementary health care benefits organizations, providing benefit
programs, health education programs, and health-related products, administering benefit
programs for 12.1 million members and affinity discount programs for over 80 million members.
American Specialty Health
1-800-972-4226
Routine Hearing Exams and Hearing Devices*
Through a special arrangement with Hearing Care Solutions (HCS), members are now eligible
for a valuable new hearing care program. Hearing Care Solutions offers Soundpath Health
members an annual hearing exam at no charge. Members can choose from a wide selection of
hearing aids at fixed prices, from $825 to $1,750, depending on level of technology. HCS works
with several major manufacturers to offer a wide variety in products. We offer a 3-year warranty,
1 year of free batteries and routine in-office servicing. Call Hearing Care Solutions today to
schedule your complete hearing exam at no charge 1-866-344-7756 or visit
www.hearingcaresolutions.com.
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Fitness Benefit*
The SilverSneakers program offered by Healthways provides no-cost fitness club memberships
to fitness clubs and exercise centers. In addition to a standard fitness club/exercise center
membership, Members may have access to senior-oriented fitness classes at participating fitness
clubs.
SilverSneakers
1-888-423-4632
silversneakerswebcontact@healthways.com
Discount Programs*



NutriSystem. Members have access to NutriSystem products at a discount off of retail
prices. Members should contact Soundpath Health Customer Service who can provide the
online discount code.
QuickMedical. Members have access to Omron blood pressure monitoring products at a
discount off of retail prices. Members should contact Soundpath Health Customer Service
who can provide the online discount code.
Mayo Clinic. Members have access to Mayo Foundation for Medical Education and
Research products at a discount off of retail prices. Members should contact Soundpath
Health Customer Service who can provide the online discount code.
*The products and services described above are neither offered nor guaranteed under Soundpath
Health’s contract with the Medicare program. In addition, these programs are not subject to the
Medicare appeals process. Any disputes regarding these products and services may be subject to
the Soundpath Health grievance process.
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CMS Regulations
§ 422.501(i)(3)(i) and 422.504 (g)(1)(i)
For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for
Medicare Part A and B cost sharing when the State is responsible for paying such amounts.
Providers will be informed of Medicare and Medicaid benefits and rules for enrollees eligible for
Medicare and Medicaid. First Tier or Downstream Entities may not impose cost-sharing that
exceeds the amount of cost-sharing that would be permitted with respect to the individual under
title XIX if the individual were not enrolled in such a plan. Providers will: (1) accept the MA
plan payment as payment in full, or (2) bill the appropriate State source.
§ 422.200 Basis and scope.
This subpart is based on sections 1852(a)(1), (a)(2), (b)(2), (c)(2)(D), (j), and (k) of the Act;
section 1859(b)(2)(A) of the Act; and the general authority under 1856(b) of the Act requiring
the establishment of standards. It sets forth the requirements and standards for the MA
organization's relationships with providers including physicians, other health care professionals,
institutional providers and suppliers, under contracts or arrangements or deemed contracts under
MA private fee-for-service plans. This subpart also contains some requirements that apply to
non-contracting providers.
§ 422.202 Participation procedures.
(a) Notice and appeal rights. An MA organization that operates a coordinated care plan or
network MSA plan must provide for the participation of individual physicians, and the
management and members of groups of physicians, through reasonable procedures that include
the following:
(1) Written notice of rules of participation including terms of payment, credentialing, and other
rules directly related to participation decisions.
(2) Written notice of material changes in participation rules before the changes are put into
effect.
(3) Written notice of participation decisions that are adverse to physicians.
(4) A process for appealing adverse participation procedures, including the right of physicians to
present information and their views on the decision. In the case of termination or suspension of a
provider contract by the MA organization, this process must conform to the rules in §422.202(d).
