Illinois Medicaid Provider Manual 2015 - 2016 - WellCare

2015-2016 MEDICAID PROVIDER MANUAL ILLINOIS

Table of Contents Table of Contents .......................................................................................................... 1 Harmony Provider Manual Table of Revisions ............................................................ 5 Section 1: Overview ...................................................................................................... 9 About Harmony........................................................................................................ 9 Mission and Vision ................................................................................................... 9 Purpose of this Provider Manual .............................................................................. 9 Harmony’s Health Plans ........................................................................................ 10 Covered Services .................................................................................................. 10 Provider Services .................................................................................................. 15 Website Resources ............................................................................................... 15 Section 2: Provider and Member Administrative Guidelines ................................... 17 Provider Administrative Overview .............................................................................. 17 Excluded Services ................................................................................................. 19 Responsibilities of All Providers ............................................................................. 19 Access Standards.................................................................................................. 21 Responsibilities of Primary Care Providers ............................................................ 22 Early and Periodic Screening, Diagnostic and Treatment ...................................... 23 Closing of Physician Panel .................................................................................... 24 Covering Physicians/Providers .............................................................................. 24 Termination of a Member ....................................................................................... 24 Domestic Violence and Substance Abuse Screening............................................. 25 Smoking Cessation ................................................................................................ 25 Adult Health Screening .......................................................................................... 26 Hospital / Facility Responsibilities .......................................................................... 26 Hospitalist Program ............................................................................................... 27 Cultural Competency Program and Plan.................................................................... 27 Overview ............................................................................................................... 27 Cultural Competency Survey ................................................................................. 30 Member Administrative Guidelines ............................................................................ 30 Overview ............................................................................................................... 30 New Member Resources ....................................................................................... 30 Member Identification Cards .................................................................................. 31 Eligibility Verification .............................................................................................. 31 Member Rights and Responsibilities ...................................................................... 31 Assignment of Primary Care Physician .................................................................. 33 Changing Primary Care Physicians ....................................................................... 33 Women’s Health Care Providers ............................................................................ 33 Hearing-Impaired, Interpreter and Sign Language Services................................... 33 Section 3: Quality Improvement ................................................................................. 34 Overview ............................................................................................................... 34 Provider Participation in the Quality Improvement Program ................................... 35 Provider Satisfaction .............................................................................................. 35 Member Satisfaction .............................................................................................. 35 Clinical Practice Guidelines ................................................................................... 36 Healthcare Effectiveness Data and Information Set ............................................... 36 Harmony Health Plan of IL, A WellCare Company Illinois Medicaid Provider Manual Effective: October 30, 2015 Page 1 of 118 Provider Services: (toll-free): 1-800-504-2766

Medical Records .................................................................................................... 36 Early and Periodic Screening, Diagnosis and Treatment ....................................... 38 Obstetrical Care..................................................................................................... 39 Adult Preventive Health ......................................................................................... 40 Web Resources ..................................................................................................... 40 Overview ............................................................................................................... 40 Quality of Care Issues ........................................................................................... 40 Section 4: Utilization Management (UM), Care Management (CM) and Disease Management (DM) ....................................................................................................... 44 Utilization Management ............................................................................................. 44 Overview ............................................................................................................... 44 Medically Necessary Services ............................................................................... 44 Criteria for Utilization Management Decisions ....................................................... 45 Utilization Management Process............................................................................ 45 After-Hours Utilization Management ...................................................................... 46 Notification............................................................................................................. 46 Referrals ................................................................................................................ 46 Prior Authorization ................................................................................................. 46 Prior Authorization for Inpatient Services ............................................................... 49 Review and Functions for Authorized Hospitals ..................................................... 50 Concurrent Review ................................................................................................ 51 Retrospective Review ............................................................................................ 51 Service Authorization Decisions ............................................................................ 52 Observation ........................................................................................................... 53 Discharge Planning ............................................................................................... 54 Harmony Proposed Actions ................................................................................... 54 Peer-to-Peer Reconsideration of Adverse Determination ....................................... 54 Services Requiring No Authorization ..................................................................... 55 Second Medical Opinion ........................................................................................ 55 Individuals with Special Health Care Needs........................................................... 55 Emergency/Urgent Care and Post-Stabilization Services ...................................... 56 Continuity of Care .................................................................................................. 58 Out-of-State Providers and Service Limitations...................................................... 58 Dialysis .................................................................................................................. 59 Rehabilitation Services .......................................................................................... 59 ProviderLimits to Abortions, Sterilizations and Hysterectomy Coverage ................ 60 Care Management Program ...................................................................................... 62 Overview ............................................................................................................... 62 Transition of Care .................................................................................................. 63 Disease Management Program ................................................................................. 64 Overview ............................................................................................................... 64 Candidates for Disease Management .................................................................... 65 Access to Care and Disease Management Programs ............................................ 65 Section 5: Claims ........................................................................................................ 66 Overview ............................................................................................................... 66 Updated Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Process .......................................................................................................... 66 Timely Claims Submission ..................................................................................... 66 Harmony Health Plan of IL, A WellCare Company Illinois Medicaid Provider Manual Effective: October 30, 2015 Page 2 of 118 Provider Services: (toll-free): 1-800-504-2766

