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<br /> Sponsored by Johns Hopkins HealthCare LLC and The Maryland Community Health Systems<br /> 2014-2015<br /> Provider Manual<br /> Introduction to the Provider Manual<br /> HealthChoice is Maryland’s Medicaid managed care program. Overseen by the Maryland<br /> Department of Health and Mental Hygiene (DHMH), the HealthChoice program serves over<br /> 500,000 individuals. These individuals are enrolled in one of the participating Managed Care<br /> Organizations (MCOs). Each MCO has policies and procedures that providers who deliver services<br /> to recipients must adhere to. Any questions a provider has about the policies of individual MCOs<br /> should be addressed by the provider information supplied by the MCO they participate in.<br /> While each HealthChoice MCO has its own policies and procedures, many program elements apply<br /> to all providers, regardless of the MCO. The purpose of this manual is to explain those elements<br /> and be a useful reference for <a title="PPprovider2014_2015.pdf page 1" href="http://viewer.zmags.com/publication/b0a584ae?page=1"> Sponsored by Johns Hopkins HealthCare LLC and The</a> <a title="PPprovider2014_2015.pdf page 2" href="http://viewer.zmags.com/publication/b0a584ae?page=2"> Introduction to the Provider Manual HealthChoice</a> <a title="PPprovider2014_2015.pdf page 3" href="http://viewer.zmags.com/publication/b0a584ae?page=3"> TABLE OF CONTENTS SECTION I – General Informati</a> <a title="PPprovider2014_2015.pdf page 4" href="http://viewer.zmags.com/publication/b0a584ae?page=4"> TABLE OF CONTENTS MEDICAL RECORD STANDARDS . . .</a> <a title="PPprovider2014_2015.pdf page 5" href="http://viewer.zmags.com/publication/b0a584ae?page=5"> TABLE OF CONTENTS OTHER POPULATION HEALTH BASED </a> <a title="PPprovider2014_2015.pdf page 6" href="http://viewer.zmags.com/publication/b0a584ae?page=6"> TABLE OF CONTENTS Oxygen and Related R</a> <a title="PPprovider2014_2015.pdf page 7" href="http://viewer.zmags.com/publication/b0a584ae?page=7"> TABLE OF CONTENTS SECTION VI – DHMH Quality Impr</a> <a title="PPprovider2014_2015.pdf page 8" href="http://viewer.zmags.com/publication/b0a584ae?page=8"> SECTION 1 General Information </a> <a title="PPprovider2014_2015.pdf page 9" href="http://viewer.zmags.com/publication/b0a584ae?page=9"> THE MARYLAND HEALTHCHOICE PROGRAM HealthChoice is</a> <a title="PPprovider2014_2015.pdf page 10" href="http://viewer.zmags.com/publication/b0a584ae?page=10"> Reimbursement for hospitals and other applicable </a> <a title="PPprovider2014_2015.pdf page 11" href="http://viewer.zmags.com/publication/b0a584ae?page=11"> PRIMARY CARE PROVIDER (PCP) CONTRACT TERMINATIONS</a> <a title="PPprovider2014_2015.pdf page 12" href="http://viewer.zmags.com/publication/b0a584ae?page=12"> SECTION 1I Provider Responsibilities </a> <a title="PPprovider2014_2015.pdf page 13" href="http://viewer.zmags.com/publication/b0a584ae?page=13"> CONFIDENTIALITY Providers are expected to maintai</a> <a title="PPprovider2014_2015.pdf page 14" href="http://viewer.zmags.com/publication/b0a584ae?page=14"> Reportable Communicable Diseases Amebiasis Anapla</a> <a title="PPprovider2014_2015.pdf page 15" href="http://viewer.zmags.com/publication/b0a584ae?page=15"> APPOINTMENT