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

Gateway Health Plan Medicare Assured ®
Provider Manual 2011
Paper Claim Submission ........................................................................................................... 45
Billing Procedures ..................................................................................................................... 45
Claim Payment Disagreements ................................................................................................. 46
Administrative Claims Review ................................................................................................. 47
Claim Re-submission ................................................................................................................ 47
Resubmission of Corrected Claims ........................................................................................... 47
Resubmission for COB Request and Third Party Liability (TPL) ............................................ 47
Expectations for Gateway Health Plan Medicare Assured ® Response to Claims Submission . 48
Checking on the Status of a Claim ............................................................................................ 48
Claims Appeals ......................................................................................................................... 48
CMS-1500 (08-05) Data Elements for Submission of Paper Claims Forms ............................ 49
Hospital Services ...................................................................................................................... 51
UB-04 Data Elements for Submission of Paper Claims Forms ........................... 51
CHAPTER VII QUALITY IMPROVEMENT ...................................................................................... 53
Purpose of the Quality Improvement/Utilization Management Program ................................. 53
Goal of the Quality Improvement/Utilization Management Program ...................................... 53
Objective of the Quality Improvement/Utilization Management Program .............................. 53
Scope of the Quality Improvement/Utilization Management Program .................................... 54
Quality Improvement Manual ................................................................................................... 55
Patient Safety ............................................................................................................................ 55
CHAPTER VIII APPEALS AND GRIEVANCES ......................................................................... 57
Introduction ............................................................................................................................... 57
What are appeals and grievances? ............................................................................................ 57
Acting as an Appointed Representative .................................................................................... 58
Appeals Regarding Hospital Discharge .................................................................................... 58
Skilled Nursing Facility (SNF), Home Health (HHA) or Comprehensive Outpatient
Rehabilitation Facility (CORF) Services .................................................................................. 59
Quality Improvement Organization (QIO) Review .................................................................. 59
APPEALS FOR COVERAGE OF OTHER MEDICAL SERVICES .................................................... 60
IRE REVIEW 61
Administrative Law Judge Review ........................................................................................... 62
Medicare Appeals Council ........................................................................................................ 62
Federal Court ............................................................................................................................ 62
APPEALS FOR COVERAGE OF PART D DRUGS ............................................................................ 62
Independent Review Entity (IRE) ............................................................................................. 64
Administrative Law Judge (ALJ) Review ................................................................................ 64
MEDICARE APPEALS COUNCIL .................................................................................................... 65
Member Grievances .................................................................................................................. 66
Second Level Grievance ........................................................................................................... 67
EXPEDITED GRIEVANCES ............................................................................................................. 67
Quality Improvement Organization Review ............................................................................. 67
How to file a quality of care complaint with the QIO .............................................................. 68
Provider Appeals ....................................................................................................................... 68
First Level Appeal (The Informal Dispute Resolution Process) ............................................... 68
Second Level Appeal (The Informal Dispute Resolution Process) .......................................... 68
Revised 12/12/10 4