PROVIDER MANUAL - Cigna

PROVIDER MANUAL

Cigna-HealthSpring? CarePlan (Medicare-Medicaid Plan)

Hidalgo county Publication Date: February 2017 Provider Services Department: 1-877-653-0331 healthcare-professionals/tx-mmp

H8423_16_52212_PR 02202017

? 2017 Cigna

Dear Valued Provider and Staff:

I would like to extend a warm welcome and thank you for participating with Cigna-HealthSpring Texas' Network of Participating Providers. We value our relationship with all of our providers and are committed to working with you to meet the needs of your CignaHealthSpring patients.

Cigna-HealthSpring has provided managed care services to Medicare and dually-eligible members since 1996. We are excited to extend our passion for offering quality health care delivery to Cigna-HealthSpring CarePlan, Medicare-Medicaid Plan members.

We look forward to working with you to serve the needs of members in order that they may live life well.

Sincerely,

Jay Hurt Senior Vice President President ? Texas Division Cigna-HealthSpring

TABLE OF CONTENTS

TABLE OF CONTENTS....................................................................................................................................... 2

IMPORTANT PHONE NUMBERS ....................................................................................................................... 5

INTRODUCTION .................................................................................................................................................. 5 Medicare-Medicaid Plan Program Overview ..........................................................................................................................................6 Objectives of the MMP Program.............................................................................................................................................................6 Role of the Primary Care Provider (PCP) ..............................................................................................................................................7 Role of the Specialty Care Provider........................................................................................................................................................8 Missed Appointments by Members.........................................................................................................................................................8 Role of the Long-Term Services and Supports (LTSS) Provider............................................................................................................8 Role of Service Coordinator....................................................................................................................................................................9 Role of the Pharmacy Provider.............................................................................................................................................................10 Network Limitations ..............................................................................................................................................................................10 Focus Studies and Utilization Management reporting requirements. ...................................................................................................12

COVERED SERVICES ...................................................................................................................................... 12 Medicare-Medicaid Managed Care Covered Services .........................................................................................................................12 Behavioral Health Covered Services ....................................................................................................................................................13 Long-Term Support Covered Services .................................................................................................................................................17 Pharmacy Prescription Benefit .............................................................................................................................................................20 Pharmacy Quality Programs.................................................................................................................................................................22 Non-Medicaid Managed Care Covered Services (Non-Capitated Services) ........................................................................................25 Medical Transportation Program (MTP) ...............................................................................................................................................26

EMERGENCY SERVICES ................................................................................................................................. 26 Definitions .............................................................................................................................................................................................26 Emergency Prescription Supply............................................................................................................................................................27 Emergency Transportation ...................................................................................................................................................................27 Emergency Dental Services .................................................................................................................................................................27 Non-Emergent Ambulance Transportation ...........................................................................................................................................27 Non-Emergency Dental Services..........................................................................................................................................................28 Durable Medical Equipment and Other Products Normally Found in a Pharmacy ...............................................................................28

MEDICARE-MEDICAID PLAN ELIGIBILITY & ENROLLMENT ....................................................................... 28 Cigna-HealthSpring CarePlan (Medicare-Medicaid Plan) Eligibility ....................................................................................................28 Enrollment.............................................................................................................................................................................................28 Verifying Eligibility.................................................................................................................................................................................29 Disenrollment ........................................................................................................................................................................................ 30 Span of Eligibility ..................................................................................................................................................................................31 Automatic Re-Enrollment......................................................................................................................................................................31 Retroactive Eligibility Changes .............................................................................................................................................................31 Long-Term Services and Supports .......................................................................................................................................................32 Authorization of Services through the Service Coordinator .................................................................................................................32 Disease Management (DM)..................................................................................................................................................................32 Care and Service Plans (CSPs) ...........................................................................................................................................................33 Coordination with Other Agency Providers..........................................................................................................................................33

UTILIZATION MANAGEMENT .......................................................................................................................... 33 Utilization Review Criteria.....................................................................................................................................................................34 Discharge Planning...............................................................................................................................................................................36 Direct Access Services .........................................................................................................................................................................36 Out of Network Authorizations ..............................................................................................................................................................36 Continuity of Care .................................................................................................................................................................................36 Member Moves Out of Service Area.....................................................................................................................................................37 Pre-existing Conditions.........................................................................................................................................................................37

