WellCare of Iowa, Inc.

Transcription

1 Prior authorization Notice of Admission or Admission Request Prior authorization is required for all Nursing Facility, Skilled Nursing Facility and Long Term Support Services (LTSS) services. Prior Authorization requests must be submitted at least 72 hours in advance for SNF admissions. See page 46 of the Provider Manual for more information about Prior Authorization requests. promptly notify the MCO of admission or request for admission to the facility as soon as facility has knowledge of such admission or request. See Section of the Medicaid Attachment to the Provider Iowa, Prior Authorization is required for all Waiver and LTSS services. Residents in a LTSS Facility must be reauthorized every 120-days in most cases. See Section V. in the Provider Manual starting on Page 77. promptly notify MCO of admission or request for admission to the facility as soon as facility has knowledge of such admission or requests. See Section 18 of Schedule 9-2 of the Ancillary Services Prior authorization is required for select elective or nonemergency services as designated by the MCO. The provider manual instructs providers to check the MCO website or call Provider Services to determine whether prior authorization is required for a specific service. See Page 49 of the Provider promptly notify MCO of admission or request for admission to the facility as soon as facility has knowledge of such admission or request. See Section 36 of Attachment B-1 to Participating Provider Valley, Prior authorization is not directly addressed in the LTSS Agreement, although the Agreement does state that prior authorization is not required for emergency services. See Section 3.1 of the Prior Authorization is discussed in Chapter 3 of the Provider Not addressed in draft Agreement or Provider Providers should be familiar with the different prior authorization procedures for each MCO. These procedures may differ from the procedures traditionally used with Iowa Medicaid. Although not included in the draft Agreement reviewed for this chart, the notice of admission language included in the other agreements is standard language that the state requires the MCOs include in the agreements. 1 For LeadingAge Iowa Members

2 Notice of Discharge Notice of Change in Condition immediately notify the MCO if the facility is considering discharging a member and must consult with the member s care coordinator. The facility must also notify the member in writing prior to discharge as required by Iowa law. See Sections and of the Medicaid Attachment to the Provider notify the MCO of any change in a member s medical or functional condition that could impact the member s level of care eligibility See Section of the Medicaid Attachment to the Provider Iowa, immediately notify MCO if the facility is considering discharging a member and must consult with the member s care coordinator. The facility must also notify the member in writing prior to discharge as required by Iowa law. See Section 18 of Schedule 9-2 of the Ancillary Services notify MCO of any change in a member s medical or functional condition that could impact the member s level of care eligibility. See Section 18 of Schedule 9-2 of the Ancillary Services immediately notify MCO if the facility is considering discharging a member and must consult with the member s care coordinator. The facility must also notify the member in writing prior to discharge as required by Iowa law. See Section 36 of Attachment B-1 to notify MCO of any change in a member s medical or functional condition that could impact the member s level of care eligibility. See Section 36 of Attachment B-1 to Valley, Not addressed in draft Agreement or Provider Not addressed in draft Agreement or Provider Although not included in the draft Agreement reviewed for this chart, the notice of discharge obligations is standard language that the state requires the MCOs include in the agreements. Although not included in the draft Agreement reviewed for this chart, the notice of change in condition is standard language that the state requires the MCOs include in the agreements. 2 For LeadingAge Iowa Members

3 Eligibility Verification Nondiscrimination Providers must establish a Member s eligibility prior to rendering services except in the case of an emergency condition. See Section 2.10 of the Medicaid Attachment to the Provider Details on how to verify member eligibility with the MCO is provided in Chapter 7 of the Provider Providers may not discriminate against any member as a result of his or her enrollment in the MCO plan, or because of race, color, creed, national origin, ancestry, religion, sex, marital status, age, disability, payment source, state of health, need for services, Iowa, Providers must verify a member s eligibility with the MCO prior to rendering services except in emergency situations. Eligibility can be verified a variety of ways, including via the MCO s website, a dedicated phone number, a real-time eligibility service or member ID card. See Page 11 of the Provider Provider may not discriminate against any patient or other person as a result of that individual s race, color, religion, gender, sexual orientation, handicap, age, national origin, source of payment, or any other basis prohibited by law. See Section 10.7 of the Providers are required to verify a member s eligibility prior to providing services. Providers may verify eligibility using the provider portal on the MCO website, accessing the MCO s interactive voice response system or contacting provider services. See Page 36 of the Provider Providers shall not discriminate in their treatment of Members based on Members health status, source of payment, cost of treatment, participation in Benefit Plans, race, ethnicity, national origin, religion, gender, age, mental or physical Valley, Providers are instructed to use the MCO s website to check member eligibility status or by calling a dedicated phone number. See Section 3 of Agreement and Section 14.2 of the Provider Provider is obligated to comply with Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, the Rehabilitation Act of 1973 and the Americans with Disabilities Act. See 3 For LeadingAge Iowa Members Providers should be aware of the various methods of verifying member eligibility for each MCO. Although member s are supposed to carry ID cards, providers are encouraged to verify eligibility using one of the other methods since ID cards are not returned when a member loses eligibility. Most of the nondiscrimination provisions are very broad and prohibit discrimination based on payer-source or status as a Medicaid beneficiary. This could impact the ability of a provider to control its payer mix.

