IPA, HOSPITAL, & ANCILLARY PROVIDER
PROVIDER MANUAL
January 1, 2017
Table of Contents EASY CHOICE HEALTH PLAN PROVIDER MANUAL REVISION TABLE ............................................... 6 SECTION I: INTRODUCTION AND OVERVIEW .......................................................................................... 9 MISSION AND VISION ...............................................................................................................................................10 PURPOSE OF THIS MANUAL ......................................................................................................................................10 EASY CHOICE SERVICE AREA ..................................................................................................................................11 EASY CHOICE COMPLIANCE PROGRAM ...................................................................................................................11 FRAUD, WASTE AND ABUSE PREVENTION ...............................................................................................................11 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) .............................................................13 SECTION II: EASY CHOICE HEALTH PLAN – BENEFITS ....................................................................... 15 EASY CHOICE BENEFIT SUMMARY ..........................................................................................................................16 VALUE ADDED SERVICES (VAS) .............................................................................................................................16 Acupuncture .......................................................................................................................................................17 Comprehensive Dental .......................................................................................................................................17 Comprehensive Vision and Eyewear ..................................................................................................................17 Hearing Aids ......................................................................................................................................................17 Transportation to Medical Appointments ..........................................................................................................17 Gym Membership ...............................................................................................................................................17 CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES ................................................................................17 SECTION III: COORDINATION OF DENTAL & VISION SERVICES ...................................................... 19 DENTAL SERVICE REQUESTS ...................................................................................................................................20 VISION SERVICE REQUESTS .....................................................................................................................................20 SECTION IV: MEMBER ENROLLMENT & ELIGIBILITY ........................................................................ 21 MEMBER ENROLLMENT OVERVIEW.........................................................................................................................22 MEMBER ELIGIBILITY OVERVIEW ...........................................................................................................................22 ELIGIBILITY LIST .....................................................................................................................................................23 ELIGIBILITY VERIFICATION PROCESS ......................................................................................................................23 ELIGIBILITY DISCREPANCY......................................................................................................................................24 MEMBER DISENROLLMENT ......................................................................................................................................24 Voluntary Disenrollment ....................................................................................................................................24 Involuntary Disenrollment .................................................................................................................................24 Provider Initiated Member Disenrollment .........................................................................................................24 SECTION V: CUSTOMER SERVICE ............................................................................................................. 26 TOLL-FREE NUMBERS .............................................................................................................................................27 INTERPRETER SERVICES...........................................................................................................................................27 MEMBER COMPLAINTS & GRIEVANCES ...................................................................................................................27 MEMBER RIGHTS & RESPONSIBILITIES ....................................................................................................................28 TRANSPORTATION SCHEDULING ..............................................................................................................................29 CALL CENTER STANDARDS & REQUIREMENTS ........................................................................................................29 CALL CENTER REPORTING REQUIREMENTS .............................................................................................................29 SECTION VI: IPA ADMINISTRATION ......................................................................................................... 31 MANAGEMENT SERVICES ORGANIZATIONS (MSO) .................................................................................................32 PROFESSIONAL NETWORK MANAGEMENT ...............................................................................................................32 Easy Choice Health Plan Provider Manual 1 of 162
CAPITATION PAYMENT ............................................................................................................................................33 Overview ............................................................................................................................................................33 Payment..............................................................................................................................................................33 Report.................................................................................................................................................................33 Non-Standard Deductions/Payments .................................................................................................................34 RISK POOL REPORTING ............................................................................................................................................34 Hospital Risk Pool .............................................................................................................................................34 Pharmacy Risk Pool ...........................................................................................................................................34 Surplus/Deficit Sharing ......................................................................................................................................34 Settlement Calculations......................................................................................................................................34 SECTION VII: PROVISION OF PROFESSIONAL SERVICES ................................................................... 36 PRIMARY CARE SERVICES .......................................................................................................................................37 TERMINATIONS ........................................................................................................................................................37 PCP Terminations ..............................................................................................................................................37 Ancillary Provider/Hospital Terminations .........................................................................................................37 SPECIALTY AND ANCILLARY PROVIDERS ................................................................................................................37 ADVANCE DIRECTIVE ..............................................................................................................................................37 DISABLED MEMBER SERVICES ................................................................................................................................38 ON-CALL COVERAGE (24 HOUR HOURS/DAY, 7 DAYS/WEEK) ...............................................................................38 EMERGENCY ROOM UTILIZATION ............................................................................................................................38 CONFIDENTIALITY AND DISCLOSURE OF MEDICAL INFORMATION ..........................................................................38 Release of Confidential Information to the Patient ............................................................................................39 Release of Confidential Information to Personal Representatives .....................................................................39 Release of Confidential Information to Employers ............................................................................................39 Release of Confidential Information to Providers .............................................................................................39 Release of Confidential Information – Outpatient Psychotherapy Records .......................................................40 Guidelines for the Written Request ....................................................................................................................40 Release of Confidential Information – Pursuant to a Subpoena ........................................................................40 MEDICAL RECORD STANDARDS...............................................................................................................................41 CONFIDENTIALITY AND AVAILABILITY OF MEDICAL RECORDS ...............................................................................41 RETENTION OF MEDICAL RECORDS .........................................................................................................................41 SECTION VIII: CLAIMS & ENCOUNTER DATA SUBMISSION ............................................................... 43 CLAIMS SUBMISSION GUIDELINES ...........................................................................................................................44 UNLISTED PROCEDURES/CODES ..............................................................................................................................45 PAYMENT BASED ON AUTHORIZED LEVEL OF CARE ...............................................................................................45 PAYMENT TO NON-CONTRACTED PROVIDERS .........................................................................................................45 CLAIM CORRECTIONS/RESUBMISSIONS ...................................................................................................................46 CONTINUITY OF CARE - REIMBURSEMENT FOR SERVICES FOR INPATIENT MEMBER AT THE TIME OF ENROLLMENT OR DISENROLLMENT ................................................................................................................................................ 46 Enrollment..........................................................................................................................................................46 Disenrollment .....................................................................................................................................................46 Exception............................................................................................................................................................46 INELIGIBLE MEMBERS .............................................................................................................................................46 UNDERPAYMENTS/OVERPAYMENTS ........................................................................................................................46 MISDIRECTED CLAIMS .............................................................................................................................................47 MONTHLY TIMELINESS REPORTS.............................................................................................................................47 QUARTERLY REPORTS .............................................................................................................................................47 COORDINATION OF BENEFITS ..................................................................................................................................48 When Easy Choice is the Primary Payer ...........................................................................................................48 When Easy Choice is the Secondary Payer ........................................................................................................48
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CLAIMS PROCESSING TIMELINES .............................................................................................................................49 PROVIDER APPEALS AND DISPUTE RESOLUTION .....................................................................................................49 Definitions ..........................................................................................................................................................49 To Submit an Contracted/Non Contracted Provider Appeals & Claims Payment Disputes ..............................49 HOLD HARMLESS ....................................................................................................................................................50 ENCOUNTER DATA SUBMISSION GUIDELINES ..........................................................................................................51 SECTION IX: PHARMACY SERVICES ........................................................................................................ 53 PHARMACY BENEFIT MANAGEMENT COMPANY – CVS CAREMARK .......................................................................54 PHARMACY NETWORK.............................................................................................................................................54 MAIL ORDER PHARMACY PROVIDER .......................................................................................................................54 SPECIALTY PHARMACY PROVIDER ..........................................................................................................................54 FORMULARY ............................................................................................................................................................54 FORMULARY EXCEPTIONS PROCESS ........................................................................................................................55 REQUESTS FOR FORMULARY CHANGES ...................................................................................................................55 Information to Include in the Request ................................................................................................................55 Address to Submit Formulary Requests .............................................................................................................55 NOTIFICATION OF FDA RECALLS ............................................................................................................................55 MEDICATION THERAPY MANAGEMENT PROGRAM (MTMP) ...................................................................................55 ATTACHMENTS ........................................................................................................................................................57 Mail Service Order Form ...................................................................................................................................57 Prior Authorization (DER) Request Form .........................................................................................................59 A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) Programs .....................63 SECTION X: UTILIZATION MANAGEMENT ............................................................................................. 69 UTILIZATION MANAGEMENT PROGRAM ..................................................................................................................70 REFERRAL PROCESSING RESPONSIBILITIES..............................................................................................................70 NON-DISCRIMINATION IN THE DELIVERY OF HEALTH CARE SERVICES ...................................................................71 AFFIRMATIVE STATEMENT ......................................................................................................................................71 OUT-OF-NETWORK SERVICES ..................................................................................................................................71 AUTHORIZATION RESPONSE AND DECISION MAKING NOTIFICATION TIME FRAMES ...............................................71 DENIAL NOTICES .....................................................................................................................................................71 UTILIZATION MANAGEMENT CRITERIA ...................................................................................................................71 INPATIENT ACUTE CARE, SNF, PSYCHIATRIC AND REHABILITATION ADMISSIONS .................................................72 OUT-OF-AREA INPATIENT ACUTE CARE SNF, PSYCHIATRIC AND REHABILITATION ADMISSIONS ..........................72 RULES FOR COVERAGE THAT BEGINS OR ENDS DURING AN INPATIENT STAY .........................................................72 REQUIRED NOTIFICATION TO MEMBERS FOR OBSERVATION SERVICES ...................................................................73 INPATIENT ACUTE DISCHARGE / IMPORTANT MESSAGE NOTICE LETTER ................................................................73 SKILLED NURSING FACILITY, HOME HEALTH, CORF DISCHARGE/NOTICE OF MEDICARE NONCOVERAGE/DETAILED EXPLANATION OF NON-COVERAGE .....................................................................................73 IPA REPORTING REQUIREMENTS .............................................................................................................................74 SECTION XI: QUALITY IMPROVEMENT................................................................................................... 75 EASY CHOICE QUALITY IMPROVEMENT PROGRAM..................................................................................................76 PROGRAM SUMMARY ..............................................................................................................................................76 ACCESS-TO-CARE STANDARDS ...............................................................................................................................76 Standards for Telephone Access ........................................................................................................................77 Standards for Office Wait Times ........................................................................................................................77 ACCESS AUDIT ........................................................................................................................................................77 MEDICAL RECORD REVIEW .....................................................................................................................................77 HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS)..................................................................78 CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) ...................................................83