(b) Consultation. The MA organization must establish a formal mechanism to consult with the
physicians who have agreed to provide services under the MA plan offered by the organization,
regarding the organization's medical policy, quality improvement programs and medical
management procedures and ensure that the following standards are met:
(1) Practice guidelines and utilization management guidelines—
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(i) Are based on reasonable medical evidence or a consensus of health care professionals in the
particular field;
(ii) Consider the needs of the enrolled population;
(iii) Are developed in consultation with contracting physicians; and
(iv) Are reviewed and updated periodically.
(2) The guidelines are communicated to providers and, as appropriate, to enrollees.
(3) Decisions with respect to utilization management, enrollee education, coverage of services,
and other areas in which the guidelines apply are consistent with the guidelines.
(c) Subcontracted groups. An MA organization that operates an MA plan through subcontracted
physician groups must provide that the participation procedures in this section apply equally to
physicians within those subcontracted groups.
(d) Suspension or termination of contract. An MA organization that operates a coordinated care
plan or network MSA plan providing benefits through contracting providers must meet the
following requirements:
(1) Notice to physician. An MA organization that suspends or terminates an agreement under
which the physician provides services to MA plan enrollees must give the affected individual
written notice of the following:
(i) The reasons for the action, including, if relevant, the standards and profiling data used to
evaluate the physician and the numbers and mix of physicians needed by the MA organization.
(ii) The affected physician's right to appeal the action and the process and timing for requesting a
hearing.
(2) Composition of hearing panel. The MA organization must ensure that the majority of the
hearing panel members are peers of the affected physician.
(3) Notice to licensing or disciplinary bodies. An MA organization that suspends or terminates a
contract with a physician because of deficiencies in the quality of care must give written notice
of that action to licensing or disciplinary bodies or to other appropriate authorities.
(4) Timeframes. An MA organization and a contracting provider must provide at least 60 days
written notice to each other before terminating the contract without cause.
[64 FR 7981, Feb. 17, 1999, as amended at 65 FR 40324, June 29, 2000; 68 FR 50857, Aug. 22,
2003; 70 FR 4724, Jan. 28, 2005]
§ 422.204 Provider selection and credentialing.
(a) General rule. An MA organization must have written policies and procedures for the
selection and evaluation of providers. These policies must conform with the credential and recredentialing requirements set forth in paragraph (b) of this section and with the
antidiscrimination provisions set forth in §422.205.
(b) Basic requirements. An MA organization must follow a documented process with respect to
providers and suppliers who have signed contracts or participation agreements that—
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(1) For providers (other than physicians and other health care professionals) requires
determination, and redetermination at specified intervals, that each provider is—
(i) Licensed to operate in the State, and in compliance with any other applicable State or Federal
requirements; and
(ii) Reviewed and approved by an accrediting body, or meets the standards established by the
organization itself;
(2) For physicians and other health care professionals, including members of physician groups,
covers—
(i) Initial credentialing that includes written application, verification of licensure or certification
from primary sources, disciplinary status, eligibility for payment under Medicare, and site visits
as appropriate. The application must be signed and dated and include an attestation by the
applicant of the correctness and completeness of the application and other information submitted
in support of the application;
(ii) Re-credentialing at least every 3 years that updates information obtained during initial
credentialing, considers performance indicators such as those collected through quality
improvement programs, utilization management systems, handling of grievances and appeals,
enrollee satisfaction surveys, and other plan activities, and that includes an attestation of the
correctness and completeness of the new information; and
(iii) A process for consulting with contracting health care professionals with respect to criteria
for credentialing and re-credentialing.
(3) Specifies that basic benefits must be provided through, or payments must be made to,
providers and suppliers that meet applicable requirements of title XVIII and part A of title XI of
the Act. In the case of providers meeting the definition of “provider of services” in section
1861(u) of the Act, basic benefits may only be provided through these providers if they have a
provider agreement with CMS permitting them to provide services under original Medicare.