4 status as a litigant, status as a Medicare or Medicaid beneficiary, sexual orientation, gender identity or any other basis prohibited by law. See Section 2.2 of the Provider Ancillary Services disability, sexual orientation, or genetic information. See Section of the Participating Provider Section 3.14 of the Iowa Medicaid Appendix to the The Provider Manual states that members have the right to be cared for with respect and dignity, no matter what their health status, sex, race, color, religion, national origin, age, marital status or sexual orientation. Section For LeadingAge Iowa Members

5 Quality Assessment and Performance Improvement Utilization Management Providers must comply with the MCO s quality assessment and performance improvement initiatives. See Section 2.9 of the Provider Chapter 20 of the Provider Manual details the MCO s Quality Assessment and Performance Improvement programs. Providers must participate in the MCO s utilization management program. See Section 2.9 of the Provider The MCO s Medical Management Program is described in Chapter 8 of the Provider Iowa, Providers must comply with the MCO s quality assurance and performance improvement programs outlined in Section VII of the Provider Providers must comply with the MCO s Utilization Management Program. See Section 2.2 of the Ancillary Services The MCO s Utilization Management program is described in Section V of the Provider Providers must comply with the MCO s quality improvement program. See Section 4.7 of the The MCO s quality improvement program is described in Section 3 of the Provider Providers must participate in the MCO s utilization management program. See Section 4.8 of the The MCO s Utilization Management program is described in Section 4 of the Provider Valley, Provider agrees to cooperate with MCO s quality assessment activities. See Section 3.25 of the Iowa Medicaid Appendix. Provider agrees to cooperate with MCO s utilization management activities. See Section 3.25 of the Iowa Medicaid Appendix. Providers should review the Quality Assessment and Performance Improvement sections of the provider manuals and be prepared to work with the MCOs on Performance Improvement initiatives. Each MCO appears to have robust utilization management programs that providers should be familiar with prior to the January 1 st transition date. 5 For LeadingAge Iowa Members

6 Referrals Credentialing Providers must refer certain services within network as required by the MCO. See Section 2.11 of the Provider Agreement and Page 172 of the Provider Providers must comply with the MCO s credentialing and recredentialing requirements set forth in Chapter 15 of the Provider Iowa, Providers must refer Members to other participating providers when provider is unable to provide covered services when consistent with sound medical judgment. See Section 2.13 of the Ancillary Services The credentialing and recredentialing process and requirements for LTSS providers is described on Pages 128 through 131 of the Provider Providers are prohibited from referring to other providers, including participating providers, without MCO approval except in limited circumstances. See Section of the MCO requires initial credentialing and periodic re-credentialing which may include site reviews. See Section of the The specific credentialing and recredentialing requirements are set forth in Section 6 of the Provider Valley, Referrals should be made to providers, facilities and contractors who are contracted with the MCO. See Chapter 12 of the Provider The Agreement suggests that the MCO may delegate credentialing responsibility to the provider. See Section 3.7 of the Iowa Medicaid Appendix to the According to the Provider Manual, the MCO follows the provider requirements guidelines in the Iowa Medicaid Provider Manual to credential nursing facility providers and providers of HCBS services. See Section 10.5 of the Provider In order to comply with these requirements, providers should confirm whether another provider is in-network before referring to that provider. Providers likely will receive, or have received already, additional documentation from each of the four MCOs related to credentialing. 6 For LeadingAge Iowa Members