SCHEDULING AND OUTREACH REQUIREMENTS </a> <a title="PPprovider2014_2015.pdf page 16" href="http://viewer.zmags.com/publication/b0a584ae?page=16"> SERVICES FOR CHILDREN For children younger than 2</a> <a title="PPprovider2014_2015.pdf page 17" href="http://viewer.zmags.com/publication/b0a584ae?page=17"> comply with a regimen of treatment for the child,</a> <a title="PPprovider2014_2015.pdf page 18" href="http://viewer.zmags.com/publication/b0a584ae?page=18"> • We have a special needs coordinator on staff t</a> <a title="PPprovider2014_2015.pdf page 19" href="http://viewer.zmags.com/publication/b0a584ae?page=19"> Pregnancy-related service providers will follow, </a> <a title="PPprovider2014_2015.pdf page 20" href="http://viewer.zmags.com/publication/b0a584ae?page=20"> • When a member opts for early discharge from th</a> <a title="PPprovider2014_2015.pdf page 21" href="http://viewer.zmags.com/publication/b0a584ae?page=21"> Individuals with HIV/AIDS Children with HIV/AIDS </a> <a title="PPprovider2014_2015.pdf page 22" href="http://viewer.zmags.com/publication/b0a584ae?page=22"> Providers who treat individuals with physical or </a> <a title="PPprovider2014_2015.pdf page 23" href="http://viewer.zmags.com/publication/b0a584ae?page=23"> Adult Members with Impaired Cognitive Ability/ Ps</a> <a title="PPprovider2014_2015.pdf page 24" href="http://viewer.zmags.com/publication/b0a584ae?page=24"> Special Needs/Enhanced Care Management (Care or C</a> <a title="PPprovider2014_2015.pdf page 25" href="http://viewer.zmags.com/publication/b0a584ae?page=25"> Each medical record must include: • Hi</a> <a title="PPprovider2014_2015.pdf page 26" href="http://viewer.zmags.com/publication/b0a584ae?page=26"> Regardless of the process used to notify Priority</a> <a title="PPprovider2014_2015.pdf page 27" href="http://viewer.zmags.com/publication/b0a584ae?page=27"> Referral Extensions Referrals for specialty care </a> <a title="PPprovider2014_2015.pdf page 28" href="http://viewer.zmags.com/publication/b0a584ae?page=28"> Free Communication with Members As stated in the </a> <a title="PPprovider2014_2015.pdf page 29" href="http://viewer.zmags.com/publication/b0a584ae?page=29"> SERVICES REQUIRING PRE-AUTHORIZATION FOR MEDICAL </a> <a title="PPprovider2014_2015.pdf page 30" href="http://viewer.zmags.com/publication/b0a584ae?page=30"> Maternity Notification • When a Priori</a> <a title="PPprovider2014_2015.pdf page 31" href="http://viewer.zmags.com/publication/b0a584ae?page=31"> patient’s condition. If requested information is </a> <a title="PPprovider2014_2015.pdf page 32" href="http://viewer.zmags.com/publication/b0a584ae?page=32"> Case Management Case Management is intensive coor</a> <a title="PPprovider2014_2015.pdf page 33" href="http://viewer.zmags.com/publication/b0a584ae?page=33"> • Arrange/coordinate needed services/care • Inf</a> <a title="PPprovider2014_2015.pdf page 34" href="http://viewer.zmags.com/publication/b0a584ae?page=34"> Complex Case Management Complex Case Management i</a> <a title="PPprovider2014_2015.pdf page 35" href="http://viewer.zmags.com/publication/b0a584ae?page=35"> SPECIALTY CASE MANAGEMENT PROGRAMS Partners with </a> <a title="PPprovider2014_2015.pdf page 36" href="http://viewer.zmags.com/publication/b0a584ae?page=36"> Physical