(4) Ensures compliance with the requirements at §422.752(a)(8) that prohibit employment or
contracts with individuals (or with an entity that employs or contracts with such an individual)
excluded from participation under Medicare and with the requirements at §422.220 regarding
physicians and practitioners who opt out of Medicare.
[65 FR 40324, June 29, 2000, as amended at 66 FR 47413, Sept. 12, 2001; 70 FR 4724, Jan. 28,
2005]
§ 422.205 Provider antidiscrimination rules.
(a) General rule. Consistent with the requirements of this section, the policies and procedures
concerning provider selection and credentialing established under §422.204, and with the
requirement under §422.100(c) that all Medicare-covered services be available to MA plan
enrollees, an MA organization may select the practitioners that participate in its plan provider
networks. In selecting these practitioners, an MA organization may not discriminate, in terms of
participation, reimbursement, or indemnification, against any health care professional who is
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acting within the scope of his or her license or certification under State law, solely on the basis of
the license or certification. If an MA organization declines to include a given provider or group
of providers in its network, it must furnish written notice to the effected provider(s) of the reason
for the decision.
(b) Construction. The prohibition in paragraph (a)(1) of this section does not preclude any of the
following by the MA organization:
(1) Refusal to grant participation to health care professionals in excess of the number necessary
to meet the needs of the plan's enrollees (except for MA private-fee-for-service plans, which may
not refuse to contract on this basis).
(2) Use of different reimbursement amounts for different specialties or for different practitioners
in the same specialty.
(3) Implementation of measures designed to maintain quality and control costs consistent with its
responsibilities.
[65 FR 40324, June 29, 2000]
Additional CMS language requirements. For this section Soundpath Health will be represented
by “SPH” and “SPH’s.”
1.01
Participation Requirements. Participant represents and warrants that Participant is not
excluded, and will not employ or contract with any individual who is excluded from
participation in any federal or state program, including, without limitation, Medicare
under Sections 1128 or 1128A of the Social Security Act.
1.02
Medicare Members. Participant agrees to provide Health Services to Enrollees who are
enrolled in a Benefit Contract for Medicare recipients. Participant acknowledges that
SPH’s agreements for Medicare Advantage products with Facilities and Participants are
subject to review and approval by the Center for Medicare and Medicaid Services (CMS)
1.03
Quality and Utilization Management. Participant agrees to participate in the SPH’s
internal Quality Management and Utilization Management activities. This participation
includes, but is not limited to, (1) providing access to on-site office and medical record
review, (2) providing copies of medical records, (3) participating in focused studies
and/or committees, and (4) cooperation with complaint resolution. Participant authorizes
SPH’s Medical Director, or his/her designee, to obtain from internal and external
sources, information which is relevant to quality and utilization management programs.
Participant agrees that he or she shall not bring any suit, claim or other action which he
or she may otherwise be entitled to bring against SPH or any of their respective
employees or agents as a result of any communication, report, recommendation or
disclosure made or received by SPH if such information is provided responsibly, in good
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faith and without malice or carelessness, and for the purpose of achieving and
maintaining quality, cost effective care of Enrollees. Participant acknowledges that SPH
must report certain information and actions to the National Practitioner Data Bank,
Healthcare Integrity and Protection Data Bank, and/or the appropriate regulatory entity.
SPH is bound by law to report such incidents.
1.04
Access to Care. Participant shall cooperate with SPH’s written standards for adequate
access to covered services to meet the needs of the population served and should be
offered in a culturally competent manner by SPH and its Participants. Where a Benefit
Contract requires certain services to be provided only upon the referral of a primary care
Participant, the following Health Services may be provided to SPH Enrollees without
such a referral: (1) screening mammography and influenza vaccination Health Services;
and (2) for women, routine and preventive Health Services from a Participant that is a
women’s health specialist.
No Enrollee expenses shall apply to influenza and
pneumococcal vaccines.