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HEALTH OUTCOMES SURVEY (HOS) .......................................................................................................................83 APPEALS AND GRIEVANCES .....................................................................................................................................83 REQUESTS TO DISENROLL A MEMBER .....................................................................................................................84 CHRONIC CARE IMPROVEMENT PROGRAM / DISEASE MANAGEMENT......................................................................84 SECTION XII: CARE/CASE MANAGEMENT .............................................................................................. 86 CARE/CASE MANAGEMENT PROGRAM ....................................................................................................................87 SNP MODEL OF CARE – CASE MANAGEMENT .........................................................................................................87 HEALTH RISK ASSESSMENT .....................................................................................................................................89 IPA REPORTING REQUIREMENTS .............................................................................................................................89 INITIAL HEALTH & ANNUAL HEALTH ASSESSMENT ................................................................................................89 SECTION XIII: CREDENTIALING AND RE–CREDENTIALING .............................................................. 91 CREDENTIALING AND RE-CREDENTIALING..............................................................................................................92 INITIAL CREDENTIALING .........................................................................................................................................92 RE–CREDENTIALING................................................................................................................................................92 IPA REPORTING REQUIREMENTS .............................................................................................................................93 SECTION XIV: ATTACHMENTS .................................................................................................................. 94 EASY CHOICE MEMBER ID CARD SAMPLE ..............................................................................................................95 MEMBER RIGHTS AND RESPONSIBILITIES ................................................................................................................97 EASY CHOICE MONTHLY CAPITATION DETAIL DATA FILE....................................................................................104 EASY CHOICE ELIGIBILITY MEMBER FILE LAYOUT ...............................................................................................106 Monthly Claims Timeliness Report ..................................................................................................................107 Part C Reporting Payment (Claims) Organization Determinations/Reconsiderations....................................108 CMS PDR Quarterly Reporting .......................................................................................................................110 UPDATED DELEGATED REPORTS LIST, FREQUENCY AND METHOD OF SUBMISSION ..............................................111 ICE 2014 UM DELEGATION REQUIRED REPORTS TABLE OF CONTENTS ................................................................112 A. Instructions ..................................................................................................................................................113 B. Definition .....................................................................................................................................................120 C. Signature Page ............................................................................................................................................125 1. Inpatient Utilization Metrics ........................................................................................................................126 2. Inpatient Work Plan & Reports ....................................................................................................................127 3. Referral Metrics ...........................................................................................................................................128 4. Referral Work Plan & Reports .....................................................................................................................130 5. Emergency Room Utilization Metrics ..........................................................................................................131 6. Emergency Room Work Plan & Reports ......................................................................................................132 7. Appeal Metrics & Turnaround Time ............................................................................................................133 8. Appeal Work Plan & Reports .......................................................................................................................134 9. Complex Case Management Metrics ............................................................................................................135 10. Complex Case Management Work Plan & Reports ...................................................................................136 11. Special Needs Plan Metrics........................................................................................................................138 12. Special Needs Plan Work Plan & Reports .................................................................................................140 13. Experience Work Plan & Reports ..............................................................................................................142 14. Utilization and Referral Timeframe Compliance Metrics ..........................................................................143 15. Over/Under Utilization and Referral Timeframe Compliance Work Plan & Reports ...............................145 16. Other UM Work Plan & Reports................................................................................................................146 CASE MANAGEMENT REPORT................................................................................................................................147 HOSPICE LOG.........................................................................................................................................................148 PART C ATTESTATION NOTE .................................................................................................................................149 MEDICARE PART C REPORTING UM DETERMINATIONS ........................................................................................150 COMPLEX & HIGH RISK CASE MANAGEMENT REFERRAL .....................................................................................152 Easy Choice Health Plan Provider Manual 4 of 162
DELEGATED IPA CASE MANAGEMENT PROGRAM REQUIREMENTS .......................................................................153 CONNECTIVITY AND COMMUNICATION (FTP) / TESTING .......................................................................................157 COMPLIANCE PROGRAM MANUAL .........................................................................................................................159 Compliance Program – Overview ....................................................................................................................159 Marketing Medicare Advantage Plans .............................................................................................................159 CODE OF CONDUCT AND BUSINESS ETHICS ...........................................................................................................160 Overview ..........................................................................................................................................................160 Confidentiality of Member Information and Release of Records .....................................................................160 Disclosure of Information ................................................................................................................................161 DELEGATED ENTITIES............................................................................................................................................162 Overview ..........................................................................................................................................................162 Compliance ......................................................................................................................................................162
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Easy Choice Health Plan Provider Manual Revision Table Date
Section
Comments
Page
1/1/2017
Easy Choice Service Area – updated service area
11
Acupuncture – updated PBP and coverage
17
Transportation to Medical Appointments – updated transportation provider Gym Membership – updated PBP and coverage
17
Dental Service Requests – removed TTY number
20
Member Enrollment Overview – updated service area
22
1/1/2017
Section I: Introduction and Overview Section II: Easy Choice, Inc. – Benefits Section II: Easy Choice, Inc. – Benefits Section II: Easy Choice, Inc. – Benefits Section III: Coordination of Dental & Vision Services Section IV: Member Enrollment & Eligibility Section V: Customer Service
Toll-Free Numbers – updated Easy Choice TDD/TTY number
27
1/1/2017
Section V: Customer Service
Interpreter Services – updated available languages
27
1/1/2017
Section V: Customer Service
Transportation Scheduling – updated transportation provider
29
1/1/2017
Section V: Customer Service
Added Call Center Standards and Requirements section
29
1/1/2017
Section V: Customer Service
Added Call Center Reporting Requirements section
29-30
1/1/2017
Section VI: IPA Administration Section VIII: Claims & Encounter Data Submission Section VIII: Claims & Encounter Data Submission
Added Management Services Organizations (MSO) section and content related to Professional Network Management Claims Submission Guidelines – added content related to claim submission process Claim Corrections/Resubmissions – added content related to claim re-submission process
32-33
Section VIII: Claims & Encounter Data Submission Section VIII: Claims & Encounter Data Submission
Monthly Timeliness Reports – added content related to submission of reports Quarterly Reports - added content related to submission of reports
47
1/1/2017
Section VIII: Claims & Encounter Data Submission
Coordination of Benefits – added content related to when Easy Choice is the second payer
48
1/1/2017
Section VIII: Claims & Encounter Data Submission
50
1/1/2017
Section IX: Pharmacy Services
To Submit a Contracted/Non Contracted Provider Appeals & Claims Payment Disputes - added Appeals fax number and revised content related to submission of appeals Pharmacy Network – removed content related to Preferred Network Pharmacy providers
1/1/2017
Section IX: Pharmacy Services Section IX: Pharmacy Services
Mail Order Pharmacy Provider – added content related to copay and mail order form Formulary – updated frequency of formulary updates
54
1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017
1/1/2017 1/1/2017 1/1/2017 1/1/2017
1/1/2017
17
44 46
47-48
54
54
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Section IX: Pharmacy Services Section IX: Pharmacy Services Section X: Utilization Management
Formulary Exceptions Process – added content related Medicare Prescription Drug Coverage Determination Updated content related to Medication Therapy Management Program Utilization Management Program – added content related to Utilization Management program requirements
55
Section X: Utilization Management Section X: Utilization Management Section X: Utilization Management Section X: Utilization Management Section XI: Quality Improvement
Updated content related to Referral Processing Responsibilities Denial Notices – added content related to denial decision
70
Utilization Management Criteria – added content related to denial letter Required Notification to Members for Observation Services added content related to MOON notice Medical Record Review – updated percentage requiring a Corrective Action Plan
71-72
1/1/2017
Section XI: Quality Improvement
78
1/1/2017
Section XI: Quality Improvement
Healthcare Effectiveness Data and Information Set (HEDIS) – added Breast Cancer Screening CPT codes & revised Colorectal Cancer Screening CPT4 codes and screening frequency Added content related to MTM Program Completion Rate for Comprehensive Medication Review (New Measure)
1/1/2017
Section XI: Quality Improvement Section XII: Care/Case Management Section XII: Care/Case Management Section XII: Care/Case Management Section XIII: Credentialing and Re-Credentialing
Health Outcomes Survey (HOS) – added content related to Management of Urinary Incontinence Health Risk Assessment – added content related to HRA stratification IPA Reporting Requirements – removed Case Management Opt In/Opt Out Report Initial Health & Annual Health Assessment – added content related to delegation of Case Management IPA Reporting Requirements – added content related to submission of reports
83
1/1/2017
Section XIV: Attachments
Updated Easy Choice Member ID Card Sample
95-96
1/1/2017
Section XIV: Attachments
Updated Easy Choice Monthly Capitation Detail Data File
1/1/2017
Section XIV: Attachments
Updated Easy Choice Eligibility Member File Layout
104105 106
1/1/2017
Section XIV: Attachments
Updated Delegated Reports List, Frequency and Method of Submission attachment
111
1/1/2017
Section XIV: Attachments
146
1/1/2017
Section XIV: Attachments
Added content related to submission of Other Work Plan & Reports Removed Utilization Management Approvals Report
1/1/2017
Section XIV: Attachments
Removed Management Denials Report
1/1/2017
Section XIV: Attachments
Case Management Report - removed email address
147
1/1/2017
Section XIV: Attachments
Hospice Log – updated submission process
148
1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017
1/1/2017 1/1/2017 1/1/2017 1/1/2017
55-56 70
71
73 77-78
82
89 89 89-90 93
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1/1/2017
Section XIV: Attachments
Removed Claims Report
1/1/2017
Section XIV: Attachments
Removed Credentialing Report
1/1/2017
Section XIV: Attachments
151
1/1/2017
Section XIV: Attachments
Medicare Part C Reporting UM Determinations – updated submission process Removed Case Management Delegation Activities
1/1/2017
Section XIV: Attachments
Delegated Entities – revised content related to Overview
162
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Section I: Introduction and Overview
Mission and Vision
Purpose of this Manual
Easy Choice Service Area
Easy Choice Compliance Program
Fraud, Waste and Abuse Prevention
Health Insurance Portability and Accountability Act (HIPAA)
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Section I: Introduction and Overview Easy Choice Health Plan, a WellCare Company, (Easy Choice) is a federally approved Medicare Advantage Prescription Drug (MAPD) and Special Needs Plan (SNP) designed to provide medical and prescription drug coverage for qualifying individuals with Medicare eligibility.
Mission and Vision Easy Choice’s vision is to be a leader in government-sponsored health care programs in partnership with the Members, Providers, governments, and communities it serves. Easy Choice 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
Easy Choice’s core values include:
Partnership - Members are the reason Easy Choice is in business; Providers are partners in serving Members; and regulators are the stewards of the public's resources and trust. Easy Choice will deliver excellent service to its partners. Integrity - Easy Choice’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 Easy Choice makes and the results it delivers. Teamwork - With fellow associates, Easy Choice can expect - and is expected to demonstrate - a collaborative approach in the way it works.
Purpose of this Manual This Manual is intended for Providers who are contracted with Easy Choice to deliver quality health care services to Members enrolled in MAPD and SNP Benefit Plans. This Manual serves as a guide to Providers and their staff to comply with the policies and procedures governing the administration of Easy Choice’s Benefit Programs, and is an extension of the Provider participation agreements with Easy Choice. This Provider Manual replaces and supersedes any previous versions dated prior to December 31, 2016 and is available on Easy Choice’s website at: www.easychoicehealthplan.com. In accordance with the Agreement, Participating Providers must abide by all applicable provisions contained in this Manual. Revisions to this Manual reflect changes made to Easy Choice’s policies and procedures. Unless otherwise provided in the Agreement, Easy Choice will communicate changes to the Manual through a Table of Revisions in the front of the Manual, Provider Bulletin posted to the Provider Portal on Easy Choice’s website. For material changes, Easy Choice will send a formal notice in accordance with the terms of the Agreement. Should there be a conflict or inconsistency between what is stated in this Provider Manual and your participation agreement, the terms and provisions contained in your participation agreement will supersede and control.
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Easy Choice Service Area The member’s Evidence of Coverage (EOC) defines a service area as the geographic area approved by the Centers for Medicare & Medicaid Services (CMS) in which a person must live in order to become, or to remain, a member of Easy Choice. Members who temporarily move outside of the service area (as defined by CMS as six months or less) are eligible to continue to receive emergency and urgently needed services only when outside of the service area. At this time, Easy Choice is approved to service the following counties: Los Angeles, Orange, Riverside and San Bernardino.
Easy Choice Compliance Program Easy Choice has a comprehensive values based Compliance Program which reflects how fundamental components of Easy Choice’s business operations are conducted. Easy Choice recognizes that its employees and provider affiliates are the keys to providing quality health care services and is committed to managing its business operations in an ethical manner, in accordance with contractual obligations, and consistent with all applicable statutes, regulations and rules. An overview of the Easy Choice Compliance Program can be found under Section XIV: Attachments. It applies to all Easy Choice personnel, its Board members, contractors, suppliers and participating providers.
Fraud, Waste and Abuse Prevention In accordance with CMS regulations, Easy Choice has a comprehensive plan to detect, correct and prevent fraud, waste and abuse (FWA). Easy Choice is committed to complying with all Federal and State statutory, regulatory and other requirements related to the Medicare program. Fraud, Waste and Abuse is defined as: Fraud – Federal health care fraud generally involves a person or entity’s intentional use of false statements or fraudulent schemes (such as kickbacks) to obtain payment for, or to cause another to obtain payment for items or services payable under a Federal health care program. Waste – To use or expend carelessly, extravagantly, or to no purpose Abuse – Activity or actions that may intentionally or unintentionally, directly or indirectly result in unnecessary or increased costs to the Medicare Program. Compliance with State and Federal laws and regulations has always been a priority of Easy Choice. The purpose of Easy Choice’s Fraud, Waste and Abuse Plan is to organize and implement an antifraud strategy to detect, prevent and control fraud, waste and abuse in order to reduce cost caused by fraudulent activities and to protect members in the delivery of health care services. The Fraud, Waste and Abuse Plan is designed to establish methods to identify, investigate and refer incidents of suspected fraud and/or abuse in Easy Choice’s Medicare Program delivery systems. Easy Choice monitors, investigates and corrects possible fraud, waste and abuse issues in conjunction with the contracted Pharmacy Benefit Manager not just by identifying errors but also through educating providers and members. The Pharmacy Benefit Manager produces and provides various reports listed below to Easy Choice on a quarterly basis for review and investigation of potential issues. Claims (including demographic claims) High quantity drugs High dollar drugs
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Decimal package size Compounds dollar amounts Controlled substances by Member Summary of all controlled substance claims by member Summary of total claims and quantity of CII, CIII & CIV drug classes dispensed. Count of the number of physicians and pharmacies each member used during the reporting period. Summary of total dollars paid by plan and co-pays paid by member. Detail of each claim by member. Controlled substances by Physician Identifies the top 3% of prescribers of Class II, III, and/or IV drugs during the reporting period based on total number of drugs dispensed in that class for the plan. Physician utilization Identifies prescribers to help identify Prescriber Dispensing Pattern to Total Number of Utilizing Pharmacies to Total Number of Utilizing Members, average number of prescriptions per member and other trend information. This report allows the plan to look at various data elements “side by side” in order to detent potential aberrant patterns of behavior. Pharmacy utilization Identifies pharmacies dispensing 100 or more prescriptions for the plan during the reporting period. This report helps identify those pharmacies that are dispensing significant quantities for the plan. It makes the pharmacies more visible for continuing oversight.
Easy Choice will review and utilize these reports to initiate investigations of potential FWA issues and implement corrective actions when applicable. In addition, Easy Choice monitors the following activities in order to identify possible FWA issues:
Calls from members with inquiries or concerns about their prescriptions not being filled correctly (less count than the written prescription); Multiple calls from the same provider (pharmacy) regarding the approval of multiple fills for the same prescription; Providers (pharmacy) calls regarding member filling consecutive prescriptions in a short period of time from different prescribers; Ongoing FWA trainings.
Easy Choice is committed to the prevention, detection and reporting of health care fraud and abuse according to applicable federal and state statutory, regulatory and contractual requirements. Easy Choice has developed an aggressive, proactive fraud and abuse program designed to collect, analyze and evaluate data in order to identify suspected fraud and abuse. Detection tools have been developed to identify patterns of health care service use, including over-utilization, unbundling, up-coding, misuse of modifiers and other common schemes. Federal and state regulatory agencies, law enforcement, and Easy Choice vigorously investigate incidents of suspected fraud and abuse. Providers are cautioned that unbundling, fragmenting, up-coding, and other activities designed to manipulate codes contained in the International Classification of Diseases, Ninth Edition (ICD-10), CPT-4, the Healthcare Common Procedure Coding System (HCPCS), and/or Universal Billing Revenue Coding Manual as a means of increasing reimbursement may be considered an improper billing practice and may be a misrepresentation of the services actually rendered. In addition, providers are reminded that medical records and other documentation must be legible and support the level of care and service indicated on claims. Providers engaged in fraud and abuse may be subject to disciplinary and corrective actions, including but not limited to, warnings, monitoring, administrative sanctions, suspension or termination as an authorized provider, loss of licensure, and/or civil and/or criminal prosecution, fines and other penalties. Participating providers must be in compliance with all CMS rules and regulations. This includes the CMS requirement that all employees who work for or contract with a Medicaid managed care organization meet annual Easy Choice Health Plan Provider Manual 12 of 162
compliance and education training requirements with respect to FWA. To meet federal regulation standards specific to Fraud, Waste and Abuse (§ 423.504) providers and their employees must complete an annual FWA training program. Please contact the Easy Choice Compliance Department to report any issues of potential fraud, waste and abuse. If you have general question, please call Easy Choice toll–free at (866) 999-3945. If you want to report any issues of potential fraud, waste and abuse, please call: Special Investigation Unit 24-hour Fraud hotline at 1-866-678-8355 *Callers may leave a message on voicemail and remain anonymous, if so desired. Please be prepared to provide the following information: Contact information or you may chose to remain anonymous Type of item or service involved in the allegation Place of service Nature of allegation
Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires covered entities such as health plans, health care clearinghouses and most health care providers, including pharmacies, to safeguard the privacy of patient information. Covered entities are required to conduct HIPAA Privacy training on an annual basis and to ensure ongoing organizational compliance with the regulations. A major goal of the Privacy Rule, is to assure that an individual’s personal health information is properly protected, while still allowing the flow of health information needed to provide and promote high quality health care as well as to protect the public’s health and wellbeing. A covered entity must maintain reasonable and appropriate administrative, technical, and physical safeguards to prevent inappropriate uses and disclosures of Protected Health Information (PHI). The following are examples of appropriate safeguards that organizations/providers should take to protect the security and privacy of PHI:
Ensure that data files are not saved on public or private computers while accessing corporate e-mail through the Internet.