Tax Identification and National Provider Identifier Requirements ........................... 67 Claims/Encounter Submission Requirements ........................................................ 68 Claims Processing ................................................................................................. 70 Encounters Data .................................................................................................... 71 Balance Billing ....................................................................................................... 73 Provider-Preventable Conditions ........................................................................... 74 Hold Harmless Dual Eligible Members ................................................................... 74 Claim Payment and Policy Disputes ...................................................................... 74 Corrected or Voided Claims ................................................................................... 75 Reimbursement ..................................................................................................... 77 Overpayment Recovery ......................................................................................... 78 Benefits During Disaster and Catastrophic Events ................................................. 79 Section 6: Credentialing ............................................................................................. 80 Overview ............................................................................................................... 80 Practitioner Rights ................................................................................................. 81 Baseline Criteria .................................................................................................... 82 Liability Insurance .................................................................................................. 83 Site Inspection Evaluation ..................................................................................... 83 Covering Physicians .............................................................................................. 83 Allied Health Professionals .................................................................................... 83 Ancillary Health Care Delivery Organizations ........................................................ 84 Re-Credentialing.................................................................................................... 84 Updated Documentation ........................................................................................ 84 Office of Inspector General Medicare/Medicaid Sanctions Report ......................... 84 Sanction Reports Pertaining to Licensure, Hospital Privileges or Other Professional Credentials..................................................................................................... 84 Provider Appeal through the Dispute Resolution Peer Review Process ................. 85 Delegated Entities ................................................................................................. 86 Section 7: Appeals, Complaints and Grievances ...................................................... 87 Appeals Process ....................................................................................................... 87 Provider Appeals Process ..................................................................................... 87 Member Appeals Process ...................................................................................... 88 Expedited Appeals Process ................................................................................... 91 Provider State Fair Hearing ................................................................................... 91 External Independent Review Process .................................................................. 92 Complaints and Grievances....................................................................................... 93 Provider Complaints .............................................................................................. 93 Member Grievances .............................................................................................. 93 Section 8: Compliance ................................................................................................ 96 Harmony’s Compliance Program ............................................................................... 96 Overview ............................................................................................................... 96 Code of Conduct and Business Ethics....................................................................... 97 Overview ............................................................................................................... 97 Fraud, Waste and Abuse ....................................................................................... 97 Confidentiality of Member Information and Release of Records ............................. 98 Disclosure of Information ....................................................................................... 99 Section 9: Delegated Entities ................................................................................... 100 Overview ............................................................................................................. 100 Harmony Health Plan of IL, A WellCare Company Illinois Medicaid Provider Manual Effective: October 30, 2015 Page 3 of 118 Provider Services: (toll-free): 1-800-504-2766

Delegated Entities ............................................................................................... 100 Compliance ......................................................................................................... 100 Section 10: Behavioral Health .................................................................................. 102 Overview ............................................................................................................. 102 Continuity and Coordination of Care Between Medical and Behavioral Health Providers...................................................................................................... 102 Responsibilities of Behavioral Health Providers ................................................... 102 Section 11: Pharmacy ............................................................................................... 105 Overview ............................................................................................................. 105 Preferred Drug List .............................................................................................. 105 Generic Medications ............................................................................................ 106 Step Therapy ....................................................................................................... 106 Quantity Limits ..................................................................................................... 106 Age Limits............................................................................................................ 107 Pharmacy Lock-In Program ................................................................................. 107 Coverage Determination Review Process ............................................................ 107 Injectable and Infusion Service ............................................................................ 108 Medication Appeals ............................................................................................. 108 Coverage Limitations ........................................................................................... 108 Over-the-Counter Medications ............................................................................. 108 Member Co-Payments ......................................................................................... 109 Pharmacy Management - Network Improvement Program .................................. 109 Member Pharmacy Access .................................................................................. 109 Exactus Pharmacy Solutions for Specialty Medications ....................................... 109 Section 12: Definitions and Abbreviations .............................................................. 111 Definitions ............................................................................................................... 111 Abbreviations .......................................................................................................... 116

Harmony Health Plan of IL, A WellCare Company Illinois Medicaid Provider Manual Effective: October 30, 2015 Page 4 of 118 Provider Services: (toll-free): 1-800-504-2766

Harmony Provider Manual Table of Revisions Date

Section

Comments

12/1/2014

Section 1: Overview

About Harmony.