1.05
Cooperation with Procedures and Programs. Participant shall cooperate and comply
with the following: (1) all credentialing and re-credentialing processes and all utilization
management, quality assessment and performance improvement, medical, peer review,
on site review, and advance directives; (2) SPH’s Enrollee grievance and
appeal/expedited appeal processes, including gathering and forwarding information to
SPH on a basis that will permit SPH to meet CMS required timeframes for disposition of
grievances and appeals; (3) the activities of any independent quality review and
improvement organization approved by CMS that is under contract with SPH; (4) as
applicable, SPH processes for identifying SPH Enrollees with complex or serious
medical conditions, assessment of those conditions, and establishment and
implementation of a treatment plan appropriate to those conditions; and (5) Participant
process to include conducting an initial assessment of each SPH Enrollee’s health care
needs within 90 days of the effective date of their enrollment.
1.06
Accordance with SPH’s Contractual Obligations. Participant agrees that all services
performed under this Agreement will be done so in a manner that is consistent and
complies with SPH’s contractual obligations.
1.07
Accordance with SPH’s Policies and Procedures. Participant agrees that all services
performed under this Agreement will be done so in a manner that is consistent and
complies with CMS and SPH’s policies and procedures.
1.08
Accountability Provisions. Participant agrees that SPH retains the right to approve,
suspend or terminate the delegated activities and reporting requirements in instances
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where CMS or SPH determines that Contractor or a Participant has not performed
satisfactorily;
(a)
(b)
(c)
(d)
Reporting Responsibilities. Participant agrees to comply with CMS and
SPH reporting requirements.
Revocation. Participant agrees that this Agreement may be revoked in
the event CMS or SPH determines that Participant has not performed it’s
duties in a satisfactory manner.
Monitoring. Participant agrees that SPH has the right and responsibility
to monitor performance under this Agreement on an ongoing basis.
Credentialing. Participant agrees that the credentials of medical
professionals affiliated with the party or parties will either be reviewed by
SPH; or the credentialing process will be reviewed and approved by SPH;
or SPH must audit the credentialing process on an ongoing basis.
1.09
Data Collection Requirements. Participant acknowledges that SPH is required by CMS
to maintain a health information system that collects, analyzes and integrates all data
necessary to compile, evaluate and report certain statistical data related to costs,
utilization and quality, and such other matters as CMS may require from time to time.
Participant hereby agrees to submit to SPH within the timeframes specified by SPH to
meet CMS requirements, upon request, all data necessary for SPH to fulfill these
obligations.. Contractor and each Participant hereby represent and warrant, and to the
extent required by SPH, hereby agree to certify in writing at the time of submission to
SPH or its designee, that all data including, but not limited to, encounter data and other
information that CMS may specify, shall be truthful, reliable, accurate and complete.
1.10
Payment.
(a)
Provision of Health Services. For the provision of Health Services to
SPH Enrollees, Participants shall be paid in accordance with their
Participant Agreement. Enrollee expenses, if any, may be collected directly
from the SPH Enrollee. If Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
then the Participant shall make such payments in accordance with the CMS
and State of Washington regulations. Participant shall ensure that payment
and incentive arrangements with subcontractors, if any, are specified in a
written agreement and comply with CMS and State of Washington laws and
regulations. Additional information regarding payment and incentive
payments to subcontracting Participants must be made available to the
subcontracted Participants upon request.
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(b)
Prompt Payment. For covered services provided to Enrollees, SPH or
Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
shall pay Contractor or Participant as soon as practical but subject to the
following minimum standards:
1) Ninety-five percent (95%) of the monthly volume of Clean
Claims shall be paid within thirty (30) days of receipt; and
2) Ninety-five percent (95%) of the monthly volume of all claims
shall be paid or denied within sixty (60) days of receipt, except as
agreed to in writing on a claim by claim basis.
