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«Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 1 of 57 Table of Contents Table of Contents SECTION 1: GENERAL OVERVIEW ...»

-- [ Page 1 ] --

Administrative Manual for Providers

for

Medicaid

including

Children’s Special Health Care Services (CSHCS),

Healthy Michigan Plan (HMP)

&

MIChild

Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual

Page 1 of 57

Table of Contents

Table of Contents

SECTION 1: GENERAL OVERVIEW

MISSION STATEMENT

CONTACT INFORMATION

SECTION II: PROVIDER SERVICES

PCP AS THE COORDINATOR OF CARE

COMMUNICATION WITH THE PCP

MEMBER ADVOCACY

PCP REPORTING REQUIREMENTS

PAYMENT STRUCTURE

LABORATORY SERVICES

PCP PERFORMANCE AND PAY FOR PERFORMANCE (P4P) BONUS PROGRAM........ 7 PCP ACCESSIBILITY AND AVAILABILITY

ACCESS TO CARE STANDARDS

PCP REQUEST FOR MEMBER TRANSFER

SECTION III: CREDENTIALING

SECTION IV: NETWORK DEVELOPMENT/CONTRACTING

PROCESS

PROVIDER TERMINATIONS

DEMOGRAPHIC CHANGES

COMPLIANCE RFEPORTS

NETWORK ADAQUACY

SECTION V: HEALTH SERVICES

REFERRALS AND AUTHORIZATIONS

REFERRALS

ELECTIVE HOSPITAL ADMISSIONS

EMERGENT HOSPITAL ADMISSIONS

AMBULATORY SERVICES/OUTPATIENT AUTHORIZATIONS

SKILLED NURSING

SECOND OPINION

Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 2 of 57 VISION SERVICES

APPEALS PROCESS

BEHAVIORAL HEALTH CARE

CASE MANAGEMENT

SECTION VI: PHARMACY BENEFIT

PHARMACY DRUG PLAN COVERAGE

OBTAINING A DRUG PRIOR AUTHORIZATION

DIABETIC SUPPLIES

MEDICAID BENEFIT DRUG COVERAGE

SECTION VII: CLAIMS MANAGEMENT

CLEAN CLAIMS SUBMISSION REQUIREMENTS

CLAIM CORRECTION AND RESUBMISSION

HOW TO CHECK CLAIMS STATUS ON THE HAP MIDWEST HEALTH PLAN

WEBSITE

PAYMENT PROCEDURE

EXPLANATION CODES

POST PAYMENT REVIEW

FILING LIMITATIONS

BILLING INSTRUCTIONS

COORDINATION OF BENEFITS (COB)

DME/PROSTHETICS/ORTHOTICS

E & M SERVICES

EMERGENCY ROOM

IMMUNIZATIONS: VACCINES AND TOXOIDS

NEWBORNS

NATIONAL CORRECT CODING INITIATIVE

OB SERVICES

OUT-OF-NETWORK PROVIDERS

URGENT CARE SERVICES

WELL WOMAN/WELL CHILD VISITS

RECONSIDERATION OF CLAIMS PAYMENT DECISIONS

Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 3 of 57 REDETERMINATION REQUEST PROCESS

PROVIDER APPEALS PROCESS

BINDING ARBITRATION PROCESS

RAPID RESOLUTION PROCESS

SECTION VIII: CUSTOMER SERVICE

NEW MEMBERS

HOW TO IDENTIFY A HAP MIDWEST HEALTH PLAN MEMBER

MEMBER ACCESSIBILITY TO PCP SERVICES

MEMBERS’ RIGHTS AND RESPONSIBILITIES..................Error! Bookmark not defined.

MEMBER REQUEST FOR PCP TRANSFERS

MEMBER COMPLAINTS AND GRIEVANCE RESOLUTION

TRANSPORTATION

LANGUAGE INTERPRETATION AND SERVICES FOR HEARING AND SPEECH

IMPAIRED

SECTION IX: QUALITY MANAGEMENT

MEMBER MEDICAL RECORDS

MEDICAL RECORD MAINTENANCE REQUIREMENTS

CONTINUITY OF CARE

VFC, MCIR AND REPORTING OF COMMUNICABLE DISEASES

DISEASE MANAGEMENT PROGRAMS

HEALTH OUTREACH

MEMBER FINANCIAL INCENTIVES

OFFICE STAFF INCENTIVES

CONFIDENTIALITY POLICY

NOTICE OF PRIVACY PRACTICES

SECTION X: CORPORATE COMPLIANCE PROGRAM

FRAUD/WASTE/ABUSE

DEFICIT REDUCTION/FALSE CLAIMS

WHISTLEBLOWER PROTECTION

Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 4 of 57

SECTION 1: GENERAL OVERVIEW

HAP Midwest Health Plan is a for-profit, licensed Health Maintenance Organization (HMO), wholly- owned subsidiary of Health Alliance Plan (HAP) and is based in Dearborn, Michigan.

