20 Provider Manual - PA Health & Wellness

2020 Provider Manual

Provider services: 1-844-626-6813

TDD/TTY 1-844-349-8916



? 2020 PA Health & Wellness. All rights reserved.

Welcome ...................................................................................................... 6

About Us ..................................................................................................................... 6

About this Manual ...................................................................................................... 6

Key Contacts ............................................................................................... 7

Populations Served .................................................................................... 8

Verifying Eligibility ...................................................................................... 9

Participant Identification Card .................................................................................. 9

Online Resources ..................................................................................................... 10

Secure Website ......................................................................................... 10

Functionality ............................................................................................................. 11

Secure Portal Disclaimer ......................................................................................... 11

Guidelines for Providers .......................................................................... 11

Medical Home Model ................................................................................................ 11

Referrals .................................................................................................................... 12

Self-Referral .............................................................................................................. 13

Non-Covered Services ............................................................................................. 13

Appointment Availability and Access Standards .................................................. 14

Covering Providers .................................................................................................. 16

Telephone Arrangements ........................................................................................ 16

24-Hour Access ........................................................................................................ 17

Confidentiality Requirements .................................................................................. 18

Cultural Competency ............................................................................................... 19

Americans with Disabilities Act (ADA) ................................................................... 22

Reporting Suspected Abuse and Neglect .............................................................. 22

Mainstreaming .......................................................................................................... 23

Advance Directives .................................................................................................. 23

Primary Care Practitioner (PCP) ............................................................................. 25

Specialist Responsibilities ...................................................................................... 27

Hospital Responsibilities ......................................................................................... 28

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Long-Term Services and Supports Provider Responsibilities ............................. 29

New Provider Orientation ........................................................................................ 29

Voluntarily Leaving the Network ............................................................................. 30

Benefit Explanations and Limitations .................................................... 30

Covered Services ..................................................................................................... 30

LTSS Service Definitions ......................................................................................... 34

Network Development and Maintenance................................................ 58

Non-Discrimination .................................................................................................. 59

Tertiary Care ............................................................................................................. 59

Out-of-Network ......................................................................................................... 59

Network Termination ................................................................................................ 59

Medical Management ................................................................................ 60

Overview ................................................................................................................... 60

Medically Necessary ................................................................................................ 60

Care Management Program ..................................................................................... 60

Long Term Services and Supports (LTSS) ............................................. 69

Role of the Service Coordinator .............................................................................. 69

Provider¡¯s Role in Service Planning and Service Coordination ........................... 69

Service Request Process for LTSS Services ......................................................... 69

Service Request Grievance Process ...................................................................... 70

Emergency Care Services ....................................................................................... 70

Utilization Management ............................................................................ 71

Prior Authorizations ................................................................................................. 72

Second Opinion ........................................................................................................ 76

Assistant Surgeon .................................................................................................... 77

New Technology ....................................................................................................... 77

Notification of Pregnancy ........................................................................................ 77

Concurrent Review and Discharge Planning ......................................................... 77

Retrospective Review .............................................................................................. 78

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Speech Therapy and Rehabilitation Services ........................................................ 78

Advanced Diagnostic Imaging ................................................................................ 78

Cardiac Solutions ..................................................................................................... 78

Clinical Practice Guidelines ..................................................................... 80

Pharmacy ................................................................................................... 80

Working With the Pharmacy Benefit Manager (PBM) ............................................ 80

Utilization Management (UM) .................................................................................. 81

Pharmacy Prior Authorization ................................................................................. 81

Preferred Drug List (PDL)......................................................................................... 82

Pharmacy and Therapeutics Committee (P&T) ...................................................... 83

Unapproved Use of Preferred Medication .............................................................. 83

Prior Authorization Process .................................................................................... 84

Step Therapy............................................................................................................. 85

Benefit Exclusions.................................................................................................... 86

Injectable Drugs........................................................................................................ 86

Specialty Pharmacy Program .................................................................................. 86

Dispensing Limits, Quantity Limits and Age Limits............................................... 86

Mandatory Generic Substitution.............................................................................. 87

Over-The-Counter Medications (OTC) ..................................................................... 87

Prior Authorization by Phone .................................................................................. 87

Recipient Restriction Program ................................................................................ 87

Provider Relations and Services ............................................................. 88

Provider Relations .................................................................................................... 88

Provider Services ..................................................................................................... 89

Credentialing and Re-Credentialing ....................................................... 89

Overview ................................................................................................................... 89

Which Providers Must be Credentialed? ................................................................ 89

Information Provided at Credentialing ................................................................... 90

Credentialing Committee ......................................................................................... 92

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Re-Credentialing ....................................................................................................... 92

Loss of Network Participation ................................................................................. 92

Right to Review and Correct Information ............................................................... 93

Right to Be Informed of Application Status ........................................................... 93

Right to Appeal Adverse Credentialing Determinations ....................................... 93

Disclosure of Ownership and Control Interest Statement .................................... 93

Provider Education ................................................................................... 94

Overview ................................................................................................................... 94

Provider Education: Training Offered..................................................................... 94

Rights and Responsibilities ..................................................................... 96

Participant Rights ..................................................................................................... 96

Participant Responsibilities .................................................................................... 97

Provider Rights ......................................................................................................... 98

Provider Responsibilities ........................................................................................ 98

Complaint and Grievance Process ....................................................... 101

Participant Complaints .......................................................................................... 102

Participant Grievances........................................................................................... 104

Second Level Grievance Review ........................................................................... 106

Expedited Grievances ............................................................................................ 106

External Grievance Review Process ..................................................................... 107

Reversed Grievance Resolution ........................................................................... 107

Provider Disputes ................................................................................... 108

Waste, Fraud and Abuse ........................................................................ 109

Self-Audit Protocol ................................................................................................. 111

Quality Management ............................................................................... 112

Program Structure .................................................................................................. 112

Provider Involvement ............................................................................................. 113

Quality Assessment and Performance Improvement Program .......................... 113

Patient Safety and Quality of Care ........................................................................ 114

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