The receipt date of a claim shall be the date SPH or Participant, if Participant
is responsible for making payment to subcontracting Participants for Health
Services provided to SPH Enrollees, receives either written or electronic
notice of the claim. SPH or Participant, if Participant is responsible for
making payment to subcontracting Participants for Health Services provided
to SPH Enrollees, shall pay Contractor or Participant interest on un-denied
and unpaid Clean Claims more than sixty-one (61) days old. Interest shall be
assessed at the rate required by applicable state or federal law, or as
otherwise agreed by contract between Contractor and Participant, and shall
be calculated monthly as simple interest prorated for any portion of a month.
SPH or Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
shall add the interest payable to the amount of unpaid claims without the
necessity of the Contractor or Participant submitting an additional claim.
SPH or Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
shall not apply any interest to an Enrollee’s deductible, copayment,
coinsurance or any similar obligation of the Enrollee.
SPH or Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
shall reimburse Contractor or Participant for covered services following
receipt of a clean claim in accordance with Medicare Secondary Payer rules.
Claim denials shall include the specific reason why the claim was denied. If
the denial is based upon Medical Necessity or similar grounds, SPH or
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Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
upon request from Contractor or Participant shall promptly disclose the
supporting basis for the decision.
These standards do not apply to claims about which there is substantial
evidence of fraud or misrepresentation by Contractor, Participant or Enrollee
or instances where SPH or Participant, if Participant is responsible for
making payment to subcontracting Participants for Health Services provided
to SPH Enrollees, has not been granted reasonable access to information
under Contractor or Participant’s control.
(c)
Hold Harmless Provisions. Participant shall hold SPH Enrollees harmless
for payment of fees that are the legal obligation of SPH and its contract to
fulfill. Such provision will apply but not be limited to insolvency of SPH, or
Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees,
contract breach and provider billing; Participant hereby agrees that they will
not bill, charge, collect a deposit from, seek compensation, remuneration
from or have any recourse against an Enrollee or other person acting on an
Enrollee’s behalf, other than SPH, for services provided pursuant to this
Agreement. This provision shall not prohibit collection of deductible,
copayments, coinsurance and/or non-covered services which have not
otherwise been paid by a primary or secondary carrier in accordance with
regulatory standards for coordination of benefits, from Enrollees in
accordance with the terms of the Enrollee’s Subscriber Agreement.
1.11
Private Contracts. SPH or Participant, if Participant is responsible for making payment to
subcontracting Participants for Health Services provided to SPH Enrollees, may not pay,
directly or indirectly, on any basis, for services rendered by a Participant to a SPH
Enrollee if Participant files or is required to file an affidavit with a Medicare carrier
agreeing to furnish Medicare covered services to any Medicare beneficiary through a
private contract, except that payment may be made by SPH for emergency and urgent
care services. Such payment shall be limited to the Medicare allowable charge.
1.12
Excluded Individuals. Participant is prohibited from employing or contracting with an
individual who is excluded from participation in Medicare under Section 1128 or 1128A
of the Social Security Act (or with an entity that employs or contracts with such an
individual) for the provision of any of the following: (1) health care; (2) utilization
review; (3) medical social work; or (4) administrative services.
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1.13
Laws and Regulations. Participants and SPH shall each maintain, without material
restriction, all applicable federal, state and local licenses, certifications and permits which
are required to fulfill their obligations under this Attachment and this Exhibit in the
applicable jurisdiction. Participant shall comply with all applicable Medicare laws,
regulations, reporting requirements, and CMS instructions (and shall cooperate, assist and
provided information, as requested), and shall comply with all other applicable federal,
state and local laws, rules and regulations including, but not limited to, Title VII of the
Civil Rights Act of 1964, The Age Discrimination Act of 1975, and The Americans With
Disabilities Act. Facilities and Participants shall also cooperate with SPH in its efforts to
comply with the laws, regulations and other requirements of applicable regulatory
authorities. Participant shall require that all health care professionals employed by or
under contract to render Health Services to SPH Enrollees, including covering
Participants, comply with this provision.