HAP Midwest Health Plan was first licensed in 1998 and has been continuously accredited by the National Committee for Quality Assurance (NCQA). HAP Midwest Health Plan has over 92,000 Medicaid enrollees in Livingston, Macomb, Oakland, St. Clair, Washtenaw and Wayne counties.

HAP Midwest Health Plan contracts with a primary care physicians (PCPs) and specialty care physicians (SCPs) who are licensed in the state of Michigan as either a Medical Doctor (MD) or a Doctor of Osteopathic Medicine (DO). PCPs in the plan include Internal Medicine, Family/General Practice, Pediatrics, and OB/GYN physicians. SCPs include cardiologists, gastroenterologists, rheumatologists, endocrinologists, surgeons, etc. All physicians in the HAP Midwest Health Plan program must meet the credentialing standards and uphold the managed care philosophy of the plan.

The PCP performs the majority of ambulatory services in his/her office and is reimbursed through either capitation or fee for service contracts. Services provided by contracted specialists in most cases will not require plan approval. Care provided by non-contracted providers will require the PCP to submit a request for plan approval.

Members are entitled to and are provided with the same services, benefits and conditions as traditional Medicaid. HAP Midwest Health Plan is experienced with managed services for the Medicaid population have been effective in lowering overall health care costs, improving access to care, and either maintaining or improving upon the delivery and quality of care.





MISSION STATEMENT

HAP Midwest Health Plan is committed to providing excellence in our managed care product lines for our members, through fiscally responsible programs that assure access to and the delivery of cost effective and quality medical services.

HAP Midwest Health Plan health care providers are accountable for:

 Member satisfaction  Health care access to comprehensive and quality medical care / preventative services;

 Promote sharing of the responsibility of heath care decisions with members and their families, caregivers, etc.

–  –  –

SECTION II: PROVIDER SERVICES

PCP AS THE COORDINATOR OF CARE

HAP Midwest Health Plan utilizes the PCP to manage resource utilization, assure that all necessary and required medical care is provided for each member/patient, and promote the quality and continuity of medical care and services. The PCP is responsible for supervising, coordinating, and providing all primary care to each assigned HAP Midwest Health Plan member. A PCP may be a primary specialist in any of the following: family practice, general practice, internal medicine, pediatrics or OB/GYN. There are situations when a SCP, physician assistant or nurse practitioner can act as the PCP for certain chronic conditions or circumstances.

A primary care physician is usually the first medical practitioner contacted by a patient, due to factors such as ease of communication, accessible location, familiarity, and increasingly issues of cost and managed care requirements. Ideally, the primary care physician works collaboratively with the member to develop a plan of care with participants of the health care team. These may include referral specialists, social workers, hospitals or rehabilitation clinics, and other clinicians and family members.

COMMUNICATION WITH THE PCP

HAP Midwest Health Plan strives to keep the PCP informed of any changes within HAP Midwest Health Plan and/or the State of Michigan Medicaid Program. Our website provides the most up to date information for Providers. This information includes our monthly Provider Newsletters, pertinent policies and procedures, weekly eligibility, financial information (pay for performance information, financial reports, remittance advices, opportunity reports, etc.), clinical guidelines, and the entire administrative manual. Each PCP is assigned a Provider Services Representative that will assist in keep providers informed of the most current information at HAP Midwest Health Plan.

MEMBER ADVOCACY

HAP Midwest Health Plan does not prohibit any Participating Practitioner or Allied Health Professional from discussing treatment options with members, regardless of benefit coverage, or from advocating on behalf of a member in any grievance or utilization review process, or individual authorization process to obtain health care services. Practitioners may freely communicate with patients about their treatment, including medication treatment options, regardless of benefit coverage limitations. HAP Midwest Health Plan encourages the PCP along with all health providers to develop plans of care with their patients (or patient’s guardian or Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 6 of 57 representative) since the member’s participation is an integral part of the decision making for their treatment and care options.

