Provider and Billing Manual - Ambetter from Meridian

Provider and Billing Manual

2021



AMBPROV20-MI-C-00024

Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. ? 2020 Meridian Health Plan of Michigan, Inc. All rights reserved.

TABLE OF CONTENTS

WELCOME---------------------------------------------------------------------------------- 6 HOW TO USE THIS PROVIDER MANUAL ---------------------------------------- 7 NONDISCRIMINATION OF HEALTH CARE SERVICE DELIVERY--------- 8 KEY CONTACTS AND IMPORTANT PHONE NUMBERS -------------------- 9 SECURE PROVIDER PORTAL ----------------------------------------------------- 11

Functionality--------------------------------------------------------------------------------------------------------------------- 11 Disclaimer ------------------------------------------------------------------------------------------------------------------------ 11

CREDENTIALING AND RECREDENTIALING---------------------------------- 12

Eligible Providers -------------------------------------------------------------------------------------------------------------- 13 Non Registered CAQH Providers ----------------------------------------------------------------------------------------- 13 Credentialing Committee ---------------------------------------------------------------------------------------------------- 13 Recredentialing ----------------------------------------------------------------------------------------------------------------- 13 Practitioner Right to Review and Correct Information------------------------------------------------------------- 14 Practitioner Right to Be Informed of Application Status---------------------------------------------------------- 14 Practitioner Right to Appeal or Reconsideration of Adverse Credentialing Decisions ----------------- 14

PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER -------- 15

Provider Types That May Serve As PCPs------------------------------------------------------------------------------ 15 Member Panel Capacity------------------------------------------------------------------------------------------------------ 15 Member Selection or Assignment of PCP ----------------------------------------------------------------------------- 15 Withdrawing from Caring for a Member -------------------------------------------------------------------------------- 16 PCP Coordination of Care to Specialists------------------------------------------------------------------------------- 16 Specialist Provider Responsibilities------------------------------------------------------------------------------------- 16 Appointment Availability and Wait Times------------------------------------------------------------------------------ 17 Wait Time Standards for All Provider Types -------------------------------------------------------------------------- 17 Travel Distance and Access Standards -------------------------------------------------------------------------------- 17 Covering Providers------------------------------------------------------------------------------------------------------------ 18 Provider Phone Call Protocol ---------------------------------------------------------------------------------------------- 18 Provider Data Updates and Validation ---------------------------------------------------------------------------------- 19 Hospital Responsibilities---------------------------------------------------------------------------------------------------- 19

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AMBETTER BENEFITS --------------------------------------------------------------- 20

Overview -------------------------------------------------------------------------------------------------------------------------- 20 Additional Benefit Information -------------------------------------------------------------------------------------------- 21 Covered Services -------------------------------------------------------------------------------------------------------------- 23 Benefit Limits ------------------------------------------------------------------------------------------------------------------- 23 Preventive Services ----------------------------------------------------------------------------------------------------------- 23 Notification of Pregnancy --------------------------------------------------------------------------------------------------- 24 Non-Covered Services ------------------------------------------------------------------------------------------------------- 24 Transplant Services ----------------------------------------------------------------------------------------------------------- 24 Tribal Provider (AIAN) American Indian Alaska Native ------------------------------------------------------------ 25

MEMBER BENEFITS, MEMBER IDENTIFICATION CARD, ELIGIBILITY, AND COST SHARES ------------------------------------------------------------------ 27

Member Benefits --------------------------------------------------------------------------------------------------------------- 27 Member Identification Card------------------------------------------------------------------------------------------------- 27 Preferred Method to Verify Benefits, Eligibility, and Cost Shares --------------------------------------------- 28 Other Methods to Verify Benefits, Eligibility and Cost Shares-------------------------------------------------- 29 Importance of Verifying Benefits, Eligibility, and Cost Shares ------------------------------------------------- 29 Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) ----------- 29

MEDICAL MANAGEMENT ----------------------------------------------------------- 30

Utilization Management ------------------------------------------------------------------------------------------------------ 30 Medically Necessary ---------------------------------------------------------------------------------------------------------- 30 Timeframes for Prior Authorization Requests and Notifications----------------------------------------------- 30 Care Management and Concurrent Review --------------------------------------------------------------------------- 37 Ambetter's Member Wellbeing Survey---------------------------------------------------------------------------------- 38 Ambetter's My Health Pays Member Rewards Program ---------------------------------------------------------- 38

CLAIMS------------------------------------------------------------------------------------ 41

Verification Procedures------------------------------------------------------------------------------------------------------ 41 Clean Claim Definition-------------------------------------------------------------------------------------------------------- 42 Non-Clean Claim Definition------------------------------------------------------------------------------------------------- 42 Upfront Rejections vs. Denials -------------------------------------------------------------------------------------------- 42 Timely Filing --------------------------------------------------------------------------------------------------------------------- 43 Refunds and Overpayments------------------------------------------------------------------------------------------------ 43 Who Can File Claims? -------------------------------------------------------------------------------------------------------- 44