1.14
Records:
(a)
Maintenance and Accuracy of Records. Participant will assure that
adequate medical, financial and administrative records related to the
services rendered under this Agreement are maintained in an accurate and
timely manner, including prominent documentation of an executed
Advance Directive, if any.
(b)
Access to Records.
(i)
SPH, The Secretary of Health and Human Services (the
“Secretary”), the Comptroller General or their designees shall have the
right to audit, evaluate or inspect any books, contracts, medical records,
patient care documentation and other records of Facilities and Participants
that pertain to: (1) the services performed under this Agreement; (2)
reconciliation of benefit liabilities (3) determination of amounts payable;
or (4) other relevant matters as such person conducting the audit,
evaluation or inspection deems necessary.
(ii)
The right described above shall extend through 10 years from the
final date of the applicable SPH Contract period or completion of audit,
whichever is later; provided, however, that such access may be required
for a longer time period if: (1) CMS determines that there is a special need
to retain a particular record or group of records for a longer period and
CMS provides notice at least 30 days before the normal disposition date;
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(2) CMS determines that there has been a termination, dispute, fraud or
similar fault, in which case the retention may be extended to 10 years from
the date of any resulting final resolution of the matter; or (3) CMS
determines that there is a reasonable possibility of fraud, in which case it
may perform the inspection, evaluation or audit at any time.
(iii)
For the purpose of conducting the above activities, Participants
shall make available their premises, physical facilities and equipment,
records relating to SPH Enrollees, and any additional relevant information
that CMS may require.
(c)
Enrollee Access to Records. Participant agrees to establish procedures to
ensure timely access by SPH Enrollees to medical records and other health
and enrollment information that pertains to them.
(d)
Confidentiality of Records. SPH and each Participant shall safeguard the
privacy and confidentiality of any SPH Enrollee information consistent
with all federal and state laws. SPH and Participant shall also abide by all
federal and state laws regarding confidentiality and disclosure of medical
records and other health and enrollee information.
1.15
Rules of Participation. SPH’s rules of participation are set forth in this Agreement, and
in the Participant manual, which shall be made available to Participant. Written notice of
material changes to the rules of participation shall be provided prior to the effective date
of such changes.
1.16
Additional Termination Provisions. Notwithstanding any provision in this Attachment
to the contrary, the following provisions shall apply to SPH’s network of Participants
only:
(a)
Participant’s participation in the SPH Medicare Advantage network of
Participants may be terminated by SPH immediately upon written notice
due to: (1) loss or suspension of licensure or certification; (2) sanction by
Medicare; or (3) Participant entering into a private contract with any
Medicare beneficiary; or
(b)
If this Attachment contains any provision permitting termination of this
Attachment without cause, notice of such termination shall be given by
either party in accordance with the applicable provision of this
Attachment, but in no such case shall the notice period be less than 60
days prior to the termination date.
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1.17
that:
(c)
Any written notice to Participant by SPH regarding its, his or her
suspension or termination shall include the following, to the extent
applicable: (1) the reason for the suspension or termination; (2) the
standards and profiling data used by SPH to evaluate the Participant; (3)
the numbers and mix of applicable Participants needed in the network; (4)
right to appeal the action; and (5) the process and timing for requesting a
hearing.
(d)
Participant shall provide SPH with a list of its, his or her patients who are
SPH Enrollees within fifteen (15) business days of the date that Participant
either gives or receives notice of termination. SPH will make a good faith
effort to notify all affected SPH Enrollees of the termination of this
Attachment, within the time period required by applicable law, after notice
of termination is given.
Acknowledgements and Delegated Activities. Participant acknowledges and agrees
(a)
Agreements with Participants are subject to review and approval by CMS;
(b)
Participant agrees to adhere to CMS marketing provisions.
(c)
SPH receives payments in whole or in part from federal funds.
