GATEWAY Health Plan Medicare AssuredÂ® Provider ... - CBHNP

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Gateway Health Plan Medicare Assured ® Provider Manual 2011 TABLE OF CONTENTS PRODUCT DESCRIPTION ................................................................................................................. 6 Summary of the Gateway Health Plan Medicare Assured ® ........................................................ 6 Summary of Responsibilities of CBHNP and Contracted Providers .......................................... 6 GENERAL INFORMATION ................................................................................................................ 8 CHAPTER I INFORMATION PAGE .............................................................................................. 9 Mailing Address for Claims ........................................................................................................ 9 Telephone Numbers .................................................................................................................... 9 CHAPTER II MEMBER ELIGIBILITY .......................................................................................... 10 The Enrollment/Disenrollment Process .................................................................................... 10 Member ID Cards ..................................................................................................................... 10 Determining Eligibility through Gateway Health Plan Medicare Assured ® ............................. 10 CHAPTER III PROVIDER RELATIONS SERVICES ....................................................................... 12 Credentialing/Re-credentialing ................................................................................................. 12 Individual Provider Application ............................................................................................... 12 Professional Provider Organization and Facility Application Process ..................................... 13 Credentialing Site Visit ............................................................................................................. 13 Re-credentialing ........................................................................................................................ 14 Adding a New Site or Service ................................................................................................... 14 Policies for Suspension, Reduction of Privileges and Termination .......................................... 14 Progressive Discipline Policy ................................................................................................... 14 Reporting of Serious Quality Deficiencies to Appropriate Authorities .................................... 15 Provider Appeal Process ........................................................................................................... 15 Contracting and Rate Notices ................................................................................................... 16 Provider Data Updates .............................................................................................................. 16 Provider Profiling...................................................................................................................... 17 Provider Profile Reporting ........................................................................................................ 17 Individual Outcome Measures .................................................................................................. 17 Complaints against Providers ................................................................................................... 18 Actions ...................................................................................................................................... 18 Provider Staff Credentialing ..................................................................................................... 18 Provider Appeals of Payment Denial ........................................................................................ 19 CHAPTER IV PROVIDER RESPONSIBILITIES ............................................................................ 21 Compliance with Law and Regulation ...................................................................................... 21 Members Rights and Responsibilities ....................................................................................... 21 Compliance with the Americans with Disabilities Act ............................................................. 21 Use of an Interpreter ................................................................................................................. 22 Resources for Consumers and Providers .................................................................................. 23 Cultural/Ethnic/Racial Sensitivity ............................................................................................ 24 Confidentiality .......................................................................................................................... 24 Release of Information Forms .................................................................................................. 24 Appointment Availability ......................................................................................................... 25 Access Standards ...................................................................................................................... 25 Revised 12/12/10 2
Gateway Health Plan Medicare Assured ® Provider Manual 2011 Life Threatening Emergencies .................................................................................................. 26 Non-Life Threatening Emergencies .......................................................................................... 26 Urgent ....................................................................................................................................... 26 Routine ...................................................................................................................................... 26 Critical Incident Reporting ....................................................................................................... 26 Medical Records Standards ....................................................................................................... 28 Accessibility and Availability of Medical Records .................................................................. 28 Recordkeeping .......................................................................................................................... 28 Communication Requirements and Continuity of Care ............................................................ 30 Referral for Medically Necessary Behavioral Health Services ................................................ 30 Provision of Emergency Care ................................................................................................... 31 Broken/Missed Appointments and AMA Discharge ................................................................ 31 Continued Stay Review ............................................................................................................. 31 Determination of Medical Necessity ........................................................................................ 32 Discharge Planning ................................................................................................................... 32 CHAPTER V CLINICAL HANDBOOK .......................................................................................... 33 Definitions................................................................................................................................. 33 Non-Incentive Statement .......................................................................................................... 33 Member Services (MSS) ........................................................................................................... 33 Authorization Procedures by Level of Care .............................................................................. 34 Mental Health Outpatient Treatment Registration .................................................................... 34 SA Outpatient Treatment Registration ...................................................................................... 35 MH Partial Hospitalization ....................................................................................................... 36 MH Inpatient ............................................................................................................................. 36 SA Hospital Based Detoxification and Rehabilitation .............................................................. 36 Discharge Planning ................................................................................................................... 36 Outpatient Discharge ................................................................................................................ 37 AMA and Discharge Plans........................................................................................................ 37 Medical Necessity Denial ......................................................................................................... 38 Community Integration ............................................................................................................. 38 Improvement of Quality of Life ................................................................................................ 38 Outcome Focus ......................................................................................................................... 38 Cultural Competence ................................................................................................................ 39 Clinical Practice Guidelines ...................................................................................................... 39 CBHNP MH Inpatient and Partial Hospitalization Initial Assessment, Continued Stay Review and Discharge Information ....................................................................................................... 39 Initial Assessment – Pre-certification for Inpatient/Partial Hospitalization ............................. 40 Continued Stay Review ............................................................................................................. 40 Discharge Information .............................................................................................................. 41 Excluded Services ..................................................................................................................... 42 CHAPTER VI CLAIMS HANDBOOK ............................................................................................. 44 Completing & Submitting Claims Forms ................................................................................. 44 Electronic Billing ...................................................................................................................... 44 Requirements for Submitting Claims to Gateway Health Plan ® through Emdeon and RelayHealth............................................................................................................................... 44 Revised 12/12/10 3
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