IL - Meridian Medicaid Provider Manual 2021

PROVIDER MANUAL

Revised June 2021

Illinois Provider Manual 300 S. Riverside Plaza, Suite 500 Chicago, IL 60606

312-705-2900 866-606-3700



Meridian Medicaid Provider Manual 2021 ? Illinois (Revised 6/2021)

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Dear MeridianHealth Provider,

MeridianHealth (Meridian) would like to welcome you to the Meridian network of providers. Our Provider Manual was designed to assist you with understanding plan policies, procedures, and other protocols, as well as to be used as a reference tool for you and your staff.

The Provider Manual is a dynamic tool and will evolve with MeridianHealth. Minor updates and revisions will be communicated to you via Provider Bulletins and digital newsletters, which serve to replace the information found within this Provider Manual. Major updates and revisions will be communicated to you via a revised edition of the Provider Manual, which will be provided to you. The revised edition will replace older versions of the Provider Manual. Furthermore, any material modifications to the Provider Manual shall be communicated to you with a sixty day written notice.

The current Provider Manual is always available on our website at .

Please contact your local Network Provider Relations Representative or our Member and Provider Services department at 866-606-3700 with any questions or concerns.

Thank you for your participation.

MeridianHealth

Table of Contents

Section 1: General Information ......................................................................................................... 8 Our Mission, Vision, and Philosophy........................................................................................................ 8 About MeridianHealth ............................................................................................................................. 8 Contact Information................................................................................................................................. 9

Section 2: Member-Related Information ......................................................................................... 10 Member Services Department............................................................................................................... 10 Member Rights and Responsibilities...................................................................................................... 10 Interpretive Services and Alternative Formats ...................................................................................... 11 Eligibility Requirements ......................................................................................................................... 12 Medicaid................................................................................................................................................. 12 Member Identification ........................................................................................................................... 12 Eligibility Information............................................................................................................................. 13 Medicaid................................................................................................................................................. 13 PCP Identification and Verification ........................................................................................................ 13 PCP Changes........................................................................................................................................... 14 Non-Emergent Transportation: Medicaid.............................................................................................. 14 Transportation Procedure...................................................................................................................... 14 Member Enrollment and Disenrollment................................................................................................ 15 Notice of Privacy Practices..................................................................................................................... 15 Member Satisfaction.............................................................................................................................. 15 Grievances and Appeals......................................................................................................................... 15 Member Grievances............................................................................................................................... 15 Member Appeals.................................................................................................................................... 16 Member Expedited Appeal .................................................................................................................... 17 Medicaid External Independent Review of Appeals (Home and Community Based Services excluded) ............................................................................................................................................... 17 Medicaid Expedited External Independent Review of Appeals (Home and Community Based Services excluded) ............................................................................................................................................... 18 State Fair Hearing................................................................................................................................... 18 Provider Directory.................................................................................................................................. 19

Section 3: Member Benefit Information .......................................................................................... 19 Member Benefits ................................................................................................................................... 19 Services Covered under MLTSS.............................................................................................................. 20 Medicaid Benefits Not Covered by Meridian......................................................................................... 21 Non-Covered Services ............................................................................................................................ 21 Non-Covered For Medicaid Only............................................................................................................ 21



Meridian Medicaid Provider Manual 2021 ? Illinois (Revised 4/2021)