12/1/2014

Section 1: Overview

Covered Services – Added additional services to Covered Services, Added Additional Benefits, Added Non-Covered Services, Removed Not Covered Services.

10-12

12/1/2014

Section 1: Overview

12-13

12/1/2014

Section 2: Provider and Member Administrative Guidelines Section 2: Provider and Member Administrative Guidelines

Additional Covered Services for HCBS Waiver Members. Overview – Added Cooperate with QI Activities. Type of Appointment chart – Added PCPs (Adult) Routine (State Requirement), PCPs (Adult) Routine (NCQA Requirement), Pediatric Routine (State Requirement) and Pediatric Routine (NCQA Requirement). Responsibilities of Primary Care Providers – Added Provide Health Education to Members. Overview – Updated Objectives Harmony’s Cultural Competency Program, Updated Culturally and linguistically appropriate services (CLAS), Updated Components of Harmony’s Cultural Competency Program. Overview – Added introductory HEDIS® measures paragraph.

22

12/1/2014

12/1/2014

12/1/2014

12/1/2014

Section 2: Provider and Member Administrative Guidelines Section 2: Cultural Competency Program

Section 3: Quality Improvement

Page Number 9

17

22

27-30

36

Harmony Health Plans, Inc. Illinois Medicaid Provider Manual Effective: October 30, 2015

Page 5 of 118 Provider Services: (toll-free): 1-800-504-2766

12/1/2014

Section 4: UM, CM, DM

12/1/2014


12/1/2014


12/1/2014

Section 5: Claims

12/1/2014

Section 5: Claims

12/1/2014

Section 5: Claims

Prior Authorization – Removed Request for prior authorization should be submitted at least 10 business days prior to the planned admission or procedure. Prior Authorization for Inpatient Services – Reimbursement for psychiatric services is limited to short term acute care. Disease Management Program Overview – Added the DM Clinician also collaborates with Providers by using the Interdisciplinary Care Team approach. Claims Submission Requirements – Added verbiage related to Ambulatory services, Claims for emergency department or observation services and Value Code for 54 Birth Weight. Claims Processing – Added COB information can be submitted to Harmony by an EDI transaction with the COB data completed in the appropriate COB elements. Encounters Data – Added Capitated vendors and Providers who fail to comply with the timely and complete submission of encounters will be subject to review and possible adverse action, including penalties or loss of delegation status.

46

49

65

69

71

71



12/1/2014

Section 5: Claims

12/1/2014

Section 5: Claims

12/1/2014

Section 6: Credentialing

12/1/2014

Section 7: Appeals and Grievances

12/1/2014


12/1/2014


12/1/2014


12/1/2014

Section 7: Appeals and Grievances Section 7: Appeals and Grievances

12/1/2014

Balance Billing – Added Missed appointments to bulleted list of items Providers may not bill Harmony. members for. Corrected Claims – Updated image of claims submission form for professional claims. Practitioner’s Rights – Changed email address for credentialing inquiries. Member Appeals Process – Added sentence that a Member may present his or her appeal in person by contacting Member Services to make arrangements for an in person appeal. Removed Standard PreService and Retrospective Appeals Process. Standard Pre-Service and Retrospective Appeals Decisions – Added information for HCBS right to request a State Fair Hearing with HFS. Expedited Appeals Process – Removed sentence that in light of the short timeframe for deciding expedited appeals, a Provider does not need to be an Authorized Representative to request an expedited appeal on behalf of the Member. State Fair Hearing – Added. External Independent Review Process – Changed timelines for the EIR organization to make a determination within forty-

74

75

81

88

90

90

90

91 92



12/1/2014

12/1/2014

12/1/2014

12/1/2014

12/1/2014

12/1/2014 12/1/2014

eight (48) hours for expedited reviews and five (5) calendar days for standard requests. Section 8: Compliance Provider Education and Outreach information removed. Section 8: Compliance Fraud, Waste and Abuse – Changed Harmony’s tollfree fraud hotline. Section 10: Behavioral Continuity and Health Coordination of Care Between Medical and Behavioral Health Providers – Changed DSM-IV to DSM-IV/DSM-V. Section 10: Behavioral Responsibilities of Health Behavioral Health Providers – Added Children’s Mental Health and Mobile Crisis Response information. Section 10: Behavioral Responsibilities of Health Behavioral Health Providers – Added Illinois Crisis and Referral Entry Services (CARES) program information. Section 11: Pharmacy Prescription Reviews – Removed. Section 11: Pharmacy Exactus Pharmacy Solution for Specialty Medications – Removed mail order service.