7 Non-covered Services Medical Necessity Providers may provide and bill members for non-covered services but must follow certain notice and consent requirements before providing the service. See Chapter 10 of the Provider The Provider Manual defines medical necessity as consistent with Iowa law. Iowa, Prior to providing a noncovered service to a member, the provider must inform the member about the associated costs, that the costs will not be paid by the MCO and obtain a signed document acknowledging the member s payment obligations. See Section 2.4 of the Ancillary Services Agreement and Page 60 of the Provider Medically Necessary is defined in the Provider Manual as services or supplies that are needed for the diagnosis or treatment of the member s medical condition according to accepted standards of medical practice. See Page 82 of the Provider Providers must obtain the written consent from member that member will pay prior to providing a non-covered service. See Section of the Medical necessity is determined through the MCO utilization management program. See Section 5.4 of the The Provider Manual provides a list of conditions a service must meet to be considered medically necessary. See page 47 of the Provider Valley, Provider must obtain written consent from a member before providing and billing the member for noncovered services. See Section 14.2 of the Provider Provider agrees to cooperate with MCO s utilization management activities. See Section 3.25 of the Iowa Medicaid Appendix to the 7 For LeadingAge Iowa Members Each of the contracts appear to have similar requirements for when a provider provides noncovered services to a member, including the obligation to obtain written consent from the member in advance of providing the non-covered service Although each of the MCOs defines medical necessity slightly differently, the definitions are similar and should be consistent with medical necessity definitions used by Medicaid and other payers.

8 Definition of Clean Claim Claim Submission Timeframe Clean claims are defined as claims filed within the time filing period and without any defects and with all required information necessary for processing. See Page 92 of the Provider If MCO is primary or secondary payer, the time period for submitting claims is 90 days from the last date of service on the claim. See Page 96 of the Provider The Provider Agreement states that the 90 days does not run on Secondary Payer claims until the provider receives notification of the primary payer s responsibility. See Section 3.1 of the Medicaid Attachment. Iowa, A claim that has no defect of impropriety. See Section 1.4 of the Ancillary Services All claims for services rendered by in-network providers must be submitted to the MCO within 90 days from the date of service (or the date of discharge for inpatient admissions). See Page 108 of the Provider A clean claim is a timely received claim on a legible CMS 1500 or UB 04 form with complete and accurate information. The claim is also not subject to COB and is not under review for Medical Necessity. See Section 2.4 of the Claims must be submitted within 90 days from date of service or from date of discharge for inpatient services. See Section of the Participating Provider Valley, A claim that can be processed without obtaining additional information. This does not include claims from a provider who is under investigation for fraud and abuse, or a claim under review for medical necessity. See Chapter 15 of the Provider All information necessary to process a claim must be received by the MCO no more than ninety (90) days from the date the services were rendered. See Section 3.4 of the 8 For LeadingAge Iowa Members The definitions of clean claim are fairly typical, but providers should be familiar with the specific claim submission procedures for each MCO prior to the January 1 st transition date. Each of the MCOs requires that providers submit claims within 90 days. Failure to submit a claim within this timely filing period may result in automatic denials.

9 Timeframe for payment of claims Timeframe for requests for additional information The Provider Agreement states that the MCO will adjudicate claims in accordance with applicable law. See Section of the Medicaid Attachment to the Provider If additional information requested, provider must reply within 60 days. See Section of Medicaid Attachment to the Provider Iowa, If a provider does not receive payment for a claim within 45 days, the provider may check claim status via a secure web portal, by calling provider services or by calling the provider s account executive. See Page 110 of the Provider Rejected claims must be re-submitted within 365 days of the original date of service. See Page 109 of the Provider The MCO shall either accept or pay or deny a clean claim within 30 days of receipt. See Section 19 of Attachment B-1 to the The MCO must request additional information within 30 days of claim submission. See Paragraph 19 of Attachment B-1 to the Valley, The Provider Manual states that clean claims will be paid within 30 days unless otherwise stated in the provider agreement. See Section 11.3 of the Provider Any additional information requested by the MCO must be provided within 90 days of the request. See Section 3.4 of the The state has said that the MCOs are obligated to pay 90% of clean claims within 20 calendar days, 99% of clean claims within 60 calendar days and 100% of claims within 90 calendar days. 9 For LeadingAge Iowa Members