Ensure that electronic systems for beneficiary mailings are properly programmed in order to prevent documents containing PII from being sent to the wrong beneficiaries.
Ensure that PHI data on all portable devices are encrypted.
Implement security measures to restrict access to PHI based on an individual’s need to access the data.
Perform an internal risk assessment or engage an industry-recognized security expert to conduct an external risk assessment of the organization to identify and address security vulnerabilities.
Shredding documents containing PHI before discarding them.
Securing medical records with lock and key or pass code.
Limiting access to keys and pass codes.
Locking computer screens when away from your desk/work station. Easy Choice Health Plan Provider Manual 13 of 162
Refraining from discussing member information outside the workplace, lunch-rooms, elevators, lobby etc.
Please refer to the Compliance Program for additional Information.
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Section II: Easy Choice Health Plan – Benefits
Easy Choice Benefit Summary
Value Added Services
Acupuncture
Comprehensive Dental
Comprehensive Vision and Eyewear
Hearing Aids
Transportation to Medical Appointments
Gym Membership
Culturally and Linguistically Appropriate Services
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Section II: Easy Choice Health Plan – Benefits Easy Choice’s benefit plans are open to all Medicare beneficiaries who meet all of the additional applicable eligibility requirements for membership (including those under age 65 who are entitled to Medicare on the basis of Social Security disability benefit); have voluntarily elected to enroll; and, whose enrollment in Easy Choice has been confirmed by the Centers for Medicare and Medicaid Services (CMS). Easy Choice provides comprehensive, coordinated medical services to members on a prepaid basis through established provider networks. Easy Choice Medicare Advantage Plan members must choose a Primary Care Physician (PCP) or Clinic and have all their care coordinated through this provider. Medicare Advantage plans are regulated by the Centers for Medicare and Medicaid Services (CMS), the same federal agency that administers Medicare, and by the California Department of Managed Health Care (DMHC).
Easy Choice Benefit Summary Easy Choice offers its members benefits such as, but not limited to, the following for 2017:
Inpatient Acute Hospital, Skilled Nursing and Psychiatric Care Home Health Care Doctor Office Visits Chiropractic Services Podiatry Services Outpatient Mental Health Care Outpatient Substance Abuse Care Outpatient Services/Surgery Ambulance Services Emergency Medical Services Outpatient Rehabilitation Services Durable Medical Equipment (DME) Prosthetic Devices Part D Prescription Drugs Hearing Aids Preventative Exams Acupuncture Out-of-Area Urgent and Emergent Medical Services Worldwide Emergency Travel Care Medical Nutrition Therapy Chiropractic Services Preventative and Comprehensive Dental Care Vision Services Transportation Services Gym Membership OTC Drugs
Value Added Services (VAS) Easy Choice is continually implementing programs to enhance its services to its members. These Value-Added Services are designed to provide members with additional services not usually covered by Traditional Medicare or other health plans. Value Added Services include:
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Acupuncture Easy Choice Members may self-refer to a contracted Acupuncturist without having to obtain authorization from their Primary Care Provider (PCP) or Easy Choice. For 2017, see the table below for the amount of covered visits per calendar year under this benefit. Please direct any questions to the Easy Choice Customer Services Department at (866) 999-3945. PBP Visits
001 12
002 18
005 12
016 6
017 18
Comprehensive Dental Easy Choice offers coverage for dental services, which is administered through Liberty Dental Plan of California, Inc. For 2017, all Members have access to dental services as part of their Easy Choice Benefits. Please refer to Section III: Coordination of Dental and Vision Services of the Provider Manual for additional information.
Comprehensive Vision and Eyewear Easy Choice Members have coverage for routine vision exam and eyewear through Premier Eye Care for 2017. Please refer to Section III: Coordination of Dental and Vision Services of the Provider Manual for additional information.
Hearing Aids Hearing Aids are not a Medicare-covered benefit. However, Easy Choice benefits offer a supplemental benefit through HearUSA. Because benefits may change each year, please refer members to their annual Summary of Benefits and Evidence of Coverage documents, which are available on the Easy Choice website at: www.easychoicehealthplan.com. Please direct any questions regarding Hearing Aids benefits to the Easy Choice Customer Services Department at (866) 999-3945.
Transportation to Medical Appointments Easy Choice has partnered with Veyo to provide transportation for medically necessary services. The purpose of this service is to 1) ensure that members obtain timely evaluation and treatment as recommended by their physicians; and 2) ensure that a member’s health care is not compromised by a lack of transportation. This benefit has some restrictions and limitations so please check the member’s Summary of Benefits or Evidence of Coverage or call the Easy Choice Customer Services Department at (866) 999-3945.
Gym Membership Easy Choice has partnered with 24 Hour Fitness to further promote health and wellness, and is offering members an annual basic gym membership as part of their covered benefits for 2017. See the table below to identify which plans offer the gym membership. Please direct any questions to the Easy Choice Customer Services Department at (866) 999-3945. PBP Gym
001 Yes
002 Yes
005 Yes
016 Yes
017 Yes
Culturally and Linguistically Appropriate Services
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Easy Choice recognizes that providing culturally and linguistically appropriate services is a crucial component to ensuring member access to quality health care services. As such, Easy Choice has a policy that when our enrolled membership reaches ten percent (10%) of the benefit plan population, member documents are translated into the spoken language. Currently, Easy Choice offers member information in Chinese, English, Spanish, Vietnamese, and Korean. In order to ensure culturally and linguistically appropriate services, Easy Choice: 1.
Recruits and employs qualified bilingual and bicultural staff who have the knowledge and experience of working within the culture.
2.
Provides cultural diversity and sensitivity training to its staff and provider office staff to promote understanding of cultural differences among ethnic communities.
3.
Provides access to interpreter services at key points of contact for all members, including those who may be deaf or hard of hearing. Program information is available and understandable to any non-English speaking member. This is accomplished through the use of a 24-hour interpretation service for telephone calls and a contract for face-to-face interpreter services to provide interpretation on a scheduled basis.
4.
Provides written materials in languages most familiar to Easy Choice members when any given population segment is equal to or greater than ten percent (10%) of the total member population. Member educational materials are developed at appropriate member literacy level and quantity for the given language.
5.
Conducts regular informational presentations and targeted outreach for different ethnic communities at community-based organizations to ensure that information on Easy Choice programs and benefits are dispersed to a wide range of members.
6.
Works closely with community and faith-based organizations across the county to ensure our members have a wide range of culturally and linguistically appropriate services available to them.
7.
Ensures that Easy Choice’s members have direct access to contracted specialist services whenever the member’s PCP in collaboration with the appropriate specialist and network medical director determine that the medical or service complexity warrants ongoing care by a specialist over a prolonged period of time. Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS) and complex cancer members are examples of conditions or members who require specialized medical care over a prolonged period of time.
8.
Assigns a Case Manager to members who are identified as high risk through the initial risk assessment or subsequently through a variety of avenues, such as inpatient, emergency room or outpatient access to ensure that care is provided in a timely, efficient and cost effective manner.
For More Information For information regarding any of Easy Choice’s Benefits, Value-added Services and/or Cultural and Linguistic Services, please contact Easy Choice at (866) 999-3945. If Easy Choice members have questions regarding the Easy Choice, please direct them to call our Customer Services Department at (866) 999-3945.
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Section III: Coordination of Dental & Vision Services
Dental Service Requests
Vision Service Requests
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Section III: Coordination of Dental & Vision Services For 2017, Easy Choice Health Plan members automatically receive preventative and comprehensive dental coverage when enrolling in a benefit plan. Easy Choice Members have coverage for routine vision exams and eyewear through Premier Eye Care for 2017. Because benefits may change each year, please refer members to their annual Summary of Benefits and Evidence of Coverage documents, which are available on the Easy Choice website at: www.easychoicehealthplan.com
Dental Service Requests Dental benefits are administered through Liberty Dental Plan of California, Inc. Easy Choice members may call any Dentist from the Liberty Dental Plan participating network to schedule an appointment. Members will receive a separate I.D. card from Liberty Dental Plan for their dental benefits. Any questions pertaining to dental services should be directed to Liberty Dental Plan of California, Inc. Member Services Department: Liberty Dental Plan of California, Inc. 3200 El Camino Real, Ste. #290 Irvine, CA 92602 (888) 704-9830 www.libertydentalplan.com
Vision Service Requests Easy Choice has partnered with Premier Eye Care to administer vision benefits. Covered members may schedule an appointment with any participating provider with Premier Eye Care to access their vision benefits. Questions may be directed to: Premier Eye Care (855) 865-9729 www.premiereyecare.net Rosters are provided to members for both dental and vision services upon enrollment with Easy Choice, on an annual basis, and also upon request. For further information, please contact our Customer Services Department at (866) 999-3945.
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Section IV: Member Enrollment & Eligibility
Member Enrollment Overview
Member Eligibility Overview
Eligibility List
Eligibility Verification Process
Eligibility Discrepancy
Member Disenrollment
Voluntary Disenrollment
Involuntary Disenrollment
Provider Initiated Member Disenrollment
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Section IV: Member Enrollment & Eligibility Member Enrollment Overview Easy Choice uses the following criteria to determine eligibility for membership:
A person must be entitled to Medicare Part A and enrolled in Medicare Part B as of the effective date of coverage under Easy Choice. This includes those under age 65 and qualified by Social Security as disabled.
A person must reside within the Center for Medicare and Medicaid Services (CMS) approved service area for Easy Choice (currently Los Angeles County, Orange County, Riverside County, San Bernardino County), and must not reside outside of the service area for periods of six (6) or more consecutive months.
A person must not have End Stage Renal Disease (ESRD) or have ongoing dialysis prior to signing an enrollment application for Easy Choice unless 1) the individual received a transplant which restores kidney function and dialysis is no longer needed or 2) the individual was previously enrolled with a M+C plan that terminated or withdrew from the county.
With the exception of ESRD, all pre-existing conditions are covered.
A person must make a valid enrollment request and submit to Easy Choice during an election period.
Individuals become enrolled with Easy Choice effective on the first day of the month after completing an enrollment application. When approaching the age of 65 and becoming entitled to Medicare Parts A and B on a prospective basis, Easy Choice may enroll these beneficiaries for future effective dates, up to ninety (90) days in advance. These individuals are referred to as “Age-Ins”. In the event a Primary Care Physician (PCP) and IPA is not selected on the enrollment form, Easy Choice will assist with selecting a PCP and IPA near his or her residence. Easy Choice encourages selection of a PCP within thirty (30) minutes or thirty (30) miles of a member’s residence.
Member Eligibility Overview Hospitals, Physicians, and all other healthcare providers are responsible for verifying each member’s eligibility prior to rendering services, unless it is an emergency. All members should have a health plan identification card, which should be presented each time services are requested. Please refer to Section XIV: Attachments of this manual for sample. The Health Plan Identification Card identifies the following information:
Health Plan: Easy Choice (plus specific Benefit Plan name such as “Freedom SNP”) HMO Member Name/Subscriber Name Member Health Plan Identification Number Primary Care Physician Effective Date (which could differ from Health Plan Effective Date) Primary Care Physician - name and phone number Affiliated IPA Pharmacy Information, including PBM name, phone numbers, and claims mailing address Non-Emergent Transportation phone number Customer Services - toll-free number
It is the responsibility of each provider to verify eligibility prior to providing services. Although the ID card is a primary method of identification, it does not guarantee coverage or benefits. Please see eligibility verification
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process below. Members are allowed to change health plans several times during election periods, thus his/her eligibility can change from month to month.
Eligibility List In order to ensure the proper management of care for members enrolled with Easy Choice, our contracted IPAs will have access to the Easy Choice FTP site to obtain current eligibility files by IPA. The electronic eligibility data will be updated on the 1st and the 15th day of every month. In the event that these days fall on a weekend or holiday, the eligibility files will be available on the next business day. The following three files will be posted on the FTP site using the bi-monthly schedule outlined above: 1.
System Import Eligibility File-in CSV format. a.
2.
Member Eligibility Summary List-in PDF format a.
3.
This will be used to import all electronic Easy Choice member eligibility into your internal member systems. (File Layout as found under Section XIV: Attachments).
This will outline all members accepted by CMS and currently enrolled with Easy Choice.
Member Pre-Enrollment Eligibility Summary List-in PDF format a.
This will outline all pre-enrolled members who have not yet been accepted by CMS but whose services are covered by Easy Choice.
Easy Choice provides an Eligibility List to all contracted IPAs bimonthly. These lists contain information regarding the member’s status with the health plan for that particular month. It is the responsibility of the IPA to share this information with its Primary Care Physicians and other contracted providers. Please refer to Section XIV: Attachments to obtain information on how to download eligibility files. For other provider inquiries, please contact our Customer Services Department at (866) 999-3945.
Eligibility Verification Process If a member does not have his/her ID card, or the member is not listed on the current eligibility list at the time of service, please verify eligibility by calling Easy Choice at (866) 999-3945. When contacting Easy Choice, please be prepared to give the following information:
Member’s name Member’s date of birth Member's Medicare ID number and/or Easy Choice ID number
Easy Choice also offers online eligibility verification. To check member eligibility online: 1.
Go to www.easychoicehealthplan.com
2.
Click on the “Providers” tab
3.
Click on the hyperlink for “Online Member Eligibility Verification”
4.
Enter the following information: Member's Easy Choice ID number Member’s date of birth Service Date
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5.
Member eligibility status along with the PCP and IPA information will be provided.
Please contact the Customer Services Department at (866) 999-3945 for questions related to member benefit information.
Eligibility Discrepancy In the event that an eligible member does not appear correctly on the monthly eligibility report, please notify Easy Choice’s Customer Services Department at (866) 999-3945. For example: 1. 2. 3. 4.
The member is eligible with the health plan but is not listed on the eligibility list. The member is not eligible with the health plan but is listed on the eligibility list. The PCP or IPA assignment is not accurate. The identification information on the eligibility list is not accurate.
