Fidelis SecureCare of North Carolina Provider Manual

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Definitions: Fidelis SecureCare 2011 Prior Authorization Requirements for Covered Services 1. Prior Authorization: A medical service that requires Health Plan approval prior to receiving the service in order for it to be covered. 2. Emergency Services: Services provided after the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that, in the absence of immediate medical attention, could reasonably be expected to result in: a) placing the patient’s health in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or part. Covered Services NOT Requiring Prior Authorization Requirements: List of Services: ƒ Requires written order by PCP/NP/PA except for urgent or emergent services ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ Labs (i.e. WBC, CBC, urine/blood cultures) Basic X-rays (i.e., Skeletal/chest x-rays, Doppler studies done on site) Diagnostic tests (EEG, EKG, Ultrasound, MRI, CT, Endoscopies, Angiography, Allergy, Cardiology, Vascular, Pulmonology, Gastroenterology, Sleep Study) Radiation therapy and chemotherapy services Blood transfusions and blood products Services performed on-site at the Nursing Facility, including: ¾ Podiatry ¾ Psych services Routine yearly physicals Routine yearly OB/GYN care, including mammogram screening, pap smear, pelvic and breast exams Routine yearly retinal eye exams for members with diabetes Screening tests (Prostate, Colorectal, AAA, Bone Mass Measurement, Cardiovascular Disease, Diabetes, Glaucoma) Influenza (yearly), Pneumococcal and Hepatitis B vaccines Renal Dialysis services Urgently needed services Emergency Room services (Notification required within 1 business day) Emergency Ambulance services dispatched through 911 or its local equivalent Benefits not traditionally covered by Medicare including those covered in the basket of benefits (Hearing, Vision, Dental, Incontinence supplies, etc.) Transportation to and from a covered medical appointment Covered Services Requiring Prior Authorization Requirements: List of Services: ƒ Services must be performed by a Contracted/In-Network FSC Provider ƒ Requires a written order by the PCP/NP/PA ƒ Requires prior authorization by Health Plan before service is rendered for benefit interpretation and clinical review of medical necessity ƒ ƒ ƒ ƒ ƒ All Part A Covered services including but not limited to: ƒ Observation Stays ƒ Inpatient Stays ƒ Elective Hospitalizations ƒ Skilled Nursing Facility ƒ Home Health Care Partial Hospital Program Non-PCP physician services provided by a non-participating physician All other Part B covered services (unless listed in the next section) including but not limited to: ƒ Therapies (PT, OT, ST) ƒ Cardiac Rehabilitation ƒ Outpatient Mental Health services (not delivered on-site at Nursing Facility) ƒ DME, Prosthetics & Orthotics (includes parenteral/enteral nutrition) ƒ Wound and Ostomy Supplies and services ƒ Medicare covered Hearing, Dental, and Vision ƒ Outpatient procedures Escort services Sitter services Covered Services NOT Requiring Prior Authorization When Provider is Contracted Requirements: List of Services: ƒ Requires a written order by the PCP/NP/PA ƒ ƒ Services performed by the PCP Non-PCP physician services (specialists) Fidelis SecureCare Not to be Reproduced without Permission. 12.09 (v9)
OUTPATIENT CARE COORDINATION PHONE: (877) 372-6121 FAX: MICHIGAN (866) 596-1054: NORTH CAROLINA: (866) 596-1054 TEXAS (866) 511-5906 Service Request Fax Transmission Cover Sheet # OF PAGES (INCLUDING COVER SHEET): SERVICE REQUEST DATE: TO: FAX: PHONE: FROM: FAX: PHONE: MEMBER NAME: DOB: FACILITY/COMMUNITY NAME: REQUESTED SERVICE DESCRIPTION: ***** Doctors Order Must Also Be Faxed **** NAME OF DOCTOR WRITING ORDER: PURPOSE/DX FOR ORDER: PREFERRED PROVIDER FOR APPOINTMENT: IS AN ESCORT NEEDED? NO YES IS TRANSPORTATION NEEDED? NO YES IF YES, WHEELCHAIR OR STRETCHER ADDITIONAL COMMENTS: THE INFORMATION CONTAINED IN THIS COMMUNICATION IS HIGHLY CONFIDENTIAL AND IS INTENDED SOLELY FOR THE USE OF THE INDIVIDUAL(S) TO WHOM THIS COMMUNICATION IS DIRECTED. IF YOU ARE NOT THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY VIEWING, COPYING, DISCLOSURE OR DISTRIBUTION OF THIS INFORMATION IS PROHIBITED. PLEASE NOTIFY THE SENDER OF ANY UNINTENDED RECEIPT AND DELETE THE ORIGINAL MESSAGE WITHOUT MAKING ANY COPIES. WWW.FIDELISSC.COM V3.2010
Page 1 and 2: Provider Manual North Carolina
Page 3 and 4: Utilization Management Affirmative
Page 5 and 6: Fraud, Waste and Abuse Provider and
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: Fidelis SecureCare Criteria for Aut
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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