Rehabilitation Comprehensive case manage</a> <a title="PPprovider2014_2015.pdf page 37" href="http://viewer.zmags.com/publication/b0a584ae?page=37"> OTHER POPULATION HEALTH-BASED SERVICES INCLUDE: •</a> <a title="PPprovider2014_2015.pdf page 38" href="http://viewer.zmags.com/publication/b0a584ae?page=38"> To receive a copy of the Priority Partners formul</a> <a title="PPprovider2014_2015.pdf page 39" href="http://viewer.zmags.com/publication/b0a584ae?page=39"> Subrogation (MVA) Priority Partners requires prov</a> <a title="PPprovider2014_2015.pdf page 40" href="http://viewer.zmags.com/publication/b0a584ae?page=40"> • Office visit notes; ■ May be required </a> <a title="PPprovider2014_2015.pdf page 41" href="http://viewer.zmags.com/publication/b0a584ae?page=41"> Remittance Advice Statement The items below corre</a> <a title="PPprovider2014_2015.pdf page 42" href="http://viewer.zmags.com/publication/b0a584ae?page=42"> PRIORITY PARTNERS QUALITY MANAGEMENT 1. Purpose:</a> <a title="PPprovider2014_2015.pdf page 43" href="http://viewer.zmags.com/publication/b0a584ae?page=43"> QUALITY IMPROVEMENT PLAN Objectives The Quality I</a> <a title="PPprovider2014_2015.pdf page 44" href="http://viewer.zmags.com/publication/b0a584ae?page=44"> Quality of Care Program In the course of their d</a> <a title="PPprovider2014_2015.pdf page 45" href="http://viewer.zmags.com/publication/b0a584ae?page=45"> ENCOUNTER DATA REPORTING REQUIREMENTS The Marylan</a> <a title="PPprovider2014_2015.pdf page 46" href="http://viewer.zmags.com/publication/b0a584ae?page=46"> PRIVACY PRACTICES Safeguarding Your Protected Hea</a> <a title="PPprovider2014_2015.pdf page 47" href="http://viewer.zmags.com/publication/b0a584ae?page=47"> Research purposes: In certain circumstances, and </a> <a title="PPprovider2014_2015.pdf page 48" href="http://viewer.zmags.com/publication/b0a584ae?page=48"> Accounting of disclosures: You have a right to re</a> <a title="PPprovider2014_2015.pdf page 49" href="http://viewer.zmags.com/publication/b0a584ae?page=49"> • Misusing codes on a claim; </a> <a title="PPprovider2014_2015.pdf page 50" href="http://viewer.zmags.com/publication/b0a584ae?page=50"> SECTION III SECTION III Care Manage</a> <a title="PPprovider2014_2015.pdf page 51" href="http://viewer.zmags.com/publication/b0a584ae?page=51"> OVERVIEW • Priority Partners must provide a comp</a> <a title="PPprovider2014_2015.pdf page 52" href="http://viewer.zmags.com/publication/b0a584ae?page=52"> COVERED BENEFITS AND SERVICES Audiology Services </a> <a title="PPprovider2014_2015.pdf page 53" href="http://viewer.zmags.com/publication/b0a584ae?page=53"> Dialysis Services Members in HealthChoice who suf</a> <a title="PPprovider2014_2015.pdf page 54" href="http://viewer.zmags.com/publication/b0a584ae?page=54"> • Providers are responsible for making appropria</a> <a title="PPprovider2014_2015.pdf page 55" href="http://viewer.zmags.com/publication/b0a584ae?page=55"> Laboratory Services Diagnostic services and labor</a> <a title="PPprovider2014_2015.pdf page 56" href="http://viewer.zmags.com/publication/b0a584ae?page=56"> If a member is not exempted, complete the ID Scre</a> <a title="PPprovider2014_2015.pdf page 57" href="http://viewer.zmags.com/publication/b0a584ae?page=57"> Pharmaceutical