Member Disenrollment Voluntary Disenrollment A member may choose to end his/her membership with Easy Choice by calling the Customer Services Department at (866) 999-3945. The disenrollment is effective the first of the month following the month in which the request was received. There should be no discontinuation or disruption of any health care services and treatments for members despite disenrollment with Easy Choice.
Involuntary Disenrollment Per CMS guidelines, Easy Choice may initiate member disenrollment for the following reasons:
Member loses or no longer has Medicare Part A & B coverage. Member permanently moves outside of Easy Choice’s service area or resides outside of Easy Choice’s service area for six (6) or more consecutive months. Member supplies fraudulent information or misrepresents himself/herself on the membership application to enroll with Easy Choice. Member commits fraud or allows another person to use his/her Easy Choice ID card to obtain services. The Member is disruptive, abusive, unruly, or uncooperative to the extent that Easy Choice’s ability to provide services is impaired. Please note that CMS must review this type of request.
Provider Initiated Member Disenrollment The Easy Choice Customer Services Department has developed a Policy and Procedure for documenting the process of disenrolling Medicare members from a physician practice. Providers may not end a relationship with a member because of the member’s medical condition or the cost and type of care that is required for treatment. Easy Choice procedures for involuntary transfer or disenrollment of members are based on the Centers for Medicare & Medicaid Services (CMS) requirements. A member may not be disenrolled without the consent of CMS. A Primary Care Physician may submit a request to initiate disenrollment for a member under any of the following circumstances:
Repeated (documented) abusive behavior by the patient. Physical assault to the provider, office staff or another member. Easy Choice Health Plan Provider Manual 24 of 162
Serious threats by the member or family member(s). Disruption to medical group operations. Inappropriate use of Out-of-Network services. Inappropriate use of medical services. Inappropriate use of Medicare services. Non-compliance with prescribed treatment plan. The member moves out of the Easy Choice service area. The member is temporarily absent from the Easy Choice service area for more than six consecutive months.
In instances where the member is disruptive, abusive, unruly or uncooperative, CMS must review any request for disenrollment from Easy Choice. The CMS review for most situations looks for evidence that the individual continued to behave inappropriately after being counseled/warned about his/her behavior and that an opportunity was given to correct the behavior. Counseling done by plan providers is considered informal counseling and an initial warning related to the member’s behavior must be sent by Easy Choice. Easy Choice requires documentation/records from the IPA prior to sending the member an official warning from the plan. If the inappropriate behavior was due to a medical condition, Easy Choice must demonstrate that the underlying medical condition was controlled and was not the cause of the inappropriate behavior. Please note that documentation in the patient’s medical record is pertinent evidence, along with police reports, if applicable. All requests to initiate disenrollment of a member along with supporting documentation should be sent via facsimile to the Manager of Membership Operations at (877) 999-3945. The information submitted will be reviewed and, if appropriate, forwarded to the CMS for consideration. Both the provider and the member will be notified via mail of the decision of Easy Choice and CMS. Please also refer to Requests to Disenroll a Member under Section XI: Quality Improvement of this Provider Manual for additional information.
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Section V: Customer Service
Toll-Free Numbers
Interpreter Services
Member Complaints and Grievances
Member Rights and Responsibilities
Transportation Scheduling
Call Center Standards & Requirements
Call Center Reporting Requirements
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Section V: Customer Service Toll-Free Numbers The Customer Service Department is designed to assist members and providers with all of Easy Choice’s ValueAdded Services and health plan benefit coordination.
Easy Choice can be reached as follows: Phone: (866) 999-3945 Fax: (877) 999-3945 TDD/TTY: (877) 247-6272 The Customer Services Department has friendly, knowledgeable and bilingual representatives that are available 8AM to 8PM every day of the week from October 1 st – February 14th and 8AM to 8PM Monday thru Friday from February 15th – September 30th. Our Customer Services Representatives assist Easy Choice members by answering questions regarding, but not limited to: Eligibility, General Benefits, Assigned Physician, Hospital Information and Pharmacy Locations. The Customer Services Department can also provide your patients with information about any of the following:
Status of Referrals and Authorizations Billing Questions Hospital Services Health Plan Options Community Resources and Support Groups Pharmacy Benefits and Coverage Grievances and Appeals Process ID Card Replacements
Interpreter Services In order to provide care to all eligible members in the language that the beneficiary is most comfortable with, Easy Choice has representatives who are fluent in Spanish, Korean, Vietnamese and English available onsite, and has contracted with Language Select for other languages. When a member needs to interact with the customer service department and does not speak a language in which the other party is fluent, the Language Line Service is to be utilized. When a member interacts with their Provider (PCP or Specialist) and does not speak a language in which the other party is fluent, it is the responsibility of the IPA to obtain an interpreter. A friend or family member is only to be used as an interpreter if specifically requested by the member. If the member asks to use a friend or relative as an interpreter, the Provider must document the member’s refusal to utilize the services of a qualified interpreter. Please reference your participating provider agreement with Easy Choice for clarification on the Interpreter Service requirements.
Member Complaints & Grievances
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The Customer Services Department is designed to assist members in obtaining health services according to their needs. If a member has a complaint regarding Easy Choice or any of its contracted providers, they may contact Customer Services toll free at (866) 999-3945. For example, a member could file a grievance if they had a problem with the following: Quality of medical care Difficulty in scheduling appointments Long wait times in a providers office or at the pharmacy Member complaints are documented, forwarded to the appropriate department for resolution, and kept on file. If the member’s complaint cannot be resolved informally to the member’s satisfaction he or she may file a formal grievance directly with the Easy Choice Customer Services Department at (866) 999-3945. Once the Member files a formal grievance, Easy Choice will work to resolve the grievance within thirty (30) calendar days of receipt. Easy Choice retains the responsibility for resolving its members’ grievances. All Easy Choice providers agree to cooperate and use best efforts to help resolve member grievances when brought to their attention.
Member Rights & Responsibilities Easy Choice communicates to members what their rights and responsibilities are when attempting to access care or are in the act of obtaining health care services. These rights and responsibilities are for all members, regardless of race, sex, culture, economic, educational or religious backgrounds. When a member exercises his/her rights to receive more information in regard to their “Rights and Responsibilities,” their first point of reference should be their Health Plan Member Services Evidence of Coverage Booklet. A second point of contact for the member is the Customer Services Department at (866) 999-3945. Easy Choice requires that the Member’s Rights and Responsibilities be posted in all provider offices. All members will receive a member handbook upon enrollment along with the Evidence of Coverage information, which details their right and responsibilities. Please refer to Section XIV: Attachments of this manual to view a copy of the Member Rights and Responsibilities from the 2017 Evidence of Coverage Booklet. In summary:
Each member has the following rights:
Dignified, courteous and considerate treatment Access to clinical and non-clinical services Access to medical records Confidentiality and privacy Communication in the language that works best for the member Explanation of the medical problem and treatment plan Notification when providers will be no longer contracted with Easy Choice Notification of appeals and grievance procedures with Easy Choice Prompt resolution of issues, concerns, complaints and grievances Access to emergency care as defined by a layperson Benefits included and excluded Information on procedures for prior authorization, quality assurance programs, disenrollment and other procedures affecting member access to care Selection of PCP from panel, including the right to relevant credentialing information Non-discrimination practices Participation in treatment decisions, information on treatment options, including the right to refuse care Privacy and confidentiality Information on durable power for health care
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Each member has the following responsibilities:
Understanding, and following the information in the Easy Choice Member Handbook Following his/her doctor’s treatment plan Notifying his/her doctor of medical condition Making and keeping appointments with provider and notifying the office when canceling a visit Learning about his/her medical condition and what maintains his/her health Actively joining in health care programs that maintain his/her wellbeing
Transportation Scheduling Easy Choice has partnered with Veyo to coordinate the transportation benefit for seniors enrolled in all Easy Choice Medicare Advantage (MAPD) plans. Transportation may be scheduled by the member or by the provider’s office staff each day of the week from 8AM to 8PM (PST) by calling (855) 388-8188. This does not apply to medicallynecessary transportation services, such as ambulance service. Veyo requests a minimum of forty-eight (48) hours advance notice for scheduling appointments. This benefit has some restrictions and limitations so please check the member’s Evidence of Coverage or call the Easy Choice Customer Services Department at (866) 999-3945.
For further information regarding the Transportation benefit, refer to Section II: Easy Choice Benefits of this Manual.
Call Center Standards & Requirements Call centers must meet the following operating standards:
Follow an explicitly defined process for handling customer complaints.
Provide interpreter service to all non-English speaking, limited English proficient and hearing impaired beneficiaries.
Inform callers that interpreter services are “free.”
Limit average hold time to two (2) minutes. The average hold time is defined as the time spent on hold by the caller following the interactive voice response (IVR) system, touch tone response system, or recorded greeting and before reaching a live person.
Answer eighty (80) percent of incoming calls within thirty (30) seconds.
Limit the disconnect rate of all incoming calls to five (5) percent.
Call Center Reporting Requirements The MSO/IPA will be required to submit monthly call center reports to the FTP site in folder identified as "Delegation Reports". Reports are due no later than the 15th of each month to capture the previous month’s data. Reports are required (at minimum) to consist of the following data elements below:
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Service Level (by month and YTD) demonstrating compliance with the requirement to answer 80% of all calls within 30 seconds.
Abandonment Rate (by month and YTD) demonstrating compliance with the requirement to have an abandonment rate below 5%.
Hold Times (by month and YTD) demonstrating compliance with the requirement to not exceed 2 minute hold times.
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Section VI: IPA Administration
Management Services Organizations (MSO)
Professional Network Management
Capitation Payment
Overview
Payment
Report
Non-Standard Deductions/Payments
Risk Pool Reporting
Hospital Risk Pool
Pharmacy Risk Pool
Surplus/Deficit Sharing
Settlement Calculations
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Section VI: IPA Administration The success of the relationship between the IPA and Easy Choice is contingent upon the cooperative efforts put forth by each party. The IPA must identify a Medical Director who will coordinate all matters related to patient care, quality assessment and utilization. The IPA must also identify a Health Plan Liaison who will assume the dayto-day responsibilities with regard to the IPA’s contractual obligations to Easy Choice. Easy Choice’s Network Management Department will work directly with the IPA to ensure that Easy Choice is fulfilling its obligations, and will act as the liaison for all administrative matters.
Management Services Organizations (MSO) IPAs that utilize Management Service Organizations (MSOs) to perform delegated functions must provide a copy of the contractual agreement between the IPA and MSO. MSOs not currently affiliated with Easy Choice are required to pass a Pre-Delegation Oversight Audit before the MSO can perform delegated activities on behalf of the IPA. Should an IPA determine to change or terminate their existing MSO, the IPA must provide Easy Choice ninety (90) days prior written notification of the change.
Professional Network Management Pursuant to the terms of its agreement with Easy Choice, the IPA must: A. Provide or arrange for the provision of all covered professional services and maintain 24-hour practice coverage. Primary care services must be provided by physician members of the IPA. If the IPA subcontracts for any non-primary care services, all subcontracts must meet the requirements stated in the Easy Choice participation agreement. B. Have written contracts that bind the provider to the applicable terms of the Easy Choice contract. C. Provide sample boilerplate templates of all IPA agreements. D. Provide and maintain access to, in accordance with CMS Time and Distance Standards, the following specialty medical services:
Primary Care Physicians o Family Practice o General Practice o Internal Medicine Allergy and Immunology Cardiology Cardiothoracic Surgery Chiropractor Dermatology Endocrinology ENT/Otolaryngology Gastroenterology General Surgery Gynecology, OB/GYN Infectious Diseases Nephrology Neurology Neurosurgery Oncology – Medical, Surgical
Oncology – Radiation/Radiation Oncology Ophthalmology Orthopedic Surgery Physiatry, Rehabilitative Medicine Plastic Surgery Podiatry Psychiatry Pulmonology Rheumatology Urology Vascular Surgery Urgent Care
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E. Provide readily accessible lab and other diagnostic services. F.
Provide signature pages to Easy Choice from all IPA agreements with contracted providers.
G. Ensure adequate practice coverage for their providers when specific providers are not available. H. Maintain and provide current information to Easy Choice on all physician providers. Easy Choice should be notified, in writing of any changes to an IPA’s physician network. I.
Provide the following information for each IPA provider participating in the Easy Choice Provider Network: 1.
Credentialing profile to include the following: Complete Name Primary Office Location(s) Telephone Numbers Office Hours Specialty Board Status (Board Name, Certification Specialty, Issue Date, Expiration Date) Completed Malpractice History Questionnaire California License Number Hospital Staff Privileges (List Hospitals and Types of Privilege) IRS Number Proof of Professional Liability Coverage DEA Certificate NPI Number Languages Spoken New Patient Acceptance Status
2.
A copy of the Recital and Signature Pages of the executed Agreement between the IPA and the provider.
Capitation Payment Overview Easy Choice shall pay the IPA a Capitation payment based upon the rate and methodology agreed to in the Capitated IPA Agreement.
Payment Easy Choice will make a Capitation payment by the 15th business day of each month to all contracted capitated IPAs. The Capitation Payment will include both current member eligible and retroactive member eligible capitation.
Report The Capitation Report will be available to the IPA utilizing an FTP Site. The report will be uploaded by the 15th day of each month. In the event the 15th falls on a non-business day, the Capitation Report will be available on the next business day. A file layout of the report can be found under Section XIV: Attachments.
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It is the responsibility of the IPA to forward a copy of the report to its Primary Care Physicians and other contracted providers. To request access to our FTP Site please refer to Connectivity and Communication under Section XIV: Attachments of this Provider Manual or contact the Easy Choice Network Management Department at (714) 2262800.
Non-Standard Deductions/Payments Details for any non-standard deductions or payments included in the IPA’s capitation will be provided in the form of a supplemental report which will also be made available on the FTP site.
Risk Pool Reporting Easy Choice may establish annual risk pool arrangements to provide an incentive for the efficient and effective utilization management of certain covered services. Risk pools shall be calculated, reconciled, reported and settled in accordance with established contractual terms included in the applicable Capitated IPA Agreement.