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101

103

104

105 111



Section 1: Overview About Harmony Harmony Health Plan of Illinois, Inc. (Harmony), a WellCare Company, is a licensed Illinois Managed Care Organization (MCO). WellCare provides managed care services targeted exclusively to government-sponsored health care programs, focused on Medicaid and Medicare, including prescription drug plans, health plans for families, and the aged, blind and disabled. WellCare’s corporate office is located in Tampa, Florida. As of September 30, 2015, WellCare serves approximately 3.8 million members nationwide. Harmony serves approximately 153,000 Medicaid Members across the state. WellCare’s experience and commitment to government-sponsored health care programs enables it to serve its Members and Providers as well as manage its operations effectively and efficiently. Mission and Vision WellCare’s vision is to be the leader in government-sponsored health care programs in partnership with the Members, Providers, governments and communities it serves. WellCare will:  Enhance its Members' health and quality of life  Partner with Providers and governments to provide quality, cost-effective health care solutions  Create a rewarding and enriching environment for its associates WellCare’s Values are:  Partnership – Members are the reason WellCare is in business; Providers are WellCare’s partners in serving its Members; and regulators are the stewards of the public's resources and trust. WellCare will deliver excellent service to its partners.  Integrity – WellCare’s actions must consistently demonstrate a high level of integrity that earns the trust of those it serves.  Accountability – All associates must be responsible for the commitments WellCare makes and the results it delivers.  Teamwork – WellCare and its associates expect – and are expected to – demonstrate a collaborative approach in the way they work. Purpose of this Provider Manual This Provider Manual is intended for Harmony’s contracted (participating) Medicaid Providers delivering health care service(s) to Harmony Members enrolled in a Harmony Medicaid Managed Care plan. This Provider Manual serves as a guide to the policies and procedures governing the administration of Harmony’s Medicaid plans and is an extension of and supplements the Provider Participation Agreement (Agreement) between Harmony and health care Providers who include, without limitation: physicians, physician groups, independent physician associations (IPAs), hospitals and ancillary Providers (collectively, Providers). This Provider Manual replaces and supersedes any previous versions dated prior to October 30, 2015 and is available on Harmony’s website at: www.wellcare.com/Wellcare/Illinois/Providers/Medicaid. A

Harmony Health Plan, Inc. Illinois Medicaid Provider Manual Effective: October 30, 2015


paper copy, at no charge, may be obtained upon request by contacting the Provider’s Provider Relations representative. In accordance with the Policies and Procedures clause of the Agreement, Harmony Medicaid Providers must abide by all applicable provisions contained in this Provider Manual. Revisions to this Provider Manual reflect changes made to Harmony’s policies and procedures. Revisions shall become binding thirty (30) days after notice is provided by mail or electronic means, or such other period of time as necessary for Harmony to comply with any statutory, regulatory, contractual and/or accreditation requirements. As policies and procedures change, updates will be issued by Harmony in the form of Provider Bulletins and will be incorporated into subsequent versions of this Provider Manual. Provider Bulletins that are state-specific may override the policies and procedures in this Provider Manual. Harmony’s Health Plans Harmony has contracted with the Illinois Department of Healthcare and Family Services (HFS) to provide Medicaid managed care services. Enrollment Harmony Membership consists of enrollees who live in contracting areas that may voluntarily choose Harmony or may be subject to auto assignment by IL Department of Healthcare and Family Services. Harmony accepts all eligible individuals without restrictions and abides by all federal and state laws and regulations that prohibit discrimination based on race, color, religion, sex, national origin, ancestry, age or physical or mental disability. Harmony will not tolerate discrimination against eligible or prospective Members based on health status or need for health services. The State is responsible for determining eligibility for the HFS medical program. Covered Services The following services are provided as medically necessary to eligible Harmony Members:             

