2019 Provider Manual

[Pages:117]2019 Provider Manual

Provider services: 1-844-626-6813

TDD/TTY 1-844-349-8916



? 2017 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 Voluntarily Leaving the Network.............................................................................29

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

Covered Services .....................................................................................................30 LTSS Service Definitions .........................................................................................33

Network Development and Maintenance .............................................. 56

Non-Discrimination ..................................................................................................57 Tertiary Care .............................................................................................................57

Medical Management ............................................................................. 57

Overview ...................................................................................................................57 Medically Necessary ................................................................................................57 Care Management Program.....................................................................................58

Long Term Services and Supports (LTSS) ........................................... 64

Role of the Service Coordinator..............................................................................64 Provider's Role in Service Planning and Service Coordination...........................65 Service Request Process for LTSS Services .........................................................65 Service Request Grievance Process ......................................................................65 Emergency Care Services .......................................................................................66

Utilization Management ......................................................................... 66

Prior Authorizations .................................................................................................67 Second Opinion........................................................................................................71 Assistant Surgeon....................................................................................................72 New Technology.......................................................................................................72 Notification of Pregnancy ........................................................................................72 Concurrent Review and Discharge Planning .........................................................72 Retrospective Review ..............................................................................................73 Speech Therapy and Rehabilitation Services ........................................................73 Advanced Diagnostic Imaging ................................................................................73 Cardiac Solutions.....................................................................................................73

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Clinical Practice Guidelines................................................................... 75 Pharmacy ................................................................................................ 75

Working With the Pharmacy Benefit Manager (PBM) ............................................75 Pharmacy Prior Authorization.................................................................................76 Preferred Drug List (PDL).........................................................................................77 Pharmacy and Therapeutics Committee (P&T) ......................................................77 Unapproved Use of Preferred Medication ..............................................................78 Prior Authorization Process ....................................................................................78 Step Therapy.............................................................................................................79 Benefit Exclusions....................................................................................................80 Injectable Drugs........................................................................................................80 Specialty Pharmacy Program..................................................................................80 Dispensing Limits, Quantity Limits and Age Limits...............................................80 Mandatory Generic Substitution..............................................................................81 Over-The-Counter Medications (OTC).....................................................................81 Participant Lock-In Program ...................................................................................82

Provider Relations and Services ........................................................... 83

Provider Relations....................................................................................................83 Provider Services .....................................................................................................83

Credentialing and Re-Credentialing...................................................... 83

Overview ...................................................................................................................83 Which Providers Must be Credentialed?................................................................84 Information Provided at Credentialing ...................................................................84 Credentialing Committee .........................................................................................86 Re-Credentialing....................................................................................................... 86 Loss of Network Participation.................................................................................87 Right to Review and Correct Information...............................................................87 Right to Be Informed of Application Status ...........................................................87 Right to Appeal Adverse Credentialing Determinations .......................................87

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Disclosure of Ownership and Control Interest Statement ....................................88

Rights and Responsibilities................................................................... 88

Participant Rights.....................................................................................................88 Participant Responsibilities ....................................................................................90 Provider Rights.........................................................................................................91 Provider Responsibilities ........................................................................................91

Complaint and Grievance Process........................................................ 94

Participant Complaints ............................................................................................94 Participant Grievances.............................................................................................96 Second Level Grievance Review.............................................................................98 Expedited Grievances ..............................................................................................98 External Grievance Review Process.......................................................................99 Reversed Grievance Resolution ...........................................................................100

Provider Disputes................................................................................. 100 Waste, Fraud and Abuse...................................................................... 101

Self-Audit Protocol .................................................................................................103

Quality Management ............................................................................ 103

Program Structure..................................................................................................104 Provider Involvement .............................................................................................105 Quality Assessment and Performance Improvement Program..........................105 Patient Safety and Quality of Care ........................................................................106 Performance Improvement Process .....................................................................106 Feedback on Provider Specific Performance ......................................................107 Healthcare Effectiveness Data and Information Set (HEDIS) .............................108 Critical Incidents and Preventable Serious Adverse Events (PSAEs) ...............109

Medical Records Review...................................................................... 111

Required Information .............................................................................................111 Medical Records Release ......................................................................................113 Medical Records Transfer for New Participants ..................................................113

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Regulatory Matters ............................................................................... 113

Section 1557 of the Patient Protection and Affordable Care Act .......................113 Chapter 1101. General Provisions ........................................................................114

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WELCOME

Welcome to PA Health & Wellness! Thank you for being part of our network of healthcare professionals. We look forward to working with you to improve the health of our Pennsylvania communities, one person at a time. About Us PA Health & Wellness was established to deliver quality healthcare in the state of Pennsylvania through local, regional, and community-based resources. PA Health & Wellness is a Managed Care Organization and subsidiary of Centene Corporation (Centene). PA Health & Wellness exists to improve the health of its Participants through focused, compassionate, and coordinated care. Our approach is based on the core belief that quality healthcare is best delivered locally. PA Health & Wellness will serve Participants in the Community HealthChoices program. Community HealthChoices is a new program designed to coordinate physical healthcare and long-term services and supports (LTSS) for older persons, persons with disabilities, and Pennsylvanians who are dually eligible for Medicare and Medicaid (dual eligible). About this Manual The Provider Manual contains comprehensive information about PA Health & Wellness operations, benefits, policies, and procedures. The most up-to-date version can be viewed from the "For Providers" section of our website . You will be notified of updates via notices posted on our website and/or in Explanation of Payment (EOP) notices. Billing guidelines and information can be found in the PA Health & Wellness Provider Billing Manual, located in the "For Providers" section of our website .

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KEY CONTACTS

The following chart includes several important telephone and fax numbers available to your office. When calling PA Health & Wellness, please have the following information available:

? NPI (National Provider Identifier) number ? Tax ID Number (TIN) ? Participant's PA Health & Wellness ID number or Medicaid ID number

Department

Telephone Number

Fax Number

Provider Services

1-844-626-6813 TTY: 1-844-349-8916

Participant Services

1-844-626-6813 TTY: 1-844-349-8916

Prior Authorization Request

1-844-626-6813 TTY: 1-844-349-8916

Concurrent Review

1-844-626-6813 TTY: 1-844-349-8916

Self-Referral

1-844-626-6813 TTY: 1-844-349-8916

Care Management

1-844-626-6813 TTY: 1-844-349-8916

24 Hour Nurse Advice Line (24/7 1-844-626-6813

Availability)

TTY: 1-844-349-8916

DHS FFS Provider Service Center 1-800-537-8862

1-844-706-7719 1-844-706-7719 1-844-360-1034 1-844-883-4140

1-844-360-9981

DHS FFS Recipient Service Center

1-800-537-8862

HealthChoices MCO Plan Enrollment

1-800-440-3989

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