Table of Contents. Terms and Conditions of Participation... 5

Transcription

1 Provider Guide

2 Table of Contents Enrollment... 1 Eligibility Criteria... 1 Enrollment Periods... 2 Change of Membership Status... 2 Identification Card... 3 Customer Service... 4 Group Retiree Notification... 4 Member Appeals & Grievance... 4 Terms and Conditions of Participation... 5 Claims Processing... 6 Required Data Elements of a Claim... 6 Submission of Claims... 6 Electronic Submission... 6 Hard Copy Submission... 7 Timely Filing Limit... 7 Clean Claim Definition... 7 Reimbursement... 8 Checking Claims Status... 8 Provider Dispute Resolution Process... 8 SecureHorizons Direct SM Provider Guide 2006 i

3 Introduction The Balanced Budget Act of 1997 created the Private Fee For Service (PFFS) Plan as a private plan option for Medicare beneficiaries in areas underserved by Medicare Advantage HMO plans. The PFFS plan offers many of the best features of both a Medigap plan and an HMO product including low premiums and cost sharing, guaranteed issue, open access to physicians, and an out-of-pocket maximum. PacifiCare Life and Health Insurance Company (PLHIC) has contracted with the Center for Medicare and Medicaid Services (CMS) to offer a PFFS Plan to Medicare beneficiaries who choose to enroll in SecureHorizons Direct SM and to employer groups for their retired employees. The SecureHorizons Direct SM Provider Guide supplies information and policies and procedures to assist providers in administering the benefits of the plan. SecureHorizons Direct SM offers comprehensive health care services to enrollees from any doctor, hospital or other health care provider that accepts the terms and conditions of participation in the plan and agrees to see the enrollee. The enrollee is free to see any provider who accepts the terms and conditions of participation, without prior authorization. PacifiCare is one of the oldest and largest companies serving the health care coverage needs of people on Medicare. When PacifiCare launched its Secure Horizons plan in 1985 we became one of the first health care organizations to be approved by Medicare to provide private coverage to individuals eligible for Medicare. Today, PacifiCare s Secure Horizons Medicare Advantage plans cover more than 740,000 Medicare beneficiaries nationwide. SecureHorizons Direct Provider Guide 2006 ii

4 Enrollment Enrollment and Eligibility Individuals who want to enroll in the SecureHorizons Direct SM plan must complete and sign an Individual Election Form. Group Retirees individuals who are provided coverage by their former employer may enroll in the plan through that employer. New enrollees who submit a completed Individual Election Form by the end of the month will be effective the first day of the following month. Eligibility Criteria Medicare beneficiaries are eligible to enroll in SecureHorizons Direct SM plan if they meet the following criteria and submit a completed enrollment application to SecureHorizons Direct SM. Enrollee must reside within the SecureHorizons Direct SM licensed service area. Enrollee must be entitled to Medicare Part A and enrolled in Part B. Enrollee must not be diagnosed as having end-stage renal disease (ESRD permanent kidney failure that requires regular kidney dialysis or a transplant to maintain life). An individual who receives a transplant that restores kidney function is not considered to have ESRD for purposes of Medicare eligibility Three exceptions have been granted for SecureHorizons Direct SM Group Retiree enrollees with ESRD: 1. If an employer or union group offers SecureHorizons Direct SM as a new option to its employees and retirees, ESRD retirees may select this new plan option (regardless of whether it has been an option in the past) as the employer or union s open enrollment rules allow. 2. If an employer or union group that has been offering a variety of coverage options consolidates its employee/retiree offerings (i.e., it drops one or more plans), current enrollees of the dropped plans may be accepted into SecureHorizons Direct SM 3. If an employer or union group contracts locally with SecureHorizons Direct SM in more than one geographic area (for example, in two or more states), an ESRD retiree who relocates permanently from one geographic location to another may remain with SecureHorizons Direct SM in the local employer or union Medicare Advantage plan. If the Medicare beneficiary is already a member of another PFFS or Medicare Advantage plan that membership will automatically terminate on the effective date of enrollment in the SecureHorizons Direct SM plan. SecureHorizons Direct SM Provider Guide