Contractors and subcontractors, including Participant, are subject to
certain laws that are applicable to individuals and entities receiving federal
funds. Participant agrees that any services or activity performed by him or
her in connection with this Agreement and its attachment will be
consistent with and comply with SPH’s contractual obligations to CMS
and other applicable state and federal laws and regulations; and
(d)
SPH oversees and is accountable to CMS for any functions or
responsibilities that are contained in the SPH Contract, including those
that SPH may delegate to others. Activities or responsibilities under the
SPH Contract that are delegated by SPH to Contractor or a Participant
must be set forth in a written agreement that contains, at a minimum, the
following CMS delegation requirements: (1) the specific delegated
activities and reporting requirements; (2) the right of revocation in the
event CMS or SPH determines that Participant has not performed the
delegated duties in a satisfactory manner; (3) a right to approve, suspend
or terminate the delegated activities and reporting requirements in
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instances where CMS or SPH determines that Contractor or a Participant
has not performed satisfactorily; (3) a provision specifying that the
performance of Contractor and Participant is monitored by SPH on an
ongoing basis; (4) a provision specifying that the credentialing processes
must be reviewed and approved by SPH, and SPH shall audit the
credentialing process on an ongoing basis; and (5) a requirement that
Contractor and each Participant must comply with all applicable Medicare
laws, regulations, reporting requirements and CMS instructions. Any
written delegation agreement between SPH and Contractor or a Participant
is hereby amended to include these requirements.
1.18
Regulatory Amendment. SPH may amend this Agreement to comply with the
requirements of state and federal regulatory authorities, and shall give written notice to
Participant of such amendment and its effective date. Unless such regulatory authorities
direct otherwise, the signature of Participant will not be required.
1.19
Non-interference with Advice to SPH. Nothing in this Attachment and this Exhibit is
intended to prohibit or restrict Participant from advising or advocating on behalf of a SPH
Enrollee about (1) the SPH Enrollee’s health status, medical care, or treatment options
(including alternative treatments that may be self-administered), including providing
sufficient information to the SPH Enrollee to provide an opportunity to decide among all
relevant treatment options, (2) the risks, benefits and consequences of treatment or nontreatment, and (3) the opportunity for the SPH Enrollee to refuse treatment and express
preferences about future treatment decisions. Participant must assure that individuals
with disabilities are furnished with effective communications in making decisions
regarding treatment options.
1.20
Individual Participants and Facilities.
(a)
If Contractor is a Participant, Participant or other entity whose staff of
health care professionals consists wholly or partially of employees,
Contractor represents and warrants that it has the unqualified authority to
bind all such employees to the terms of this Attachment and this Exhibit.
If Contractor or a Participant has any arrangements with subcontractors, as
defined in subsection (b), below, to render Health Services to SPH
Enrollees, they shall ensure that all such subcontracts are duly amended to
incorporate the terms contained in this Agreement through one of the
methods described in subsections (b)(i) and (b)(ii), below.
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(b)
If Contractor is an independent practice association, physician hospital
organization, or other network organization contracting on behalf of health
care Participants and/or facilities, Contractor shall ensure that all
arrangements with subcontractors for participation in SPH’s network of
Participants are in writing and duly executed. A “subcontractor” is defined
as a person or entity that is contracted by Contractor or a Participant,
directly or through another person or entity, to provide Health Services to
SPH Enrollees, and that does not hold a direct contract with SPH.
Contractor and each Participant shall ensure that all agreements with
subcontractors are duly amended to incorporate the terms contained in this
Exhibit through one of the following methods:
(i)
Contractor and each Participant shall ensure that the terms of this
Agreement are included in all future and pending agreements with
subcontractors who agree to provide services to SPH.
(ii)
Contractor and each Participant shall promptly amend the
agreements with subcontractors to meet any additional CMS
requirements.
Refusal of any subcontractor to agree to the terms in this Exhibit, and any subsequent
amendments, shall be grounds for the termination of such subcontractor from the SPH
network of Participants.
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