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BILLING AND CLAIMS ADMINISTRATION ..................................................................................................... 37 Claims Submission ...............................................................................................................................................................................37 Claims Addresses.................................................................................................................................................................................38 Claims Filing Deadline ..........................................................................................................................................................................38 Claim Filing Formats.............................................................................................................................................................................39 National Provider Identification (NPI) Numbers ...................................................................................................................................39 FQHC Claim Filing Instructions ............................................................................................................................................................42 RHC Claim Filing Instructions...............................................................................................................................................................42 Coordination of Benefits .......................................................................................................................................................................58 Prior Authorization ................................................................................................................................................................................58 Claims Payment....................................................................................................................................................................................58 Electronic Funds Transfer.....................................................................................................................................................................58 Claim Status and Resolution of Claims Issues ....................................................................................................................................59 Claims Appeals.....................................................................................................................................................................................59 Payment Disputes.................................................................................................................................................................................59 Balance Billing ......................................................................................................................................................................................60 Private Pay Agreement.........................................................................................................................................................................60 Claim Filing Tips ...................................................................................................................................................................................61 Sample of Explanation of Payment (EOP)............................................................................................................................................62

PROVIDER RESPONSIBILITIES ...................................................................................................................... 63 Communication Among Providers ........................................................................................................................................................63 Provider Access and Availability Standards ........................................................................................................................................63 Demographic Changes.........................................................................................................................................................................64 Advanced Medical Directives................................................................................................................................................................64 Coordination with Texas Department of Family and Protective Services (TDFPS)............................................................................65 Termination of Provider Contracts ........................................................................................................................................................65 Attendant Care Enhancement Program (ACEP) .................................................................................................................................65 Community First Choice Provider Responsibilities ...............................................................................................................................66 Electronic Visit Verification (EVV).........................................................................................................................................................67 Cigna-HealthSpring Provider Compliance and Waste, Abuse, and Fraud Policy.................................................................................70 Provider Complaint and Appeal Process ..............................................................................................................................................71 REPORTING ABUSE, NEGLECT, OR EXPLOITATION (ANE)...........................................................................................................72

QUALITY MANAGEMENT................................................................................................................................. 73 Overview ............................................................................................................................................................................................... 73 QI Department Functions......................................................................................................................................................................73 Quality Improvement Committee (QIC) ................................................................................................................................................73 Clinical Practice Guidelines ..................................................................................................................................................................74 Healthcare Plan Effectiveness Data and Information Set (HEDIS?)....................................................................................................74 On-Site Assessments ...........................................................................................................................................................................74 Medical Record Requirements .............................................................................................................................................................75 Credentialing.........................................................................................................................................................................................77 Direct Access to a Specialty Care Provider for Members with Special Health Care Needs .................................................................84 Member Rights and Responsibilities ....................................................................................................................................................84 Member's Right to Designate an OB/GYN ..........................................................................................................................................86 Member Complaint and Appeal Process .............................................................................................................................................86 Hospital Discharge Appeals..................................................................................................................................................................89

APPENDICES .................................................................................................................................................... 90 Appendix A, Cigna-HealthSpring Member Identification Card..............................................................................................................91 Appendix B, Sample Texas Benefits Medicaid Card ............................................................................................................................92 Appendix C, Sample Form 1027-A Temporary Medicaid Identification ................................................................................................93 Appendix D, Authorization Requirements.............................................................................................................................................94 Appendix D, Authorization Requirements.............................................................................................................................................95 Appendix D, Authorization Requirements.............................................................................................................................................96 Appendix E, Prior Authorization Request Form ....................................................................................................................................97 Appendix F, Inpatient Authorization Form ............................................................................................................................................98

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Appendix G, Outpatient Authorization Form .........................................................................................................................................99 Appendix H, Sample UB-04 Claim Form ............................................................................................................................................100 Appendix I, Sample CMS 1500 Claim form ........................................................................................................................................101 Appendix J, Sample of Claims Appeal Form ......................................................................................................................................102 Appendix K, Payment Dispute Form...................................................................................................................................................103 Appendix L, Member Acknowledgement Statement...........................................................................................................................104 Appendix M, Private Pay Agreement..................................................................................................................................................105 Appendix N, Clinical Practice Guidelines............................................................................................................................................106

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