5 Enrollment Periods Medicare has defined specific enrollment windows during which beneficiaries may enroll in a PFFS plan or change their health plan coverage in 2006: Annual Election Period (AEP) the AEP for the 2006 benefit year occurs between November 15, 2005 and May 15, The AEP is the period of time during which enrollees and eligible beneficiaries may elect a different health plan or may elect coverage through Original Medicare. Open Enrollment Period (OEP) the OEP occurs between January 1, 2006 and June 30, The OEP is the period of time during which enrollees and eligible beneficiaries may make an additional health plan election for their medical and/or prescription drug coverage. Enrollees may only elect a like plan using their open enrollment election. A like plan provides coverage identical to the coverage the enrollee elected using their AEP. Once the enrollee has made a second health plan change the enrollee is locked in to that health plan for the remainder of the calendar year and may not make another change until the annual election period for the following year. Lock-in Period - the lock-in period occurs between July 1, 2006 and December 31, The lock-in period is the period of time during which all enrollees are locked into the health plan that they elected during the Annual Enrollment Period or Open Enrollment Period. Special Election Period (SEP) the enrollee is allowed to change health plans in the event of a SEP, which is defined as an enrollee household move, or when the PFFS plan reduces its service area. The Group Retiree enrollment period is based on the plan sponsor s open enrollment period. Change of Membership Status If an individual enrollee is an inpatient at any of the following facilities at the time his/her SecureHorizons Direct SM plan becomes effective, the previous carrier is financially responsible for Part A services until the day after the enrollee is discharged to a lower level of care: Acute hospital Rehabilitation hospital Psychiatric hospital Long-term care facility Enrollment and Eligibility SecureHorizons Direct SM becomes financially responsible for Part B services (physician care) as of the enrollee s effective date with the plan. SecureHorizons Direct SM Provider Guide

6 Enrollment and Eligibility If a Group Retiree is an inpatient at any of the above facilities at the time his/her SecureHorizons Direct SM plan becomes effective, the previous carrier is no longer financially responsible for the enrollee s services as of the date the enrollee is effective with SecureHorizons Direct SM. Identification Card SecureHorizons Direct SM will issue membership cards to all enrollees of the SecureHorizons Direct SM plan within 7 10 days of receipt of the completed Individual Election Form. SecureHorizons Direct SM enrollees may use a copy of the Individual Election Form as a temporary membership card, until they receive the permanent identification card. Individual Plan Identification Card NAME: John Doe ID #: COPAYMENTS: PCP OV SPEC OV ER $5.00 $12.00 $50.00 medco Offered by PacifiCare Life and Health Insurance Company Rx Bin: XXXXX Rx Grp: XXXXXX Rx PCN: XXXXXX H8888 PBP#888 Notice to Providers: Possession of this card does not guarantee eligibility. To confirm eligibility call Customer Service. Do NOT bill Original Medicare. Providers MUST call for Terms and Conditions of payment at or P.O. Box , San Antonio, TX or visit Providers submit claims to P.O. Box , San Antonio, TX Important Enrollee Information: You may seek covered services from any Medicare eligible physician in the U.S. Except in emergency situations, once your physician knows that you are a SecureHorizons Direct SM enrollee, has access to the terms and conditions, and has provided a service to you, your physician must accept PLHIC reimbursement as payment in full. If you select a non-participating physician who does not accept Medicare Assignment, you may incur expenses not covered by SecureHorizons Direct SM SecureHorizons DirectSM Customer Service Department: Call Toll-Free , or for the hearing impaired, (TTY ) 8 a.m p.m. EST, Monday through Friday. Send claims or other inquiries to P.O. Box , San Antonio, TX PRINT DATE 05/01/06 Electronic Claim Payer ID # Group Retiree Plan Identification Card NAME: John Doe ID #: Group Retiree COPAYMENTS: PCP OV SPEC OV ER $5.00 $12.00 $50.00 medco Offered by PacifiCare Life and Health Insurance Company Rx Bin: XXXXX Rx Grp: XXXXXX Rx PCN: XXXXXX H8888 PBP#888 Notice to Providers: Possession of this card does not guarantee eligibility. To confirm eligibility call Customer Service. Do NOT bill Original Medicare. Providers MUST call for Terms and Conditions of payment at or P.O. Box , San Antonio, TX or visit Providers submit claims to P.O. Box , San Antonio, TX Important Enrollee Information: You may seek covered services from any Medicare eligible physician in the U.S. Except in emergency situations, once your physician knows that you are a SecureHorizons Direct SM enrollee, has access to the terms and conditions, and has provided a service to you, your physician must accept PLHIC reimbursement as payment in full. If you select a non-participating physician who does not accept Medicare Assignment, you may incur expenses not covered by SecureHorizons Direct SM SecureHorizons DirectSM Customer Service Department: Call Toll-Free , or for the hearing impaired, (TTY ) 8 a.m p.m. EST, Monday through Friday. Send claims or other inquiries to P.O. Box , San Antonio, TX PRINT DATE 05/01/06 Electronic Claim Payer ID # SecureHorizons Direct SM Provider Guide

