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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