Hospital Risk Pool For capitated IPAs with a Hospital Risk Pool, a Hospital Risk Pool budget shall be established based on a percentage of CMS Part A and Part B premiums per member per month. Services and costs charged to the Hospital Risk Pool are defined in the Division of Financial Responsibility of the Capitated IPA Agreement. Such services typically include, but are not limited to, the following:
Actual costs for inpatient and other hospital services rendered to Easy Choice members assigned to participating and non-participating providers. A reasonable amount to account for hospital services incurred during the period but not reported at the time of settlement. Reinsurance Premiums. Any reinsurance recoveries or third party recoveries during the settlement period are credited to the Hospital Risk Pool.
In the event an IPA receives capitation for medical services and a hospital receives capitation for hospital and select outpatient services received by members assigned to that IPA, the parties may create and administer their own Hospital Risk Pool.
Pharmacy Risk Pool The Pharmacy Risk Pool budget is based on a percentage of premiums received from CMS for Part D benefits for each eligible member assigned to the capitated IPA. Easy Choice receives data from its Pharmacy Benefit Manager (PBM) of all prescriptions filled by members for formulary drugs at network pharmacies during the settlement period. Actual costs to Easy Choice for these drugs are charged to the Pharmacy Risk Pool.
Surplus/Deficit Sharing In the event the actual costs for risk pools are less than the budget and a surplus is generated, then the capitated IPA will receive a share of the savings. Conversely, in the event actual costs for risk pools exceed the budget and a deficit is incurred, the deficit shall first be applied to the risk pool surplus then carried-forward to the subsequent contract period. Surplus and deficit risk sharing are defined by and subject to the applicable terms of the IPA’s participation agreement.
Settlement Calculations Unless otherwise stated in the IPA’s participation agreement, settlements will be conducted on an annual basis. The Hospital Shared Risk Pool and Pharmacy Risk Pool shall be combined and offset each other prior to distribution. Easy Choice will provide Risk Pool reports and any payments owed to the capitated IPA within one hundred twenty Easy Choice Health Plan Provider Manual 34 of 162
(120) days following the close of the calendar year. These reports will include the following information for IPA to review:
Total member months Total budget amount Total expenses paid, including member detail, date(s) of service, description of service, payment amount and date of payment
Any questions or concerns pertaining to the information provided in the Risk Pool reports should be forwarded onto the Easy Choice Network Management Department at (714) 226-2800.
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Section VII: Provision of Professional Services
Primary Care Services
Terminations
PCP Terminations
Ancillary Provider/Hospital Terminations
Specialty and Ancillary Providers
Advance Directive
Disabled Member Services
On-Call Coverage (24 Hours/Day, 7 Days/Week)
Emergency Room Utilization
Confidentiality and Disclosure of Medical Information
Release of Confidential Information To The Patient
Release of Confidential Information To Personal Representatives
Release of Confidential Information To Employers
Release of Confidential Information To Providers
Release of Confidential Information – Outpatient Psychotherapy Records
Guidelines for the Written Request
Release of Confidential Information – Pursuant To A Subpoena
Medical Record Standards
Confidentiality and Availability of Medical Records
Retention of Records
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Section VII: Provision of Professional Services Primary Care Services Primary Care Physicians (PCP) are responsible for providing certain basic health care services to Easy Choice members. The PCP has primary responsibility for coordinating the member’s overall health care, which may include care planning during the member’s transition of care from one care setting to the next as well as ensuring the appropriate use of pharmaceutical medications. All Easy Choice members must choose a PCP or clinic at the time of enrollment, or one will be chosen for them.
Terminations PCP Terminations For a PCP termination, a minimum of forty-five (45) days prior written notice is required to allow for thirty (30) day advance notification to members. Terminations will be processed for the last day of the month. In the event a request for a PCP termination is received, the membership will be retained within the original IPA unless the PCP’s termination notice is accompanied with their termination letter to/from the originating IPA. Upon receipt of a written termination notice from the PCP with a request to transfer his/her membership from one IPA to another, the membership will follow the PCP to the designated IPA.
Ancillary Provider/Hospital Terminations For Ancillary Providers and Hospitals, it is not necessary for termination dates to be strictly at the end of the month; they are pursuant to the termination provision in the agreement.
Specialty and Ancillary Providers IPAs must comply with the following procedures in the event it is determined that an Easy Choice member may need to be referred for specialty or ancillary care services: 1.
When a member requests specific services, treatment or referral for specialty or ancillary services, the PCP is responsible for reviewing the request for medical necessity.
2.
Depending on the member’s IPA, an approved referral authorization may be required prior to a member having health care services rendered by a specialty or ancillary provider. Providers should refer to IPA specific Provider Manuals for these exceptions.
3.
The IPA and/or referring PCP is responsible for verifying a member’s eligibility with Easy Choice to ensure payment for services rendered and must also verify participating provider listings on all referral authorization requests so that referrals are to the appropriate network provider.
4.
All non-emergent inpatient and/or outpatient services for Easy Choice members are to be performed at a contracted facility with an approved referral authorization, if required.
5.
Easy Choice will distribute a participating Ancillary Provider list to contracted IPAs on a quarterly basis.
Advance Directive At the time of initial enrollment, Easy Choice will inform members of their rights to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate
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advance directives. (Medicare Managed Care Manual, Chapter 4 – Benefits and Beneficiary Protections, Section 160.2). A provider office shall have available written information regarding the member’s right to establish an Advance Directive, pursuant to the Patients Self Determination Act (PSDA). Members shall be asked whether they are aware of the PSDA and their right to execute an Advance Directive. If the member is unaware of the PSDA and their right, the provider shall give the member an informational pamphlet and inform the member of where he/she may obtain further information. Providers are required to document advance directive education in the member’s medical record. If an Advance Directive is executed, a copy must be filed in the member’s chart. Advance care planning is part of the Care for Older Adults Healthcare Effectiveness Data and Information Set (HEDIS) measurement which is reviewed annually by CMS. In order to be complaint with this measure, a member’s medical record must contain a copy of an Advance Directive or documentation, including dates, showing that discussions with the member regarding advance directives have taken place on an annual basis.
Disabled Member Services The Americans with Disabilities Act (ADA) requires public accommodations, including the professional office of a health care provider, to provide goods and services to people with disabilities on an equal basis as people without disabilities. If a provider is unable to accommodate a disabled patient, the IPA should arrange for the patient to be seen by a provider who is able to accommodate the member. For any inquiries or assistance, please contact the Easy Choice Customer Services Department at (866) 999-3945.
On-Call Coverage (24 Hour Hours/Day, 7 Days/Week) 1.
IPAs are responsible for arranging for on-call coverage.
2.
Individual providers arranging for on-call coverage should contact contracted IPAs with any questions relative to on-call services.
Emergency Room Utilization Emergency services are defined as the sudden, unexpected onset of a medical condition or injury manifesting itself by acute symptoms of sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention may result in:
Placing the health of the member (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part.
(NCQA UM Audit Tool, UM 12 Emergency Services, Element A) The IPA shall take into consideration the presenting and discharge diagnosis when reviewing emergency service claims for a potential retrospective denial (NCQA UM Audit Tool, UM 12 Emergency Services, Element B). Retrospective denial of services for what appears to the “prudent layperson” to be an emergency is prohibited.
Confidentiality and Disclosure of Medical Information
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The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires all physicians and health care professional to make reasonable efforts to limit disclosure of Protected Health Information (PHI), or individually identifiable health information that is transmitted or maintained, in any form or medium. The HIPAA Privacy Rule has established that written member authorization is required for any use or disclosure of PHI that is not related to treatment, payment or health care operations. The person or entity that is seeking to obtain medical information must obtain authorization from the member and is to use that information only for the purpose it was requested and retained only for the duration needed.
Release of Confidential Information to the Patient Information may be released to a member who is the subject of the information without a written request.
Release of Confidential Information to Personal Representatives 1.
A person authorized (under State or other applicable law, e.g., tribal or military law) to act on behalf of the member in making health care related decisions is the individual’s “personal representative.”
2.
Personal Representatives are appointed for members who are legally or otherwise incapable of exercising their rights, or simply choose to designate another to act on their behalf (this also includes minors that lack the statutory ability to consent to treatment).
3.
Covered entities shall treat a member’s personal representative as the member with respect to uses and disclosures of the member’s protected health information, as well as the member’s rights under the Privacy Rule.
4.
Members with mental retardation and/or who lack capacity, have the control over dissemination of their protected health information to the extent that state law provides such members with the ability to act on their own behalf.
5.
A covered entity can choose not to disclose information pursuant to a consent or authorization, in cases where state law has determined that a member has mental retardation, who lacks capacity and is not competent to act, but however expresses his/her desire that such information not be disclosed.
45 CFR 164 §164.502(g) Note: Covered entities must verify the authority of a personal representative, in accordance with applicable State law by, acceptable documentation (Health Care Power of Attorney; General Power of Attorney; Dual Power of Attorney or Letters of Conservatorship).
Release of Confidential Information to Employers 1.
A covered entity must obtain the member’s written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations.
2.
An authorization must be written in specific terms. It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party.
3.
Uses or disclosure of information that is inconsistent with the statements in the authorization constitute a violation of the Privacy Rule.
45 CFR 164 §164.508(a)
Release of Confidential Information to Providers
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Provider requests may be honored if the request pertains to that provider’s services. All other requests require the member’s or member representatives’ signed release. Electronic, facsimile, or written clinical information sent must be secured with limited access to those persons who are facilitating appropriate patient care and reimbursement for such care.
Release of Confidential Information – Outpatient Psychotherapy Records A written request must be received from the person or entity requesting member outpatient psychotherapy records. The only situation where a written request is not required is when the member has signed a waiver or form waiving notification to the patient and treating provider. The request must be sent to the patient within thirty (30) days of the receipt of the records except when the patient has signed a written letter or form waiving notification.
Guidelines for the Written Request The Written Request must be signed by the requestor identifying the following: 1. 2. 3.
What information is requested; Purpose of the request; and, Length of time the information will be kept;
The timeframe may be extended provided that the person or entity notifies the practitioner of the extension. Any notification of the extension must include the following: 1. 2. 3.
Specific reason for extension; Intended use of the information during the extended time; and, Expected date of destruction of the information.
The Written Request must specifically include the following: 1.
A statement that the information will not be used for any purpose other than its intended use;
2.
A statement that the person or entity requesting the information will destroy the information when it is no longer needed;
3.
Specifics on how the information will be destroyed, or specify that the person or entity will return the information and all copies of it before or immediately after the length of time indicated in the request.
4.
Specific criteria and process for confidentially faxing and copying outpatient psychotherapy records.
Release of Confidential Information – Pursuant to a Subpoena Member information is to be released in compliance with a subpoena duces tecum by an authorized designee in Administration. 1.
The subpoena must be accepted, dated and timed.
2.
The subpoena must allow at least twenty (20) days from the date of the subpoena to allow a reasonable time for the member to object to the subpoena and/or preparation and travel to the designated stated location.
3.
All subpoenas must be accompanied by either a written authorization for the release of medical records or a “proof of service” demonstrating the member has been “served” with a copy of the subpoena. Easy Choice Health Plan Provider Manual 40 of 162
4.
Alcohol or substance abuse records are protected by both Federal and State law (42 USC Section 290dd2;42C, CR 2.1 et.seq,; and Health and Safety Code Sections 1182 and 11977), and may not be released unless there is also a court order for release which complies with the specific requirements.
5.
Only the requested information is to be submitted, (HIV and AIDS information is excluded). HIV and AIDS or AIDS related information require a specific subpoena (Health & Safety Code Section 120980).
6.
If a notice contesting the subpoena be received prior to the required date, records will not be released without a court order requiring so.
7.
If no notice is received, records may be released at the end of the twenty (20) day period.
8.
Records should be sent through the US Postal Service by registered receipt or certified mail.
Medical Record Standards Medical records should reflect the following: A. All services provided directly by a practitioner who provides primary care services. B. All ancillary services and diagnostic tests ordered by a practitioner. C. All diagnostic and therapeutic services for which a member was referred by a practitioner, such as: Home health nursing reports Specialty physician reports Hospital discharge reports Physical therapy reports D. Each medical record must include: History and physicals Allergies and adverse reactions Problem list Medications Documentation of clinical finding and evaluation of each visit Preventive services/high risk screening
Confidentiality and Availability of Medical Records All medical records are required to be organized and stored in a manner that allows easy retrieval. Medical records should be kept in a secure location that allows access by authorized personnel only. Providers and employees are required to receive periodic training in member information confidentiality and must sign confidentiality statements. Providers must also have policies and procedures in place to protect and ensure confidentiality of member information at all times. In addition, providers must have a written policy regarding the release of medical records. Easy Choice reserves the right to review medical records. Providers must produce medical records to Easy Choice within 30 days of request for treatment, payment and Healthcare operations.
Retention of Medical Records Medical records and patient related data are to be retained in a locked storage area according to the following time periods:
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Data
Retention Period
Adult Patient Charts
10 years
Minor Patient Charts
(< 18 years of age) 1 year after the 18th birthday but not less than 10 years
X-rays
10 years
Sign-in Sheets
10 years
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Section VIII: Claims & Encounter Data Submission
Claims Submission Guidelines
Unlisted Procedures/Codes
Payment Based on Authorized Level of Care
Payment to Non-Contracted Providers
Claims Corrections/Resubmissions
Continuity of Care – Reimbursement for Services for Inpatient Member at the Time of Enrollment or Disenrollment
Enrollment
Disenrollment
Exception
Ineligible Members
Underpayments/Overpayments
Misdirected Claims
Monthly Timeliness Reports
Quarterly Reports
Coordination of Benefits
When Easy Choice is the Primary Payer
When Easy Choice is the Secondary Payer
Claims Processing Timelines
Provider Appeals and Dispute Resolution
Definitions
To Submit an Contracted/Non Contracted Provider Appeals & Claims Payment Disputes
Hold Harmless
Encounter Data Submission Guidelines
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Section VIII: Claims & Encounter Data Submission Note: Claims payment is determined according to the Division of Financial Responsibility (DOFR) in the provider participation agreement between Easy Choice and the IPA or Hospital, when applicable. If you are a provider, currently contracted with Easy Choice through a contracted and delegated IPA, please submit all claims to your contracted IPA. For all other Easy Choice contracted providers, please follow the guidelines in this Section.