7 Customer Service & Notification Customer Service Customer Service Representatives are available to answer provider questions related to member eligibility, benefits, copayments and claims inquires at: :00 a.m. 10:00 p.m. (EST) Monday through Friday SecureHorizons Direct SM encourages providers to verify the enrollee s eligibility each time he/she is seeking services. Group Retiree Notification of Hospital Admission / Inpatient Stay SecureHorizons Direct SM requests that a Group Retiree Enrollee or an authorized representative notify us of inpatient stays by calling , or for the hearing impaired, (TTY ), Monday-Friday 8:00 a.m. to 10:00 p.m. (EST). A doctor, hospital or other health care provider may also notify SecureHorizons Direct SM on the Group Retiree Enrollee s behalf. The Group Retiree Enrollee or an authorized representative should call SecureHorizons Direct SM at least 72 hours in advance of a scheduled inpatient admission. For emergency admissions, SecureHorizons Direct SM requests that a Group Retiree Enrollee call within 48 hours of admission or as soon as reasonably possible. Member Appeals & Grievance The enrollee is encouraged to let SecureHorizons Direct SM know if they have concerns or experience any problems with SecureHorizons Direct SM. The enrollee has the right to appeal any organization determination about a requested health care service or SecureHorizons Direct s payment for, or what the enrollee believes are, Covered Services under the SecureHorizons Direct SM plan. We have representatives available to help enrollees with their questions and concerns by contacting SecureHorizons Direct SM at or on the PacifiCare Web site at SecureHorizons Direct SM Provider Guide

8 Terms and Conditions of Participation The enrollee is required to inform the provider in advance of receiving covered services that he or she is enrolled in the SecureHorizons Direct SM plan. Additionally, before furnishing covered services the provider must either know the terms and conditions of participation or have reasonable access to the terms and conditions. The terms and conditions for participation in the SecureHorizons Direct SM plan are: You agree to bill SecureHorizons Direct SM rather than Medicare or a Med Supplement carrier for reimbursement You agree to accept the Medicare Allowable Charge for Covered Services as payment in full, which includes the combined payment from SecureHorizons Direct SM and the enrollee You agree to collect from the enrollee the share of cost as identified in the enrollee s Schedule of Benefits If you are a Medicare participating provider, you agree to NOT balance bill the enrollee for any amounts in excess of what you are paid by SecureHorizons Direct SM and the enrollee, which is the Medicare Allowable Charge If you are a provider who does not accept Medicare assignment, you agree to accept the Medicare Allowable Charge from SecureHorizons Direct SM and the enrollee, and you may balance bill the enrollee up to the Medicare Limiting Rate. You may not balance bill the enrollee such that your total payment from SecureHorizons Direct SM and the enrollee combined is more than the Medicare Limiting Rate You agree to abide by the rules and regulations under the Medicare Modernization Act, which include, but are not limited to the appeals and grievance processes By agreeing to these terms and conditions and agreeing to render services to SecureHorizons Direct SM enrollees the provider is considered deemed Hospital and other facilities agree to comply with Medicare regulatory requirements to issue the Notice of Medicare Non-Coverage (NOMNC), Detailed Explanation of Non- Coverage (DENC), and the Notice of Discharge & Medicare Appeals Rights (NODMAR), as applicable Additionally, the provider must meet the following requirements: You are a Medicare certified provider, licensed to practice in your state You have or are eligible for a Medicare billing number You agree to follow the standards for confidentiality and patient privacy rights outlined in HIPAA regulations Providers automatically agree to accept the terms and conditions under the SecureHorizons Direct SM plan when they are aware their patient is enrolled in the SecureHorizons Direct SM plan and provide service to the enrollee. SecureHorizons Direct SM Provider Guide