Advance practice nurse services Alcohol and substance abuse treatment services Ambulatory surgical treatment center services Assistive/augmentative communication devices Audiology services Behavioral health and substance abuse services Chiropractic services (limited to enrollees under age 21) Contraceptive devices Dental services (Adult) Dental services (Children) FQHC and RHC and other approved clinic visits Durable and non-durable medical equipment and supplies Early periodic screenings and diagnostic testing services Emergency services



                     

Family planning services (also at non-affiliated Providers covered by the Illinois Medical Assistance Program) Health education Home health care services Hospice Hospital ambulatory services Hospital inpatient services Hospital outpatient services Immunizations Laboratory and X-ray services Podiatric services for Members under age 21 Podiatric services for diabetic Members 21 and older (effective 10/01/2014 Podiatric services for all Members age 21 and over are covered) Post-stabilization services Practice visits for Members with special needs Preventive services Renal dialysis services Respiratory equipment and supplies Skilled nursing care for Members under age twenty-one (21) not in the Home and Community-Based services (HCBS) Speech and language therapy Transplant services (non-experimental) Transportation Well-child care services Whole blood and blood products

Additional Benefits  No Co-Pays: For doctor visits, hospital visits or generic drugs, children under 19 years of age, pregnant women, Native Americans and Native Alaskans do not have co-pays for Covered Services.  Adult Dental (for Members age 21 and older): Free cleanings every six months with no co-pays.  Diaper Program: Members who complete their postpartum appointment and baby recommended immunizations receive a free pack of diapers per visit (up to six packs of diapers).  Discounted Gym Membership: Discounted Gym Membership: Members receive 10% off monthly dues and 50% off a one-time enrollment fee to Anytime Fitness or a no cost enrollment fee and a $24.95 discounted monthly membership fee to LA Fitness.  Expanded Vision: Members age 21 and older receive a free pair of approved glasses annually.  Free GED Tests: Members’ GED testing costs are covered if the following requirements are met: o Member is at least 17 years old o Member has not graduated from an accredited high school or received a high school equivalency certificate or diploma Harmony Health Plan, Inc. Illinois Medicaid Provider Manual Effective: October 30, 2015


   



o Member is currently enrolled in a regular high school o Member has a valid Harmony ID card o Member completes classroom work at an adult testing center Free Hypoallergenic Bedding: Provided to qualified Members to help avoid asthma triggers. Free Weight Loss Program: Qualified Members will receive a 3-month membership to a Curves gym, which includes one-to-one counseling with a health coach. Harmony +15 (free over-the-counter (OTC) supplies): Members receive $15 for OTC items each month per family. Healthy Kids Club: o Free program that provides healthy tips and tools to kids ages 4–11 to encourage immunizations and checkups o Effective August 1, 2014, birthday club parties are no longer covered Healthy Behaviors Program: Members who complete specific qualified healthy behaviors as listed in the chart below will be rewarded with a $20 CVS Select® card.



Reward Type

Healthy Behaviors Program New Enrollee Healthy Behavior Engagement Initial PCP Visit

Reloadable CVS Select Card

Reward Amount

Reward Criteria

$20

Initial PCP Visit within 90 days of enrollment

$20

0-15 Months: Well child visit per periodicity schedule (reward for each visit, up to 6 visits)

$20

3-6 years: Child health checkup visit (reward for each visit)

$20

7-21 years: Adolescent checkup visit. (reward for each visit)

Children’s Healthy Behavior Engagement Reloadable CVS Select Card Reloadable Child Health Checkup: 3-6 CVS Select years Card Reloadable Adolescent Checkup: CVS Select 7-21 years Card Healthy Pregnancy Behaviors Reloadable CVS Select Card Well Child Visit: 0-15 months

Prenatal care visits

Postpartum care visit

Baby stroller or portable play pen Reloadable CVS Select Card

$20 and choice of stroller or playpen

Completion of 6 doctor visits prior to birth of baby

$20-$40

Reloadable $20 CVS Select® Card



Completion of all doctor visits before and after baby is born and receive an extra $20 reward Well Woman Healthy Behaviors Cervical Cancer Screening

Screening mammogram

Reloadable CVS Select Card Reloadable CVS Select Card

Diabetes Healthy Behavior Program Eye Exam Reloadable CVS Select Card HgbA1C control Reloadable CVS Select Card LDL control Reloadable CVS Select Card

$20

Completion of office visit for cervical cancer screening (pap smear) (ages 21 - 64)

$20

Completion of Screening mammogram - (ages 40-65)

$20

Complete eye exam (enrollees with diabetes ages 18 - 75)

$20

Goal achievement for HgbA1C (