Provider and Billing Manual - Ambetter from Meridian

[Pages:193]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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Appendix I: Common Causes for Upfront Rejections ----------------------------------------------------------- 103 Appendix II: Common Cause of Claims Processing Delays and Denials---------------------------------- 104 Appendix III: Common EOP Denial Codes and Descriptions -------------------------------------------------- 104 Appendix IV: Instructions for Supplemental Information------------------------------------------------------- 105 Appendix V: Common Business EDI Rejection Codes ---------------------------------------------------------- 107 Appendix VI: Claim Form Instructions -------------------------------------------------------------------------------- 107 Appendix VII: Billing Tips and Reminders --------------------------------------------------------------------------- 107 Appendix VIII: Reimbursement Policies ------------------------------------------------------------------------------ 139 Appendix IX: EDI Companion Guide Overview--------------------------------------------------------------------- 142

STATE MANDATED REGULATORY REQUIREMENTS-------------------- 152

Arkansas------------------------------------------------------------------------------------------------------------------------ 152 Arizona -------------------------------------------------------------------------------------------------------------------------- 152 Florida --------------------------------------------------------------------------------------------------------------------------- 153 Georgia -------------------------------------------------------------------------------------------------------------------------- 154 Illinois---------------------------------------------------------------------------------------------------------------------------- 155 Indiana--------------------------------------------------------------------------------------------------------------------------- 159 Kansas--------------------------------------------------------------------------------------------------------------------------- 160 Michigan ------------------------------------------------------------------------------------------------------------------------ 161 Missouri ------------------------------------------------------------------------------------------------------------------------- 165 Mississippi --------------------------------------------------------------------------------------------------------------------- 168 North Carolina ---------------------------------------------------------------------------------------------------------------- 169 New Hampshire --------------------------------------------------------------------------------------------------------------- 175 Nevada--------------------------------------------------------------------------------------------------------------------------- 176 Ohio ------------------------------------------------------------------------------------------------------------------------------ 179 Pennsylvania ------------------------------------------------------------------------------------------------------------------ 181 South Carolina ---------------------------------------------------------------------------------------------------------------- 183 Tennessee---------------------------------------------------------------------------------------------------------------------- 184 Texas----------------------------------------------------------------------------------------------------------------------------- 185

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WELCOME

Welcome to Ambetter from Meridian. Thank you for participating in our network of high quality physicians, hospitals, and other healthcare professionals.

Ambetter's Health Insurance Marketplace plans target a consumer population of lower income, previously uninsured individuals and families who, prior to having this health insurance, may have been Medicaideligible or unable to access care due to financial challenges.

Partnering with Ambetter provides an opportunity for you to access a previously untapped consumer population by providing coverage to those who qualify for generous premium and cost sharing subsidies. Ambetter has been very successful in attracting and retaining our target population, and continues to focus on engaging and acquiring these subsidy-eligible consumers through its unique plan designs, incentive programs, and effective communication.

Ambetter is a Qualified Health Plan (QHP) as defined in the Affordable Care Act (ACA). Ambetter is offered to consumers through the Health Insurance Marketplace, also known as the Exchange. The Health Insurance Marketplace makes buying health insurance easier.

The Affordable Care Act is the law that has changed healthcare. The goals of the ACA are:

? To help more Americans get health insurance and stay healthy

? To offer consumers a choice of coverage leading to increased health care engagement and empowerment

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HOW TO USE THIS PROVIDER MANUAL

Ambetter is committed to assisting its provider community by supporting their efforts to deliver wellcoordinated and appropriate health care to our members. Ambetter is also committed to disseminating comprehensive and timely information to its providers through this provider manual regarding Ambetter's operations, policies, and procedures. Updates to this manual will be posted on our website at . Additionally, providers may be notified via bulletins and notices posted on the website and potentially on Explanation of Payment notices. Providers may contact our Provider Services department at 1-866-796-0542 to request that a copy of this manual be mailed to you. In accordance with the Participating Provider Agreement, providers are required to comply with the provisions of this manual. Ambetter routinely monitors compliance with the various requirements in this manual and may initiate corrective action, including denial or reduction in payment, suspension, or termination if there is a failure to comply with any requirements of this manual.

Dental and Vision Provider Manuals

Envolve Dental and Vision provider manuals are available on the Secure Provider Portal. Providers may visit or and log on or contact us for these provider manuals.

Ancillary Provider Manuals

Additional provider manuals are available on the Secure Provider Portal. Providers may visit the following and log on or contact us for these provider manuals:

? Envolve (RX) ? RX ADvanced ? Teledoc ? Babylon ? NIA ? Evicore ? Ash (AZ) ? Home Town Health ? Logisticare Ambulance Emergency Non-Emergency and Non-Medical Vendor ? USMM ? MEDXM

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