Claims Submission Guidelines Easy Choice utilizes State and Federal guidelines as well as standard industry claims adjudication practices to process claims. All claims are reviewed and evaluated for medical necessity and irregularities prior to being processed. Reimbursement may be adjusted by Easy Choice based on its findings. Providers must ensure the following when submitting claims for payment to Easy Choice: A. All claims must be typed or electronic generated, Easy Choice does not accept handwritten claims. B. All claims information must be accurate, complete and truthful based upon the provider’s best knowledge, information and belief. C. Claims must be submitted on a CMS-1500 form, UB04 (CMS 1450), and follow the CMS-1500 form or UB04 (CMS 1450) guidelines/requirements or any other form approved by Easy Choice. This will expedite processing of your claim. Incomplete claims and/or illegible claims will be returned. Claims must adhere to the following guidelines: 1.
Claims must be itemized to include CPT/HCPC codes, quantities/units, diagnosis and revenue codes with modifiers and correlating ICD-9 codes. Billed services may be contested for correction of coding.
2.
Claims must include the following information: a. b. c. d. e. f. g. h. i. j. k. l.
Member Name Member’s Easy Choice ID Number Member’s Social Security Number Member's Date of Birth Member’s Gender Health Plan Provider’s Name Provider Address Provider Phone Number Date of Service ICD-9 & ICD-10 Code(s) CPT Code(s) or HCPCS Codes(s) - Current and valid codes for dates of service and per CMS guidelines m. Number of Services/Units n. Charge Per Services and Total Billed Charges o. Place of Service Easy Choice Health Plan Provider Manual 44 of 162
p. q. r. s. t. u.
Authorization Number, when applicable Copies of Reports when billing by Report Procedures National Provider Identifier (NPI). (Note: NPI should be included for both the treating physician and the vendor, regardless if they are same) Revenue Code(s) Tax Identification Number (TIN) Diagnosis codes, principal and others, if applicable, to the highest level of specificity with the applicable Present on Admission (POA) indicator on hospital inpatient claims per CMS guidelines
3.
Copies of operative, pathology, consultative reports and referral/ authorization form should be submitted with the claim for processing.
4.
ER claims must have ER notes attached.
5.
Modifier -25 required on UB’s for CPT code 9928X.
6.
Current National Drug Code (NDC) must be submitted for drugs.
7.
Copy of W9 form.
Please submit all claims to: Easy Choice Health Plan Attn.: Claims Department P.O. Box 260519 Plano, TX 75026-0519
Unlisted Procedures/Codes Easy Choice follows CMS payment guidelines and does not generally reimburse for services that are not recognized by CMS or do not have an associated CMS rate. All payments for services are subject to the applicable terms of your provider participation agreement with Easy Choice.
Payment Based on Authorized Level of Care All claims submitted to Easy Choice for reimbursement will be reviewed to ensure that the billed level of care is consistent with the level of care authorized by the IPA or Easy Choice. In the event a higher level of care is billed, Easy Choice will make payment to the provider based on the authorized level of care. Should a lower level of care than what has been authorized be billed, Easy Choice will assume the provider of service determined that a lower level of care was appropriate and pay the provider based on the lower level of care billed.
Payment to Non-Contracted Providers Pursuant to federal regulations, any provider who is approved or certified to participate in the Medicare program but not contracted with Easy Choice must accept the Medicare fee schedule for reimbursement if rendering services to an Easy Choice member. Providers sanctioned by Medicare or those who have opted out of participating in the Medicare program are not eligible to render services to Easy Choice members, unless on an emergent basis (for example, Emergency Room physician services needed to stabilize a member’s medical condition).
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Claim Corrections/Resubmissions In the event a corrected claim is needed, please submit the new CMS-1500 or UB-04 with the correction to: Easy Choice Health Plan Attn.: Claims Department P.O. Box 260519 Plano, TX 75026-0519 All original lines and charges, as well as the corrected or additional information should be included in any claims corrections/resubmissions. Claims should be flagged as a corrected or resubmitted claim. Any corrections written by hand will not be accepted; Easy Choice does not accept handwritten claims.
Continuity of Care - Reimbursement for Services for Inpatient Member at the Time of Enrollment or Disenrollment Enrollment Should a member be inpatient at an acute hospital facility on his/her first date of enrollment, Easy Choice is not required to provide nor assume responsibility to pay for any inpatient services covered under Medicare Part A during the member’s stay. It is the financial responsibility of the member’s prior Health Plan (or Medicare FFS) to reimburse the facility for all Part A services until the member has been discharged from the hospital. Payment for Part B (Physician) services is determined by the Division of Financial Responsibility in the participating provider agreements between Easy Choice and the IPA, and begins on the member’s effective date with Easy Choice.
Disenrollment In the event a member is inpatient on the date of disenrollment from Easy Choice, we continue to be financially responsible for inpatient services until he/she is discharged from the facility, except when the facility is exempt from the Prospective Payment System. Easy Choice or the IPA’s liability for Part B (Physician) services ends on the date a member is effectively disenrolled with Easy Choice. Payment falls under the financial responsibility of Medicare FFS or the member’s new Health Plan.
Exception The above rules do not apply to those hospitals that are not part of the Medicare Prospective Payment System (PPS). Should the member be inpatient at a non-PPS facility, Easy Choice will be financially responsible for services covered under Medicare Part A beginning on member’s effective date with Easy Choice or ending on the termination date, or disenrollment date, with Easy Choice.
Ineligible Members Easy Choice will not be financially responsible for services rendered to ineligible members, regardless of whether member may have been eligible at the time services were provided and retrospectively terminated. Providers may bill and collect payment directly from these members or from another source, as permitted by law.
Underpayments/Overpayments
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In the event an underpayment or overpayment is identified, please provide appropriate documentation, at minimum, that outlines the overpayment/underpayment, member information (ID, date of birth), date of service(s), billed amount and expected payment from Easy Choice. Any information pertaining to a third party payor is to be provided at this time as well. This information should be submitted to: Easy Choice Health Plan Attn.: Claims Department P.O. Box 260519 Plano, TX 75026-0519 Easy Choice will provide notification when any additional information is needed. Upon determination that a claim has been underpaid, Easy Choice will provide payment for the additional amount owed within forty-five (45) working days following the receipt of receiving or such request. In the event of an overpayment, Easy Choice may recoup the overpaid amount against future claim payments or through other means pursuant to the terms outlined in the provider participation agreement.
Misdirected Claims In the event an IPA or Hospital receives a claim that is the financial responsibility of Easy Choice, the claim should be denied as a misdirected claim and forwarded to Easy Choice within ten (10) calendar days from receipt of the claim. Each IPA or Hospital is responsible for maintaining a log of all misdirected claims that were forwarded to Easy Choice. The log is to be used as a record of claims that were sent to Easy Choice for future audit purposes and does not need to be submitted until requested. A sample of template of a Misdirected Claims Log can be found on the Industry Collaboration Effort (ICE) website at: https://www.iceforhealth.org/ (Refer to the Approved Documents under the Library tab) At minimum, the misdirected claims log must display the following: line of business, member name, member ID number, provider name, received date, date of service, billed amount and date forwarded. Should Easy Choice receive a claim that is the financial responsibility of a contracted IPA or Hospital, the claim will be denied as a misdirected claim and forwarded to the appropriate payer within ten (10) calendar days from receipt of the claim.
Monthly Timeliness Reports Monthly Timeliness Reports (MTR) should be submitted to Easy Choice by no later than the tenth (10th) of each month. These reports will be accepted via email and should be sent via FTP in folder “Delegation Reports”.
Quarterly Reports CMS Provider Dispute Request Quarterly Report and Medicare Advantage Part C Reporting Payment (claims) Organization Determinations/Considerations Report should be submitted to Easy Choice by no later than the following: Medicare Advantage Part C Reporting Payment (Claims) Organization Determinations/Considerations Report submit via FTP in folder “Part C Claims”: 1st Quarter
10th of April
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2nd Quarter 3rd Quarter 4th Quarter
10th of July 10th of October 10th of January
CMS PDR Quarterly Reporting submit via FTP in folder “Delegation Reports”: 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
10th of May 10th of August 10th of November 10th of February
Coordination of Benefits Occasionally, an Easy Choice member may have secondary healthcare insurance. For those members who are over 65 years of age and retired, Easy Choice will generally be the primary payer. However, a provider should always verify eligibility and ask the member whether he/she has healthcare insurance other than with Easy Choice.
When Easy Choice is the Primary Payer A. When Easy Choice is the primary payer, the IPA may bill the secondary carrier for usual and customary fees and receive compensation in addition to that received from Easy Choice. B. Under no circumstances may a member be billed for any balance due amount.
When Easy Choice is the Secondary Payer Easy Choice will be the secondary payer in the following situations: A. The member is age 65 or older and has coverage under an employer group health plan through an employer with 20 or more employees, either through the member’s own employment or the enrollee’s spouse’s employment. B. The member is under age 65 and is entitled to Medicare due to disability other than ESRD, and the member has coverage under a large employer (100 or more employees) group health plan, either through the enrollee's own employment or the enrollee's spouse's employment. C. The member is being treated for an accident or illness that is work-related or otherwise covered under Workers' Compensation. D. The member has ESRD and an employer group health plan. Easy Choice will be secondary for up to thirty (30) months; Medicare will be the primary payer after 30 months. E. The member is being treated for an injury, ailment, or disease caused by a third party, and automobile or other liability insurance is available. F.
The member has elected Hospice while enrolled with Easy Choice. During the hospice election period original Medicare is financially responsible for part A and B that are related or unrelated to the terminal illness.
Questions regarding Coordination of Benefits can be directed to the Easy Choice Customer Services Department at (866) 999-3945.
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Claims Processing Timelines Clean claims will be processed within sixty (60) calendar days of the date of receipt for contracted providers and within thirty (30) calendar days of the date of receipt for non-contracted providers.
Provider Appeals and Dispute Resolution Easy Choice has established fair, fast and cost-effective procedures to process and resolve Provider Appeals.
Definitions Contracted Provider Appeals A written notice to Easy Choice, submitted to the designated Provider Appeal address, challenging, appealing or requesting reconsideration of a claim, or requesting resolution of billing determinations, such as bundling/unbundling of claims/procedures codes or allowances; and a written notice to Easy Choice, submitted to the designated Provider Appeal address, disputing administrative policies & procedures, administrative terminations, retro-active contracting, or any other contract issue. Please refer specific language in your contract. Non Contracted Provider Appeals A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contracted provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal. Claims Payment Disputes
Provider Dispute Request (PDR) – A telephone or written dispute between non-contracted and Private Fee for Service Plans to include disputes between non-contracted providers and all: Medicare Advantage Organizations (HMO, PPO, RPPO, and PFFS), 1876 Cost Plans, Medi-Medi Plans, and Program of AllInclusive Care for the Elderly (PACE) organizations. Includes decisions where a non-contracted provider contends that the amount paid by the payer for a covered service is less than the amount that would have been paid under Original Medicare or instances where there is a disagreement between a non-contracted provider and the payer about the plan’s decision to make payment on a more appropriate code (down coding).
Provider Inquiry - A telephone or written request for information, or question, regarding claim status, submission of corrected claims, member eligibility, payment methodology rules (bundling/unbundling logic, multiple surgery rules), Medical Policy, coordination of benefits, or third party liability/workers compensation issues submitted by a provider to Easy Choice, or a telephone discussion or written statement questioning with the way Easy Choice processed a claim (i.e. wrong units of service, wrong date of service, clarification of payment calculation).
To Submit a Contracted/Non Contracted Provider Appeals & Claims Payment Disputes Must contain the following information: 1. 2. 3. 4. 5. 6.
The provider's name The provider's identification number - the Easy Choice provider identification number (PIN) and/or the provider's tax or social security number. Contact information - mailing address and phone number Easy Choice's Internal Control Number (ICN), when applicable The patient's name, when applicable The patient's Easy Choice subscriber number, when applicable Easy Choice Health Plan Provider Manual 49 of 162
7. 8. 9.
The date of service, when applicable A clear explanation of issue the provider believes to be incorrect, including supporting medical records when applicable. Completed claim form based on the Claims Submission Guidelines stated above.
Appeals must be submitted to the following: Non Contracted Provider Appeals: Easy Choice Health Plan 10803 Hope St., Ste. B Cypress, CA 90630 Fax: (855) 571-2053 Submission of appeals must be filed within a 120 calendar days after the notice of initial determination (i.e. EOB/RA/Letters). (42 CFR 405.940-405.942) Claims Payment Disputes must be submitted in writing to the following address: Easy Choice Health Plan Attn.: Claims Provider Disputes P.O. Box 260519 Plano, TX 75026-0519 Submission of a Contracted Provider Dispute must be filed based on the timeframe outlined in your agreement. NOTE: THE CMS PROVIDER DISPUTE MUST BE RESOLVED WITHIN 30 CALENDAR DAYS FROM RECEIPT. Claims processing errors should be brought to the attention of the Claims Department as soon as possible so that they may be corrected. These types of errors may be telephoned in by calling (866) 999-3945. Easy Choice will respond within thirty (30) working days of your Claims Provider Dispute. NOTE: THE CMS PROVIDER DISPUTE MUST BE RESOLVED WITHIN 30 CALENDAR DAYS FROM RECEIPT. Claims processing errors should be brought to the attention of the Claims Department as soon as possible so that they may be corrected. These types of errors may be addressed telephonically by calling (866) 999-3945.
Hold Harmless According to federal law, Providers may not bill HMO members for covered services except for applicable copayments. Title 42, Section 422.502(g)(1) and (i) states, "...protect its enrollees from incurring liability ...for payment of any fees that are the legal obligation of the M+C [now called Medicare Advantage or MA] organization". This requirement includes any services where the member is responsible for any co-payment (even if that copayment is $0). There can be no balance billing of the member for any portion of the billed charges that are in excess of that co-payment. Per the Medicare Managed Care Manual, Chapter 6, Section 100, "Consistent with §1852(a)(2) and §1852(k)(1) of the Social Security Act, non-contract providers must accept as payment in full, payment amounts applicable in Easy Choice Health Plan Provider Manual 50 of 162
Original Medicare. Thus, this provision of law imposes a cap on payment to non-contract providers of provide payment amounts plus beneficiary [member] cost-sharing amounts applicable in Original Medicare, and ensures that non-contract providers not balance bill M+C [now Medicare Advantage or MA] plan enrollees [members] for other than M+C [MA] cost-sharing amounts." In addition, under Federal law, non-contracted providers are subject to penalties if they accept more than Original Medicare amounts. None of the above precludes providers from billing members for any non-covered services (i.e., travel vaccinations or cosmetic surgery).