services and counseling ordered by</a> <a title="PPprovider2014_2015.pdf page 58" href="http://viewer.zmags.com/publication/b0a584ae?page=58"> A member’s PCP is responsible for making the dete</a> <a title="PPprovider2014_2015.pdf page 59" href="http://viewer.zmags.com/publication/b0a584ae?page=59"> When, in the PCP’s judgment, a member’s need for </a> <a title="PPprovider2014_2015.pdf page 60" href="http://viewer.zmags.com/publication/b0a584ae?page=60"> • In-vitro fertilization, ovum transplants and g</a> <a title="PPprovider2014_2015.pdf page 61" href="http://viewer.zmags.com/publication/b0a584ae?page=61"> • Priority Partners will assist members to secur</a> <a title="PPprovider2014_2015.pdf page 62" href="http://viewer.zmags.com/publication/b0a584ae?page=62"> Medicaid Covered Services Not the Responsibility </a> <a title="PPprovider2014_2015.pdf page 63" href="http://viewer.zmags.com/publication/b0a584ae?page=63"> • Renal dialysis services. • Pharmaceutical and</a> <a title="PPprovider2014_2015.pdf page 64" href="http://viewer.zmags.com/publication/b0a584ae?page=64"> Practitioners are required to: • Submi</a> <a title="PPprovider2014_2015.pdf page 65" href="http://viewer.zmags.com/publication/b0a584ae?page=65"> Rights to Appeal Termination No appeal rights are</a> <a title="PPprovider2014_2015.pdf page 66" href="http://viewer.zmags.com/publication/b0a584ae?page=66"> SECTION 1V SECTION 1V Benefits Spe</a> <a title="PPprovider2014_2015.pdf page 67" href="http://viewer.zmags.com/publication/b0a584ae?page=67"> INTRODUCTION Under the HealthChoice program we ar</a> <a title="PPprovider2014_2015.pdf page 68" href="http://viewer.zmags.com/publication/b0a584ae?page=68"> Access to Specialty Mental Health Services </a> <a title="PPprovider2014_2015.pdf page 69" href="http://viewer.zmags.com/publication/b0a584ae?page=69"> Once a call is received, care managers assess req</a> <a title="PPprovider2014_2015.pdf page 70" href="http://viewer.zmags.com/publication/b0a584ae?page=70"> SECTION V Rare an</a> <a title="PPprovider2014_2015.pdf page 71" href="http://viewer.zmags.com/publication/b0a584ae?page=71"> OVERVIEW The Department of Health and Mental Hygi</a> <a title="PPprovider2014_2015.pdf page 72" href="http://viewer.zmags.com/publication/b0a584ae?page=72"> CARE COORDINATION REM case managers are also expe</a> <a title="PPprovider2014_2015.pdf page 73" href="http://viewer.zmags.com/publication/b0a584ae?page=73"> Provider Manual 2014-2015 www.ppmco.org 73</a> <a title="PPprovider2014_2015.pdf page 74" href="http://viewer.zmags.com/publication/b0a584ae?page=74"> 74 www.ppmco.org Provider Manual 2014-2015</a> <a title="PPprovider2014_2015.pdf page 75" href="http://viewer.zmags.com/publication/b0a584ae?page=75"> Provider Manual 2014-2015 www.ppmco.org 75</a> <a title="PPprovider2014_2015.pdf page 76" href="http://viewer.zmags.com/publication/b0a584ae?page=76"> 76 www.ppmco.org Provider Manual 2014-2015</a> <a title="PPprovider2014_2015.pdf page 77" href="http://viewer.zmags.com/publication/b0a584ae?page=77"> Provider Manual 2014-2015 www.ppmco.org 77</a> <a title="PPprovider2014_2015.pdf page 78" href="http://viewer.zmags.com/publication/b0a584ae?page=78"> 78 www.ppmco.org Provider Manual 2014-2015</a> <a