10 Retroactive Denials Overpayments The issue of retroactive denials is not directly addressed in the Provider Agreement, but the MCO does have general audit and review rights and may seek refunds in the event it determines it overpaid a provider. Providers must refund overpayments within 30 days when receive notice of overpayment from the MCO and the MCO may offset overpayments against future amounts owed to the provider. Providers must also refund self-identified overpayments within 60 days. See Section 2.7 of the Provider Agreement and Pages 101 and 102 of the Provider Iowa, The issue of retroactive denials is not directly addressed in the Provider Agreement, but the MCO does have general audit and review rights and may seek refunds in the event it determines it overpaid a provider. Providers are required to refund improper or overpayment claims from the MCO. The MCO has the right to offset future claim payments by any amount owed by Provider to the MCO. See Page 111 of the Provider Manual and Section 3.1 of the Ancillary Services The MCO has right to retrospective medical record reviews for utilization management and payment purposes. See Section 5.4 of the Providers must refund overpayments within 30 days (from notice from MCO or selfidentification). The MCO has the right to offset overpayments against future payments. See Section 5.5 of the Valley, The issue of retroactive denials is not directly addressed in the Provider Agreement, but the MCO does have general audit and review rights and may seek refunds in the event it determines it overpaid a provider. Providers must refund overpayments within 30 days (from notice from MCO or selfidentification). The MCO may offset overpayments against future payments. See Section 3.9 of the Agreement and Section 11.7 of the Provider Providers should anticipate that the MCOs will conduct post-payment claim reviews and audits and may retroactively deny or seek refunds in certain cases. Providers should have systems in place to identify potential overpayments and be prepared to refund any identified overpayments in a timely manner. 10 For LeadingAge Iowa Members

11 Payment Rate and Methodology Term The Provider Agreement includes a chart outlining the payment methods for certain services. That chart states that for most LTSS and HCBS services providers will be paid 100% of the Amerigroup Iowa Medicaid Fee Schedule/Amerigroup Iowa Medicaid Rates. Initial term of 3 or 4 years with automatic renewals. See Section 8.1 of the Provider Iowa, The template Ancillary Services Agreement does not include a specific compensation schedule for services. One year with automatic renewal periods. See Section 8 of the Ancillary Services For both facility services and HCBS services the agreement states that compensation shall be 100 percent of the MCO s Medicaid rate schedule as based on the current Iowa Medicaid fee for service rate as published or otherwise established by DHS on the date the covered services are rendered. If a service is not on the fee for service schedule, the MCO will pay at the current Iowa Medicaid rate. See Section 2 of Attachment C- 1 of the Participating Provider One year with automatic renewal periods. See Section 7.1 of the Valley, The Agreement states that for HCBS and LTSS services payment will be based on the lesser of the provider s charges or 100% of the Iowa Medicaid fee schedule. In the event a specific fee amount is not published, the Agreement states that providers will be paid 30% of the provider s usual and customary charges. See Payment Appendix to the Two year initial term with automatic renewals. See Section 6.1 of the The Department of Human Services recently issued an Informational Letter (No. 1562) setting reimbursement rate floors for most provider types. That Informational Letter is available on the Iowa Medicaid Modernization website. Providers may attempt to negotiate rates above these floors but the MCOs will be prohibited from paying below the floors. Although the initial terms technically vary in length, all of the agreements automatically renew. 11 For LeadingAge Iowa Members

12 Termination Patient Payment Responsibility Without cause by either party with 180 days notice. The agreement also includes for cause termination provisions. See Section 8.2 of the Provider Balance billing is prohibited. Some members may be responsible for a member liability/client participation payment. The state will continue to make these determinations but the MCO s will notify providers when the provider is obligated to collect a member liability payment. See Page 99 of the Provider Iowa, Either party may terminate at the end of any current term with at least 90 days notice. The agreement also includes for cause termination provisions. See Section 8 of the Ancillary Services Balance billing of members is prohibited. See Page 110 of the Provider Costsharing may be applicable in limited circumstances. Without cause by either party with 90 days notice. The Agreement also includes for cause termination provisions. See Section 7.2 of the Balance billing is prohibited. Applicable cost sharing is allowed as permitted by state law. See Section 15 of Attachment B-1 to Valley, Either party may terminate at the end of the current term with at least 180 days notice. For cause termination provisions. See Section 6.9 of the Balance billing is prohibited. Applicable cost sharing is allowed as permitted by state law. The Provider Manual states that nursing facilities are expected to collect the patient client participation amounts from the members. See Section 10.7 of the Provider Providers have an obligation to continue to treat members during a transition period following termination of the Participation Iowa law generally prohibits providers from denying care or services to any member because of his or her inability to pay a copayment. 12 For LeadingAge Iowa Members