9 Claims Processing Claims Processing SecureHorizons Direct SM processes all claims for services rendered to individual enrollees and Group Retiree enrollees. The provider must follow all Medicare billing guidelines when submitting the claim to SecureHorizons Direct SM. Required Data Elements of a Claim A completed claim must include the following information: Enrollee name SecureHorizons Direct SM identification number Date(s) of service Procedure/service/supply/NDC codes Diagnosis code(s) Provider s billing name and address Provider s tax identification number, UPIN or Social Security number Days/units of service Place of service All claims should include diagnosis coding to the highest level of specificity. Submission of Claims EDI Claims Submission: SecureHorizons Direct SM accepts electronic transactions from multiple clearinghouses for our Private Fee-For-Service plan. We suggest that you contact your clearinghouse to determine their available connectivity to UnitedHealthcare. Submit all of your SecureHorizons Direct SM claims using the: UnitedHealthcare Payer ID To avoid processing delays, you must validate the appropriate SecureHorizons Direct SM Payer ID number with your clearinghouse or refer to your clearinghouse s Published Payer Lists. Using a clearinghouse may help ensure that EDI requirements outlined in the Health Insurance Portability and Accountability Act (HIPPAA) are met. SecureHorizons Direct SM Provider Guide

10 Claims Processing Hard Copy Claims Submission: Submit completed, hard copy CMS 1500 or UB92 claims to: SecureHorizons Direct SM P.O. Box San Antonio, TX Important note - Do not submit claims for SecureHorizons Direct SM enrollees to Medicare or a Med Supplement carrier. Claims received by Medicare or a Med Supplement carrier for these enrollees will be denied. Timely Filing Limit The timely filing limit is defined as the calendar day period between the claim s last date of service, or payment/denial and the date by which SecureHorizons Direct SM must first receive the claim. SecureHorizons Direct SM adheres to the timely filing limit established by CMS. The provider is responsible to submit all claims to SecureHorizons Direct SM as follows: On or before December 31 st of the following year for services that were furnished during the first 9 months of a calendar year; and On or before December 31 st of the second following year for services that were furnished during the last 3 months of the calendar year. Clean Claim Definition A clean claim is defined as a claim that is complete and includes all information reasonably required by SecureHorizons Direct SM in order to process the claim for reimbursement. SecureHorizons Direct SM Provider Guide

11 Claims Processing Reimbursement Reimbursement for services rendered will be based on the applicable Medicare Allowable rate minus the enrollee s copayment as indicated below: SecureHorizons Direct SM will reimburse all Medicare Part A Covered Services at the Medicare Allowable Charge unless specified differently in the PFFS Reimbursement Guide. SecureHorizons Direct SM will reimburse all Medicare Part B Covered Services at the Medicare Allowable Charge unless specified differently in the PFFS Reimbursement Guide. Medicare participating provider MAY NOT balance bill enrollees for any amounts in excess of what they are paid by SecureHorizons Direct SM and the enrollee SecureHorizons Direct SM will reimburse physicians who do not accept Medicare assignment at the Medicare Allowable Charge from SecureHorizons Direct SM and the enrollee. These providers may balance bill the enrollee up to the Medicare Limiting Charge These providers may not balance bill the enrollee such that the total payment from SecureHorizons Direct SM and the enrollee combined is more than the Medicare Limiting Charge Checking Claims Status The provider may check the status of a claim previously submitted for reimbursement by contacting SecureHorizons Direct SM at Provider Dispute Resolution Process The purpose of the Provider Dispute Resolution Process is to research and resolve claims issues. Claim inquiries may come from enrollees who are receiving bills or from providers of service who have not received payment for services rendered or do not agree with the payment received. The Provider Dispute Resolution process includes two levels of appeal an initial verbal inquiry and a formal written provider dispute resolution request. Providers who render care to SecureHorizons Direct SM enrollees are responsible to bill their claim(s) directly to SecureHorizons Direct SM under the terms and conditions of the plan. A copy of the SecureHorizons Direct SM Provider Dispute Resolution policy and procedure is located on the PacifiCare Web site or, by contacting SecureHorizons Direct SM at SecureHorizons Direct SM Provider Guide