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Member Self Referrals ? Medicaid ........................................................................................................ 22 Family Planning ...................................................................................................................................... 22 Women's Health .................................................................................................................................... 22 Children's Health.................................................................................................................................... 22 Clinical Laboratory Improvement Amendment (CLIA)........................................................................... 22 Therapy .................................................................................................................................................. 23 Section 4: Pharmacy Benefit Management ...................................................................................... 23 Prescription Drug Plan Coverage ........................................................................................................... 24 Medicaid-Specific Benefits..................................................................................................................... 24 Obtaining a Formulary Exception........................................................................................................... 24 Obtaining a Drug Prior Authorization .................................................................................................... 24 Federally Qualified Health Centers and Rural Health Centers............................................................... 25 Advance Directives................................................................................................................................. 25 Section 5: Utilization Management, Care Coordination and Disease Management............................ 27 Utilization Management ........................................................................................................................ 27 Behavioral Health Utilization Review..................................................................................................... 28 Concurrent Review, Discharge Planning, and Transition of Care: ......................................................... 29 Requesting Prior Authorization/Precertification ................................................................................... 29 Services Requiring Authorization........................................................................................................... 30 Classifying Your Prior Authorization Request ........................................................................................ 31 Turnaround Times for Processing Service Requests .............................................................................. 32 Notification of Determination................................................................................................................ 32 Peer to Peer Discussion.......................................................................................................................... 32 Specialized Services: ProgenyHealth...................................................................................................... 33 Reconsideration of an Adverse Determination ..................................................................................... 33 Pre-Service Appeal ................................................................................................................................. 33 Post-Service Appeal ............................................................................................................................... 33 Care Coordination Program ................................................................................................................... 35 Home and Community Based Services (HCBS) Program........................................................................ 36 Home and Community Based Services include the following: .............................................................. 37 HCBS Provider Responsibility ................................................................................................................. 37 Smoking Cessation Program .................................................................................................................. 38 Section 6: Billing and Payment ........................................................................................................ 39 Claims Billing Requirements................................................................................................................... 39 Coordination of Benefits (COB).............................................................................................................. 41 Claims Guidelines for Dual-Eligible Members........................................................................................ 41 Explanation of Benefits (EOB) ................................................................................................................ 42 Encounter Billing Guidelines ? ERC, FQHC, and RHC ............................................................................. 42

Electronic Claims Submission................................................................................................................. 42 Provider Appeal and Claim Dispute Process...................................................................................................44 How to File an Appeal........................................................................................................................................44 Appeals Process for Denied Claims........................................................................................................ 44 What Types of Issues Can Providers Appeal? ........................................................................................ 44 How to File a Post-Service Appeal ......................................................................................................... 44 Time Frame for Filing a Post Service Appeal.......................................................................................... 45 Response to Post-Service Appeals ......................................................................................................... 45 Medicaid-Specific Guidelines ................................................................................................................. 46 Section 7: Quality Improvement (QI) ............................................................................................... 46 QI Introduction....................................................................................................................................... 46 QIP Goals and Objectives ....................................................................................................................... 46 Medicaid Performance Improvement Projects...................................................................................... 47 Community Based Care Coordination Overview ................................................................................... 47 Follow-Up After Hospitalization Overview ............................................................................................ 47 QIP Processes and Outcomes................................................................................................................. 47 Provider Opportunities in QIP Activities ................................................................................................ 48 Quality Improvement Committee.......................................................................................................... 48 Credentialing Committee....................................................................................................................... 50 Physician Advisory Committee............................................................................................................... 50 Grievance Committee ............................................................................................................................ 51 Contractual Arrangements..................................................................................................................... 51 Non-Delegated ....................................................................................................................................... 51 Delegated ............................................................................................................................................... 51 Quality Improvement Program Activities .............................................................................................. 52 Monitoring Quality Performance Indicators ? Clinical and Operational ............................................... 52 Monitoring Quality Performance Indicators ? Surveys.......................................................................... 52 Members................................................................................................................................................ 52 Providers ................................................................................................................................................ 53 Meridian Medical Policies and Clinical Practice Guidelines................................................................... 53 Monthly Provider HEDIS? Education...................................................................................................... 53 Peer Review ........................................................................................................................................... 53 Management of Quality of Care Complaints ......................................................................................... 54 Patient Safety......................................................................................................................................... 54 Confidentiality and Conflict of Interest.................................................................................................. 55 Confidentiality........................................................................................................................................ 55 Conflict of Interest ................................................................................................................................. 55



Meridian Medicaid Provider Manual 2021 ? Illinois (Revised 4/2021)

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