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Electronic Claims Submission -------------------------------------------------------------------------------------------- 44 Rejected electronic claims may be resubmitted electronically once the error has been corrected. Be sure to submit the rejected claim as an original claim. ------------------------------------------------------- 45 Corrected EDI Claims--------------------------------------------------------------------------------------------------------- 46 Electronic Billing Inquiries-------------------------------------------------------------------------------------------------- 46 Online Claim Submission --------------------------------------------------------------------------------------------------- 47 Paper Claim Submission ---------------------------------------------------------------------------------------------------- 48 Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA)-----------------------------49 Corrected Claims, Requests for Reconsideration or Claim Disputes ---------------------------------------- 50 Risk Adjustment and Correct Coding ----------------------------------------------------------------------------------- 52

CODE EDITING-------------------------------------------------------------------------- 58

CPT and HCPCS Coding----------------------------------------------------------------------------------------------------- 58 International Classification of Diseases (ICD-10) ------------------------------------------------------------------- 59 Revenue Codes ----------------------------------------------------------------------------------------------------------------- 59 Edit Sources --------------------------------------------------------------------------------------------------------------------- 59 Code Editing Principles------------------------------------------------------------------------------------------------------ 60 Invalid Revenue to Procedure Code Editing -------------------------------------------------------------------------- 62 Inpatient Facility Claim Editing -------------------------------------------------------------------------------------------- 63 Administrative and Consistency Rules --------------------------------------------------------------------------------- 64 Prepayment Clinical Validation-------------------------------------------------------------------------------------------- 64 Claim Reconsiderations Related To Code Editing ------------------------------------------------------------------ 66 Viewing Claims Coding Edits ---------------------------------------------------------------------------------------------- 67 Automated Clinical Payment Policy Edits ----------------------------------------------------------------------------- 67 Clinical Payment Policy Appeals ----------------------------------------------------------------------------------------- 68

THIRD PARTY LIABILITY ------------------------------------------------------------ 69 BILLING THE MEMBER -------------------------------------------------------------- 70

Covered Services -------------------------------------------------------------------------------------------------------------- 70 Non-Covered Services ------------------------------------------------------------------------------------------------------- 70 Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) -----------71

MEMBER RIGHTS AND RESPONSIBILITIES ---------------------------------- 72

Member Rights------------------------------------------------------------------------------------------------------------------ 72 Member Responsibilities ---------------------------------------------------------------------------------------------------- 73

PROVIDER RIGHTS AND RESPONSIBILITIES ------------------------------- 75

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Provider Rights ----------------------------------------------------------------------------------------------------------------- 75 Provider Responsibilities --------------------------------------------------------------------------------------------------- 75

CULTURAL COMPETENCY --------------------------------------------------------- 78

Language Services ------------------------------------------------------------------------------------------------------------ 79 Provider Accessibility Initiative ------------------------------------------------------------------------------------------- 80 Americans with Disabilities Act (ADA)---------------------------------------------------------------------------------- 80

COMPLAINT PROCESS -------------------------------------------------------------- 84

Complaint/Grievance --------------------------------------------------------------------------------------------------------- 84 Member Appeals --------------------------------------------------------------------------------------------------------------- 84 Mailing Address ---------------------------------------------------------------------------------------------------------------- 85

QUALITY IMPROVEMENT PLAN -------------------------------------------------- 86

Overview -------------------------------------------------------------------------------------------------------------------------- 86 QAPI Program Structure----------------------------------------------------------------------------------------------------- 86 Patient Safety and Quality of Care --------------------------------------------------------------------------------------- 89 Quality Rating System ------------------------------------------------------------------------------------------------------- 90 Provider Satisfaction Survey----------------------------------------------------------------------------------------------- 92 Qualified Health Plan (QHP) Enrollee Survey ------------------------------------------------------------------------- 92 Provider Performance Monitoring and Incentive Programs ----------------------------------------------------- 92

REGULATORY MATTERS ----------------------------------------------------------- 94

Medical Records --------------------------------------------------------------------------------------------------------------- 94 Access to Records and Audits by Ambetter from Meridian ----------------------------------------------------- 96 EMR Access --------------------------------------------------------------------------------------------------------------------- 96 Medical Records Release --------------------------------------------------------------------------------------------------- 96 Medical Records Transfer for New Members ------------------------------------------------------------------------- 97 Federal And State Laws Governing The Release Of Information ---------------------------------------------- 97 National Network --------------------------------------------------------------------------------------------------------------- 98 Section 1557 of the Patient Protection and Affordable Care Act ----------------------------------------------- 98

FRAUD, WASTE AND ABUSE----------------------------------------------------- 100

FWA Program Compliance Authority and Responsibility ------------------------------------------------------ 101 False Claims Act ------------------------------------------------------------------------------------------------------------- 101 Physician Incentive Programs------------------------------------------------------------------------------------------- 101

APPENDIX ------------------------------------------------------------------------------- 103

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