Fidelis SecureCare of North Carolina Provider Manual

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Introduction to Fidelis Fidelis SeniorCare is a leader in the development of Medicare Advantage Special Needs Plans for eligible individuals residing in nursing facilities and assisted living communities, and for those institutionally qualified individuals who live at home. Fidelis contracts with the federal government under the Medicare Advantage Program to provide Medicare benefits plus enhanced coverage specifically designed for this special needs population. Today the company administers Fidelis SecureCare plans in three states, Michigan, North Carolina and Texas. Fidelis SecureCare plans are available for those qualified individuals who require more focused coordination of clinical care than traditional Medicare can provide. Our contracted physicians and their extenders, nurse practitioners and care managers provide the highest quality care while effectively managing the medical and psychosocial needs of these frail members. At Fidelis SecureCare, we firmly believe that the quality of life of our members can be significantly improved—and their rate of decline measurably reduced—through clinically superior, consistently attentive care. In concert with nursing facility staff, our physician partners and our network of expert healthcare professionals, we strive daily to achieve improved health outcomes for every chronically ill member we serve. Our Vision Fidelis SecureCare is committed to achieving the highest level of care for our frail and more vulnerable senior population, one that is compassionate and focused on the needs of the whole person. Our Mission To fundamentally improve the way healthcare is delivered for the long term care resident by partnering with physicians to provide care in the most effective and efficient clinical setting. Customer Service Hours: October through February 14th - 8:00 a.m. to 9:00 p.m. EST seven days per week February 15 through September - 8:00 a.m. to 8:00 p.m. EST Monday through Friday Outside of these timeframes, please leave a detailed voice message. Introduction to Fidelis
Fraud, Waste and Abuse Provider and Fidelis have an obligation to comply with all federal and state laws and Medicare requirements related to fraud, waste, and abuse. Provider Responsibilities: By December 31, 2009, and annually thereafter, affected providers and entities should: 1. Complete training as defined in 42 CFR 422.503 and 42 CFR 423.504 2. Submit an attestation to Fidelis verifying completion of training The topics that providers must be trained on: • Laws and regulations related to Medicare Advantage and Part D fraud, waste and abuse (i.e., False Claims Act, Anti-Kickback statute, HIPAA, etc.) • Your obligation to make sure that your downstream contractors and related entities have appropriate policies and procedures in place to address fraud, waste, and abuse • The need to have a process in place for reporting suspected fraud, waste and abuse in first tier, downstream, and related entities to Fidelis along with protections for employees of downstream contractors and related entities who report suspected fraud, waste and abuse • An understanding of the types of fraud, waste and abuse that can occur with downstream contractors and related entities Provider is also responsible for cooperating with Fidelis during any investigation of suspected fraud, waste or abuse on the part of the provider or any of its downstream contractors. Fidelis Responsibility: Fidelis is responsible for monitoring the activities of its providers, vendors, and other downstream contractors to ensure that claim submission / billing practices, utilization practices, and business practices meet federal, state and Medicare requirements. Fidelis will notify any provider or vendor that it suspects is not complying with these requirements and request a review of its records and/or activities. In certain cases, this could include suspension of payment until corrective action plans are in place. Effective January 1, 2009, The Centers for Medicare and Medicaid Services (CMS) is requiring that all Medicare Advantage Organizations and Prescription Drug Plan Sponsors must apply Fraud, Waste and Abuse (FWA) training to all entities that they are partnering with to provide benefits or services in the Part C or the Part D programs Fidelis is offering this service in accordance with the requirement of the “Revisions to the Medicare Advantage and Part D Prescription Drug Contract Determinations, Fraud, Waste and Abuse Training
Page 1 and 2: Provider Manual North Carolina
Page 3: Utilization Management Affirmative
Page 7 and 8: Regulations and Responsibilities Co
Page 9 and 10: • Contracted providers agree to r
Page 11 and 12: Physician Responsibilities Primary
Page 13 and 14: Access to Care Fidelis has adopted
Page 15 and 16: The Care Management team is compris
Page 17 and 18: • Psychotropic Medication Managem
Page 19 and 20: Credentialing Credentialing Program
Page 21 and 22: SecureCare members only as a result
Page 23 and 24: • Have no significant utilization
Page 25 and 26: Medical/treatment record keeping re
Page 27 and 28: Eligibility You may verify the elig
Page 29 and 30: You can receive your username and p
Page 31 and 32: Quality Program Purpose The purpose
Page 33 and 34: Referral and Prior Authorization Pr
Page 35 and 36: Referrals to Non-Participating Prov
Page 37 and 38: Criteria for Authorizing Part A Ski
Page 39 and 40: Fidelis SecureCare Criteria for Aut
Page 41 and 42: OUTPATIENT CARE COORDINATION PHONE:
Page 43 and 44: Remittance Advice (RA) Payments rec
Page 45 and 46: Claims Look-Up Once logged in, you
Page 47 and 48: Claim Disputes and Appeals Appealin
Page 49 and 50: Fidelis will reimburse the facility

Fidelis SecureCare of North Carolina Provider Manual

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