PCP REPORTING REQUIREMENTS

PCPs participating with HAP Midwest Health Plan are contractually obligated to submit documentation of all encounters (visits) with assigned members. The Plan is mandated to provide encounter information to the Michigan Department of Health and Human Services (MDHHS).

PAYMENT STRUCTURE

FEE FOR SERVICE

The PCP “Fee for Service” contract will make payment for all Primary Care Plan and Referral Services at amounts equal to the current Medicaid fee for service rates.

CAPITATION

Based on meeting certain criteria a PCP may qualify for a month capitation payment amount for each enrolled person assigned to that physician or group of physicians.

Prior to the last week of the month, HAP Midwest Health Plan will remit the capitation payment to the capitated PCPs. The financial reports are located on the HAP Midwest Health Plan website. A separate user ID and password is given to each PCP to log on and review this information. This series of reports consist of all capitation payments and adjustments for both the past month and any prior months that may require additional reconciliation as well as remittance advices. Contact your Provider Services Representative for more information.

LABORATORY SERVICES

HAP Midwest Health Plan has contracted with Joint Venture Hospital Laboratories (JVHL) to provide laboratory services for HAP Midwest Health Plan members. PCP's requesting laboratory work for their members must send all specimens to a JVHL participating lab, or direct member to a JVHL lab drawing station. A list of JVHL participating labs and drawing stations is found on our website.

Failure to utilize contracted JVHL laboratories will result in the PCP being responsible for the laboratory bill for their member. Any questions or concerns regarding the JVHL contract should be directed to your Provider Services Representative.

PCP PERFORMANCE AND PAY FOR PERFORMANCE (P4P) BONUS PROGRAM

HAP Midwest Health Plan will pay providers additional money for increasing the quality of patient care received by enrollees of HAP Midwest Health Plan. Payment is based on quality outcomes for specific measures as outlined by the Plan.

Each year HAP Midwest Health Plan reviews its P4P program and may make revisions to the program based on quality outcomes from the measurement year and goals set for the upcoming year. PCPs are notified of P4P changes through their contract (found on our website in the financial section) as well as the HAP Midwest Health Plan website prior to the start of the Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 7 of 57 calendar year. The P4P criteria, the Opportunity Reports, and remittance advices for these programs are found in the Provider’s secure financial section of the website.

HAP Midwest Health Plan reserves the right to use practitioner performance data for quality improvement activities designed to improve quality of care and services and the member’s overall experience.

PCP ACCESSIBILITY AND AVAILABILITY

Every PCP site shall provide twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365) days per year, and physician on-call coverage to their assigned recipients. Every physician contracted as a PCP must be available to see patients a minimum of twenty (20) hours per location/per week. The PCP shall give written prior notice to HAP Midwest Health Plan of alternative coverage arrangements during times of non-availability.

PCP's should encourage their members to contact them whenever possible, prior to seeking health care services outside of their office. HAP Midwest Health Plan requires the hours of operation that providers and practitioners offer to Medicaid members be no less than those offered to commercial members and comparable to those for Medicaid Fee-for-Service (FFS) members.

ACCESS TO CARE STANDARDS

All HAP Midwest Health Plan PCPs are available (or will make the appropriate coverage available in their absence) for all HAP Midwest Health Plan members, on a 24-hours per day/7 days per week/52 weeks per year basis for urgent care and emergency care.

–  –  –

HAP Midwest Health Plan requires 100% of our PCPs meet appointment standards and 90% of Wait-Time standards. Monitoring is accomplished through annual surveys.

HAP Midwest Health Plan requires SCPs to follow the same guidelines for wait times as our PCPs. However, an annual study is not conducted for SCPs. Pharmacy services are within 30 minutes travel time of all HAP Midwest Health Plan members with availability during evenings and weekends.

PCP REQUEST FOR MEMBER TRANSFER

On occasion, a HAP Midwest Health Plan member may exhibit actions that are inconsistent with Plan membership, including fraud, abuse of the plan, or other intentional misconduct; or the PCP may feel that a member’s behavior is such as to make it medically unfeasible for the PCP to safely or prudently render care to the member. If this occurs, the PCP may need to request that a Revised: 9/28/15 HAP Midwest Health Plan Provider Administrative Manual Page 8 of 57 member transfer to another HAP Midwest Health Plan provider or that the member be removed

from the plan. Some of the reasons for such requests may be as follows:



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