title="PPprovider2014_2015.pdf page 79" href="http://viewer.zmags.com/publication/b0a584ae?page=79"> Provider Manual 2014-2015 www.ppmco.org 79</a> <a title="PPprovider2014_2015.pdf page 80" href="http://viewer.zmags.com/publication/b0a584ae?page=80"> 80 www.ppmco.org Provider Manual 2014-2015</a> <a title="PPprovider2014_2015.pdf page 81" href="http://viewer.zmags.com/publication/b0a584ae?page=81"> Provider Manual 2014-2015 www.ppmco.org 81</a> <a title="PPprovider2014_2015.pdf page 82" href="http://viewer.zmags.com/publication/b0a584ae?page=82"> SECTION VI DHMH Qua</a> <a title="PPprovider2014_2015.pdf page 83" href="http://viewer.zmags.com/publication/b0a584ae?page=83"> QUALITY ASSURANCE MONITORING PLAN The quality ass</a> <a title="PPprovider2014_2015.pdf page 84" href="http://viewer.zmags.com/publication/b0a584ae?page=84"> Quarterly Complaint Reporting We are responsible </a> <a title="PPprovider2014_2015.pdf page 85" href="http://viewer.zmags.com/publication/b0a584ae?page=85"> APPEALS – a request for review of an action If th</a> <a title="PPprovider2014_2015.pdf page 86" href="http://viewer.zmags.com/publication/b0a584ae?page=86"> Provider Appeals Process Johns Hopkins HealthCare</a> <a title="PPprovider2014_2015.pdf page 87" href="http://viewer.zmags.com/publication/b0a584ae?page=87"> The EHL has the capability to address callers in </a> <a title="PPprovider2014_2015.pdf page 88" href="http://viewer.zmags.com/publication/b0a584ae?page=88"> The Ombudsman program is operated locally in each</a> <a title="PPprovider2014_2015.pdf page 89" href="http://viewer.zmags.com/publication/b0a584ae?page=89"> Member Appeal A HealthChoice member may exercise </a> <a title="PPprovider2014_2015.pdf page 90" href="http://viewer.zmags.com/publication/b0a584ae?page=90"> SECTION VII Corrective Man</a> <a title="PPprovider2014_2015.pdf page 91" href="http://viewer.zmags.com/publication/b0a584ae?page=91"> SUSPECTED PHARMACY MISUSE PROCESS AND PROCEDURES </a> <a title="PPprovider2014_2015.pdf page 92" href="http://viewer.zmags.com/publication/b0a584ae?page=92"> 8. A 30-day waiting period is allowed for the m</a> <a title="PPprovider2014_2015.pdf page 93" href="http://viewer.zmags.com/publication/b0a584ae?page=93"> 18. A monthly Excel report will be submitted to D</a> <a title="PPprovider2014_2015.pdf page 94" href="http://viewer.zmags.com/publication/b0a584ae?page=94"> SECTION VIII SECTION VII</a> <a title="PPprovider2014_2015.pdf page 95" href="http://viewer.zmags.com/publication/b0a584ae?page=95"> IMPORTANT PHONE NUMBERS Priority Partners 800-65</a> <a title="PPprovider2014_2015.pdf page 96" href="http://viewer.zmags.com/publication/b0a584ae?page=96"> PRIORITY PARTNERS IDENTIFICATION CARD Name </a> <a title="PPprovider2014_2015.pdf page 97" href="http://viewer.zmags.com/publication/b0a584ae?page=97"> AUTOMATED VOICE RESPONSE UNIT (AVRU) The Automate</a> <a title="PPprovider2014_2015.pdf page 98" href="http://viewer.zmags.com/publication/b0a584ae?page=98"> Accessing the AVRU Cl</a> <a title="PPprovider2014_2015.pdf page 99" href="http://viewer.zmags.com/publication/b0a584ae?page=99"> Provider Manual 2014-2015 www.ppmco.org 99</a> <a title="PPprovider2014_2015.pdf page 100" href="http://viewer.zmags.com/publication/b0a584ae?page=100"> www.ppmco.org</a>