Encounter Data Submission Guidelines Encounter data and professional claims data for Easy Choice members are required. This information is needed by Easy Choice in order to comply with regulatory requirements, various reporting requirements and for Utilization Management oversight. In addition, reimbursement to Medicare Advantage plans by CMS is based on health status, or Hierarchical Condition Category (HCC), of each member, which is driven by the diagnoses codes submitted on claims and encounter data received by Easy Choice from IPAs, facilities and other health care professionals. At minimum, capitated IPAs, or other submitting entities, must submit encounter data by the fifteenth (15th) of the month for the previous month, based on the processed or finalized date of claim(s), for all Easy Choice members. All encounter data submissions are monitored for quality as well as quantity. Easy Choice has established a threshold of one hundred percent (100%) for encounter data submissions. In the event submissions fall below this level, capitated IPAs, or other submitting entities will be viewed as non-compliant. All encounter data must be accurate, complete and truthful based upon the provider’s best knowledge, information and belief. Because CMS may audit the data Easy Choice submits at any time, it is important that encounter data be reflective of the original CMS1500 or UB04 submitted by the provider of service. In order for encounters/claims data to be included and used in the calculation of CMS reimbursement to Easy Choice for each member, they must pass through audits which CMS applies. Any data that does not successfully pass the CMS audits will be returned to Easy Choice. Given that only the provider can make changes to or submit new claims data, Easy Choice will request correct or missing information from capitated IPAs or other submitting entities in order to resubmit the data to CMS. Easy Choice requires that encounters/claims data is submitted on a CMS 1500 or UB04 Form for all capitated services, including in the HIPAA mandated version EDI format ANSI 837P for Professional and 837I for Institutional. Please refer to the Connectivity and Communication under Section XIV: Attachments for more information regarding File Transfer Protocol (FTP) transmissions. For any questions pertaining to EDI or to obtain a companion guide, please contact:
[email protected]. Should encounter data need to be submitted on paper form, it should include the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Member Name Easy Choice Member ID Date of Birth Gender Date of Service ICD-9 Code(s) – ICD-10 Codes CPT Code(s) Revenue Code(s) IPA Name Provider Name NPI
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Please send hard copy or paper encounter data to: Easy Choice Health Plan Attn.: Encounter Data P.O. Box 260519 Plano, TX 75026-0519 Easy Choice shall have the right to perform routine medical record chart audits on IPA’s participating providers to determine accuracy and completeness of encounter data coding. Easy Choice may invoke a penalty in the event the IPA, or other submitting entity, fails to submit or meet the encounter data element requirements pursuant to terms of its participation agreement with Easy Choice.
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Section IX: Pharmacy Services
Pharmacy Benefit Management Company – CVS Caremark
Pharmacy Network
Mail Order Pharmacy Provider
Specialty Pharmacy Provider
Formulary
Formulary Exceptions Process
Requests for Formulary Changes
Information to Include in the Request
Address to Submit Formulary Requests
Notification of FDA Recalls
Medication Therapy Management Program (MTMP) Attachments Mail Service Order Form
Prior Authorization (DER) Request Form
A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) Programs
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Section IX: Pharmacy Services Pharmacy Benefit Management Company – CVS Caremark Easy Choice is changing its Pharmacy Benefit Manager (PBM) to CVS Caremark effective January 1, 2016.
Pharmacy Help Desk Phone: 1-844-803-1379 Website: www.cvscaremark.com
Pharmacy Network Participating pharmacies are part of the Easy Choice Pharmacy Network. A list of participating pharmacies can be found in the Easy Choice Provider Directory or online at www.easychoicehealthplan.com. In the event a member obtains a prescription from a non-participating pharmacy, any charges incurred will not be eligible for reimbursement, except if the prescription was not available at a participating pharmacy site (i.e., after hours, out of area, urgent/emergent prescriptions). In addition to having the ability to fill a prescription at one of the many Easy Choice participating pharmacy locations/sites, members also have the option to use a prescription mail order service.
Mail Order Pharmacy Provider CVS Caremark will continue to offer Pharmacy Mail Order Services. Members receive a 50% discount off one month’s copay for a 90-day supply. (Members will pay two full months copay and half off the third month copay amount). Beginning on January 1, 2017, members will have a zero copay for a 90-day supply of Tier 1 drugs if filled at a CVS mail service pharmacy. The mail order form can be found on our website as well as in the Appendix. CVS Caremark PO Box 94467, Palatine, IL 60094-4467 Phone: 1-866-808-7471 Fax: 1-800-378-0323 Website: www.cvscaremark.com
Specialty Pharmacy Provider Exactus Pharmacy Solutions will continue to offer specialty pharmacy services for those with complex and chronic illnesses. Representatives are available from Monday-Friday, 8 a.m. to 6 p.m. (ET). Exactus Pharmacy Solutions™ PO Box 31412, Tampa, FL 33631-3422 Phone: 1-888-458-9246 (TTY 1-855-516-5636) Fax: 1-866-458-9245 Website: www.exactusrx.com
Formulary Easy Choice’s formulary is a list of generic and brand name drugs reviewed and approved by our Pharmacy and Therapeutics Committee and CMS to be covered as a pharmacy plan benefit. The formulary is updated monthly throughout the year. Please check the Easy Choice website on a regular basis to obtain current formulary information at: www.easychoicehealthplan.com.
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Formulary Exceptions Process For any members participating in a treatment plan that requires a medication which was on the formulary at the beginning of the year, but was later removed, or members requesting coverage of a non-formulary medication, please contact Easy Choice’s Coverage Determination line at (866) 999-3945 to request information regarding the exceptions process or fax the Request for Medicare Prescription Drug Coverage Determination Form to (877) 2771809. You can also visit the Easy Choice website to download the “Medicare Prescription Drug Coverage Determination Form” at: www.easychoicehealthplan.com (under the Providers tab), also available in the Appendix. The exceptions process allows for providers to submit a request for consideration for a member to continue on a specific medication for the remainder of the benefit year or to have a non-formulary medication covered by Easy Choice.
Requests for Formulary Changes Any requests for changes to the formulary should be made in writing to Easy Choice.
Information to Include in the Request 1. 2. 3. 4. 5. 6. 7.
Name of the Drug Classification of the Drug Dosage (if more than one dosage is available) Rationale for the Request Requesting Provider’s Name Requesting Provider’s Contact Telephone and Facsimile Number Name of IPA
Address to Submit Formulary Requests Easy Choice Health Plan, Inc.’s, Clinical Pharmacy Department Director of Formulary Services Pharmacy & Therapeutics Committee PO Box 31577 Tampa, FL 33631-3577 Requests will be reviewed, and the results will be communicated to the requesting provider.
Notification of FDA Recalls Easy Choice will notify providers and any affected members of any FDA recalls. For any questions or additional information, please contact the Easy Choice Customer Services Department at (866) 999-3945.
Medication Therapy Management Program (MTMP) The Medication Therapy Management (MTM) program (MTM Program) is required by the Centers for Medicaid and Medicare Services (CMS) for all Part D Prescription Drug Plans (PDP) and Medicare Advantage Plans (MA). The program is not considered a benefit, but rather a free service offered to those who are eligible and qualify for the program. There is no change to a member’s insurance benefits, co-pays, prescription coverage, or available doctors or pharmacies. The MTM Program helps members get the greatest health benefit from their medications by:
Preventing or reducing drug-related risks Increasing member awareness Supporting good habits
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Please visit our website at www.easychoicehealthplan.com for the MTM eligibility criteria. Note that the eligibility criteria are subject to change yearly as set forth by CMS. A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) Programs document is also included in the Appendix for your reference.
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Attachments Mail Service Order Form
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Prior Authorization (DER) Request Form
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A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) Programs
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Section X: Utilization Management
Utilization Management Program
Referral Processing Responsibilities
Non-Discrimination in the Delivery of Health Care Services
Affirmative Statement
Out-of-Network Services
Authorization Response and Decision Making Notification Time Frames
Denial Notices
Utilization Management Criteria
Inpatient Acute Care, SNF, Psychiatric and Rehabilitation Admissions
Out-of-Area Inpatient Acute Care, SNF, Psychiatric and Rehabilitation Admissions
Rules for Coverage that Begins or Ends During an Inpatient Stay
Required Notification to Members for Observation Services
Inpatient Acute Discharge / Important Message Notice Letter
Skilled Nursing Facility, Home Health, CORF Discharge/Notice of Medicare NonCoverage/Detailed Explanation of Non-Coverage
IPA Reporting Requirements
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Section X: Utilization Management Utilization Management Program IPAs are delegated for all Utilization Management (UM) activities. The IPA is required to develop a UM program to include, but not limited to, the following:
A written program description Annual Work Plan Evaluation of Prior Year Work Plan A senior physician who actively participates in the UM Committee, signature is reflective on UM policies and procedures and has extensive involvement in the execution of and oversight of the UM program A designated behavioral healthcare practitioner to provider key behavioral healthcare aspects of the UM program Adoption and/or development of UM decision making criteria that are objective and based on medical evidence Annual review of interrater reliability to ensure consistent decision making of physician reviewers and nonphysician clinical reviewers Annual satisfaction assessment with UM processes A mechanism to assist members with transition to other care, if necessary, when benefits end
Referral Processing Responsibilities Each IPA has its own policies and procedures relative to the authorization process. The IPA is delegated to authorize all types of services to include, but not limited to, the following: 1. 2. 3. 4. 5. 6. 7. 8.
Professional Services including referrals for Specialty Care Outpatient Diagnostic and Surgical Procedures Rehabilitation Therapy including Acute Rehabilitation Unit (ARU) Inpatient Acute Care Long Term Acute Care (LTAC) Skilled Nursing Facility Admissions Home Health Services Durable Medical Equipment
Qualified licensed health professionals are required to supervise all medical necessity decisions. For services in which Easy Choice is responsible for payment, the IPA is required to authorize services to a provider that is contracted with Easy Choice. The Easy Choice Contracting Department will distribute an Ancillary Roster to all IPAs on a quarterly basis. Easy Choice may authorize and/or provide a tracking number for the following types of services: 1. 2. 3. 4.
Urgent or Emergent out-of-area professional and facility services (refer to your IPA Division of Financial Responsibility for services in which Easy Choice holds the responsibility) Power Operated Vehicles (POV) – IPA remains responsible for making the UM determination using Medicare coverage guidelines and evidence based criteria Organ Transplantation (the IPA remains responsible for all work up services prior to listing) Investigational or experimental services
IPA will notify Easy Choice UM Department prior to transferring members to LTAC or ARU.
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Non-Discrimination in the Delivery of Health Care Services Easy Choice and its IPAs are to ensure members are not discriminated against in the delivery of health care services consistent with benefits based on race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, such as ESRD, sexual orientation, claims experience, medical history, or evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment as outlined in the Medicare Managed Care Manual Chapter 4, 10.6 Anti-Discrimination Requirements. The following websites contain useful information about discrimination: http://www.eeoc.gov/policy/adea.html http://www.ada.gov
Affirmative Statement All UM decision making is to be based only on appropriateness of care and service and existence of coverage. Neither IPA nor Easy Choice shall specifically reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives for UM decision makers shall not encourage decisions that result in underutilization. Practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination, promotion, or any other similar matters. (NCQA UM Audit Tool UM 4, Element F)
Out-of-Network Services IPAs must make every attempt to authorize services that are the financial responsibility of Easy Choice to a provider within Easy Choice’s contracted network. If a member requires out-of-network services because Easy Choice is not contracted with a provider of like specialty, the IPA is required to notify Easy Choice’s Utilization Management Department prior to issuing an authorization. The Utilization Management Department will discuss the case with the Easy Choice Contracting Department and notify the IPA accordingly whether an authorization may be issued. For services that are the financial responsibility of the IPA, the IPA is required to follow its organization’s policy in reference to authorization of out-of-network providers.
Authorization Response and Decision Making Notification Time Frames At a minimum, IPAs are required to adhere to the CMS ICE Timeliness Standards. Please refer to the ICE website at www.iceforhealth.org to obtain the current Timeliness Standards document.
Denial Notices An offer of peer to peer to the requesting provider is required before rendering a denial decision. Documentation in the file must demonstrate evidence of offer of peer to peer including that the reviewing practitioner is available to discuss any UM denial and the notice must contain how the requesting practitioner can contact a physician reviewer.
Utilization Management Criteria The IPA is required to adopt or develop UM decision-making criteria that is objective and based on medical evidence. Criteria must be reviewed annually and updated as appropriate. Easy Choice criteria are available to practitioners on the Easy Choice website under “Clinical Coverage Guidelines,” and the criteria must be made available to members upon request.
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The denial letter rationale for denial reason must include clinical criterion and section used for the denial decision or if benefits or administrative denial evidence of coverage.
Inpatient Acute Care, SNF, Psychiatric and Rehabilitation Admissions A. The IPA is also responsible for authorizing and performing concurrent review on all acute care, SNF, psychiatric and rehabilitation admissions. B. The IPA or hospital is to notify Easy Choice’s Health Services Department of all admissions within one (1) business day of the admission. Notification should take place as follows: Phone: (866) 999-3945 Fax: (855) 547-9764 C. Easy Choice may assign a Case Manager to co-manage the inpatient stay. Note: It is the responsibility of the IPA’s Concurrent Review Nurse to obtain medical information and update Easy Choice as frequently as mutually agreed upon.
Out-of-Area Inpatient Acute Care SNF, Psychiatric and Rehabilitation Admissions A. Urgent or Emergent Out-of-Area admissions are monitored by the Easy Choice Health Services Department. B. If notified of an Urgent or Emergent Out-of-Area-Admission, the IPA is required to notify the Easy Choice Health Services Department within one (1) business day of the notification as follows: Phone: (866) 999-3945 Fax: (855) 547-9764 C. Unless specifically delegated to the IPA, Easy Choice Health Plan’s Utilization Management Department will be responsible for issuing an authorization, performing concurrent review, and working with the IPA to coordinate transfer of the member to an in-network facility once he/she has been stabilized. Upon notification of an Out-of-Area admission, it is the responsibility of the assigned IPA/MSO to secure a receiving hospital and a receiving physician.
Rules for Coverage that Begins or Ends During an Inpatient Stay This section applies to inpatient services in a hospital, psychiatric hospital, rehabilitation hospital, distinct part rehabilitation unit, or a long term acute care hospital. Should a member’s coverage with Easy Choice begin during an inpatient stay in an acute care hospital, psychiatric hospital, rehabilitation hospital, a distinct part rehabilitation unit, or a long term acute care hospital, Easy Choice is not financially responsible for services until the member is discharged from the facility. Payment for Part B (Physician) services is determined by the Division of Financial Responsibility in participating provider agreements with IPAs, and begins on the member’s effective date with Easy Choice. If a member’s coverage with Easy Choice ends during an inpatient stay in an acute care hospital, psychiatric hospital, rehabilitation hospital, a distinct part rehabilitation unit, or a long term acute care hospital, Easy Choice shall remain responsible for inpatient services until the date of discharge. Easy Choice or contracted IPA’s liability for Part B (Physician) services ends the date a member is effectively disenrolled with Easy Choice.
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(42 CFR – Public Health, Part 422 – Medicare Advantage Program §422.318) The above rules are not applicable to inpatient services in a Skilled Nursing Facility or to those hospitals that are not part of the Medicare Prospective Payment System (PPS).
Required Notification to Members for Observation Services In compliance with the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE ACT) effective August 6, 2015, contracted hospitals and critical access hospitals must deliver the Medicare Outpatient Observation Notice (MOON) to any Member who receives observation services as an outpatient for more than 24 hours. The MOON is a standardardized notice to a Member informing that the Member is an outpatient receiving observation services and not an inpatient of the hospital or critical access hospital and the implications of such status. The MOON must be delivered no later than 36 hours after observation services are initiated, or if sooner upon release. The OMB approved Medicare Outpatient Observation Notice and accompanying form instructions can be found at www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html. Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) Public Law 114-42, amending Section 1866(a)(1) of the Social Security Act (the Act) (42 U.S.C. 1395cc(a)(1)) 42 CFR 489.20 and 405.926
Inpatient Acute Discharge / Important Message Notice Letter As a delegated entity, the IPA must be aware of CMS Notification of Hospital Discharge Appeal Rights. Beginning July 2, 2007, hospitals must deliver a revised version of the Important Message from Medicare to inform Medicare beneficiaries who are hospital inpatients about their hospital discharge appeal rights. Notice is required both for Original Medicare beneficiaries and for those enrolled in Medicare health plans. Beneficiaries who choose to appeal a discharge decision will receive a more detailed notice. All members hospitalized in an acute care setting have the right to appeal to the Quality Improvement Organization (QIO) for an immediate review when a practitioner determines inpatient care is no longer necessary. If the member decides to appeal the discharge he/she must notify the QIO no later than midnight of the day of discharge and before the member leaves the hospital. If the member files an appeal with the QIO, Easy Choice will be notified by the QIO. The Easy Choice Health Services Department will phone the IPA and request the IPA to deliver the Detailed Notice of Discharge. This letter provides the member with an explanation why the hospital and IPA agree with the practitioner’s determination that the member should be discharged. The Detailed Notice of Discharge must be delivered as soon as possible, but no later than noon of the day after the QIO’s notification. Easy Choice will gather all supporting documents, to include, but not limited to: a copy of the IM, a copy of the Detailed Notice of Discharge and hospital medical records. These documents will be sent to the QIO as soon as possible but no later than noon of the day after the QIO notifies Easy Choice. If all of the above is submitted in a timely manner, the QIO will make a determination within one calendar day of receiving all of the pertinent information, and will notify Easy Choice of the outcome.
Skilled Nursing Facility, Home Health, CORF Discharge/Notice of Medicare Non-Coverage/Detailed Explanation of Non-Coverage The Notice of Medicare Non-Coverage (NOMNC) is a written notice designed to inform members that their covered skilled nursing facility (SNF), home health care, or comprehensive outpatient rehabilitation facility (CORF) care is ending.
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All members receiving any of the above services are required to receive a NOMNC upon termination of services. This notice is required to be delivered no later than two days prior to the proposed termination of services. As a delegated entity, the IPA is required to adhere to the CMS requirements surrounding notification requirements. In the event a member files an appeal with the Quality Improvement Organization (QIO), Easy Choice will be notified. Easy Choice, in turn, will notify the IPA and direct the IPA to issue a Detailed Explanation of NonCoverage (DENC). The DENC is a standardized written notice providing specific and detailed information on why the member’s services are ending. The IPA must issue the DENC immediately following notification and provide Easy Choice with a copy of the NOMNC, DENC, and medical records immediately because all documents must be forwarded to the QIO by no later than close of business (typically 4:30 PM) the day of the QIOs notification that the member requested an appeal, or the day before coverage ends, whichever is later. Members have the right to file an appeal 24 hours a day / 7 days a week including holidays and the IPA is required to comply with all QIO requests 24 hours a day / 7 days week including holidays.
IPA Reporting Requirements Utilization Management activities specific to Easy Choice members are required to be reported on a daily, monthly, quarterly, semiannual, and annual basis. Please see the Changes in Delegated Reports.
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Section XI: Quality Improvement
Easy Choice Quality Improvement Program
Program Summary
Access-to-Care Standards
Standards for Telephone Access
Standards for Office Wait Times
Access Audit
Medical Record Review
Health Effectiveness Data and Information Set (HEDIS)
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Health Outcomes Survey (HOS)
Appeals and Grievances
Requests to Disenroll a Member
Chronic Care Improvement/Disease Management
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Section XI: Quality Improvement Easy Choice Quality Improvement Program Quality Improvement (QI) is not a delegated function to the IPA. However, the IPA is required to adhere to the Quality Improvement Program as administered by Easy Choice. As a health plan, Easy Choice is responsible for the quality of care provided to our members. Throughout the year, the Quality Improvement Department, under the direction of the Quality Improvement Committee, performs audits of member/provider satisfaction, services provided, and monitors IPA activities to ensure that potential quality of care issues are identified and addressed in a timely manner. All practitioners are required to cooperate with Easy Choices QI activities, allow Easy Choice personnel with access to practitioner medical records, to the extent permitted by state and federal law, and all practitioners are required to maintain the confidentiality of member information and records. Practitioners may freely communicate with patients about their treatment, regardless of benefit coverage limitations.
Program Summary The purpose of the Easy Choice Quality Improvement Program is to establish and maintain methods for objectively and systematically evaluating and improving the quality, safety, appropriateness and outcome of clinical care and services to Easy Choice members. Quality Improvement staff work in accordance with contractual obligations to regulators and accreditation agencies. The program incorporates quality improvement methodology that focuses on the specific needs of Easy Choice’s multiple customers. It is organized to identify and analyze significant opportunities for improvement in care and service, to develop improvement strategies, and to systematically track whether these strategies result in progress towards established benchmarks or goals. The Quality Improvement Program provides for the collection, analysis, and reporting of data that measure health outcomes and indices of quality. The program measures its effectiveness through the collection, aggregation, analysis, and reporting of data that demonstrate:
Access to care Improvement in member health status Comprehensive health risk assessment A provider network having clinical expertise pertinent to the targeted special needs population Use of evidence based practices and nationally recognized clinical protocols Measurement of CMS required data on quality and outcomes measures. Data includes but is not limited to; Health Effectiveness Data and Information Set (HEDIS), Health Outcome Survey (HOS), Consumer Assessment of Healthcare Providers and Systems Plans Study (CAHPS) survey
Access-to-Care Standards Easy Choice has adopted standard criteria for the accessibility and availability of services. These guidelines are developed to ensure that health care and services provided are available and accessible to members at reasonable times. Easy Choice’s Quality Management Department conducts Access Studies no less than annually, which focus on appointment scheduling and waiting time according to the following Access-to-Care Guidelines: Primary Care Accessibility Service Urgent But Non-Emergency Non-Urgent But In Need of Attention Routine & Preventive Care
Standard within 24 hours within 7 days Within 30 days
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Mental Health Care Accessibility Service Standard Care of Non-Life Threatening Emergency Within 6 hours Urgent Care Within 48 hours Routine Office Visit Within 10 Business Days Routine Office Visits – after inpatient stay Within 7 days
Standards for Telephone Access During Normal Business Hours Answer by a Non Recorded Voice Abandonment Rate After Normal Business Hours Response Rate to After Hours Calls
Within 30 seconds Less than 5% Within 30 seconds
Standards for Office Wait Times The maximum wait time for the following services should be: Office Wait Time Urgent Routine and Preventive
Within 15 minutes Within 30 minutes
Access Audit On a bi-annual basis Easy Choice will conduct an access audit to ensure all Primary Care Providers (PCP), Specialists and Behavioral Health (BH) practitioners are compliant with the access to care standards as mandated by CMS and NCQA. The audit will include access during normal business hours and after hours. Areas to be audited will include, but is not limited to the following:
Access to routine care appointments (medical and BH) Urgent care appointments (medical and BH) After hours care and emergency direction Call answer timeliness After hours provider availability
Results will be tabulated and may be shared with the PCP, BH practitioner and/or IPA. Scores resulting in < 80% will require a Corrective Action Plan (CAP). Providers and/or the IPA will have 30 calendar days to respond to CAP requests. Audit results will be presented to the Easy Choice Quality Improvement Committee.
Medical Record Review Medical record review is one aspect of provider oversight conducted to assess and improve the quality of care delivered to members and the documentation of such care. The focus of the review may include, without limitation, patient safety issues, clinical and/or preventive guideline compliance, over- and under-utilization of services, confidentiality practices and inclusion of consideration of member input into treatment plan decisions. The review process allows for identification of the provider’s level of compliance with contractual, accreditation, and regulatory standards achieved. Provider training is conducted as needed to facilitate greater compliance in future assessments. The medical record review is completed at a minimum annually and/or as needed. Results will be tabulated and shared with the practitioner and/or the IPA. Scores resulting in < 80% will require a Corrective
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Action Plan (CAP). Providers and/or the IPA will have 30 calendar days to respond to CAP requests. Audit results are presented to the Easy Choice QIC committee.
Healthcare Effectiveness Data and Information Set (HEDIS) HEDIS Guidelines for the Effectiveness of Care Measures serve as a means by which quality improvement of health care delivery by providers and their organizations may be measured. Easy Choice and its affiliated providers are mandated by CMS to deploy the HEDIS process in determining the quality of care through an evaluation of the health care screening processes identified for a number of specific disease entities. These represent a cross-section of the most commonly occurring pathologies and therefore include: (1) Prevention and Screening: Adult BMI Assessment, Breast Cancer Screening, Colorectal Cancer Screening, , Evaluation of Care of Older Adults , (2) Respiratory Conditions: Use of Spirometry in the Assessment and Diagnosis of COPD, Pharmacotherapy Management of COPD Exacerbation, (3) Cardiovascular Conditions: Controlling High Blood Pressure, Persistence of Beta Blocker Treatment after a Heart Attack, (4) Diabetes: Comprehensive Diabetes Care, (5) Musculoskeletal Conditions: Disease–Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis, Osteoporosis Management in Women Who Had a Fracture, (6) Behavioral Health: Antidepressant Medication Management, Follow-Up After Hospitalization for Mental Illness, (7) Medication Management: Annual Monitoring for Patients on Persistent Medications, Medication Reconciliation Post-Discharge, Potentially Harmful Drug-Disease Interactions in the Elderly, Use of High–Risk Medications in the Elderly, (8) Access/Availability of Care: Adults’ Access to Preventive/Ambulatory Health Services, Initiation and Engagement of Alcohol and Other Drug Dependence Treatment. Refer to PROVIDER QUICK REFERENCE GUIDE TABLE (HEDIS MEDICARE MEASURES)
MEASURE
Annual Wellness Visit
PREVENTION AND SCREENING AGE/GENDER CRITERIA REQUIRED SERVICE
All members
At least one preventive wellness visit during the year
ACCEPTABLE CODES
HCPCS: G0439 Adult BMI values: Less than 19: V85.0 19 to 24: V85.1 25 to 29: V85.21-V85.25 30 to 39: V85.30 –V85.39 40 to 49: V85.41-V85.42 50 to 59: V85.43 60 to 69: V85.44
Body Mass Index (BMI) Assessment
Members up to 74 years old
Documentation of weight and BMI value
>70: V85.45 Adult BMI values: 19 or less: Z68.1 20 to 24: Z68.20 – Z68.24 25 to 29: Z68.25 – Z68.29 30 to 39: Z68.30 – Z68.39 40 to 49: Z68.41, Z68.42 50 to 59: Z68.43 60 to 69: Z68.44 >70: Z68.45
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MEASURE
PREVENTION AND SCREENING AGE/GENDER CRITERIA REQUIRED SERVICE
Female members 50-74 years old Breast Cancer Screening
Exclusions: hx of bilateral mastectomy or two unilateral mastectomy
ACCEPTABLE CODES
HCPCS: G0202, G0204 Mammogram screening at least every two years
ICD9PCS: 87.36, 87.37 CPT: 77055-77057
Colorectal cancer screening by any one of three test: Members: Colorectal Cancer Screening
50-75 years old 50-75 years old
Fecal occult blood test (FOBT) – Calendar year or DNA FIT Kit every 2 years Flexible Sigmoidoscopy every 5 years
CPT4 codes: 82270 – 3 gFOBTs 82274 – 1 iFOBT/FIT 81528 – DNA FIT Kit
Colonoscopy - every 10 years HCPCS: S0257 CPT II codes: 1157F, 1158F 1159F AND 1160F
Care for Older Adults 1. Advanced Care Planning 2. Medication Review 3. Functional Status Assessment 4. Pain Screening
Members 65 years old and older
1. Presence of an advanced care plan such as advance directive, actionable medical orders, living will, power of attorney, health care proxy
1170F
2. Medication list in the medical record, and evidence of a medication review by a prescribing practitioner or clinical pharmacist
HCPCS: S0257
3. Complete functional status assessment
1125F – if 1-10 pain level 1126F – if 0 pain level noted
CPT II codes: 1157F, 1158F
1159F AND 1160F
4. Evidence of pain assessment 1170F 1125F – if 1-10 pain level 1126F – if 0 pain level noted
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MANAGEMENT OF CHRONIC CONDITIONS AGE/GENDER REQUIRED SERVICE CRITERIA
MEASURE
1. Hemoglobin A1c testing – at least annually Goal:
