PROVIDER MANUAL - LA Care Health Plan

www.lacare.orgPROVIDER MANUALL.A. CARE’S MEDICARE ADVANTAGESPECIAL NEEDS PLAN 2009© 2009 L.A. Care Health Plan. All rights reserved.Accreditation of Medi-Cal, Healthy Kidsand Healthy Families Program.LA0589 05/09

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALTable of Contents1.0 L.A. CARE....................................................................... 32.0 MEMBERSHIP AND MEMBERSHIP SERVICES ........... 103.0 ACCESS TO CARE ........................................................ 244.0 SCOPE OF BENEFITS................................................... 285.0 UTILIZATION MANAGEMENT ....................................... 346.0 QUALITY IMPROVEMENT............................................. 1027.0 CREDENTIALING........................................................... 1068.0 PROVIDER NETWORK OPERATIONS (PNO) .............. 1229.0 HEALTH PROMOTION & EDUCATION ......................... 13110.0 CULTURAL AND LINGUISTIC SERVICES .................... 14011.0 FINANCE ........................................................................ 14412.0 CLAIMS........................................................................... 15113.0 MARKETING................................................................... 17714.0 ENCOUNTER DATA....................................................... 18315.0 COMPLIANCE ................................................................ 18516.0 PHARMACY.................................................................... 1932

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL1.0 L.A. CARE HEALTH PLANDear Provider:L.A. Care has information about many different topics that might be helpful to youon our website. It is a useful way to get information about L.A Care and itsprocesses. Please visit our provider website at www.lacare.org for informationabout L.A. Care’s:• Quality Improvement Program• Policy encouraging practitioners to freely communicate with patients abouttheir treatment, regardless of benefit coverage limitations• Requirement that practitioners and facilities cooperate with QI activities;provide access to their medical records, to the extent permitted by stateand federal law; and maintain confidentiality of member information andrecords.• Policy on notification of specialist termination• Access standards• Case Management services and how to refer patients• Disease Management Program information and how to refer patients• Coordination of Medicare and Medicaid benefits• Care services to members with special needs.• Clinical Practice Guidelines, including ADHD and Depression• Preventive Health Guidelines• Medical record documentation standards; policies regarding confidentialityof medical records; policies for an organized medical record keepingsystem; standards for the availability of medical records at the practicesite; and performance goals• UM Medical Necessity Criteria including how to obtain or view a copy• Policy prohibiting financial incentives for utilization management decisionmakers• Instructions on how to contact staff if you have questions about UMprocesses and the toll free number to call• Instructions for triaging inbound calls specific to UM cases/issues• Availability of, and the process for, contacting a peer reviewer to discussUM decisions• Policy on denial notices• Policy regarding the appeals notification process• Pharmaceutical procedures• Policy regarding your rights during the credentialing/recredentialingprocess including to review information and correct erroneous informationsubmitted to support your credentialing application, as well as obtaininformation about the status of your application; and how to exercise theserights• Member’s Rights and Responsibilities3

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL1.2 L.A. CARE DEPARTMENTAL CONTACT LISTL.A. Care Health Plan555 W. Fifth StreetLos Angeles, CA 90013(213) 694-1250DEPARTMENT NAME EXTENSIONCapitation Director 4236Case Management Case Management Nurse 5406DirectorClaimsFor all claims for which L.A.Care isResponsible, please mail to:L.A. Care Health PlanAttn: Claims Dept.P.O. Box 712129Los Angeles, CA 900714314Regulatory Auditing &ComplianceCultural & LinguisticServicesCompliance Officer 4292Director 4559Eligibility Verification Member Eligibility Verification 888-839-9909Encounter DataHealth Promotion &EducationProvider Information LineDirector 4559866-LA-CARE6or1-866-522-2736Marketing Marketing Manager 44646

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL.A. CARE DEPARTMENTAL CONTACT LIST (CONTINUED)DEPARTMENT NAME EXTENSIONMember ServicesNetwork OperationsGeneral Information LineDirectorDirectorProvider Relations Manager888-839-9909425040364286Pharmacy Director 4251Prior Authorizations/Hospital AdmissionsL.A. Care UM Department must be notified within24 hours or the next business day following theadmission. To obtain an Authorization:CALL TOLL-FREE: 877-HF1-CARE (431-2273)FAX: 213-623-8669WRITTEN REQUESTS:L.A. Care Health Plan555 West Fifth StreetLos Angeles, CA 90013Attn.: AuthorizationProvider Credentialing,Performance andCertificationProvider Information/DataIssuesProvider NetworkResearch and AnalysisManager 4026Provider Inquiry LineBusiness Analyst 4034866-LA-CARE6or866-522-2736Quality Management Director 4207Utilization Management Director 4427Utilization Management Manager 4270Outreach/Sales Manager 45757

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL1.3 GLOSSARY OF TERMSACRONYM ORWORD(s)AncillaryServiceBOGCAPCCSCHDPCMSDDSSDHSDMHCDOFRFSRHEDISIBNRDEFINITIONThe following services are considered ancillary: ambulancetransportation; durable medical equipment (DME) includingbut not limited to apnea monitor, artificial limbs, and hearingaids; home health care; prosthetic and orthodontic devices;and skilled nursing facilities.Board of GovernorsCorrective Action PlansCalifornia Children’s Services – This program provides healthcare services to children with certain physical limitations anddiseases whose families cannot afford all or part of the care.Child Health & Disability PreventionCenters for Medicare and Medicaid ServicesDevelopmental Disability ServicesState Department of Health ServicesDepartment of Managed Health CareDivision of Financial ResponsibilityFacility Site ReviewHealth Plan Employer Data and Information SetIncurred But Not Reported8

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALGLOSSARY OF TERMS (CONTINUED)ACRONYM ORWORD(s)IPAL.A. CareMIPPAMOUMA-PDNCQAPCPPNRAQIPSEDSNPDEFINITIONIndependent Practice Association – In the L.A. CareHealthy Families Program Provider Manual, Pisa will bereferred to Participating Physician Groups (PPGs).L.A. Care Health Plan(Local Initiative Health Authority for Los Angeles County)Medicare Improvements for Patients and Providers Act of2008Memorandum of UnderstandingMedicare Advantage Prescription DrugNational Committee for Quality AssurancePrimary Care ProviderProvider Network Research & Analysis UnitQuality Improvement ProgramSeverely Emotionally DisturbedSpecial Needs Plan9

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL2.0 MEMBERSHIP AND MEMBERSHIP SERVICESThis section covers membership and member services for L.A. CareHealth Plan members. Topics include eligibility, enrollment anddisenrollment, primary care provider assignment, complaint resolution,and member rights and responsibilities.2.1 RESPONSIBILITY OF PARTICIPATING PROVIDERSParticipating Physician Groups (PPGs) in L.A. Care are responsible foradhering to the member services provisions and guidelines specified inthis section.2.2 PROGRAM ELIGIBILITYTo enroll in L.A. Care’s MA-SNP plan, beneficiaries must reside in LosAngeles County, be entitled to Medicare Part A and enrolled in MedicarePart B, and not have End-Stage Renal Disease (ESRD), with limitedexceptions, such as if they are already a member of L.A. Care. Inaddition, beneficiaries must also be eligible for Medi-Cal specifically,beneficiaries cannot: 1) have a Medi-Cal share of cost, or 2) be in a longtermcare aid code category. Failure to meet this requirement may resultin termination of enrollment from L.A. Care after 180 days.2.2.1 Conditions of EnrollmentAll new enrollments will be confirmed with CMS. L.A. Care willenroll all MA-SNP members though the Medicare sales andenrollment process, and will comply with all of CMS’ marketing,sales and enrollment process requirements. L.A. Care staff willprovide each new enrollee with a Summary of Benefits, a ProviderDirectory, a Pharmacy Directory, a copy of the Pharmacy formularyand an effective date at the time of enrollment.2.3 MEMBER ENROLLMENT, ASSIGNMENT AND DISENROLLMENT2.3.1 Member Enrollment2.3.1.1 L.A. Care will enroll all prospective enrollees into its MA-SNP plan. Prospective enrollees will complete a CMSapprovedL.A. Care enrollment form, and the L.A. CareEnrollment Center will process all new enrollments withCMS.2.3.1.2 All dual eligibles have a Medicare Special Election Period,which allows them to enroll in and disenroll from aMedicare-Advantage plan on a monthly basis. Dual10

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALeligibles may join a Medicare-Advantage plan outside oftheir Initial Election Period and Medicare’s Annual ElectionPeriod.2.3.2 Selection, Assignment, and Change of Primary Care Physician2.3.2.1 Selection2.3.2.1.1 At the time of enrollment, MA-SNP enrollees willselect both a primary care physician and a PPG.Both of these selections are required elementson the enrollment form.2.3.2.1.2 The enrollee’s choice of primary care physicianand PPG will be listed on the member’sidentification card. The identification card will besent to the member within 10 days of enrollmentconfirmation from CMS.2.3.3 Change of Participating Physician Group (PPG) and/or PrimaryCare Physician (PCP)2.3.3.1 Member-Initiated Change2.3.3.1.1 Members may change their PCP or PPG on amonthly basis. Members requesting to change toanother PPG or PCP can do so by calling L.A.Care Health Plan at 1-888-839-9909.2.3.3.1.2 The change will occur on the 1 st of the followingmonth, provided the request is received byMember Services by the 20 th of the month.2.3.4 Notification of EnrollmentL.A. Care will mail the member a letter acknowledging receipt of thecompleted enrollment form within 10 days of receiving thecompleted enrollment election. L.A. Care will send a letterconfirming the enrollment within 10 days of receiving confirmationfrom CMS on the transaction reply listing. L.A. Care will also senda Welcome Packet to the member’s home address. The WelcomePacket includes a welcome letter, member identification card,Provider Directory, and the Evidence of Coverage/MemberHandbook.2.3.5 Disenrollment2.3.5.1 Disenrollment refers to the termination of a member’senrollment with L.A. Care Health Plan. Disenrollment does11

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALnot refer to a member transferring from one PCP or PPG toanother.2.3.5.2 Members may voluntarily disenroll from L.A. Care HealthPlan’s MA-SNP plan at their discretion. To voluntarilydisenroll from L.A. Care’s MA-SNP plan, members may:• Contact L.A. Care’s Member Services Department torequest disenrollment;• Enroll in another Medicare-Advantage Plan; or• Contact CMS directly at (1-800-MEDICARE) todisenroll from L.A. Care.2.3.5.3 Members may be involuntarily disenrolled from L.A. Care’sMA-SNP Plan. A Member may be disenrolled from L.A.Care for the following reasons:• Loss of Medicare Parts A and B• Loss of Medi-Cal eligibility. L.A. Care provides up to6 months to regain Medi-Cal eligibility beforedisenrolling.• Moved out of Los Angeles County for more than 6months.• Knowingly falsifies or withholds information aboutother parties’ reimbursement for their prescriptiondrug coverage.• Intentionally provides incorrect information on theirenrollment application, affecting their eligibility toenroll in L.A. Care.• Behave in a way that is disruptive, to the extent thatcontinued enrollment seriously impairs our ability toarrange or provide medical care for them or for otherswho are members of L.A. Care. This type ofdisenrollment requires CMS approval.• Allow someone else to use L.A. Care’s membershipcard to receive medical care. CMS may refer thecase to the Inspector General for further investigationif disenrolled for this reason.2.4 MEMBER IDENTIFICATION CARDThe L.A. Care member identification card provides a member’s programname, member ID number, date of birth, effective date, language,pharmacy claims information, PPG name, and phone number, and PCPname, phone number and address.Members who are enrolled in L.A. Care’s MA-SNP plan for their Medicarebenefits and in L.A. Care Direct for their Medi-Cal benefits will be issued12

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALan ID card that has a Medicare SNP ID number (“MA-SNP ID”) and aMedi-Cal ID number (“Member ID”). See the example below:Members who are enrolled in L.A. Care’s MA-SNP plan for their Medicarebenefits and are still enrolled in Medi-Cal fee-for-service for their Medi-Calbenefits will be issued an ID card that only as a Medicare SNP ID number.See the example below:13

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL2.5 ELIGIBILITY VERIFICATIONA member’s possession of an L.A. Care membership identification carddoes not guarantee current membership with L.A. Care or with the PPGidentified by the card. Verification of an individual’s membership andeligibility status is necessary to assure that payment is made to the PPGfor the healthcare services being rendered by the provider to the member.To verify member eligibility, providers should call L.A. Care’s ProviderInformation line at 1-866-LACARE6 (1-866-522-2736) or check L.A. CareConnect on http://www.lacare.org.2.6 EVIDENCE OF COVERAGEAn L.A. Care Evidence of Coverage (EOC)/Member Handbook is sent tomembers upon enrollment and annually thereafter. The EOC providesmembers with a description of the scope of covered services and how toaccess such services. You can obtain a copy of the EOC by logging ontowww.lacare.org, or by calling L.A. Care Health Plan’s Member ServicesDepartment at 1-888-839-9909.2.7 MEMBER’S RIGHTS AND RESPONSIBILITIESL.A. Care members have specific rights and responsibilities that arefundamental to the provision and receipt of quality healthcare services.Member rights and responsibilities are described in L.A. Care’s Evidenceof Coverage EOC)?/Member Handbook as well as listed below.Member Rights• Your right to be treated with dignity, respect and fairness. You havethe right to be treated with dignity, respect, and fairness at all times. L.A.Care and it’s providers must obey laws that protect you fromdiscrimination or unfair treatment. We don’t discriminate based on aperson’s race, disability, religion, sex, sexual orientation, health, ethnicity,creed, age, or national origin. If you need help with communication, suchas help from a language interpreter, please call Member Services.14

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMember Services can also help if you need to file a complaint aboutaccess (such as wheel chair access). You may also call the Office for CivilRights at 1-800-368-1019 or TTY 1-800-537-7697, or your local Office forCivil Rights.• Your right to the privacy of your medical records and personal healthinformation. There are federal and State laws that protect the privacy ofyour medical records and personal health information. We protect yourpersonal health information under these laws. Any personal informationthat you give us when you enroll in L.A. Care is protected. We will makesure that unauthorized people don’t see or change your records.Generally, we must get written permission from you (or from someone youhave given legal power to make decisions for you) before we can giveyour health information to anyone who isn’t providing your care or payingfor your care. There are exceptions allowed or required by law, such asrelease of health information to government agencies that are checking onquality of care. L.A. Care will release your information, including yourprescription drug event data, to Medicare, which may release it forresearch and other purposes that follow all applicable Federal statutesand regulations. The laws that protect your privacy give you rights relatedto getting information and controlling how your health information is used.We are required to provide you with notice that tells about these rights andexplains how we protect the privacy of your health information. You havethe right to look at medical records held at L.A. Care or it’s providers, andto get a copy of your records (there may be a fee charged for makingcopies). You also have the right to ask us to make additions or correctionsto your medical records (if you ask us to do this, we will review yourrequest and figure out whether the changes are appropriate). You havethe right to know how your health information has been given out andused for non-routine purposes. If you have questions or concerns aboutprivacy of your personal information and medical records, please callMember Services.• Your right to see network providers, get covered services, and getyour prescriptions filled within a reasonable period of time. You willget most or all of your care from network providers, that is, from doctorsand other health providers who are part of L.A. Care. You have the rightto choose a network provider (we will tell you which doctors are acceptingnew patients). You have the right to go to a women’s health specialist inL.A. Care (such as a gynecologist) without a referral. You have the rightto timely access of your providers and to see specialists when care from aspecialist is needed. “Timely access” means that you can getappointments and services within a reasonable amount of time.You have the right to timely access to your prescriptions at any networkpharmacy.15

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Your right to know your treatment options and participate indecisions about your health care. You have the right to get fullinformation from your providers when you go for medical care, and theright to participate fully in decisions about your health care. Yourproviders must explain things in a way that you can understand. Yourrights include knowing about all of the treatment options that arerecommended for your condition, no matter what they cost or whether theyare covered by our Plan. This includes the right to know about the differentMedication Therapy Management Programs we offer and in which youmay participate. You have the right to be told about any risks involved inyour care. You must be told in advance if any proposed medical care ortreatment is part of a research experiment, and be given the choice ofrefusing experimental treatments.You have the right to receive a detailed explanation from us if you believethat a provider has denied care that you believe you were entitled toreceive or care you believe you should continue to receive. In thesecases, you must request an initial decision called an organizationdetermination or a coverage determination.You have the right to refuse treatment. This includes the right to leave ahospital or other medical facility, even if your doctor advises you not toleave. This includes the right to stop taking your medication. If you refusetreatment, you accept responsibility for what happens as a result of yourrefusing treatment.• Your right to use advance directives (such as a living will or a powerof attorney). You have the right to ask someone such as a familymember or friend to help you with decisions about your health care.Sometimes, people become unable to make health care decisions forthemselves due to accidents or serious illness. If you want to, you can usea special form to give someone the legal authority to make decisions foryou if you ever become unable to make decisions for yourself. You alsohave the right to give your doctors written instructions about how you wantthem to handle your medical care if you become unable to make decisionsfor yourself. The legal documents that you can use to give your directionsin advance in these situations are called “advance directives.” There aredifferent types of advance directives and different names for them.Documents called “living will” and “power of attorney for health care” areexamples of advance directives.If you want to have an advance directive, you can get a form from yourlawyer, from a social worker, or from some office supply stores. You cansometimes get advance directive forms from organizations that givepeople information about Medicare such as HICAP (Health Insurance16

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCounseling and Advocacy Program). HICAP can be reached at 1-800-434-0222. Regardless of where you get this form, keep in mind that it is alegal document. You should consider having a lawyer help you prepare it.It is important to sign this form and keep a copy at home. You should givea copy of the form to your doctor and to the person you name on the formas the one to make decisions for you if you can’t. You may want to givecopies to close friends or family members as well.If you know ahead of time that you are going to be hospitalized, and youhave signed an advance directive, take a copy with you to the hospital. Ifyou are admitted to the hospital, they will ask you whether you havesigned an advance directive form and whether you have it with you. If youhave not signed an advance directive form, the hospital has formsavailable and will ask if you want to sign one.Remember, it is your choice whether you want to fill out an advancedirective (including whether you want to sign one if you are in thehospital). According to law, no one can deny you care or discriminateagainst you based on whether or not you have signed an advancedirective. If you have signed an advance directive, and you believe that adoctor or hospital hasn’t followed the instructions in it, you may file acomplaint with:Medical Board of CaliforniaCentral Complaint Unit1426 Howe Avenue, Suite 54Sacramento, CA 95825-3236• Your right to get information about L.A. Care Health Plan. You havethe right to get information from us about L.A. Care. This includesinformation about our financial condition, and how L.A. Care compares toother health plans. To get any of this information, call Member Services.• Your right to get information in other formats. You have the right toget your questions answered. L.A. Care must have individuals andtranslation services available to answer questions from non-Englishspeaking beneficiaries, and must provide information about our benefitsthat is accessible and appropriate for persons eligible for Medicarebecause of disability. If you have difficulty obtaining information from L.A.Care based on language or a disability, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.• Your right to get information about our network pharmacies and/orproviders. You have the right to get information from us about ournetwork pharmacies, providers and their qualifications and how we payour doctors. To get this information, call Member Services.17

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Your right to get information about your prescription drugs, Part Cmedical care or services, and costs. You have the right to anexplanation from us about any prescription drugs or Part C medical careor service not covered by L.A. Care. We must tell you in writing why wewill not pay for or approve a prescription drug or Part C medical care orservice, and how you can file an appeal to ask us to change this decision.You also have the right to this explanation even if you obtain theprescription drug, or Part C medical care or service from a pharmacyand/or provider not affiliated with our organization. You also have the rightto receive an explanation from us about any utilization-managementrequirements, such as step therapy or prior authorization, which mayapply to L.A. Care. Please review our formulary website or call MemberServices for more information.• Your right to make complaints. You have the right to make a complaintif you have concerns or problems related to your coverage or care. If youmake a complaint, we must treat you fairly (i.e., not retaliate against you)because you made a complaint. You have the right to get a summary ofinformation about the appeals and grievances that members have filedagainst L.A. Care in the past. To get this information, call MemberServices.Member ResponsibilitiesYour responsibilities as a member of L.A. Care include:• Getting familiar with your coverage and the rules you must follow to getcare as a member. Call Member Services if you have questions.• Using all of your insurance coverage. If you have additional healthinsurance coverage or prescription drug coverage besides L.A. Care, it isimportant that• you use your other coverage in combination with your coverage as amember of L.A. Care to pay your health care or prescription drugexpenses. This is called “coordination of benefits” because it involvescoordinating all of the health or drug benefits that are available to you.• You are required to tell L.A. Care if you have additional healthinsurance or drug coverage. Call Member Services.• Notifying providers when seeking care (unless it is an emergency) that youare enrolled in L.A. Care and you must present your Plan membershipcard to the provider.18

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Giving your doctor and other providers the information they need to carefor you, and following the treatment plans and instructions that you andyour doctors agree upon. Be sure to ask your doctors and other providersif you have any questions and have them explain your treatment in a wayyou can understand.• Acting in a way that supports the care given to other patients and helpsthe smooth running of your doctor’s office, hospitals, and other offices.• Paying your co-payment for your covered services. You must pay forservices that aren’t covered.• Notifying us if you move. If you move within our service area, we need tokeep your membership record up-to-date. If you move outside of LosAngeles County you cannot remain a member of L.A. Care, but we can letyou know if we have a Plan in that area.• Letting us know if you have any questions, concerns, problems, orsuggestions. If you do, please contact Member Services.How members can get more information about their rightsIf members have questions or concerns about their rights and protections, theymay,• Call L.A. Care’s Member ServicesError! Bookmark not defined.Department at 1-888-839-9909.• Get free help and information from their State Health InsuranceAssistance Program (SHIP).• Visit www.medicare.gov to view or download the publication “YourMedicare Rights & Protections.”• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.2.8 NOTICE TO MEMBERS REGARDING CHANGE IN COVEREDSERVICESMembers must be informed about any change in provision of services.L.A. Care must send written notification of any change to the member noless than sixty (60) days, or as soon as possible prior to the date of actualchange. In case of an emergency, the notification period will be withinfourteen (14) days prior to changes, or as soon as possible.In some circumstances, when the event includes termination of aprovider’s contract, L.A. Care makes arrangements for members affectedby the termination to continue care with their terminating provider untiltheir treatment is completed. In order for L.A. Care to make these19

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALarrangements, the medical conditions must meet specific criteria; theprovider must be willing to continue seeing the member and must bewilling to accept L.A. Care’s rate of reimbursement.2.9 Member Grievance ProcedureA Grievance is defined as any complaint or dispute, other than oneinvolving an organization determination, expressing dissatisfaction withthe manner in which L.A. Care or delegated entities provides health careservices, regardless of whether any remedial action can be taken. Thiscan include concerns about the operations of L.A. Care or its providerssuch as: waiting times, the demeanor of health care personnel, theadequacy of facilities, and the respect paid to members. An expeditedgrievance may also include a complaint that the health plan refused toexpedite an organization determination or reconsideration, or invoked anextension to an organization determination or reconsideration time frame.Grievance issues may also include complaints that a covered healthservice procedure or item during a course of treatment did not meetaccepted standards for delivery of health care.L.A. Care accepts any information or evidence concerning a grievancepertaining to its Plan either orally or in writing, for up to 60 days after theprecipitating event.L.A. Care acknowledges, investigates and resolves standard grievanceswithin thirty (30) calendar days of the oral or written request. However ifinformation is missing or if it is in the best interest of the member, L.A.Care may extend the timeframe by an additional 14 days. L.A. Careresponds to expedited grievances within 24 hours of the oral or writtenrequest. Expedited grievances include those cases where a memberobjects to: 1) L.A. Care’s decision to extend the timeframe to make anorganization determination or reconsideration; or 2) L.A. Care’s refusal togrant a request for an expedited organization determination orreconsideration.If a complaint is not resolved to the member’s satisfaction the member hasthe right to seek the opinion of the Quality Improvement Organization(QIO).L.A. Care maintains a comprehensive complaint resolution system. L.A.Care and its PPGs work together to resolve member complaints.However, it is L.A. Care’s responsibility to handle member complaints.PPGs are encouraged to attempt to address member questions orconcerns before referring members to L.A. Care. All member complaintsmust be reported to L.A. Care’s Member Services department. PPGs are20

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrequired to respond to requests for information related to grievances withinfive (5) business days. If a PPG fails to provide the requested information,L.A. Care or the designated agent will be provided access to copy theappropriate medical records or other necessary information at theexpense of the PPG.L.A. Care tracks complaints by category and PPG. Grievance reports arereviewed and analyzed for appropriate corrective action plansMember Appeal ProcedureOrganization DeterminationAn initial determination informing members of L.A. Care’s decision toprovide medical care, or pay for services already receivedAppeal Level 1: Appeal to L.A. CareStandard Reconsideration of Organization DeterminationMembers may file reconsiderations of organization determinations withL.A. Care’s Grievance and Appeals Unit. All reconsiderations must befiled within 60 days of notification of the organization determinationdecision. L.A. Care will resolve all reconsiderations regarding payment forservices already received within 60 days. L.A. Care will resolve allstandard reconsiderations regarding medical care within 30 days.However, if information is missing or if it is in the best interest of themember, L.A. Care may extend the timeframe by an additional 14 days. IfL.A. Care decides in favor of the member with respect to paymentreconsideration, L.A. Care must pay within 60 days of receiving theappeal. If L.A. Care decides in favor of the member with respect to astandard reconsideration of medical care, L.A Care must authorize orprovide services within 30 days of receiving the appeal. If L.A. Careupholds an adverse determination, L.A. Care will automatically forward thecase to the Independent Review Entity (IRE) within 30 days for casesinvolving medical care and within 60 days for cases involving paymentdecisions.Expedited Reconsideration of an Organization DeterminationL.A. Care will resolve all expedited reconsiderations within 72 hours, orsooner required based upon the health condition of the member. L.A.Care may extend the timeframe for an additional 14 days if information ismissing or if it is in the best interest of the member. If L.A. Care decides infavor of the member, L.A. Care must authorize or provide care within 72hours of receiving the expedited appeal. If L.A. Care upholds an adverse21

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALdetermination, L.A. Care will automatically forward the case to theIndependent Review Entity (IRE) within 24 hours for review.Appeal Level 2: Independent Review Entity (IRE)At the second level, the appeal is reviewed by an outside, IndependentReview Entity (IRE) that is contracted with CMS. If the IRE decides infavor of the member with respect to payment of medical services alreadyreceived, L.A. Care must pay within 30 days of receiving the decision. Ifthe IRE decides in favor of the member with respect to a standarddecision about medical care not yet received, L.A Care must authorizeservices within 72 hours or provide services within 14 days of receivingthe decision. If the IRE upholds the Plan’s determination, the membermay request a Level 3 appeal, review by an Administrative Law Judge(ALJ).Appeal Level 3: Administrative Law Judge (ALJ)During the ALJ review, members may present evidence, review the recordand be represented by counsel. The request must be filed with 60calendar days of notification of the decision made by the IRE. The ALJwill make a decision as soon as possible. If the ALJ decides in favor ofthe member, L.A. Care must pay for, authorize or provide the medical careor services within 60 days of receiving the decision. If the ALJ upholds theIRE’s determination, the member may request a Level 4 appeal, review bythe Medicare Appeals Council (MAC)Level 4: Medicare Appeals Council (MAC)Members must file with the MAC within 60 calendar days of the decisionmade by the ALJ. If the MAC reviews your case, (it does not review everycase it receives) it will make a decision as soon as possible. If the MACdecides in favor of the member, L.A. Care must pay for, authorize orprovide the medical care or services within 60 days of receiving thedecision. If the MAC upholds the ALJ’s determination, or decides not toreview the case, the member may request a Level 5, Federal Court.Appeal Level 5: Federal CourtIn order to request judicial review, the member must file a civil action in aUnited States district court within 60 calendar days after the date notifiedof the decision made by the MAC. Once a Federal Court Judge hadagreed to review the case, a decision will be made according to the rulesestablished by the Federal judiciary.When Members Disagree with Hospital Discharge22

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALA Member remaining in the Hospital that wishes to appeal L.A. Care’discharge decision that Inpatient Services are no longer necessary mayrequest an immediate review with the Quality Improvement Organization(QIO). The Member will not incur any additional financial liability if:• The Member remains in the Hospital as an Inpatient;• The Member submits the request for immediate review to the QIO thathas an agreement with the Hospital;• The request is made either in writing, by telephone or fax; and• The request is received by noon of the first working day after theMember receives written notice of the Plan’s determination that theHospital stay is no longer necessary.Special Considerations Regarding Termination of Skilled NursingFacility (SNF), Home Health Agency (HHA) and ComprehensiveOutpatient Rehabilitation Facility (CORF) ServicesRegarding Medicare Members, a termination of service is the discharge ofa Member from Covered Services, or discontinuation of Covered Services,when the Member has been authorized by L.A. Care to receive anongoing course of treatment from that Provider.• the Member must contact the QIO, verbally or in writing, no later thannoon of the day before the Covered Services are to end. At the sametime the Physician Group will notify the Plan of the NOMNC issued tothe Member. The Plan will track issuance and follow-up all NOMNC’sfrom delegated Physician Groups. If the Member disagrees with theNOMNC and requests an Appeal, the Plan will prepare the DetailedExplanation of Non-Coverage• (DENC) for the Provider to issue to the Member. If the Memberrequests an Appeal with the QIO, the Plan must obtain the Member’smedical records from the Provider and send• a copy of the DENC, along with the Member’s medical records, to theQIO by close of business on the day of the QIO submitted to Planappeal notification. The Plan may request that the records be sentdirectly to the QIO. The QIO must make a decision and• notify the Member and the Plan by close of business the following day.On the next business day, the Plan will notify the Physician Group ofthe fast-track Appeal request and the QIO’s determination. If the QIOoverturns the decision then the Physician Group shall continueauthorization to the Group Provider, provide the Plan with proof ofcontinued authorization and prepare and issue a new NOMNC noticewhen new discharge orders are written. If the Member fails to file atimely Appeal with the QIO, the Member may request an expeditedAppeal from the Plan [42 CFR 422.624; 42 CFR 422.626]23

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL3.3 PRIMARY CARE AND SPECIALIST PHYSICIAN ACCESSREQUIREMENTSServiceAppointment makingsystemsAppointments for routineprimary careServices for a memberwho is symptomatic butdoes not requireimmediate diagnosisand/or treatmentAppointments for routineprenatal careL.A. Care Access StandardAn efficient and effective written or computerizedappointment making system, which includes followingup on broken appointments30 calendar days maximum• Within two weeks from request during the 1 stand 2 nd trimester• Within three working days from request during3 rd trimesterAppointments for routinepreventive careAppointments for urgentcareRoutine specialty referralappointmentAvailability of interpreterserviceAvailability of primarycare physician – timerequirementsPreventive ExamsA periodic healthevaluation for a memberwith no acute medicalproblem, including:• Initial HealthAssessments andBehavioral RiskAssessmentsAAP periodic screeningsPhysical exam/preventive services – four (4) weeksmaximum for appointmentWithin 24 hoursWithin 10 working daysL.A. Care provides 24 hours/7 days a week interpretiveservices24 hours/7 days a weekChildren under the age of 18 months – within 60calendar days of enrollment or within the AAPperiodicity timelines for ages two and younger,whichever is less18 months of age and older – within 120 calendar daysof enrollmentEPSDT/CHDP or preventive health examination withinfour weeks from requestAs prescribed by AAP Periodicity guidelines25

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALEmergencyappointment:Services for a potentiallylife threatening conditionrequiring immediatemedical intervention toavoid disability orserious detriment tohealthNon-emergent telephoneappointmentresponsivenessOffice waiting time:The time a member witha scheduled medicalappointment is waiting tosee a doctor once in theofficeTelephone waitingtime:The maximum length oftime for office staff toanswer the phoneCall Return Time (AfterHours):The maximum length forPCP or on-call providerto return a callServices for memberswith disabilitiesImmediate, 24 hours a day/7 days a week45 minutes5 - 45 minutes30 seconds30 minutesCompliance with all provisions of the Americans withDisabilities Act:• At least one designated handicapped parkingspace• A handicapped bathroom or alternative accesswhich is equipped with handrails in the bathroom• A wheelchair access ramp• A handicapped water fountain or alternativeprovisions• An elevator26

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL3.4 PHARMACY SERVICE ACCESS REQUIREMENTSServiceDenied or modifiedprescriptionDrug priorauthorization requestAvailability ofcounseling in themembers languageEmergency pharmacyservicesL.A. Care Access StandardMedical Director or Pharmacy Director makes adetermination on denied or modified prescriptionswithin 24 hours for expedited request and 72 hours forstandard request24 hours for expedited request and 72 hours forstandard requestAvailability of verbal counseling in appropriatethreshold language30 day supply for continuity of care until determinationof request can be done3.5 MONITORINGThe PCP is responsible for responding to any access deficienciesidentified by review methods, examples of which include:• Facility Site Review (FSR)• Exception reports generated from member grievances• Medical records review• Random surveys sent to members• Feedback from PCP regarding other network services (i.e.,pharmacies, vision care, hospitals, laboratories, etc.)• Access to care studies• Provider office surveys or visits27

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL4.0 SCOPE OF BENEFITSThis section summarizes the scope of benefits for direct product linesunder L.A. Care.4.1 RESPONSIBILITY OF PARTICIPATING PROVIDERSL.A. Care is contracted with various provider organizations for theprovision of health benefits. Under the terms of provider agreements withL.A. Care, certain Participating Physician Groups (PPGs) and hospitalshave agreed to assume the financial responsibility of providing specifiedhealth benefits. To determine which health benefits a PPG and hospitalmay be delegated and therefore financially responsible for providingservices, please refer to the Division of Financial Responsibility (DOFR) ofthe entity’s agreement with L.A. Care. Each agreement summarizeswhich health benefits a PPG or hospital is financially responsible forproviding.4.2 HEALTH BENEFITS – MEDI-CALCovered services, including services for the detection of symptomaticdiseases, as defined by Title 22, Section 51301 through Section 51365 ofthe California Code of Regulations, should be provided with no copayment.A listing of these benefits and services may be found in theMedi-Cal Managed Care Evidence of Coverage or L.A. Care UM Policies.The benefits and service requirements are also available online atwww.ccr.oal.ca.gov.org.28

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL4.3 HEALTH BENEFITS – MEDICARE ADVANTAGE-SNPWith the exception of certain Part D covered drugs, there will be no cost-sharingfor any of Medicare Advantage-SNP plan benefits.Benefits Covered Member CostDoctor Visits Yes $0Inpatient Hospital Services (90 days per benefit period) Yes $0Inpatient Mental Health (up to 190 lifetime days) Yes $0Skilled Nursing facility (100 days per benefit period) Yes $0Home Health Care Yes $0Hospice (care must be provided by Medicare certified hospice; FFS Medicarepays)Yes $0Podiatry Services Yes $0Outpatient Mental Health Yes $0Outpatient Substance Abuse Yes $0Outpatient Surgery Yes $0DME and Prosthetic Devices Yes $0Medical Supplies Yes $0Emergency Care Yes $0Hearing Services Yes $0Out of Area (United States only) Yes $0Supplemental BenefitsChiropractic Services (no referrals; unlimited visits) Yes $0Non Emergency Transportation (12 one-way trips annually) Yes $0Vision Services (annual exam and glasses) Yes $0In-house Assessment (annual) Yes $0BenefitsHow to Access Mental Health Services:Both beneficiaries and providers can call Pacific Behavioral Health at(866) 908-0677 to coordinate access to care or they can call L.A. Care’sMember Services or the Provider Inquiry Line.Supplemental BenefitsHow to access Chiropractic Services:Chiropractic services can be access directly through an in-networkprovider. There is no prior authorization required and there is not limits onhow many times a beneficiary can access these services. Bothbeneficiaries and providers can call American Specialty Care HealthPlan at (800) 678-9133 to refer members for chiropractic care.29

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALSupplemental BenefitsHow to access Non Emergency Transportation:Transportation services can be accessed by contacting L.A. Care’sMember Services or the Provider Inquiry Line to have GMDTransportation pick up a member.How to access Vision Care:Contact VSP Member Services at (800) 877-7195 or (800) 428-4833 forthe hearing impaired, or visit their website at www.vsp.com to locate aparticipating provider.Annual In-house Assessment:L.A. Care’s Member Services will initiate the outreach to members toconduct assessment. If member has not been contacted or has had an Inhouseassessment within six (6) months of their enrollment with L.A. Care,please provide the (888) 4LA-CARE or (888) 452-2273 to the membersfor them to call at their convenience to set up an appointment.Medicare Part D 2009 CoverageL.A. Care Medicare Advantage-SNP members pay nothing for genericdrugs. For brand drugs, members only pay a copayment of $1.10 formulti-source brand drugs, and $3.20 for single source brand drugs, forcoverage up to $4,350 in annual drug spending only.Prescription Drug Benefits – 30 day supplyFull Scope Medicare/Medi-CalBeneficiary CostGeneric Drugs $0Brand Drugs $1.10Multi-source brand drugsBrand Drugs $3.20Single-source brand drugsCoverage after $4,350 in Total Drug CostsGeneric Drugs $0Brand Drugs $0What drugs are covered by this Plan?L.A. Care Health Plan has a formulary that lists all drugs covered. Drugson the formulary will generally be covered as long as the drug is medicallynecessary, are covered by Part D, the prescription is filled at a networkpharmacy or through our network mail order pharmacy service. Certain30

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALprescription drugs have additional requirements for coverage or limits onour coverage.How do members get their prescription filled?Beneficiaries must obtain their prescriptions from a network pharmacy orthrough the network mail order pharmacy service. A Pharmacy Directorywill be provided in the new enrollment packet.What is the mail order pharmacy service?Beneficiaries can obtain their prescriptions for medications taken on aregular basis, for a chronic or long-term medical condition through thenetwork mail order pharmacy service. Orders must be for at least a 32-daysupply, and no more than a 90-day supply of the drug. Mail orders willtake approximately thirty (30) days to process.It is not required to use the mail order service to get an extended supply. Network pharmacies can also provide extendedsupplies. All drugs listed on our formulary are available through the mail order pharmacy service.For further details regarding Part D Coverage please call our Pharmacy Department at (888) 4LA-CARE4.4 MECHANISMS TO CONTROL UTILIZATION OF SERVICESL.A. Care may create mechanisms to help contain costs for providinghealth care benefits to members. Such mechanisms may include, but arenot limited to:• Requiring prior authorizations for benefits• Providing benefits in alternative settings• Providing benefits by using alternative methods4.5 PHARMACY BENEFITS – MEDI-CALPrescription DrugsMedically necessary drugs, when prescribed by a participating licensedpractitioner acting within the scope of his or her licensure, and drugs arelisted on L.A. Care’s Drug Formulary, and filled at a participatingpharmacy. The benefits include:• Insulin and needles and syringes necessary for the administrationof insulin, blood glucose testing strips in medically appropriatequantities for the monitoring and treatment of insulin dependent,non-insulin dependent and gestational diabetes, ketone urinetesting strips for Type I diabetes, and lancets.• Prenatal vitamins and fluoride supplements included with vitaminsor independent of vitamins that require a prescription.• Medically necessary drugs administered while a member is apatient or resident in a rest home, nursing home, convalescent31

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALhospital or similar facility when provided through a participatingpharmacy.• L.A. Care requires that generic equivalent prescription drugs bedispensed, if available, provided that no medical contraindicationsexist. It is required that prescriptions be made from L.A. Care DrugFormulary. The reimbursement amount paid for a prescription byL.A. Care to a participating pharmacy is determined by a maximumallowable cost (MAC) calculation method.• L.A. Care provides coverage for one cycle or course of treatment oftobacco cessation drugs per benefit year. This benefit requires themember to attend tobacco use cessation classes or programs inconjunction with the use of tobacco cessation drugs.• Contraceptive Drugs and Devices: All FDA approved oralcontraceptive drugs and prescription contraceptive devices(diaphragms) are covered under the pharmacy benefit. Injectablecontraceptive drugs, including internally implanted time releasecontraceptives such as Norplant, are a covered benefit whenprovided under Professional Services.4.6 EXCLUDED PHARMACY BENEFITS – MEDI-CAL• Injectable drugs (except insulin), vaccines, or biologicals unlessadministered under Professional Services as part of a medicaloffice or medical facility visit.• Experimental or investigational drugs, unless accepted for use bythe standards of the medical community.• Drugs or medications for cosmetic purposes.• Medicines not requiring a written prescription order (except insulinand diabetes monitoring supplies, spacer devices, and peak flowmeters).• Dietary supplements, appetite suppressants or any other diet drugsor medications (except when medically necessary for treatment ofmorbid obesity).• Any benefits in excess of limits specified previously.• Services, supplies, items, procedures or equipment, which are notmedically necessary as determined by L.A. Care, unless otherwisespecified.4.7 NON-FORMULARY DRUGS PRIOR-AUTHORIZATION REQUIRED –MEDI-CALDrugs not included in L.A. Care’s Drug Formulary and deemed medicallynecessary may be provided subject to Prior Authorization. Providerquestions concerning non-formulary drug coverage and PriorAuthorization requirements may be directed to the National Medical HealthCard system (NMHC), L.A. Care’s pharmacy benefit manager, at 1-800-777-0074. L.A. Care’s Director of Pharmacy will review all requests not32

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALmeeting prior approval criteria. Denials may be appealed through the L.A.Care Grievance and Appeals process.4.8 PHARMACY BENEFITS – MEDICARE ADVANTAGE-SNPPlease see Chapter 16 of this manual for a description of Part D prescriptiondrug coverage for L.A. Care Health Plan’s Medicare Advantage-SNP.33

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL5.0 UTILIZATION MANAGEMENTThis section summarizes L.A. Care Health Plan’s (L.A. Care) UtilizationManagement (UM) Processes for direct contract Participating PhysicianGroups (PPGs). UM functions/ activities vary depending on specificcontractual agreements with each contracted PPG, provider, and hospital.Please check your contract Division of Financial Responsibility (DOFR), orcontact L.A. Care’s Provider Information Line at 1-866-LACARE6 orUtilization Management at 1-877- 431-2273.L.A. Care performs UM activities which are consistent with State andFederal regulations, State contracts and other L.A. Care Health Planpolicies, procedures and performance standards as set forth in L.A. Care’sUM Program Document.L.A. Care is staffed with professional registered nurses andparaprofessionals who are available to assist the PPG and their providerswith UM activities. These activities include but are not limited to:• Benefit interpretation• Referral management, outpatient and in-patient• Coordination of care and services for linked programs (CCS, DDS,Mental Health, etc.)• Coordination of End Stage Renal/Chronic Kidney Disease benefit• Coordination of services that require disenrollment (e.g.transplants, Long Term Care, Waiver Programs)• Complex care management and care coordination• Education of PPG/providers on policies, procedures and legislativeupdates5.1 GOAL AND OBJECTIVESGoalThe goal of L.A. Care Health Plan’s Utilization Management Program(UM) is to ensure and facilitate the provision of appropriate medical andbehavioral health care and services to L.A. Care Health Plan members.The program is designed to monitor, evaluate and support activities thatcontinually improve access to and quality of medical care provided to L.A.Care Health Plan members.ObjectivesThe Utilization Management Program’s objectives are designed to providemechanisms that assure the delivery of quality health care services and tooptimize opportunities for process improvement through:34

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• management, evaluation, and monitoring of the provision ofhealthcare services rendered to L.A. Care Health Plan members forthe enhancement of, and access to, appropriate services.• facilitating communication and develop partnerships betweenParticipating Provider Groups/Providers (PPGs/Providers),members, and L.A. Care Health Plan.• developing and implementing programs to encourage preventivehealth behaviors, which can ultimately improve quality outcomes.• monitoring PPGs/Providers provision of health assessments andbasic medical case management to all members.• assisting PPGs/Providers in providing ongoing medical care formembers with chronic or catastrophic illness.• developing and maintaining effective relationships with linked andcarved-out service providers available to L.A. Care Health Planmembers through County, State, Federal, and other communitybased programs to ensure optimal care coordination and servicedelivery.• facilitating and ensure continuity of care for L.A. Care Health Planmembers within and outside of L.A. Care Health Plan’s network.• integrating quality and utilization management activities.• ensuring a process for UM that is effective and coordinated throughCommittees, work groups and task forces with the involvement andcooperation of experts in all fields of medicine, management,patient advocacy and other relevant fields.• providing leadership to PPGs/Providers through the development ofand/or recommendations for program and process changes/improvements that result from data collection and analysis ofutilization activities.• ensuring that UM decisions are made independent of financialincentives or obligations.5.2 SCOPE OF SERVICE• The scope of L.A. Care Health Plan’s Utilization ManagementProgram includes all aspects of health care services delivered at alllevels of care to L.A. Care Health Plan members. L.A. Care HealthPlan offers a comprehensive health care delivery system along thecontinuum of care, including urgent and emergency services,ambulatory care, preventive services, hospital care, ancillaryservices, behavioral health (mental health and addiction medicine),home health care, hospice, rehabilitation services, skilled nursingservices, and care delivered through selected waiver programs,and through linked and carved out services.• L.A. Care Health Plan administers the delivery of health careservices to its members through different contractual agreements.35

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• L.A. Care Health Plan’s Programs are administered throughdifferent contractual arrangements with medical groups andIndependent Provider Associations (IPAs) or collectively calledParticipating Provider Groups (PPGs), which may includedelegation of some or all UM functions.• L.A. Care and L.A. Care's PPGs shall provide or arrange for allmedically necessary covered services for members.• If medically necessary services are not available within the L.A.Care, PPG contracted network contracts are initiated on anindividual basis to ensure availability of medically necessary careand services in accordance with benefit agreements.• At a minimum the UM program includes the following:• Assures that services which are medically necessary aredelivered at the appropriate level of care, including inpatient,outpatient, and the emergency room.• Assures that authorized services are consistent with thebenefits provided by the Plan.• Provides a comprehensive analysis of care by identifyingunder- and over-utilization patterns by physician and withinthe Plan.• Reviews care and identifies trends that positively andnegatively impact the quality of care provided to themembers.• Defines, monitors, and trends medical practice patternsimpacting members’ care.• Ensures that appropriate medical review guidelines areavailable and used by UM personnel.• Identifies, develops, revises, and implements appropriatepolicies, procedures, processes, and mechanisms for UMthat can be used to evaluate medical necessity for requestedservices on a timely and regular basis.• Instructs all institutions, physicians, and other health careclinicians regarding the criteria used, the information sourcesemployed, and the methods utilized in the approval andreview processes.• Provides the health plan network with information related toeffective mandated information system and communicationsfor the monitoring, management, and planning of medicalservices.• Ensures that network institutions, physicians, and otherhealth care clinicians provide services unless otherwisemandated by regulatory standards.• Determines if illness or injury is covered under otherprograms including third-party payers, California Children’sServices (CCS), Genetically Handicapped Persons Program(GHPP) or Mental Health Services.36

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Ensures that guidelines, standards, and criteria set bygovernmental and other regulatory agencies are adhered toas appropriate.• Facilitates consistent practice patterns among institutions,physicians, and other health care clinicians with L.A. CareHealth Plan by offering feedback to the PPGs/Providers toassist in optimizing appropriate medical practice patterns.• Provides case management services to ensure cost effectiveongoing care at the appropriate level.• Utilizes information in member and physician satisfactionsurveys to develop quality improvement activities asappropriate.• Conducts inter-rater reliability of physician and non-physicianreviewers to assess determinations made as part of the UMprocess.• Provides required reports.• Ensures coordination and continuity of care for membersreceiving linked and carved out services.5.3 AUTHORIZATION REVIEW PROCESSTreatment Authorization Review (TAR) ProcessesRequest for services are reviewed in accordance with approved guidelinesand criteria as adopted by L.A. Care Utilization Management Program,Utilization and Quality Management Committees. Decisions are madeaccording to medical necessity criteria and the member’s benefit structure.There are eight (8) components of the Utilization Management Referral(Treatment Authorization Request – TAR) review process.• Prior Authorization/Pre-Service Review• Concurrent Review• Retrospective/Post-service Review• Emergent/Urgent Review• Expedited Review• Second Opinion Review• External Independent Review/Independent Medical Review• Reconsideration ReviewAuthorization considerations for Services covered under Medi-CalBecause L.A.Care SNP members have full Medi-Cal coverage, therequest for services authorizations also consider services that are notcovered under Medicare. Following services not covered under Medicarewould be covered under Medi-Cal :37

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Monthly plan premium is $0 since mebers are covered by Medi-Cal• The Part B premium is $ 96.40, however SNP members will pay$0, since the premium is paid by Medi-Cal on the member’s behalf• Inpatient Hospitalization: $0 for unlimited number of days forinpatient coverage in the hospital as long as the member’s stay ismedically necessary and authorized.• Long Term care (Skilled Nursing Facility): Medi-Cal coversadditional days beyond the Medicare limit if extra days areauthorized and medically necessary• Vision Care: Member pays $0 for glasses or contact lenses everytwo years if medically necessary. In addition, member pays $0 foran office visit every other year, unless there is a medical need foradditional visits.• Hearing Aids: Members pay $0 for hearing aids that are providedby an in-network specialist.• Acupuncture: Members pay $0 for acupuncture services from theMedi-Cal fee-for-service program.• Podiatry: Member pays $0 for up to 12 additionalroutine/maintenance visits per year (24 total per year, including nailtrimmings, cutting and removal of calluses, etc).• Incontinence Supplies: Member pays $0 for medically necessaryincontinence supplies.• Dental Services: Member pays $0 for dental services from Denti-Cal.• Excluded Medicare Part D Drugs: member pays $0 for certainexcluded drugs covered by Medi-Cal, including prescribed over-thecounterdrugs. Please refer to the Pharmacy section in this manualfor details5.4 STANDARD UTLIZATION MANAGEMENT CRITERIAEstablished criteria are required for approving, modifying, deferring, ordenying requested services. L.A. Care utilizes evaluation criteria andstandards to approve, modify, defer, or deny services. UM Criteria are:• developed with involvement from actively practicing health careproviders• consistent with sound clinical principles and processes• evaluated and updated if necessary, at least annuallyL.A. Care utilizes the UM Committee to involve providers in thedevelopment and or adoption of specific criteria used by L.A. Care and itsdelegated providers.Clinical criteria are used to determine medical necessity in the referralmanagement (Treatment Authorization Request – TAR) review process to38

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALensure consistency of authorization and review decisions by UM staff.Consistency of application of criteria is checked at all levels of delegationvia the annual audit.Criteria to determine appropriateness of medical services utilized byPPGs/Providers and their networks shall be consistent with those utilizedby L.A. Care Health Plan. PPGs/Providers may develop additional clinicalcriteria for use within their system, but they must be reviewed andapproved by L.A. Care Health Plan prior to their implementation. Allapproved criteria must be transmitted and utilized throughoutPPGs/Providers and provider networks, and shall be made available bythe PPGs/Providers to providers, members and the public upon request.The potential criteria sources include but are not limited to:• Center for Medicare and Medicaid Services NationalCoverageDeterminations• InterQual• Milliman Healthcare Management Guidelines• Apollo Criteria• Other L.A. Care Health Plan approved criteriaL.A. Care Health Plan draws from and follows the recommendations of anumber of nationally recognized sources in the development of medicalpolicy and criteria related to preventive care, admissions, outpatientsurgeries and diagnostic and therapeutic services. Examples of theseorganizations include:• Centers for Disease Control• American College of Obstetrics and Gynecology• Diagnostic and Treatment Technology Assessment (DATTA)• Food and Drug Administration (FDA)For provider or member appeals resulting from a denial of services usingconsensus based criteria, L.A. Care will review the request for servicesbased on available evidence based criteria or guidelines.When appropriate, L.A. Care Health Plan’s CMO may assemble a panel ofindependent experts to assist in medical necessity determinations. At theL.A. Care Health Plan level, adverse decisions may be appealed to theL.A. Care Health Plan CMO or designee. Additional appeals may bepursued in accordance with CMS requirements and L.A. Care Health Planpolicy, if disagreements with L.A. Care Health Plan PeerReview/Grievance Committee decisions occur.Members, providers and the public may obtain UM criteria or UMPolicies and Procedures used by L.A. Care in referral management39

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALdeterminations by calling the UM Department at (877) 421-2273. UM staffshall relay the request to the UM Director (or designee) for response. Allrequests for UM criteria are logged in the UM Criteria tracking log and areprocessed upon request in accordance with state requirements.5.5 ACCESS TO CRITERIAL.A. Care and PPGs utilization management policies and review criteriaare available for disclosure to L.A. Care Health Plan, Providers, members,and the public upon request in accordance with established regulatory andcontractual requirements and L.A. Care Health Plan requirements.5.6 EMERGENCY HEALTH CARE SERVICESL.A. Care and its PPGs ensure that emergency health care services areavailable and accessible within the service area 24 hours a day, sevendays a week, and shall provide 24 hours access for members andproviders to obtain timely authorization for medically necessary care.For circumstances where the member has received emergency servicesand care is stabilized, but the treating provider believes that the membermay not be discharged safely; a licensed physician and surgeon shall beavailable for consultation and for resolving disputed requests for poststabilizationcare.5.7 REFERRAL MANAGEMENT PROCESSL.A. Care Health Plan may delegate referral management to the PPGs.While PPGs have some degree of latitude in establishing reviewprocesses, they must contain the following provisions according to theirdelegation agreement, which are established in L.A. Care Health Plan’spolicies and procedures:• Appropriately licensed health professionals conduct the supervisionof all review decisions and processes.• No other individual, other than a licensed physician or a licensedhealth care professional who is competent to evaluate the specificclinical issues involved in the health care services requested by theprovider, may deny or modify requests for authorization of healthcare services for reason of medical necessity or benefit limitations.• Review decisions are supervised by qualified medical professionalsand all denials/modifications will be reviewed by a qualifiedPhysician.• Physician consultants from the appropriate specialty areas ofmedicine and surgery who are certified by the applicable AmericanBoard of Medical Specialties shall be utilized as necessary. A list40

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALof these physician consultants (reviewers) shall be available to thePPGs and L.A. Care Health Plan.• There is a set of written criteria or guidelines for utilization reviewthat is based on sound medical evidence, updated regularly, andconsistently applied.• Reasons for decisions are clearly documented.• There is a well-publicized appeals procedure for both providers andmembers.• Decisions are made in a timely manner.• UM decisions are made independent of financial incentives orobligations.• Records, including any CMS Member Notices and MediCal Noticeof Actions, shall meet the mandated retention requirements. Theretention requirements for Medicare records is 10 years.5.8 SEPARATION OF MEDICAL DECISIONS AND FINANCIAL CONCERNSUnder Federal Code of Regulations and California Health and SafetyCode 1367(g), medical decisions regarding the nature and level of care tobe provided to an enrollee, including the decision of who will render theservice, must be made by qualified medical providers, unhindered by fiscalor administrative concerns. Utilization Management decisions aretherefore made by medical personnel and are based solely on medicalnecessity. Practitioners may openly discuss treatment alternatives(regardless of coverage limitations) with members without being penalizedfor discussing medically necessary care with the member. L.A. Carerequires that each PPG and hospitals UM program include provisions toensure that financial and administrative concerns do not affect UMdecisions.5.8.1 Over/Under Utilization Monitoring/ Detection/ CorrectionL.A. Care's and delegated providers' descriptions of over/underutilization monitoring/detection systems must include monitoringinappropriate emergency room usage for routine primary and specialtycare and the review of services for appropriateness and effectivenessof cost effective patient care for detecting/correcting over- and underutilization.L.A. Care's UM Committee performs the following over/under utilizationmonitoring/detection mechanisms at a minimum:o Medicare HEDIS measuresUse of Services• Frequency of Selected Procedures• Inpatient Utilization - General Hospital/Acute Care• Ambulatory Care41

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALoo• Inpatient Utilization - Non-Acute Care• Mental Health Utilization - Inpatient Discharges andAverage Length of Stay Mental Health Utilization -Percentage of Members Receiving Inpatient,Day/Night and Ambulatory Services• Chemical Dependency Utilization - InpatientDischarges and Average Length of Stay• Identification of Alcohol and Other Drug Services• Outpatient Drug Utilization (for those with a drugbenefit)Ambulatory and Hospitalization ServicesL.A. Care monitors potential over-under utilization of services byreviewing ambulatory and hospital data. This data includesPPG encounter data and LA Care claims data. The reportsinclude:• Outpatient Services- Primary Care- Specialty Care- Ancillary Services• Emergency Room utilization• Hospital Services- Bed Days- Average Length of Stay- Hospital ReadmissionsEmergency Room Reports - This data will be compiled intoa monthly and rolling report for analysis by the UMCommittee. Trends in Emergency Room Departmentutilization may indicate access, education or under-utilizationissues at any of these levels while indicating over-utilizationat the Emergency Room level.o Hospitalization Admit and Re-admit data will be studied byutilizing encounter data and analyzing reports at L.A. Carelevel that indicate a trend of admission and re-admission forsame/similar diagnosis. If a pattern is found at any level, thepossibility of under-utilization of inpatient services oroutpatient support services may exist and warrant furtherinvestigation.Encounter data will be run periodically against a “patterns of care”program to analyze encounter patterns by diagnosis or procedure42

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALagainst the standards in the patterns systems. Under-utilization,over-utilization or non-submission of encounter data may be reasonfor widely aberrant patterns.Review of disenrollment (voluntary and involuntary), out of planservice or grievance trends which may indicate access or qualityissues will be conducted quarterly. The results will be reviewed bythe UM and QA/QI directors reported with recommendations to theappropriate Quality CommitteesRecommendations from the various Quality Committees will beconveyed to the PPGs via the Provider Network Operationsassigned staff or Joint Operation Meetings.5.9 DELEGATION OF UTILIZATION MANAGEMENTL.A. Care Health Plan has a formal process by which UtilizationManagement functions (which includes Case Management activities) aredelegated to the PPGs. Policies and Procedures and the delegationagreement describe (in detail) delegation standards, initial delegationrequirements, and ongoing monitoring and reporting requirements.If a federal or state law does not allow the organization to fulfill NCQArequirements, NCQA holds the organization harmless for all affectedscoring elements. In other words, NCQA may score an element NA orgive the organization credit, if appropriate, when there is a direct conflictbetween an NCQA requirement and a federal or state law. Theorganization must present NCQA with documentation identifying theregulation and the conflict and alert the ASC prior to the survey start date(submission date).L.A. Care Health Plan requires that delegated PPGs have a UtilizationManagement Program in place to monitor and evaluate the care andservices provided to its members. PPGs UM program will be consistentwith L.A. Care Health Plan’s UM program and meet State and Federalrequirements and regulations. L.A. Care Health Plan will monitor theinfrastructure and activities of the PPGs and the oversight of theirrespective networks to assure compliance with contractual and regulatoryrequirements. PPGs are required to submit to L.A. Care Health Plan:• an annual Utilization Management Program document and programevaluation,• monthly encounter data,• Oversight reports as defined in the delegation agreement• referral management activity and supplemental reports as definedin the delegation agreements .43

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALPPGs/Providers must have systems in place which address themandatory requirements to coordinate care between managed care plansand identified linked and carved-out programs as defined by the contract.De-Delegation of UM ActivitiesL.A. Care Health Plan may require or impose corrective action, includingrevocation of delegated status, if the PPG does not comply with thedelegated Utilization Management requirements. If L.A. Care Health Planwithholds or withdraws delegated status for Utilization Management from aPPG, L.A. Care Health Plan’s Utilization Management department shallassume the level of UM activity appropriate to the non-delegated PPG.L.A. Care Health Plan reserves the right to continue to delegate UtilizationManagement to the PPGs if they meet L.A. Care Health Plan’s standardsfor delegation. L.A. Care Health Plan’s Utilization Managementdepartment will provide consultation to the PPG and may activelyparticipate with the PPG to assist the PPG to come into compliance with aUM delegated function prior to L.A. Care Health Plan’s revocation of a UMdelegated status.5.10 STANDARDS FOR DELEGATION OF UM FUNCTIONSL.A. Care Health Plan shall retain the ultimate responsibility for ensuringthat PPGs utilize and maintain an effective Utilization ManagementProgram.The following required guidelines provide high level descriptions ofrequired Utilization Management processes and functions to be delegatedto the PPGs through L.A. Care Health Plan’s policies and procedures:The delegated PPGs must have a written utilization managementprogram/plan in place. The program must have documented goals andobjectives and describe the organizational structure and staffing forperforming the program functions.The delegated PPG must have UM operations that meet all contractual,regulatory, and L.A. Care Health Plan regulatory requirements, includingbut not limited to meeting all timeliness and corresponding standards.The UM program must identify and correct areas of over-utilization andunder-utilization of services.The delegated PPGs must have an established utilization managementcommittee which meets at least quarterly to review utilization issues anddetermine improvement plans where indicated. L.A. Care Health Plan44

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrepresentatives may attend the committee meeting, upon advancerequest.The minutes of the utilization management committee must be madeavailable upon request to L.A. Care Health Plan.L.A. Care Health Plan Utilization Management staff must be permittedreasonable access to the PPGs utilization management files, minutes andrecords of the UM Committee meetings, for the purpose of auditingutilization management activities.PPGs and providers within their networks will have processes in place totake appropriate action in areas where problems are identified and providefeedback to L.A. Care Health Plan regarding the conclusions,recommendations, actions and follow-up. Serious quality issues, limitationof providers’ practice, suspension or sanction activity will be reported toL.A. Care Health Plan immediately.PPGs will have policies and procedures to ensure separation of clinicaldecision making from financial incentives.UM data must be sent to L.A. Care Health Plan in a timely manner and inan appropriate format as requested by L.A. Care Health Plan’s UM andInformation Services departments for trending and reporting in compliancewith State and Federal regulatory requirements.5.11 DELEGATION MONITORING AND OVERSIGHTL.A. Care is responsible to evaluate PPG ability to perform the delegatedactivities including an initial review to assure that the PPG has theadministrative capacity, task experience, and budgetary resources to fulfillits responsibilities. Delegation monitoring shall be performed to ensurePPGs meets standards set forth by the L.A. Care and regulatory bodyrequirements. This includes the continuous monitoring, evaluation andapproval of the delegated functions.L.A. Care Health Plan will monitor and oversee the delegated UMactivities of the PPGs and their networks to ensure ongoing compliancewith State, Federal, and L.A. Care Health Plan requirements. UM datasubmitted to L.A. Care Health Plan by PPGs will be analyzed and areasfor improvement identified and managed through the Corrective ActionPlan (CAP) process with the PPG/Provider or through the QualityImprovement Process, as appropriate, in accordance with L.A. CareHealth Plan’s organizational sanction policies. L.A. Care Health Plan willperform different types of audits and oversight activities of PPGs as45

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALappropriate. The UM data and oversight activities will include, but not belimited to the following:UM ReportsPPGs are required to submit to L.A. Care Health Plan on a monthly basisvia mail, electronic mail or fax:.• Oversight reports as defined in the delegation agreement• Referral management activity and• Supplemental reports as defined in the delegation agreementsModification or Denial Notice of Action letters (CMS/SDHSl/L.A. Care) andmedical records utilized in the determination must be sent to the L.A. CareUM Department concurrent to the denial.These reports, combined with information obtained via site visits andaudits, will be used to accomplish the UM oversight functions required byregulation and/or contract requirement.L.A. Care Health Plan will analyze the reports and present the results tothe PPGs at the Utilization Management Committee meeting. The goal ofperforming plan and group specific analysis is to monitor utilizationactivities, member access to care, and to validate and compare tocommunity norms/ benchmarks. Any variance(s) will be reviewed anddiscussed at the Utilization Management Committee meetings, andperiodically at the Quality of Care Committee. All the information obtainedin these reports will be shared with the PPGs/ Providers for UM and QIpurposes.Oversight AuditsOversight for L.A. Care Health Plan’s directly contracted PPGs areperformed as prescribed in the UM Oversight Plan as approved by the UMCommittee. Wherever possible these audits may be done in conjunctionwith other L.A. Care Health Plan departments to improve efficiencies anddecrease duplication. The primary objective of the oversight audit is toensure compliance with L.A. Care Health Plan’s Utilization ManagementDepartment policies and procedures, standards of care, Local, State, andNational regulatory requirements, and provisions of the purchasercontracts (e.g. SDHS, MRMIB, Community Health Plan). The oversightaudit consists of document review and staff interviews to verify thatpolicies/procedures/processes have been implemented and are beingapplied and complied with. This may include, but not be limited to, auditsof case files and medical records. The oversight audits are conducted toensure compliance with the following requirements:46

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Annual approved Utilization Management Program, Work Plan, andEvaluation• UM Policies/Procedures/Processes• UM Care Coordination for in and out of network referrals/hospitals• UM Care Coordination for Linked and Carved Out Services• Initial Health Assessments• Medicare standardsSupplemental AuditsPreviously termed focused audits, Supplemental audit topics may beidentified by the Utilization Management Committee, CMO, MedicalDirector, and/or as a mid-year assessment of new legislativeimplementation requirements or indicated as a consequence of findingsfrom internal (e.g., performed by L.A. Care) or external (e.g. State orFederal) oversight/audit activity. The purpose of a supplemental audit isto capture more specific/detailed information that may not be capturedthrough Encounter Data, Supplemental Reports or the annual oversightaudit. The goal of the supplemental audit is to ensure compliance withL.A. Care Health Plan’s Utilization Management department policies andprocedures, standards of care, regulatory requirements, and provisions ofpurchaser’s contracts with a specific issue. The supplemental audit mayconsist of document review, file review and/or medical record review andstaff interviews. Supplemental audits may be used to capture morespecific or detailed information and/or to follow-up on identifieddeficiencies or areas of concern.A sampling methodology, used to select member records, ensures arepresentative sample from the delegated entity for the supplemental audit.Supplemental audit tools are scored according to the methodology approvedby the UM CommitteeThe supplemental audit may address any Utilization Management andcoordination of care category as identified by L.A. Care Health Plan in ourpurchasers’ contract.Continuous Monitoring ActivitiesContinuous Monitoring Activities are used to further supplement the basicoversight activities of annual/focused audits and supplemental reportsubmission review in order to provide more comprehensive and timelyoversight in selected areas where episodic audits/review have not beenadequate in ensuring compliance to regulations. A sampling methodologyappropriate to each continuous monitoring activity is defined to ensurerepresentative sampling, and approved by the UM Committee. Examples ofcontinuous monitoring may include, but are not limited to:• Referral Management Review, including denials and denialnotifications47

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Care Coordination for Linked and Carved Out ServicesDecisions by the Plan or delegated PPG are tracked for any trends andappropriate actions taken as necessary.The L.A. Care UM Department reviews denials issued and submitted bythe delegated Physician Groups. Delegated PPGs are required to submitall denial letters with any supporting documentation current to the denial oron a weekly basis to the Plan.Plan and PPG denial letters are evaluated for compliance in the followingareas:1. Timeliness of the decision-making and notification process2. Physician involvement in the decision making3. Clear and concise denial reason4. Appropriate information available for decision-making5. Documentation of criteria for medical necessity denialsorbenefit reference6. Appeal rights and process ( NOTE: Appeals processdiffers for members enrolled in in the MedicareAdvantage SNP and and for members enrolled in MCLAfor Medi-Cal only, )7. Appropriate templateIf deficiencies are found in the initial review, the Plan or delegated PPGsare notified of the areas of deficiencies for immediate correction.Continued non-compliance issues are reported to the DelegationOversight Committee for recommendations.Delegated Physician Group letters are also audited during the annualoversight audits.Corrective action plans are required for those PPGs with less than 90%compliance.• PPGs with deficiencies or corrective action plans will be monitoredaccording to L.A. Care policy.• If a PPG remains non-compliant, the findings will be reported to theDelegation Oversight Committee for a decision regarding continueddelegation.The Plan will provide delegated PPGs with the approved CMS/SDHS orL.A. Care letter templates that need to be used, at least once every yearor more often as the need arises. This is to ensure that the PPG are usingstandard regulatory approved language.48

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL5.12 RESPONSIBILITY OF PARTICIPATING PROVIDER GROUPS5.12.1 PPGs are responsible for primary (basic) medical casemanagement, coordinating health care services, and referralmanagement of services for which the PPG has financialresponsibility, for members enrolled with their primary carephysicians.5.12.2 The PPG also has responsibility for notification to and obtainingprior-authorization from L.A. Care’s UM department for serviceswhich L.A. Care has sole financial responsibility.PPGs that do not obtain prior authorization for services that arethe responsibility of L.A Care and not defined as eligible under theRisk Pool arrangement are subject to assume the financial risk forsaid service. Please refer to the contract DOFR and or themutually agreed upon Delegation Agreement.5.12.3 The PPG agrees and is required to:5.12.3.1 make available to L.A. Care any requested data,documents and reports5.12.3.2 allow site visits, periodic attendance at UM meetings,evaluation and audits by L.A. Care or other agenciesauthorized by L.A. Care to conduct evaluations.5.12.3.3 have representation and involvement in activitiesscheduled to enhance and/or improve the quality ofhealth care services provided to our members.5.13 SERVICES REQUIRING PRIOR AUTHORIZATIONThe delegation of certain UM activities affords flexibility for PPG toestablish internal prior authorization requirements. These requirementsmust be reviewed and approved by L.A. Care through the delegationprocess.There are services for which the PPG must submit a request/referral toL.A. Care for prior authorization, or notification concurrently with orretrospective of the services for authorization by L.A. Care. Allauthorization requests submitted to L.A. Care will be responded to withinthe defined timeframes as identified in the most recent product specificversion of the applicable “Decision Making Timeliness Matrix” (Attachmentincluded)Unless defined in the most recent L.A. Care PPG Auto Approval Listing,the services listed below, and any future updates dependent on delegationand DOFR, must first be authorized by L.A. Care’s UM department:49

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Durable Medical Equipment (DME)• Home Health Services• Hospital admission (non-emergent/urgent)• Skilled Nursing Facility admissions, skilled and long term care• Medical Supplies not provided in physicians offices• Most elective surgical and invasive diagnostic procedures (inpatientor outpatient facility component)• Orthotics & Prosthetics• Physical/Occupational & Speech therapies (see DOFR)• Rehabilitation services• Transplant evaluation• Self-injectiblesReferrals may be submitted on paper, by phone, or electronically. Allrequests must be submitted on a L.A. Care Referral Form and include thefollowing information:• Requesting provider• Patient’s name, date of birth, address, phone number, and socialsecurity number• Confirmation of current L.A. Care eligibility• Patient’s diagnosis and medical history supportive to the servicerequested• Supportive medical records needed to make a determination• Appropriate coding (using current CPT4, ICD9, and/or HCPCScodes), identification of services requested• Identification of requested provider of service, including name, typeof provider, location and provider’s phone number5.14 ORGANIZATIONAL DETERMINATIONS - DEFERRAL, MODIFICATION,AND/OR DENIAL DETERMINATIONS AND NOTIFICATIONREQUIREMENTS – Medicare Advantage SNP OnlyReferral Status and Timelines –L.A. Care’s (LAC) Utilization Management Department reviewsreferral/authorization requests and makes organization determinationsbased on medical necessity through the application of approved clinicalcriteria and assessment of the individual needs of the member.Organization Determinations means any determination made byL.A.care for any of the following:• Requests for service50

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Discontinuation of service that the enrollee believes shouldbe continued because they believe the service to bemedically necessary.• Refusal to pay for services in whole or part, including thetype or level of services that enrollee believes should befurnished by the Medicare Advantage organization.• Payment for any health services furnished by a providerother than the Medicare Advantage organization that theenrollee believes are covered under Medicare or if notcovered by Medicare, should have been furnished orarranged for by the Medicare Advantage organization.• Payment for temporarily out of area renal dialysis services,emergency services, post stabilization care, or urgentlyneeded services.• Failure of Medicare Advantage organization to approve,furnish, arrange, or provide the enrollee of timely notice of anadverse determination, such that a delay may adverselyaffect the health of the enrollee.Routine (non expedited or standard) Organization Determinations aremade using appropriate clinical and CMS coverage guidelines and themember is notified within 14 calendar days of receipt of the request, perMedicare timeliness standards.Expedited Determination for urgent requests: To request an expediteddetermination, an enrollee or a physician must submit an oral or writtenrequest directly to L.A.Care or the delegated PPG.. Urgent requests forservices are referred to the PPG or L.A.Care depending upon the entityresponsible for reviewing the referral request.. Urgent referral requestsare submitted when services are required to prevent serious deteriorationof health following the onset of an unforeseen condition or injury. Urgentreferral requests made to L.A.Care will be reviewed by a L.A. Care UMSpecialist to assess that the care requested meets the definition for urgentprocessing. If request is approved for urgent processing, L.A.Care or thedelegated PPG makes its determination and notifies the enrollee and thephysician involved of its decision (whether adverse or favorable) asexpeditiously as the enrollee’s health condition requires, but no later than72 hours after receiving the request.Based on CMS standards, referrals that do not meet the criteria for urgentprocessing will be reviewed by L.A.Care’s Medical Director. If the servicerequested does not meet the criteria for an urgent request the referralrequest will be converted to a routine request for processing within theroutine time frame which is 14 calendar days from the date and time of the51

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrequest. Members may file an expedited grievance if they do not agreewith L.A.Care’s decision.If the referral request does not meet criteria for medical necessity orcovered benefit these requests are subject to a modification or denial byL.A.Care’s Medical Director. PPGs will be notified by L.A. Care’s UM staffmember prior to the change in referral status. Appropriate communicationsare sent to the member and provider. If the services are denied, thedenial notice must be the appropriate CMS approved denial letter (Noticefor Denial of Medical Coverage, NDMC) and must include the reason forthe denial, the criteria used, and include Medicare appeal rights.A physician will make all determinations of deferment, modification ordenial of requests for services.Extensions: L.A.Care or delegated PPG may extend the routine requestor 72 hour deadline (expedited or urgent request) by up to 14 calendardays if the enrollee requests the extension or if L.A.Care or the PPGjustifies a need for additional information and how the delay is in theinterest of the enrollee (for example, receipt additional information fromnon-contracted providers may change L.A. Care’s decision to deny).When the organization extends the deadline, it notifies the member inwriting of the reasons for the delay and informs the member of the right tofile a grievance if he or she disagrees with the organization’s decision togrant an extension. The member is given prompt oral notice of theextension (as expeditiously as the member’s health condition requires butno later than upon expiration of the extension) and a written notificationfollows within 3 calendar days. The letter confirms the oral notification.(See: Attachment A - Timeliness of UM Decision-Making Matrices (byproduct line)Only a qualified physician can make a determination to deny ormodify a request. Denials and modifications of requested services maybe issued with an alternative care option when appropriate.A request for authorization that results in a modification, reduction, ordenial of Covered Services based on medical necessity or Benefitcoverage shall be reviewed by the L.A. Care or PPG Medical Director ordesignated Physician reviewer. The Plan or PPG should clearly documentand communicate the reasons for each denial. The intent is for Providersand Members to receive sufficient information to render an informeddecision whether or not to appeal the modification or denial of coverage.This policy covers both non-behavioral and behavioral healthcare.52

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL.A. Care and delegated PPGs shall comply with the standards fortimeliness in decision making and notification of UM denial or modificationdecisions per specifications of the UM Timeliness Guidelines required byCMS or DHCS. Notifications may be given orally, electronically, or writtenas specified in regulatory guidelines. L.A. Care will notify PhysicianGroups of any changes in these standards as required.If a request is denied or modified, the Plan or the delegated PPG shallutilize either the:• CMS mandated Notice of Denial of Medical Coverage (NDMC) andthe supplemental CMS Region IX approved template letters forMedicare Members.• DHCS Notice of Action (Only for those services not covered byCMS but covered by DHCS),Denials include modifications or delays in the Covered Servicerequested.A denial letter is issued based on standard criteria (medical orBenefits) and must include the following:a) A description of the Covered Service being denied, modifiedor deferredb) Clear and concise explanation of the reason(s) for thedecision. This should be presented in a clear,understandable language.c) A description of the criteria, guidelines, protocol, or benefitprovision used to make the decision.d) Notification that a Member can obtain a copy of the criteria,guideline, protocol, or actual Benefit provision on which thedenial decision was based, upon request.e) An alternate treatment plan will be identified when medicallyindicated.f) A description of Appeal and or reconsideration rights,including the right to submit written comments, documents,or other information relevant to the Appeal.g) An explanation of the Appeal process, including the right toMember representation (for Medicare Members only) andtime frames for deciding Appeals.h) A description of the Expedited Appeal process if a denial isan urgent pre-service or urgent concurrent denial.i) Name and phone number of the Physician reviewer involvedin the initial determination.53

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALj) A Member’s right to select an authorized third party, such aslegal counsel, relative, friend or any other person as arepresentative (applies to Medicare Members only).UM REFERRAL PEER REVIEW DISCUSSION – PPG or L.A. Care arerequired to provide access to the Medical Director or physician reviewersresponsible for the UM determination .PEER REVIEW DISCUSSIONSA provider requesting a second review of a referral request forauthorization may write or call the Medical Director/ designated peerreviewer and provide additional information for further discussion. Thisprocess, or reconsideration, usually occurs prior to the issuance of thedenial notification to the member under the following terms:• Reconsideration must occur within one (1) business day fromthe receipt of the provider telephone call or written request.• If the Medical Director or designated peer reviewer reverses theoriginal determination based on additional information given bythe provider, the case will be closed.• If reconsideration does not resolve a difference of opinion, theprovider may then submit a request for review through theexpedited or standard appeal process to L.A. Care.• If the group’s reconsideration process results in a denial,deferral, and/or modification with which the provider is stilldissatisfied, the provider may request a formal appeal to L.A.Care for a higher level review.NOTIFICATIONSThe PPG or L.A.Care will send written notification of prior-authorizationrequest denial, deferral, and/or modification to the member or member’srepresentative, member’s PCP, and/or attending physicians and L.A.Care, according to the provisions below:• All denials and modifications of service requests, includingdenials for non-covered benefits, must be communicated to theprovider and member in writing within the required timeframesand utilize the appropriate CMS template notices Thecommunication must contain the following:• Specific reason(s) for the decision54

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Medical or other criteria used in making the decision• All appeal options and processes including necessaryinstructions and applications (e.g. IndependentMedical Review, routine and expedited appealprocesses, etc.)• Name and contact information of the physicianreviewer making the determination• Written notification will also include information describing thegrievance processes for CMS or Department of Health ServicesTimelines for decision making –SEE ATTACHED PRODUCT SPECIFIC DECISION-MAKINGMATRICES – Attachment ASelf-Referral Services - Medicare Advantage –SNP OnlyFor Medicare Advantage-SNP members, certain services are availablewithout referral or authorization. These include:• Routine women’s health care, which include breast exams,mammograms (x-rays of the breast), Pap tests, and pelvic exams.This care is covered without a referral from a plan provider.• Flu shots and pneumonia vaccines, as long as they are furnished bya plan provider.• Emergency services, whether provided in or out-of-network• Urgently needed care received from non-plan providers when themember is temporarily outside the Plan’s service area. Also, urgentlyneeded care that the member gets from non-plan providers when theyare in the service area but, because of unusual or extraordinarycircumstances, the Plan providers are temporarily unavailable orinaccessible.• Dialysis (kidney) services received when the member is temporarilyoutside the Plan’s service area.5.15 AFTER HOURS UM ACCESSL.A. Care and its delegated entities shall provide 24 hours/7 days/weektelephone access to utilization management professionals and ensure thatmultilingual capability is available at the 24-hour number:Multi-lingual capability is provided by L.A. Care through a telephonicinterpretation services contracted vendor.A physician or contracting physician shall be available 24 hours a day to:55

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALauthorize medically necessary post-stabilization care and coordinate thetransfer of stabilized members in an emergency department, if necessary:• response to request is required within 30 minutes or the service isdeemed approved in accordance with Title 22, CCR, Section 53855(a), or any future amendments• authorize non-urgent care following an exam in the emergencyroom• response to request is required within 30 minutes or the service isdeemed approved in accordance with Department of HealthServices (DHCS) contractual requirements• respond to expedited requests for:o appeals of denial of serviceso quality of care grievancesL.A. Care’s UM physician and staff are available after hours (24 hours, 7days/week) for provider and access to care determinations. If you have aquestion regarding UM referrals for urgent services provided after normalbusiness hours, please contact:L.A. Care Health PlanAttn: UM Department555 West Fifth Street, 29 th FloorLos Angeles, CA 90013(877) 431-2273 – Request the “Nurse on Call”Fax: 213-623-86695.16 EXCEPTIONS TO AUTHORIZATIONS5.16.1 In developing prior-authorization requirements, certain parametersand any future updates must be followed by the PPG. Theseparameters include exceptions to prior-authorization or services forwhich prior authorization is disallowed. The services include thefollowing:• Emergency services (medical screening and stabilization).• Preventative health services for all ages includingimmunizationso Medicare – SNP - flu and pneumococcal vaccinationsand screening mammograms.• Services identified in the most current version of the L.A. Care“Direct Referrals List”5.17 Hospital Inpatient Care56

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALUnless noted in the PPGs delegation agreement, the Plan is responsiblefor hospital inpatient concurrent review. The Plan UM staff or casemanager will collaborate with the attending Physician (Hospitalist),Hospital case manager and Physician Group Case Manager for continuingInpatient Services and discharge planning.The attending PPG is responsible for the professional component ofinpatient care and shall perform rounds on all Members who areInpatients, as will, when appropriate, the Member's PCP, if the attendingPhysician is a Specialist Physician. The PPG shall monitor continuingcare, collaborate with the Plan when continued Inpatient Services arerequired and initiate discharge planning and follow-up services, whenindicated.Hospital inpatient care may be pre-planned, pre-authorized, urgent oremergency admissions. The PCP is responsible for obtaining requiredpre-authorizations for inpatient care from the PPG. The PCP must notifythe PPG of an emergency admission. The PPG must notify L.A. Care ofall inpatient admissions. L.A. Care maintains a list of contractedhospitals and ancillary services. If you do not have a PPG copy, pleasecontact your L.A. Care Provide Network Operations representative.Emergent inpatient admissions – for PPGs that are managing an inpatientadmission and do not coordinated within one (1) business day of theadmission, the hospital facility charges may be subject to capitationadjustment as defined in the terms of the PPG contract at thediscretion of L.A. Care.Elective inpatient admissions – for PPGs that do not obtain priorauthorization for the admission by LA. Care, the hospital facility chargesare subject to capitation adjustment as defined by the terms of thePPG contract at the discretion of L.A. Care.While a member is hospitalized, the PPG/PCP must:• Coordinate, with the assistance of UM staff, care for membersadmitted to out of network facilities for emergency care or otherreasons. After determination of the appropriateness of anemergency admission and a transfer assessment is made, themember will either be transferred to a network facility or care willbe continuously monitored at the initial facility of admission untildischarge or a transfer is appropriate.• Respond to the concurrent review process, including level ofcare, length of stay, and medical necessary elements when57

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALhe/she acts as the attending physician or works in conjunctionwith the attending physician for a hospital stay.• Assist with the discharge planning by ordering and requestingauthorization for appropriate elements of discharge.Emergency Notification of AdmissionAll elective and emergency inpatient admissions must be brought to theattention of L.A. Care’s UM department within 24 hours of theadmission. These notifications may occur by calling in or faxing thepatient’s admission face sheet to the following:L.A. Care Utilization Management Department1-877-431-2273Fax: 213-623-8669Emergent inpatient admissions – for PPGs that are managing an inpatientadmission and do not coordinate within 1 business day of the admission,the hospital facility charges may be subject to capitation adjustment asdefined in the terms of the PPG contract.Transfers from Non-Participating ProvidersIn cases where a Member requires Emergency Services at a Hospital orfacility other than a Plan contracted Hospital, Physician Group and GroupProviders shall make best efforts to transfer such Members to a PlandesignatedHospital as soon as medically appropriate (i.e., followingstabilization of the Member). Group Providers shall coordinate and accepttransfer of care from Non-Participating Providers when and as medicallyappropriate, whether the Member's Emergency or post-EmergencyServices has been rendered Out-of-Area or In-Area. Physician Group shallconsult with the Plan regarding arrangements for Member transfers. If aMember is Out-of-Area and, in the opinion of Physician Group'sdesignated Physician and/or Plan’s Medical Director, said Memberrequires continued Physician Services upon transfer, and PhysicianGroup’s designated Physician and other Group Physicians do not accepttransfer of the Member for such Covered Services, Physician Group shallbear the costs of Physician Services rendered from the date Member isdeemed transferable. In the event disputes arise between PhysicianGroup and Plan relating to the Plan Medical Director's decision regardinga Member's transferability, Physician Group may appeal such decision toPlan’s UMC.Inpatient Concurrent Review58

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALInpatient concurrent review is usually a coordinated effort between L.A.Care and the PPG. Once notified, L.A. Care’s UM staff will performtelephone reviews with the hospital staff:• Inpatient concurrent review will begin within one (1) day ofnotification of the admission and include an assessment of theappropriateness of the level of acute care by using acceptedcriteria.• Concurrent review will be conducted on or before the datesassigned at the end of the initial review and each subsequentreview. Concurrent review includes an evaluation of thefollowing:o Appropriateness of acute admissiono Plan of treatmento Level of careo Intensity of services/treatmento Severity of illnesso Quality of careo Discharge planning• These reviews will be conducted utilizing accepted guidelinesfor acute levels of care, such as intensity of service and severityof illness criteria, Milliman Care Guidelines, or other guidelinesand criteria developed and/or approved by L.A. Care.• Concurrent quality issues noted during utilization review will bedocumented and reported to the PPG, L.A. Care’s UM MedicalDirector and Quality Improvement department. Whenappropriate, quality issues will be discussed with the attendingphysician by the UM medical staff for appropriate intervention.Depending on the urgency or gravity of the situation, discussionof the issues may also be necessary with Senior ExecutiveAdministration.• Utilization review concurrent focus will be proactive, andUM/Case Management levels of focus will be employed asappropriate.Discharge PlanningL.A. Care’s UM staff will begin discharge planning within 24 hours ofnotification of admission and facilitate the involvement of amultidisciplinary team of physicians, nursing, social work, and others, asappropriate.Patient and family intervention will occur, as appropriate, throughout thestay to assure discharge plans are in place and appropriate for eachmember. Discharge plans will consider the disease process, treatment59

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrequirements, the family situation, and available benefits and communityresources.Average length-of-stay guidelines will be used for discharge planningpurposes. Discharge screens, lower level of care guidelines, or clinicaldecision made by the physician are to be used for the final discharge dateplan.Questionable continued stay plans are to be discussed with the attendingphysician and then reviewed by L.A. Care’s physician reviewer for furtherdiscussion with the attending physician.Notification of Hospital Discharge Rights to MembersL.A.Care’s SNP members receive from affiliated hospitals the “ImportantMessage (IM) from Medicare” upon admission that explains the member’srights including the right to appeal to the Quality Improvement Organization(QIO) if they believe they should not be discharged. Medicare enrollees whoare hospital inpatients have a statutory right to appeal to the QualityImprovement Organization – which is the Health Services Advisory Group,Inc. (HSAG) in California for an immediate review when a hospital and aMedicare health plan, with physician concurrence, determine that inpatientcare is no longer necessary.• Hospitals must issue the IM within 2 calendar days of admission andmust obtain the signature of the enrollee or his or her representative andprovide a copy at that time.• The message a statutorily required notice explains the enrollee’s rights asa hospital patient, including discharge appeal rights.• Hospitals will also deliver a copy of the signed notice as far in advance ofdischarge as possible, but not more than 2 calendar days beforedischarge.• Enrollees who are being transferred from one inpatient hospital setting toanother inpatient hospital setting do not need to be provided with thefollow up copy of the notice prior to leaving the original hospital, since thisis considered to be the same level of care. Enrollees always have the rightto refuse care and may contact Health services Advisory Group [HSAG] (The Quality Improvement Organization {QIO} appointed by CMS forCalifornia) if they have a quality of care issue. The receiving hospital must60

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALdeliver the Important Message from Medicare again according to theprocedures in this rule.A “follow up” copy of the signed IM must be delivered to the enrollee prior todischarge using the following guidelines:Delivery Timeframe. Hospitals must deliver the follow up copy as far inadvance of discharge as possible, but no more than 2 calendar daysbefore the planned date of discharge. Thus, when discharge seems likelywithin 1- 2 calendar days, hospitals should make arrangements to deliverthe follow up copy of the notice, so that the enrollee has a meaningfulopportunity to act on it. However, when discharge cannot be predicted inadvance, the follow up copy may be delivered as late as the day ofdischarge, if necessary. If the follow-up copy of the notice must bedelivered on the day of discharge, hospitals must give enrollees who needit at least 4 hours to consider their right to request a QIO review.L.A.Care’s SNP members have a right to request an immediate review by theQIO when L.A. Care and the hospital (acting directly or through its utilizationreview committee), with physician concurrence, determine that inpatient careis no longer necessary.Members Submitting a Request: An L.A.Care SNP member whochooses to exercise the right to an immediate review must submit arequest to QIO (HSAG in California) as indicated on the IM notice. In orderto be considered timely, the request must be made no later thanmidnight of the day of discharge, may be in writing or by telephone, andmust be requested before the enrollee leaves the hospital. The memberupon request of HSAG, should be available to discuss the case. Themember may, but is not required to, submit written evidence to beconsidered by HSAG.Timely Requests: When the member makes a timely request for a QIOreview – that is, requests a review no later than midnight of the day ofdischarge – the member is not financially responsible for inpatient hospitalservices (except applicable coinsurance and deductibles) furnished beforenoon of the calendar day after the date the member receives notification ofthe determination from HSAG. Liability for further inpatient hospitalservices depends on HSAG decision as follows:Unfavorable determination: If QIO notifies the member that they did notagree with the member, liability for continued services begins at noon ofthe day after QIO notifies the enrollee that HSAG agreed with thehospital’s discharge determination, or as otherwise determined by HSAG.61

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALFavorable determination: If QIO notifies the enrollee that they agreedwith the member, the member is not financially responsible for continuedcare (other than applicable coinsurance and deductibles) until L.A. Careand hospital once again determine that the member no longer requiresinpatient care, secure the concurrence of the physician responsible for theenrollee’s care, and the hospital notifies the member with a follow up copyof the IM.L.A.Care to Provide the Detailed Notice of Discharge: When QIOnotifies L.A. Care that a member has requested an immediate review, theplan must, directly or by delegation, deliver a Detailed Notice ofDischarge (the Detailed Notice) to the member as soon as possible butnot later than noon of the day after HSAG’s notification. L.A. Care isresponsible for ensuring proper execution and delivery of the DetailedNotice, regardless of whether it has delegated that responsibility to itsproviders. If a member requests more detailed information prior torequesting a review, plans may, directly or by delegation, deliver thedetailed notice in advance of the member requesting a review.Use of Standardized Notice: L.A. Care uses the standardized form{(CMS-10066) . This notice is also available on www.cms.hhs.gov/bni atthe Link for Hospital Discharge Appeal Notices. Plans may not deviatefrom the content of the form except where indicated. The OMB controlnumber must be displayed on the notice. The Detailed Notice must be thestandardized notice provided by CMS and contain the following:• A detailed explanation why services are either no longer reasonableand necessary or are otherwise no longer covered.• A description of any applicable Medicare coverage rule, instruction, orother Medicare policy, including information about how the enrolleemay obtain a copy of the Medicare policy.• Any applicable Medicare health plan policy, contract provision, orrationale on which the discharge determination was based.• Facts specific to the enrollee and relevant to the coveragedetermination sufficient to advise the enrollee of the applicability of thecoverage rule or policy to the enrollee’s case.• Any other information required by CMS.Providing Information to QIO: Upon notification by QIO of the member’srequest for an immediate review, L.A. Care and hospital must supply allinformation that QIO needs to make its determination, including copies ofboth the IM and the Detailed Notices, as soon as possible, but no laterthan noon of the day after QIO notifies the L.A.Care and /or hospitalof the request. In response to a request from L.A. Care, the hospital must62

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALsupply all information that QIO needs to make its determination, includingcopies of both the IM and the Detailed Notices (if applicable) as soon aspossible, but no later than close of business of the day the plan notifiesthe hospital of the request for information. At the discretion of QIO, L.A.Care and the hospital may make the information available by telephone orin writing. A written record of any information not transmitted in writingshould be sent as soon as possible.Coverage during QIO’s expedited review: L.A. Care is financiallyresponsible for coverage of services during QIO’s review as provided forin these rules, regardless of whether it has delegated responsibility forauthorizing coverage or discharge determinations to its providers.ReconsiderationsAn enrollee who is dissatisfied with QIO’s determination can request areconsideration from QIO in accordance with CMS regulation 42 § 422.626(f).• Submitting a Request: If QIO upholds L.A. Care’s discharge decisionin whole or in part, the enrollee may request, no later than 60 daysafter notification that QIO has upheld the decision that QIO reconsiderits original decision.• Note: If the enrollee is no longer an inpatient in the hospital and isdissatisfied with QIO’s determination, the enrollee may appeal directlyto an Administrative Law Judge (ALJ), the Medicare AdvisoryCouncil (MAC), or a federal court.5.18 Medicare Advantage SNP – Standard Reconsideration ofOrganization Determination (Appeals)Any party who is dissatisfied with an L.A. Care or PPG organizationaldetermination or with one that has been reopened and revised mayrequest reconsideration of the determination in accordance with theprocedures as outlined in CMS regulations 42CFR422.582, concerning arequest for reconsideration, or 42CFR422.584, concerning certainexpedited reconsiderations. Members have the right to appeal decisionsregarding their health care if that they do not agree with:• Payment for emergency services, post-stabilization care, or urgentlyneeded services• Renal dialysis services out-of-area• Payment for any other health services furnished by a Non-ContractingPhysician Group or facility the enrollee believes are covered under63

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMedicare, or should have been arranged for, furnished, or reimbursedby L.A. Care - SNP• Services not received, but which the enrollee feels L.A. Care – SNP isresponsible to pay for or arrange• Discontinuation of services that the enrollee believes are still medicallynecessary covered servicesMA-SNP members will file reconsiderations of organization determinationswith L.A. Care’s Grievance and Appeals Unit. All reconsiderations must befiled within 60 calendar days of notification of the organizationdetermination decision. If the request for reconsideration is filed beyondthe sixty calendar (60) days from the date of the notice of the organizationdetermination, a party to the organization re-determination request mayfile a request for good cause extension with L.A. Care.L.A.Care Health Plan designates someone other than the person involvedin making the initial organization determination when reviewing areconsideration. If the original denial was based on a lack of medicalnecessity, then the reconsideration is performed by a physician withexpertise in the field of medicine that is appropriate for the services atissue. In cases involving emergency services, L.A.Care Health Planapplies the prudent layperson standard when making the reconsiderationdetermination.Request for Payment reconsiderations: L.A. Care will resolve allreconsiderations regarding payment for services already received within60 calendar days from the date of the request for reconsideration.Request for Service Reconsiderations: L.A. Care will resolve allstandard reconsiderations regarding medical care within 30 calendar days.However, if information is missing or if it is in the best interest of themember, L.A. Care may extend the timeframe by an additional 14calendar days.Favorable decision for member, payment request: If L.A. Care decidesin favor of the member with respect to a payment reconsideration, LA.Care must pay within 60 calendar days of receiving the appeal.Unfavorable decision for member, payment request: If L.A.Careupholds an adverse payment determination, it will automatically forwardthe case to the independent review entity (Maximus) within 60 calendardays for cases involving payment decisions.64

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALFavorable decision for member, service request: If L.A. Care decidesin favor of the member with respect to a standard reconsideration ofmedical care or service, LA. Care must authorize or provide serviceswithin 30 calendar days of receiving the appeal.Unfavorable decision for member service request: If L.A. Care upholdsan adverse determination, L.A. Care will automatically forward the case tothe independent review entity (Maximus) within 30 calendar days forcases involving medical careReversal of L.A.Care’s Decision by IRE (Maximus): If, onreconsideration of a request for service, L.A. Care’s determination isreversed in whole or in part by the independent review entity contracted byCMS, L.A. Care will authorize the service under dispute within 72hours from the date it receives notice reversing the determination, orprovide the service under dispute as expeditiously as the enrollee’s healthcondition requires, but no later than fourteen (14) calendar days fromthat date. L.A.Care’s Medical Management Department will inform theindependent review entity contracted by CMS that the organization haseffectuated the decision.Medicare Advantage SNP – Expedited Reconsideration of anOrganization Determination :L.A. Care will resolve all expedited reconsiderations within 72 hours, orsooner based upon the health condition of the member. LA. Care mayextend the timeframe for an additional 14 days if information is missing orif it is in the best interest of the member. If L.A. Care decides in favor ofthe member, L.A. Care must authorize or provide care within 72 hours ofreceiving the expedited appeal. If L.A. Care upholds an adversedetermination, L.A. Care will automatically forward the case to theindependent review entity within 24 hours for review.Expedited Grievance:A member may file an expedited grievance under the followingcircumstances:o L.A.Care health plan or the delegated PPG extends the time frame tomake an organization determination or reconsideration; oro A Medicare health plan refuses to grant a request for an expeditedorganization determination or reconsideration;L.A.Care or the delegated PPG must respond within 24 hours to anenrollee’s expedited grievance. L.A.Care or the delegated PPG65

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALcommunicates with the member about the right to file an expeditedgrievance using a CMS model notice.5.19 Special Considerations Regarding Termination of Skilled NursingFacility (SNF), Home Health Agency (HHA) and ComprehensiveOutpatient Rehabilitation Facility (CORF) ServicesRegarding Medicare Members, a termination of service is the discharge ofa Member from Covered Services, or discontinuation of Covered Services,when the Member has been authorized by L.A. Care to receive anongoing course of treatment from that Provider. For purposes of thisSection, “Member” shall also encompass “or Member’s representative,” asapplicable.a) The “Notice of Medicare Non-Coverage” (NOMNC) will be issuedwhen:1) A Member is being discharged from a Skilled Nursing Facility(SNF), Home Health Agency (HHA) or Comprehensive OutpatientRehabilitation Facility (CORF) services;2) The Plan has made a determination that Covered Services are nolonger covered or necessary. With respect to the exhaustion ofMedicare Benefits (100 days for SNF), per CMS directive, theNotice of Denial of Medical Coverage (NDMC) should be used toconvey this information, rather than the NOMNC. The QIO does notnormally conduct Appeal reviews related to the exhaustion ofBenefits, therefore, these Appeals will be handled by the Plan; or3) A determination that such Covered Services are no longerMedically Necessary.b) Delivery of Notice: In accordance with Medicare Valid Deliveryrequirements, the Plan, in collaboration with the Provider, issues theNOMNC that notifies the Member of the termination of CoveredServices or discharge, no later than two calendar days or at the nextto last visit, if the span of time between service visits exceeds twodays, before the proposed end of Covered Services. If the Memberdisagrees with the termination of services/discharge,1) the Member must contact the QIO, verbally or in writing, no laterthan noon of the day before the Covered Services are to end. Atthe same time the Provider entity or delegated PPG will notifyL.A.Care of the NOMNC issued to the Member. L.A.Care will trackissuance and follow-up all NOMNC’s from delegated PPGs orProvider entities.66

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL2) If the Member disagrees with the NOMNC and requests an Appeal,L.A.Care will prepare the Detailed Explanation of Non-Coverage(DENC) for the Provider to issue to the Member. If the Memberrequests an Appeal with the QIO, L.A.Care will process as follows:a. Plan must obtain the Member’s medical records from theProvider and send a copy of the DENC, along with theMember’s medical records, to the QIO by close of business onthe day of the QIO submitted to Plan appeal notification. ThePlan may request that the records be sent directly to the QIO.b. The QIO must make a decision and notify the Member and thePlan by close of business the following day. On the nextbusiness day, the Plan will notify the delegated PPG of the fasttrackAppeal request and the QIO’s determination. If the QIOoverturns the decision then the PPG or L.A.Care shall continueauthorization to the Group Provider. The delegated PPG mustprovide the Plan with proof of continued authorization andprepare and issue a new NOMNC notice when new dischargeorders are written. If the Member fails to file a timely Appeal withthe QIO, the Member may request an expedited Appeal fromthe Plan based on CMS regulation [42 CFR 422.624; 42 CFR422.626]5.20 Second Opinion ProcessThe second opinion program provides members and providers with theability to validate the need for specific procedures. The use of screeningcriteria will be employed in addition to securing a second physicianconsult, when necessary. Second opinions will be rendered by anappropriately qualified health care professional identified as a primary carephysician or a specialist who is acting within his or her scope of practice,and who possesses clinical background, including training and expertise,related to the particular illness, disease, condition or conditions associatedwith the request for a second opinion.Second opinion request will be processed in accordance with the stateregulatory requirements at no cost to the member.5.21 STANDING REFERRALSA standing referral is a referral made by the PCP for more than one (1)visit to a specialist or specialty care center as indicated in an approvedtreatment plan for a particular diagnosis. A member may request a67

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALstanding referral to a specialist through his/her PCP or through aparticipating specialist.L.A. Care Health Plan maintains a referral management process and alsodelegates the referral management process to delegated entities.Delegated entities shall maintain policies and procedures for the referralmanagement that include review of standing referrals for members whorequire specialty care or treatment for a medical condition or disease thatis life threatening, degenerative, or disabling.Authorization and Referral Processes• Authorization determinations for specialty referral/services shall beprocessed in accordance with L.A. Care's and/or its delegatedentities policies and procedures for referral management and withinrequired time frames for standing referrals as described in thisprocedure.• Services shall be authorized as medically necessary for proposedtreatment identified as part of the member's care treatment planutilizing established criteria and consistent with benefit coverage.• Once a determination is made, the referral shall be made to theSpecialist within four (4) business days of the date the proposedtreatment plan, if any, is submitted to the physician reviewer.• The duration of a standing referral authorization shall not exceedone year at a time, but may be renewed for periods up to one yearif medically appropriate.Credentialing RequirementsThe specialist provider/special care center shall be recredentialed by andcontracted with L.A. Care or its delegated entities' network to provide theneeded services or:o If standing referrals are made to providers who are not contractedwith L.A. Care or it delegated entities' network, L.A. Care and/or itsdelegated entities shall make arrangements with that provider forcredentialing prior to service, appropriate care coordination, andtimely and appropriate reimbursement.o In approving a standing referral in-network or out-of-network, L.A.Care and PPGs delegated for UM will take into account the abilityof the member to travel to the provider.o Delegated entities can request assistance from L.A. Care forlocating a specialist (See Specialty Care Liaison ProgramProcedure).HIV/AIDS Referrals68

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALWhen authorizing a standing referral to a specialist for the purpose of thediagnosis or treatment of a condition requiring care by a physician with aspecialized knowledge of HIV medicine, L.A. Care and/or its delegatedentities shall refer the member to an HIV/AIDS specialist.• When authorizing a standing referral to a specialist for purposes ofhaving that specialist coordinate the member’s health care who isinfected with HIV, L.A. Care and/or its delegated entities shall refer themember to an HIV/AIDS specialist. The HIV/AIDS specialist mayutilize the services of a nurse practitioner or physician if:o the nurse practitioner or physician assistant is under thesupervision of an HIV/AIDS specialist; ando the nurse practitioner or physician meets the qualifications specifiedin the state regulations; ando the nurse practitioner or physician assistant and that provider’ssupervising HIV/AIDS specialist have the capacity to see anadditional patientCare Coordination:The PCP shall retain responsibility for basic casemanagement/coordination of care unless a specific arrangement ismade to transfer care to the specialist for a specified period of time,in accordance with the delegated entities contract with L.A. Care.Requests for standing referrals will be processed in accordance withthe state regulatory requirements.5.22 INITIAL and PERIODIC HEALTH ASSESSMENTS (IHA)MEDICARE – SNPDelegated providers shall have processes in place to ensure the provisionof an IHA (complete history and physical examination) to each newMedicare – SNP member (for members new to Medicare) within the firstsix months of the effective date of enrollment with Medicare. This is a onetime preventive physician exam. The one-time exam includes a throughreview of:• Health issues• Health education• Preventive servicesL.A. Care Health Plan shall provide lists of new member Enrollees to thedelegated PPGs/PCPs on a monthly basis. L.A. Care and its Delegatedproviders shall make reasonable attempts to contact a member andschedule an IHA. All attempts shall be documented.69

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Documented attempts that demonstrate unsuccessful efforts tocontact a member and schedule an IHA shall be consideredevidence in meeting this requirement.• For follow-up on missed and broken appointment documentationrequirements see Section: Coordination of Medically NecessaryServicesL.A. Care and its delegated PPGs are responsible for maintaining anddisseminating to its Provider Network, protocols and High Risk Categoriesby age groupings based on the latest edition of the Guide to ClinicalPreventive Services published by the U.S. Preventive Services TaskForce (USPSTF) and Center for Medicare and Medicaide Services (CMS)for use in determining the provision of clinical preventive services.Delegated providers shall ensure that the performance of the initialcomplete history and physician exam for adults includes, but is not limitedto:• blood pressure,• height and weight,• total serum cholesterol measurement for men ages 35 and overand women ages 45 and over,• clinical breast examination for women over 40;• screening mammogram for women age 40 and over, baselinemammograms for women between ages 35-39• Pap smear (or arrangements made for performance) on all womendetermined to be sexually active or be at high risk for vaginal orcervical cancer,• Chlamydia screen for all sexually active females aged 21 and olderwho are determined to be at high-risk for Chlamydia infection usingthe most current CDC guidelines. These guidelines include thescreening of all sexually active females aged 21 through 25 yearsof age,• all adolescent girls should get a series of 3 Human Papillomavirus(HPV) shots, preferably at age 11-12 years, to prevent cervicalcancer and genital warts. The vaccine is also recommended forgirls and women 13-26 years of age who did not receive it whenthey were younger.• screening for TB risk factors including a Mantoux skin test on allpersons determined to be at high risk, and,• Colon cancer screening for members over 50 years of age (fecaloccult blood test, flexible sigmoidoscopy, screening colonoscopy orbarium enema); there is no minimal age for a screeningcolonoscopy• Prostate Cancer Screening for men over 50 years• Bone Mass Measurements for members at risk for osteoporosis• Diabetes screening70

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Glaucoma screening for members at high risk for glaucomaMedicare Advantage-SNP members are eligible to receive via directaccess (self-referral) flu and pneumococcal vaccinations at no costto the member. Female Medicare Advantage-SNP members alsohave the option of obtaining direct access to a women’s healthspecialist for women’s routine and preventive health services.The IHA must include documentation that members are informed ofspecific health care needs that require follow-up and receive, asappropriate, training in self care and other measures that they may take topromote their own healthHigh risk individuals are defined as individuals whose family history and/orlife-style indicates a high tendency towards disease, or who belong to agroup (socioeconomic, cultural, or otherwise) which exhibits a highertendency toward a disease.Each provider, supplier and practitioner furnishing services to membersshall maintain an enrollee health record in accordance with standardsestablished by Medicare and L.A Care policy taking into accountprofessional standards. These standards should ensure the appropriateand confidential exchange of information among provider networkcomponents. .Adult Preventive ServicesDelegated Providers shall cover and ensure the delivery of all preventiveservices and medically necessary diagnostic and treatment services foradult members.Delegated Providers shall ensure that the latest edition of the Guide toClinical Preventive Services published by the U.S. Preventive ServicesTask Force (USPSTF) is used to determine the provision of clinicalpreventive services to asymptomatic, health adult Members {age twentyone(21) and older}.As a result of the IHA or other examination, discovery of the presence ofrisk factors or disease conditions will determine the need for further followup,diagnostic, and/or treatment services.In the absence of the need for immediate follow-up, the core preventiveservices identified in the requirements for the IHA for adults describedabove shall b provided in the frequency required by the USPSTF Guide toClinical Preventive Services.71

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALDelegated Providers shall cover and ensure the provision of all medicallynecessary diagnostic, treatment, and follow-up services which arenecessary given the finding or risk factors identified in the IHA or duringvisits for routine, urgent, or emergent health care situations. DelegatedProviders shall ensure that these services are initiated as soon aspossible but no later than 60 days following discovery of a problemrequiring follow upImmunizations for AdultsDelegated Providers are responsible for ensuring all adults are fullyimmunized and shall cover and ensure the timely provision of vaccines inaccordance with the most current California Adult Immunizationrecommendations.In addition, Delegated providers shall cover and ensure the provision ofage and risk appropriate immunizations in accordance with the finding ofthe IHA, other preventive screenings and/or the presence of risk factorsidentified in the health education behavioral assessment.5.23 COMPREHENSIVE HEALTH RISK ASSESSMENTMedicare Advantage-SNP: Comprehensive Health Risk AssessmentsWithin ninety days (90) of enrollment, L.A. Care will make a good faitheffort to conduct perform a telephonic comprehensive health riskassessment for newly enrolled members. The assessment provides anearly identification of health care services needs to provide coordination ofplan services that integrate services through arrangements withcommunity and social services programs generally available throughcontracting or non-contracted providers, including nursing home andcommunity-based services.This information will be shared with the assigned PPG and PCP for thepurpose of providing continuity of care and services.L.A. Care conducts a comprehensive initial health risk assessment(CIHRA) by telephone or by a written survey with new members as soonas possible (and no later than 90 days) after confirmation of enrollment towelcome the member. NOTE: This is not inclusive of the initial healthassessments (IHA) performed by the PCP. L.A. Care does notdelegate the performance of comprehensive health risk assessment to thecontracted PPGs.72

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALThe purpose is to identify any potential medical needs, and assist withtransition and coordination of care. Typical medical needs identified mayinclude but are not limited to the following:• Risk of future hospitalization• Chronic, complex, or serious conditions that may require CaseManagement intervention,• Durable medical equipment in the home (or needed in thehome),• Confined to a skilled nursing facility (SNF), or• Any condition or education needs that may require interventionof the multidisciplinary team.In addition the self-reported assessment includes:• Living situation• Social needs• Special health care needs/chronic conditions• Previous health services utilization• Medication profileBased on findings from the assessment, a health risk assessment profilereport is developed. This includes the following categories:HIGH RISK: These members have been determined to havegreater than a 50% chance of being hospitalized within the next 12months.MODERATE RISK: These members are deemed to have a“Moderate Risk” patient due to high frailty score, had an inpatientstay, diabetes, treated for health problems, taking medication forheart problem, or no one to care for them for few days within thepast 12 months.LOW RISK: These members have low risk factor(s) based onanswers to the assessment questionnaire.A Care Manager will review the CHRA database on a daily basis.Members may be contacted by a care manager to review the responses toidentify any specific health care needs that require follow-up and receive,as appropriate, training in self-care; identify other measures they mayneed to promote their health status and identify systems to addressbarriers to compliance with prescribed treatments or regimes.73

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALA member specific CHRA summary is sent to the: Primary Care Provider(PCP), Participating Physician Group (PPG) and the contracted complexcare management vendor.Primary Care Physicians (PCPs) are expected to contact the assignedmember to schedule an appointment as follows:• High Risk within 7 days• Medium Risk within 30 days• Low Risk within 45 days; for new members no later than120 calendar days from enrollmentPPGs are expected to coordinate requested services from the PCP orspecialist.Based upon the CHRA score, members are assigned to L.A.Care’sappropriate care management program.5.24 COORDINATION OF MEDICALLY NECESSARY SERVICESThe PCP is responsible for providing members with routine medical careand serve as the medical case manager within each managed caresystem. Referrals are made when services are medically necessary,outside the PCP’s scope of practice, or when members are unresponsiveto treatments, develop complications, or specialty services are needed.The PCP is responsible for making referrals and coordinating all medicallynecessary services required by the member. Pertinent summaries of themember’s record should be transferred to the specialist by the PCP.Authorization flow charts are provided at the end of this section.Outpatient ReferralIf the PCP determines that a member requires specialty services orexaminations outside of the standard primary care, the provider mustrequest for these services to be performed by appropriate contractedproviders. The provider must ensure the following steps in coordinatingsuch referrals:1. Submit a referral request to the PPG or the designated hospitalphysician to obtain authorization for those services.2. The PPG will process the request, or contact the L.A. Care UMdepartment to obtain authorization for the facility component ofservices needed, as appropriate.74

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL3. After obtaining the authorization(s), PCP will refer the member to theappropriate specialist or facility. The PCP, office staff, or member mayarrange the referral appointment.• Note the referral in the member’s medical record and attach anyauthorization paperwork.• Discuss the case with the member and the referral provider.• Receive reports and feedback from the referral provider regardingthe consultation and treatment. (A written report must be sent to thePCP by the referral provider, or facility the member was referredto.)• Discuss the results of the referral and any plan for furthertreatment, if needed, and care coordination with the member.Specialty referrals that require prior authorization must be trackedby the PCP’s office and authorizing PPG for follow-up through atickler file, log or computerized tracking system. The log or trackingmechanism should note, at a minimum, the following for eachreferral:• Member name and identification number• Diagnosis• Date of authorization request• Date of authorization• Date of appointment• Date consult report receivedMissed or Broken AppointmentsAppointments may be missed due to member cancellation or no show.Providers are required to attempt to contact the member a minimum ofthree times when an appointment is missed or broken. Attempts tocontact must include:• First Attempt – phone call to member (or written letterif no telephone). If member does not respond, then;• Second Attempt – phone call to member (or written letter if notelephone). If member does not respond then;• Third Attempt – written letterPregnant member with two or more missed/broken appointments must bereferred to the L.A. Care UM Care Manager for follow-up after the brokenappointment procedure is completed without response from the members.75

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALDocumentation must be noted in the member’s medical record regardingany missed or broken appointments, reschedule dates, and attempts tocontact.Missed and Broken Procedure or Laboratory TestAppointments for procedures or tests may be missed or broken.The provider must contact the member by phone or letter toreschedule. Documentation must be noted in the medical recordregarding any missed or broken procedure or tests, rescheduledates, and any attempts to contact the member.Receipt of Specialist’s ReportThe PCP must ensure timely receipt of the specialist’s report (e.g.,use of tickler file). Specialists are required to submit a writtenreport to the referring physician. This written report must includethe specialist’s findings, recommended treatment, results of anystudies, test and procedures and recommendations for continuedcare.Reports for specialty consultations or procedures should be in themember’s chart within a given timeframe, usually two (2) weeks.For urgent and emergent cases, the specialist should initiate atelephone report to the PCP as soon as possible, and a writtenreport should be received within two (2) weeks.If the PCP has not received the specialist’s report within thedetermined timeframe, the PCP should contact the specialist toobtain the report.Unusual Specialty ServicesL.A. Care and its delegated PPGs/PCP must arrange for theprovision of seldom used or unusual specialty services fromspecialists outside the network if unavailable within network, whendetermined Medically Necessary.Services Received in an Alternative Care SettingThe PCP should receive a report with findings, recommendedtreatment and results of the treatment for services performedoutside of the PCPs office. The provider must also receiveemergency department reports and hospital discharge summariesand other information documenting services provided.Home health care agencies submit treatment plans to the PCP afteran authorized evaluation visit and every 30 days afterward forreview of continued home care and authorization.76

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALThe PCP should also receive reports regarding diagnostic orimaging services with abnormal findings or evaluations andsubsequent action.5.25 TRANSITIONSL.A. Care Medical Management Department manages the process of caretransitions and makes a special effort to coordinate care when membersmove from one care setting to another, such as when they are dischargedfrom a hospital.Transitions are the movement of a member from one care setting toanother as the member’s health status changes; for example, moving fromhome to a hospital as the result of exacerbation of a chronic condition ormoving from a hospital to a rehab facility after surgery.Managing Transitions: L.A.Care’s Care Managers facilitate safetransitions by either conducting or assigning providers the following tasksand monitoring of system performance:• For planned transitions from members’ usual setting of care to thehospital and transitions from the hospital to the next setting, identifyingthat a planned transition is going to happen• For planned and unplanned transitions from members’ usual setting ofcare to the hospital and transitions from the hospital to the next setting,sharing the sending setting’s care plan with the receiving setting withinone business day of notification of the transition• For planned and unplanned transitions from any setting to any othersetting, communicating with the member or responsible party about thecare transition process• For planned and unplanned transitions from any setting to any othersetting, communicating with the member or responsible party aboutchanges to the member’s health status and plan of care• For planned and unplanned transitions from any setting to any othersetting, providing each member who experiences a transition with aconsistent person or unit within L.A. Care’s Medical Managementdepartment who is responsible for supporting the member throughtransitions between any points in the system77

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• For planned and unplanned transitions from any setting to any othersetting, notifying the patient’s usual practitioner of the transition• For all transitions, L.A. Care Medical Management Department shallconduct an analysis of L.A. Care’s aggregate performance on theabove aspects of managing transitions at least annuallyCoordinating Services for members at high risk for transition.L.A. Care handles coordination of care through either the case management orUM staff. L.A. Care works with members (or their responsible parties) and withtheir primary care physicians or providers to stabilize the member’s conditionsand to manage care in the least restrictive setting. Examples of coordinating careinclude:• Contacting at risk member or responsible party, determining whether homehealth care would prevent a hospital admission and ordering the service asnecessary.• Contacting the member’s treating physician to alert him/her about thepotential for adverse drug events based on pharmacy claims review.• Intervening to help member receive the necessary monitoring for bloodthinningmedications as an example.Educating members or responsible parties about transitions and how toprevent unplanned transitions:As part of the identifying and coordinating care to prevent potential problems,L.A.Care’s UM/Case Management staff educates at risk members orresponsible parties about how to maintain health and remain in the leastrestrictive setting. L.A. Care contacts all SNP members at least annuallyregardless of whether or not they are at risk, with information about potentialproblems and how to avoid them.5.26 CERVICAL CANCER SCREENINGL.A. Care and/or its delegated providers shall have procedures to providefor Cervical Cancer Screening, a covered preventive health benefit for L.A.Care Health Plan members.The coverage for an annual Cervical Cancer Screening test shall includethe conventional Pap test, a human papillomavirus (HPV) screening testthat is approved by the Federal Food and Drug Administration, and theoption of any Cervical Cancer Screening test approved by the federalFood and Drug Administration, upon the referral of the member’s healthcare provider (PCP or treating physician, a nurse, practitioner, or certifiednurse midwife, providing care to the member and operating within thescope of practice otherwise permitted for the licensee).\78

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL.A. Care and/or its delegated entities shall ensure that routine referralprocesses are followed when the member, in addition to the conventionalPap test, requests a human papillomavirus (HPV) screening test that isapproved by the federal Food and Drug Administration, and the option ofany Cervical Cancer Screening test approved by the federal Food andDrug Administration.5.27 CARE MANAGEMENTL.A. Care does not delegate complex case management to the PPGs.Case Management means a collaborative process of managing theprovision of health care to enrollees with selected conditions, (e.g.,chronic, catastrophic, high cost cases, etc.). The goal is to coordinate thecare to promote both quality and continuity of care.Case management is divided into three components:• Basic medical case management,• Complex Care Management• Targeted Case ManagementIn day-to-day operations, these three components work closely together toprovide members with continuous, coordinated, quality healthcare. L.A.Care Health Plan recognizes the importance of continuous andcoordinated health care as a key element to achieving high quality, costeffective care.Basic Medical Case Management Services means services provided bya Primary Care Provider to ensure the coordination of MedicallyNecessary health care services, the provision of preventive services inaccordance with established standards and periodicity schedules and thecontinuity of care for L.A. Care enrollees. It includes health riskassessment, treatment planning, coordination, referral, follow-up, andmonitoring of appropriate services and resources required to meet anindividual's health care needs.The Primary Care Physician (PCP) has the principal role as the basicMedical Case Manager for his/her assigned members. The PCP conductsthe Initial Health Assessment, provides all basic medical care/casemanagement to assigned members, and coordinates referrals tospecialists, ancillary services and linked services as needed.79

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL.A. Care Health Plan also recognizes that some members have complexneeds that require more than usual coordination of services and thereforeprovides the targeted or complex nursing case management in assistanceto the PCP.L.A. Care’s Care Management Program includes four levels:• Basic Care Management• Complex Care Management• Targeted Care Management• Care CoordinationBasic Care ManagementThe Primary Care Physician (PCP) is responsible for Basic Care Managementfor his/her assigned members. The PCP is responsible for ensuring thatmembers receive an initial screening and health assessment, which initiatesBasic Medical Care ManagementThe PCP conducts the initial health assessment upon enrollment, and throughperiodic assessments provides age-appropriate periodic preventive health careaccording to established preventive care guidelines. The PCP also makesreferrals to specialists, ancillary services, and linked and carved out services asneeded based on the member's individual treatment plan.For members with more complex Care Management needs, L.A. Care providescomplex care management services to assist the PCP. When the PCP hasassistance from a Care Manager for Complex and/or Targeted CareManagement, the PCP continues to play the central role in the management ofthe member’s care.Complex Care ManagementComplex Care Management is provided for members with extensive utilization ofmedical services or those having chronic or immediate medical needs requiringmore management than is normally provided through the Basic CareManagement. Complex Care Management is a collaborative process betweenthe Primary Care Provider and a RN Care Manager who provides assistance inplanning, coordinating, and monitoring options and services to meet theMember’s health care needs.The program incorporates the dynamic processes of individualized screening,assessment, problem identification, care planning, intervention, monitoring andevaluation. The Care Management Program uses an interdisciplinarycollaborative team approach comprised of patient care management andeducation through experienced licensed professionals in collaboration with thePrimary Care Physician and community and state specific resources. The teamconsists of Medical Directors, Registered Nurse Care Managers, Nurse80

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALPractitioners, Clinical Pharmacists, social workers and non-clinical support staffCoordinators.The team works closely with contracted practitioners and agencies in theidentification, assessment and implementation of appropriate health caremanagement interventions for eligible children and adults with special health careneeds, including the provision of care coordination for specialty and state waiverprograms.L.A. Care’s Care Management team is responsible for working collaborativelywith all members of the health care team including the PCP, hospital dischargeplanners, specialty practitioners, ancillary practitioners, community and stateresource staff. The Care Managers, in concert with the health care team, focuson coordinating care and services for members whose needs include preventiveservices, ongoing medical care, rehabilitation services, home health and hospicecare, and/or require extensive coordination of services related to linked andcarved out services or the coordination and/or transfer of care when “carved-out”services are denied.Care Managers assist in assessing, coordinating, monitoring, and evaluating theoptions and services available to meet the individual needs of these membersacross the continuum. The essential functions of the Care Manager include:• Assessment• Care Planning• Interventions• Coordination and Implementation• Monitoring/Evaluation• Facilitation• AdvocacyThrough interaction with members, significant others and health care providers,the care manager collects and analyzes data about the actual and potential careneeds for the purpose of developing individualized care plans.Targeted Care ManagementTargeted Care Management (TCM) assists Members within specific targetgroups to gain access to needed medical, social, educational and other services.In prescribed circumstances, Targeted Care Management is available as acarve-out Medi-Cal benefit through State of California, Los Angeles CountyPublic Health Department and their contractors as specified in Title 22, Section51351. The Care Managers are responsible for identifying members that may be81

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALeligible for TCM services and must refer members as appropriate for theprovision of TCM services. TCM services are integrated into the overall careplan, as a barometer for measuring disease progression and cost of care. Stateand county TCM services may include, but is not limited to, Pediatric and adultpartial hospitalization programs (i.e. adult day health care centers, pediatric daycare centers, MSSP, AIDS Wavier Programs, community based in-homeoperation services)L.A. Care is responsible for co-management of the member’s health care needswith the TCM providers, providing preventive health services and for determiningthe medical necessity of diagnostic and treatment services. The TCM serviceswill serve to supplement care where needed to keep the member safe theircommunity based setting.Care CoordinationL.A. Care’s Care Management Program is a member advocacy programdesigned and administered to assure that the member’s healthcare services arecoordinated with a focus on continuity, quality and efficiency in order to produceoptimal outcomes.Care coordination by Care Managers or designated staff (i.e. UM Specialist,Care Coordinators) is provided for member’s needing assistance incoordinating their health care services. This service includes memberswho may have opted out of complex care management but have continuingcoordination of health care needs.These include, but are not limited to, members assigned to or receiving:• Out of Area/Network services• Hospital discharge follow up calls• Non-emergency medical transportationIdentifying Members for Care ManagementAlthough all members are actively enrolled into the care management program,the program also uses multiple data sources to identify members that are eligiblefor the program but no yet referred.These include, but are not limited to, the following:• Claims and Encounter Data• Pharmacy Data• Laboratory Data, when available82

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Behavioral Health Joint Operations Report• PPG Supplemental Reportso Catastrophic Medical Condition (e.g. Genetic conditions, Neoplasms,organ/tissue transplants, multiple trauma)o Chronic Illness (e.g. Asthma, Diabetes, Chronic Kidney Disease,HIV/AIDS)• Hospital Utilizationo Hospital discharge datao Hospital Length of Stay (LOS) exceeding 10 dayso Readmission Reportso Skilled Nursing facility (SNF), rehabilitation admissionso Acute Rehabilitation admissions• Ambulatory Care Utilization Reportso Emergency Room utilizationo Nurse Advice Line Reports/ER Referrals• Referral Management Reportso Precertification Datao Prior Authorization Datao High-technology home care requiring greater than two weeks duration ofhome careo Long Term Care referrals and monitoring logso Non-adherence with treatment planAccess to Care ManagementOn a monthly basis, Medicare Operations distributes a list of all newlyenrolled members to the SNP program to the Utilization ManagementDepartment. Members are assigned to a care management team to initiatethe program activities.In addition to the monthly enrollment list, members may be referred to caremanagement in several ways:• Physicians and Other Practitioners• PPG Medical Directors• L.A. Care Health Plan Medical Directors• Internal L.A. Care Staff (including UM Staff)• External Service Partners• Disease Management/Health Education Staff• Nurse Advice/Health Information Line• Hospital Discharge Planners/Case Managers• Member self referral• Family/Caregiver referral83

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCare Management SystemL.A. Care utilizes a care management system that is developed using analgorithmic logic scripts. The script was developed using evidence basedguidelines and is supported by prompts to guide care managers through theassessment on ongoing management of members. The care managementsystem has automated features that provide accurate documentation for eachentry; recording actions or interactions with members, practitioner or providers;and automatically date, time and user stamp entries. The system also hasautomatic prompts for follow up care.Program ActivitiesMembers are contacted telephonically to review the program elements andassess the member’s level of interest in program participation. The programelements include:• Welcome Packet and gift, includes toll free contact information for the caremanager• Periodic telephone contacts by a member of the care management team• Screening and assessments• Educational material, as the need is identified• Supportive care coordinationThe care management program is based on active participation. The membermay opt out of care management services at any time during the process. Caremanagers are responsible for fully explaining the program and the benefits of theprogram to assure that the member is making an informed decision. If themember opts out of care management, he/she is offered the opportunity to beenrolled again at any time.The initial comprehensive health risk assessments are conducted within the first90 days of enrollments and annual reassessments within 12 months of the lastrisk assessment. As special needs members may have labile health status andneed more frequent assessments; consequently, annual reassessment will beadjusted to coincide with health status changes.The health risk assessment is a standardized screening tool administered by anon-clinical staff member. Members are screened to prioritize a furtherassessment by the Care Manager. The tool includes a review of care. The tool isautomatically scored and a risk assessment profile is generated based on theresponses. Members are stratified for intervention using the risk assessment84

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALscore as defined below in Health Risk Assessment Scores – Health RiskAssessmentHEALTH RISK ASSESSMENT PROFILE SCORESHealth Risk Assessment• Risk Score • Risk• InterventionProfile• High • = or >80 • Referral tocare managerwithin 3business days• Moderate • 41 - 79 • Referral tocare managerwith 7business days• Low • = or

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALACUITY LEVELSACUITY LEVELSINTENSITY IINTENSITY 2INTENSITY 3INTENSITY 4INTENSITY 5DEFINITIONContacts > 1X per dayContacts >/=3X per week but not toexceed daily (i.e. 3-5 X/week)Contacts >/=weekly but not to exceed3X/week (i.e., 1-3X/week)Contacts >/= 2 X/month but not toexceed weekly (i.e., 2-4 X/month)Intensity level 4 X 2 months. (i.e.transplants awaiting organs, follow-upon established compliance to CarePlan)Hospice Care Services• Hospice for Medicare-SNP Hospice Care Services are available through theMedicare program. Members and providers may directly contact a federallyqualified hospice provider for assistance.If you require assistance in locating a hospice provider, you may contact theUM Department at (877) 431-2273.• Hospice for Medi-Cal MembersMembers and their families shall be fully informed of the availability ofhospice care as a covered service and the methods by which they may electto receive these services. For individuals who have elected hospice care,continuity of medical care shall be arranged, including maintainingestablished patient-provider relationships, to the greatest extent possible.L.A. Care and the delegated PPGs shall cover the cost of all hospice careprovided as defined by the DOFR. PPGs are also responsible for all medicalcare not related to the terminal conditions.Admission to a nursing facility of a member who has elected hospice servicesas described in Title 22, CCR, Section 51349, does not affect the member'seligibility for enrollment.86

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Hospice services are covered services and are not long term careservices regardless of the member's expected or actual length of stay in anursing facility.Members with a terminal condition covered by CCS must be clearly informed thatelection of hospice will terminate the child's eligibility for CCS services.PCP responsibilities:• Member is assessed by his physician (generally his PCP/HospicePhysician) as having terminal medical condition resulting in a lifeexpectancy of six (6) months or less.• Hospice services are fully explained to the member by his PCP.• Arrange for continuity of medical care, including maintaining establishedpatient-provider relationships, to the greatest extent possible.PPG Responsibilities:• Ensure contracted PPGs are educated on end-of life care and referralprocedures to a qualified hospice programMember requests or is offered hospice election for palliative and comfort leveltreatment in lieu of normal Medi-Cal coverage for services related to the terminalillness.Hospice Levels of Care:• Routine Home Care - Routine home care shall be covered for each daythe recipient is at home and is not receiving continuous care.• Continuous Home Care - Continuous home care shall be covered onlyduring periods of crisis when skilled nursing care is necessary on acontinuous basis to achieve palliation or management of the patient's painor symptoms in order to maintain the recipient in his/her residence.Continuous care may include homemaker and/or home health aideservices but must be predominantly nursing in nature.• Respite Care - shall be covered only when provided in an inpatientfacility, on an occasional, intermittent and non-routine basis and only whennecessary to relieve family members or other persons caring for theterminally ill individual.• General inpatient care shall be covered only when the patient requiresand receives general inpatient care in an inpatient facility for pain controlor chronic symptom management which cannot be managed in thepatient's residence.• Of the four levels of care described in subsection (a) above, onlygeneral inpatient care is subject to prior authorization. Authorizationfor general inpatient care shall be granted only when all applicablerequirements, as set forth in the Criteria for Authorization of Hospice Care87

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALsection of the Department's Manual of Criteria for Medi-Cal Authorization,are met. Refer to UM Procedure 5003.9 UM Referral ManagementTimeframes for the DHS required In-Patient Hospice Referral timeframe.Voluntary Statement of Election of Hospice Services: The patient orhis lawfully designated representative voluntarily files a statement ofelection with a Medicare and Medicaid-certified hospice provideracknowledging the request for palliative services only as it relates to theterminal illness and a waiver of regular medical coverage.The election statement must contain the following:o Identification of the hospice providero The individual's or representative's acknowledgement that:o He or she has full understanding that the hospice care given as itrelates to the individual's terminal illness will be palliative ratherthan curative in nature.o Certain Medi-Cal benefits as specified in subsection (f) are waivedby the election.o The effective date of the election.o Signature of the individual or representative.Elections may be made for up to two periods of 90 days each, onesubsequent period of 30 days, and one 180-day extension of the30-day period. Hospice services shall not be covered beyond 390days.An election period shall be considered to continue through the initialelection period and through subsequent election periods as long asthe hospice provider agrees to renew the election and as long asthe individual:o Remains in the care of the hospice; ando Does not revoke the electionRevocation or Modification of a Voluntary Statement of Election ofHospice: An individual's voluntary election may be revoked or modified atany time. To revoke the election of hospice care, the individual orrepresentative must file a statement with the hospice that includes thefollowing information:o A signed statement that the individual or representative revokes theindividual election for Medi-Cal coverage for the remainder of theelection period.o The effective date, which may not be earlier than the date therevocation is made.o Revocation shall constitute a waiver of the right to hospice careduring the remainder of the current 90 or 30-day election periodplus any extension.88

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALo An individual may, at any time after revocation, execute a newelection for any remaining entitled election period.o An individual may, once in each election period, elect to receiveservices through a hospice program different from the hospice withwhich the election was made. Such change shall not be considereda revocation pursuant to subparagraph (A). Such change shall bemade in accordance with the procedure specified in 42 Code ofFederal Regulations, Part 418, Subpart Bo An individual who voluntarily elects hospice care under subsection(c) shall waive the right to payment on his or her behalf for all Medi-Cal services related to the terminal condition for which hospice carewas elected, except for:• A signed statement that the individual or representativerevokes the individual election for Medi-Cal coverage for theremainder of the election period.• The effective date, which may not be earlier than the datethe revocation is made.• Revocation shall constitute a waiver of the right to hospicecare during the remainder of the current 90 or 30-dayelection period plus any extension.• An individual may at any time after revocation execute a newelection for any remaining entitled election period.• An individual may once in each election period elect toreceive services through a hospice program different fromthe hospice with which the election was made. Such changeshall not be considered a revocation pursuant tosubparagraph (A). Such change shall be made inaccordance with the procedure specified in 42 Code ofFederal Regulations, Part 418, Subpart B.• An individual who voluntarily elects hospice care undersubsection (c) shall waive the right to payment on his or herbehalf for all Medi-Cal services related to the terminalcondition for which hospice care was elected, except for:• Services provided by the designated hospice• Services provided by another hospice througharrangement made by the designated hospice.• Services provided by the individual's attendingphysician if that physician is not employed by thedesignated hospice or receiving compensation fromthe hospice for those services• A plan of care shall be established by the hospice foreach individual before services are provided. Servicesmust be consistent with the plan of care. The plan ofcare shall conform to the standards specified in 42Code of Federal Regulations, Part 418, Subpart C89

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• The following services, when reasonable andnecessary for the palliation or management of aterminal illness and related conditions are coveredwhen provided by qualified personnel:• Physician services when provided by any Medi-Calenrolled physician except that the services of thehospice medical director or the physician member ofthe interdisciplinary group, as required under 42 Codeof Federal Regulations, Part 418, Subpart C shall beperformed by a doctor of medicine or osteopathy.• Medical social services when provided by a socialworker with at least a Bachelor's degree in socialwork, from a school approved or accredited by thecouncil on Social Work Education, under the directionof a physician.• Counseling services when provided to the terminallyill individual and the family member or other personscaring for the individual at home. Counseling shall, asappropriate, be provided for the purpose of trainingthe individual's family or other caregiver to providecare and to help the individual and those caring forhim or her to adjust to the individual's approachingdeath and to cope with feelings of grief and loss.• Short-term inpatient care when provided in a hospiceinpatient unit or in a hospital or a skilled nursingfacility/Level B, that meets the standards specified in42 Code of Federal Regulations, Part 418, Subpart Eregarding staffing and patient areas.• Drugs and Biologicals when used primarily for therelief of pain and symptom control related to theindividual's terminal illness.• Medical supplies and appliances• Home health aide services and homemaker serviceswhen provided under the general supervision of aregistered nurse. Services may include personal careservices and such household services as may benecessary to maintain a safe and sanitaryenvironment in the areas of the home used by thepatient.• Physical therapy, occupational therapy and speechlanguagepathology when provided for the purpose ofsymptom control, or to enable the patient to maintainactivities of daily living and basic functional skills.90

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMEDI-CALAdmissions while in a nursing facilityAdmission to a nursing facility of a member who has elected hospiceservices as described in Title 22, CCR, Section 51349, does not affect themember's eligibility for enrollment under this Contract. Hospice servicesare Medi-Cal covered services and are not long term care servicesregardless of the member's expected or actual length of stay in a nursingfacility.Members with a terminal condition covered by CCSMembers with a terminal condition covered by CCS must be clearlyinformed that election of hospice will terminate the child's eligibility forCCS servicesHospice for Medicare Advantage-SNP MembersHospice is a Medicare covered benefit, although it is carved out of the setof benefits that can be covered by Medicare managed care plans and paidfor by Medicare fee-for-service. As a result, L.A. Care’s MedicareAdvantage-SNP plan does not cover hospice services. Claims for hospiceservices provided to L.A. Care’s Medicare Advantage SNP membersshould be submitted to the appropriate Medicare fee-for-service fiscalintermediary.TRANSPLANTSMedicare Advantage-SNP –Transplants are a covered benefit under the MA-SNP plan. The PCP anddelegated PPGs are responsible for facilitating transplant evaluationsarrangements with the Medicare Centers of Excellence or Medicareapproved transplant centers. Members referred for potential transplantsare eligible for care coordination assistance through the L.A. Care CareManagement Program (See Section: Care Management)Referrals for the facility component must be coordinated with the L.A.Care UM Department. For a copy of the L.A. Care policy for Major OrganTransplants or a listing of the Medicare transplant centers, please contactthe L.A. Care UM Department at (877) 431-2273Medi-Cal –Transplants are a covered benefit through the MediCal Fee-For-Serviceprogram. For additional information on assisting members coordinate thetransplant benefits, see Section: Care Coordination - Excluded Services91

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALRequiring Member Disenrollment/Transplants or you may contact the L.A.Care UM Department.5.28 DISEASE MANAGEMENT/CHRONIC CARE IMPROVEMENTL.A. Care does not delegate disease management to the PPGs/PCPs.The Centers for Medicare and Medicaid Services defines diseasemanagement as a “system of coordinated health care interventions andcommunication for populations with conditions in which patient self-care issubstantial”. Disease Management supports the provider-patientrelationship and treatment plan while emphasizing prevention and selfmanagement.L.A. Care offers a variety of disease management programs which focuson the development, implementation and evaluation of a system ofcoordinated health care interventions and communication for memberswith chronic conditions and individuals that care for them. Using a multidisciplinaryapproach, members are identified, stratified, assessed andcare plans are developed to assist members and their families withnavigating the managed care system and managing their chronicconditions. Programs may include:• Self-management support• Education and materials• Community referrals• Care coordinationProviders or members may contact L.A. Care Quality ManagementDepartment to inquire about the available programs.5.29 MENTAL HEALTH AND SPECIALTY MENTAL HEALTH SERVICESMEDICARE ADVANTANGE - SNP:• Mental health benefits are as defined in the CMS benefitsection.• L.A. Care Health Plan will ensure contracted PPG network PPGsand Primary Care Physicians (PCP) provide basic outpatientmental health services, within the scope of the PCP’s practice andtraining, and shall ensure appropriate referral of members to and92

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALcoordination of care with LAC for assessment and treatment ofmental health conditions, outside the scope of their practice andtraining.• All inpatient and outpatient mental health services are theresponsibility of L.A. Care and managed by Optum HealthSolutions.• Members and providers may directly refer to the contractedbehavioral health provider by calling Optum Health Solutions at(866) 908-0677.MEDI-CAL:• All inpatient mental health and outpatient specialty mental healthservices are carved out of and excluded from L.A. Care HealthPlan’s responsibilities under the Medi-Cal contract with DHS, andwill be provided by the L.A. County Department of Mental Health(LAC/DMH) in accordance with the current Memorandum ofUnderstanding (MOU) between L.A. Care Health Plan andLAC/DMH.• L.A. Care Health Plan will ensure contracted PPG network PPGsand Primary Care Physicians (PCP) provide basic outpatientmental health services, within the scope of the PCP’s practice andtraining, and shall ensure appropriate referral of members to andcoordination of care with LAC/DMH for assessment and treatmentof mental health conditions, outside the scope of their practice andtraining.• L.A. Care Health Plan’s UM Liaison will act as a resource to thePPGs/PCP’s to ensure understanding of the referral process and todefine services that are part of the PPGs’ and PCPs’ responsibility.• The resolution of disputes is a shared responsibility between L.A.Care and LAC/DMH and will be processed as defined in the fullyexecuted Memorandum of Understanding, L.A. Care policies andthe established state laws and regulations.5.30 ALCOHOL & DRUG TREATMENT PROGRAMSMEDICARE ADVANTANGE - SNP:93

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Substance abuse benefits are as defined in the CMS benefitsection.• Members and providers may directly refer to the contractedbehavioral health provider by calling Optum Health Solutions at(866) 908-0677MEDI-CAL5.30.1 Inpatient Detoxification5.30.1.1 L.A. Care will ensure appropriate medical inpatientdetoxification is provided under the followingcircumstances:5.30.1.2 Life threatening withdrawal from sedatives, barbiturates,hypnotics or medically complicated alcohol and otherdrug withdrawal.5.30.1.3 Inpatient detoxification is covered in the rare cases whereit is medically necessary to monitor the member for lifethreatening complications; two or more of the followingmust be present, tachycardia, hypertension, diaphoresis,significant increase or decrease in psychomotor activity,tremor, significant disturbed sleep pattern, nausea andvomiting, threatened delirium tremens.5.30.1.4 When the member is medically stabilized, the PCP/L.A.Care shall provide a referral and follow-up to aSubstance Abuse Treatment Program.5.30.2 Outpatient5.30.2.1 L.A. Care will maintain processes to ensure that Alcoholand Drug Abuse Treatment Services be available tomembers and are provided as a linked and carved outbenefit through the Office of Alcohol and Drug Programsof L.A. County.5.30.2.2 The following services are provided by the Alcohol andDrug Programs of L.A. County:• Outpatient Methadone Maintenance• Outpatient Drug Free Treatment Services• Perinatal Residential Services• Day Care Habilitative Services• Naltrexone Treatment Services (Opiate Addiction)• Outpatient Heroin Detoxification Services94

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL5.30.2.3 L.A. Care and its contracted PPGs will ensure PrimaryCare Physician (PCP) screening of L.A. Care Health Planmembers for substance abuse during the Initial HealthAssessment and in all subsequent visits as appropriate.When substance use is recognized as a potentialcondition, PCPs will refer to a treatment facility servingthe geographic area. Referral is done by using thesubstance abuse referral form or by referral to theCommunity Assessment Services Center toll free number(800) 564-6600.5.30.2.4 Members can access substance abuse treatmentservices by self-referral, by a family referral or referralfrom the PCP or other appropriate provider.5.30.2.5 During treatment for substance abuse, all medicalservices will continue to be provided by the PCP or otherappropriate medical provider. The PCP will makerelevant medical records available to the SubstanceAbuse Treatment Program with appropriate consent andrelease of medical record information following Federaland State guidelines.5.31 DENTAL SERVICESMEDICARE ADVANTAGE – SNP• Preventive dental care is not a covered service through L.A. Care’sMedicare Advantage-SNP Program. Medicare Advantage-SNPmembers have professional dental services covered thorugh Medi-Cal’s Denti-Cal program (please see description below). However,L.A. Care’s Medicare Advantage SNP plan covers anesthesiaservices and related medical services provided to a member in adental office, inpatient or outpatient facility, or an ambulatorysurgical center. Such services must support a dental surgery ordental procedure, provided that such anesthesia services andrelated medical services meet plan coverage and medical necessityrequirements.MEDI-CALDental Care Treatment Services are a carved out benefit to Medi-Calmembers through the Medi-Cal Denti-Cal Program. L.A. Care and itsdelegated PPGs are responsible for Dental Screening and Referral of95

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMembers to the Carved out Medi-Cal Denti-Cal Program for DentalTreatment when treatment needs are identified.Primary Care Providers should perform dental screenings as part of theIHA, periodic, and other preventive health care visits and provide referralsto Medi-Cal Denti-Cal Program for treatment in accordance with the mostcurrent:• CHDP/American Academy of Pediatrics (AAP) guidelines forMember age 21 and younger.• Guide to Clinical Preventive Services published by the U.S.Preventive Services Task Force (USPSTF) for adult members{age twenty-one (21) and older}.Dental Screening Requirements:L.A. Care recommends dental screening for all members is included aspart of the initial and periodic health assessments:For members under twenty-one (21) years of age, a dental screening/oralhealth assessment shall be performed as part of every periodicassessment, with annual dental referrals made commencing at age three(3) years or earlier if conditions warrant.Covered Medical Services not provided by Dentist or Dental Anesthetists:L.A. Care and its delegated PPGs shall cover and ensure the provision ofcovered medical services that are not provided by dentists or dentalanesthetists. Covered medical services include:• Contractually covered prescription drugs• Laboratory service• Pre-admission physical examinations required for admissionto an out-patient surgical service center or an in-patienthospitalization required for a dental procedure (includingfacility fee and anesthesia services for both inpatient andoutpatient services).Financial Responsibility for General Anesthesia and AssociatedFacility Charges:L.A. Care and its delegated PPGs are responsible to cover generalanesthesia and associated facility charges for dental procedures renderedin a hospital or surgery center setting, when the clinical status orunderlying medical condition of the patient requires dental procedures thatordinarily would not require general anesthesia to be rendered in ahospital or surgery center setting (as defined by the Division of FinancialResponsibility - DOFR). A prior authorization of general anesthesia andassociated charges required for dental care procedures is required in thesame manner that prior authorization is required for other covereddiseases or conditions.96

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALGeneral anesthesia and associated facility charges are covered for onlythe following member, and only if the members meet the criteria asfollows:• Members who are under seven years of age.• Members who are developmentally disabled, regardless ofage.• Members whose health is compromised and for whomgeneral anesthesia is medically necessary, regardless ofage.The professional fee of the dentist and any charges of the dentalprocedures itself is not covered. Coverage for anesthesia andassociated facility charges may be covered and are subject to the termsand conditions of the plan benefits as described in the Division ofFinancial Responsibility.Referral to Medi-Cal Dental Providers through Carved Out Medi-CalDental Program:L.A. Care and its delegated PPGs must refer members to the appropriateMedi-Cal dental providers for treatment of dental care needs.Updated lists of Medi-Cal dental providers are made available to networkproviders.CCS ReferralsDental services for child with complex congenital heart disease, cysticfibrosis, cerebral palsy, juvenile rheumatoid arthritis, nephrosis, or whenthe nature or severity of the disease makes care of the teeth complicatedmay be covered by CCS. Contact the L.A. Care UM Department or CCSfor assistance.Orthodontia care when a child has a handicapping malocclusionmay be covered by CCS. Contact the L.A. Care UM Department orCCS for assistance.Routine dental care and orthodontics is not covered by CCS.5.32 VISION SERVICESMEDICARE ADVANTAGE – SNP• Vision care is a covered benefit and the responsibility of L.A. Care.To access this service, members and providers should contact VSPat 800-877-7195.97

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMEDI-CALL.A. Care and its delegated PPGs shall cover and ensure the provision ofeye examinations and prescriptions for corrective lenses as appropriatefor all Members according to the current Medi-Cal benefits for eyeexaminations and lenses.Members are eligible for the eye examination with refractive services anddispensing of the prescription lenses every two years. Additional servicesand lenses are provided based on medical necessity for examinations andnew prescriptionsL.A. Care and its delegated PPGs shall arrange for the fabrication ofoptical lenses for Members through Prison Industry Authority (PIA) opticallaboratories.• Department of Health Services (DHS) is responsible forreimbursing PIA for the fabrication of the optical lenses inaccordance with the contract between DHS and PIA.5.32.1 Long Term Care (LTC) (After exhaustion of Medicare Benefits)5.32.1.1 L.A. Care and its delegated PPGs are responsible forensuring that members, other than members requestinghospice services, in need of nursing Facility services areplaced in a health care facility that provides the level ofcare most appropriate to the member's medical needs.These health care facilities include Skilled NursingFacilities, sub-acute facilities, pediatric sub-acute facilities,and Intermediate Care Facilities.5.32.1.2 Admission to a nursing Facility of a member who haselected hospice services as described, does not affect themember's eligibility for Enrollment. Hospice services arecovered services and are not long term care servicesregardless of the member's expected or actual length ofstay in a nursing facility.5.32.1.3 L.A. Care and its delegated providers shall:5.32.1.3.1 Assure that decisions to transition a member toLTC are based on the appropriate level of carebased on Medi-Cal criteria5.32.1.3.1.1 Needs assessment and potentiallength of stay should be discussedwith the treating provider andfacility.98

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL5.32.1.4 If the member requires LTC, in the Facility for longer thanthe month of admission plus one month, Delegatedproviders will submit a Disenrollment request for themember to L.A. Care to submit to DHS for approval.5.32.1.4.1 L.A. Care UM Staff are responsible for:5.321.4.1.1 Coordinating the services requiredwith the treating provider andfacility5.32.1.4.1.2 Completes appropriatedocumentation and forwards toL.A. Care Member Services tocomplete disenrollment forms.5.32.1.4.2 L.A. Care Member Services is responsible for:5.32.1.4.2.1 Initiates the disenrollment processto Health Care Options5.32.1.4.2.2 Coordinate the decision responsewith UM staff5.32.1.5 When Health Care Options notifies L.A. Care that thedisenrollment request is approved, an approvedDisenrollment request will become effective the first day ofthe second month following the month of the member'sadmission to the facility, provided that L.A. Care submittedthe disenrollment request at least 30 calendar days prior tothat date.5.32.1.6 If L.A. Care submits the disenrollment request less thanthirty (30) calendar days prior to that date, disenrollmentwill be effective the first day of the month that begins atleast thirty (30) calendar days after submission of thedisenrollment request.5.32.2 Coordination of Care5.32.2.1 L.A. Care and its delegated providers shall provide allMedically Necessary Covered Services to the member untilthe disenrollment is effective:5.32.2.1.1 Assuring that continuity of care is notinterrupted.5.32.2.1.2 Completing all administrative work necessaryto assure smooth transfer of responsibility forthe health care of the Medi-Cal beneficiary.5.32.2.1.3 Assuring that medical necessity of continuedcare is reviewed regularly until patient istransitioned to Long Term Care.99

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL5.32.2.2 Upon the disenrollment effective date, the member'sorderly transfer to the Medi-Cal Fee-For-Service provider;5.32.2.2.1 The PCP, with assistance from the CaseManager, has responsibility to ensure that themember’s medical record and all appropriateinformation is transferred to the member’s FeeFor Service provider.5.32.2.2.2 This includes notifying the member and his orher family or guardian of the disenrollment;assuring the appropriate transfer of medicalrecords from the Plan to the Medi-Cal Fee-For-Service provider; assuring that continuity ofcare is not interrupted; and, completion of alladministrative work necessary to assure asmooth transfer of responsibility for the healthcare of the Medi-Cal beneficiary.5.32.2.2.3 If the member’s PCP continues to act as thepatient’s physician under Fee For Service, thelong term care facility will be notified. If it isnecessary for the member to have anotherphysician, L.A. Care or if applicable, thedelegated PPG works with the long term carefacility to achieve an orderly transfer of careand records.5.32.2.3 When Health Care Options notifies L.A. Care that thedisenrollment request is not approved:5.32.2.3.1 L.A. Care Member Services notifies the CareManager to assist the PCP with managementof patient’s needs. Until Placement isavailable, a patient who is eligible for a waiverprogram will be monitored closely.5.33 L.A. CARE APPEALS PROCESSL.A. Care does not delegate the appeal (reconsideration) process. ThePPG must ensure timely submission of appeals to L.A.Care. If the PPGreceives an appeal from a member, it should be faxed to L.A. CareMember Services Department same day of receipt. A member has theright to appeal directly to L.A. Care for all decisions to modify or deny arequest for services. A physician, acting as the member’s representative,may also appeal a decision on behalf of the member.100

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMembers and providers may also appeal L.A. Care’s decision to modify ordeny a service request (this does not apply to the retrospective claimsreview/provider dispute resolution process). The appeal request isreviewed by a physician or physician consultant not involved in the priordetermination.Member requested appeals may be initiated orally or in writing. Requestmay be made by contacting L.A. Care at:L.A. Care Health PlanMembers Services Grievances/Appeals555 W. Fifth Street, 29 th FloorLos Angeles, CA 90013(888) 452-2273Fax # - (213) 623-8097L.A. Care follows the federal, state and NCQA requirements for the timelyresolution of member complaints. If you would like additional informationon the L.A. Care appeal resolution process, please contact the L.A. CareUM Department at (877) 431-2273.Medicare Advantage-SNP –Please see Section 5.18 for more details about reconsiderations oforganization determinations (appeals), inpatient discharge appeals, andreview of discharge from CORF, SNF and home health facilities.5.34 SATISFACTION WITH THE UTILIZATION MANAGEMENT PROCESSL.A. Care will evaluate both Member and Provider satisfaction with the UMprocess. Performance is assessed at least annually. The outcomes of thesurvey will be reported to the appropriate L.A. Care Quality Managementcommittees. The committee will identify areas of dissatisfaction, setpriorities for improvement, and evaluate the effectiveness of interventions.Where opportunities for improvement are identified, PPGs by berequested to initiate action to change processes to meet defined goals andto meet Members’ and Providers’ expectations.101

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL6.0: QUALITY IMPROVEMENT PROGRAM (QIP)L.A. Care Health Plan’s mission is to provide access to quality health care for LosAngeles County’s vulnerable and low income communities and residents and tosupport the safety net required to achieve this purpose.L.A. Care annually prepares a comprehensive Quality Improvement Program thatclearly defines L.A. Care’s QI structures and processes designed to improve thequality and safety of clinical care and services it provides to its members. Acomplete written copy of L.A. Care Quality Improvement Program is available byrequest by calling (213) 694-1250 x4027.The L.A. Care Quality Improvement Program, consistent with the L.A. Caremission, strives to:• Define, oversee, continuously evaluate and improve the quality and efficiencyof health care delivered through organizational commitment to the goals andprinciples of our organization.• Ensure medically necessary covered services are available and accessible tomembers taking into consideration the member’s cultural and linguistic needs.• Ensure our contracted network of providers cooperate with L.A. Care qualityinitiatives.• Ensure that timely, safe, medically necessary, and appropriate care isavailable.• Consistently meet quality standards as required by contract, regulatoryagencies, recognized care guidelines, industry and community standards.• Promote health education and disease prevention designed to promote lifelongwellness by encouraging and empowering the member to adopt andmaintain optimal health behaviors.• Maintain a well-credentialed network of providers based on recognized andmandated credentialing standards.• Protect members’ protected health information (PHI).Annual QI Program EvaluationAnnually, L.A. Care reviews data reports and other performance measuresregarding program activities to assess the effectiveness of its QI Program. Thisevaluation includes a review of completed and continuing program activities andaudit results; trending of performance data; analysis of the results of QI initiativesincluding barriers, successes, and challenges; an assessment of theeffectiveness of monitoring activities and identifying and acting upon quality ofcare and service issues; an evaluation of the overall effectiveness of the QIprogram including progress toward influencing network-wide safe clinicalpractices; and the goals and plans for the next year.102

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAnnual QI Work PlanThe annual QI Work Plan is developed in collaboration with staff and is based, inpart upon the results of the prior year’s QI Program evaluation. Each of theelements identified on the Work Plan has activities defined, responsibilityassigned and the date by which completion is expected. Quarterly updates tothe Work Plan are documented and reported to the Quality Oversight Committeeand the Compliance and Quality Committee of the Board.COMMITTEE STRUCTUREL.A. Care’s quality committees oversee various functions of the QI program. Thecommittees serve as the major mechanism for intradepartmental collaboration forthe Quality Program. There is physician network participation on many of L.A.Care’s QI Committees.Clinical Care MeasuresHEDISL.A. Care measures clinical performance related to Healthcare EffectivenessData and Information Set (HEDIS). L.A. Care expects that the network assist thehealth plan in continuously improving its HEDIS rates. The network is alsoexpected by contract to cooperate with the annual HEDIS data collection effortsand keep encounter data current and accurate.Service MeasuresL.A. Care monitors services and member satisfaction by collecting, analyzing andacting on numerous sources of data such as Member Satisfaction (CAHPS),Complaints and Appeals, Access to and Availability of Practitioners and ProviderSatisfaction.Medicare Advantage-SNP MeasuresAs required by CMS, the following will be conducted, annually• Healthcare Effectiveness Data and Information Set (HEDIS)• Consumer Assessment of Healthcare Providers and Systems(CAHPS)• Health Outcomes Survey (HOS) .Continuity and Coordination of Medical CareHow well does your office coordinate care? If referring to a specialist, contact thespecialist before the patient’s appointment. Have staff set up a quick phoneappointment and fax over the patient’s medical history. Request that thespecialist also contact you once the evaluation and/or treatment is finished.Keep track of specialty referrals that require prior authorization. Talk to the PPG103

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALor IPA about getting timely hospital discharge reports that will help you follow upand coordinate care after a hospitalization or emergency room visit.Continuity and Coordination of Medical and Behavioral Health CareL.A. Care contracts with PacifiCare Behavioral Health (PBH) to provide inpatientand outpatient mental health services including drug and alcohol abuse services.Mental health care is covered when services are ordered and performed by aplan mental health professional. For a directory of PacifiCare Behavioral Healthproviders, please refer to the electronic provider and hospital directory on L.A.Care's website. A search for a behavioral health provider will link you directly tothe PBH network. L.A. Care also offers a toll-free behavioral health hotline at 1-866-908-0677.Preventive Health Care Guidelines- SEE L.A. CARE WEBSITE FOR CURRENT ANDUPDATED GUIDELINESClinical Practice Guidelines for Acute and Chronic Medical Care- SEE L.A.CARE WEBSITE FOR CURRENT AND UPDATED GUIDELINES INCLUDING ASTHMA ANDDIABETESClinical Practice Guidelines for Behavioral Health Care - SEE L.A. CAREWEBSITE FOR CURRENT GUIDELINES INCLUDING DEPRESSION AND ADHD.Disease Management ProgramsThe objective of each of L.A. Care’s Disease Management Programs is toimprove the health status of its eligible members with chronic or other conditions.The programs achieve their objective by educating the member and byenhancing the member’s ability to self-manage his or her condition or illness.Disease management programs are developed from evidenced-based clinicalpractice guidelines and support the practitioner–patient relationship, plan of careand foster patient empowerment. Disease management programs have beenselected based on an analysis of internal data relating to disease prevalence inthe L.A. Care population and are currently addressing Asthma (L.A. CaresAbout Asthma) and Diabetes (L.A. Cares About Diabetes). To enroll amember contact L.A. Care at 1-866-LA-CARE6 (1-866-522-2736).Patient SafetyL.A. Care is committed to improving patient safety and promoting a supportiveenvironment for network practitioners and other providers to improve patientsafety in their practices. Many of the ongoing QI Program measurementactivities, including measures for accessibility, availability, adherence to clinicalpractice guidelines and medical record documentation include safetycomponents.104

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMember ConfidentialityL.A. Care keeps confidential information secure and makes it available only toL.A. Care employees, contractors, and affiliates who have a need to know andwho have signed a confidentiality statement. L.A. Care ensures that allindividuals or agencies who participate in the use, creation, maintenance, ordisclosure of protected health information limit the use and disclosure only to theamount necessary to complete the task. Without a signed authorization,disclosure of protected health information is limited to the purposes of treatment,payment, or health care options. These purposes include the use of protectedhealth information for quality of care activities, disease management servicereferrals, statistical evaluation, claims payment processes, medical paymentdeterminations, practitioner credentialing, peer review activities, and thegrievance and appeals process.Network practitioners and providers are obligated to maintain the confidentialityof member information and information contained in a member’s medical recordand may only release such information as permitted by applicable laws andregulation, including HIPAA.L.A. Care maintains confidentiality in written, verbal, and electroniccommunications. L.A. Care has specific policies that outline appropriate storageand disposal of electronic and hard copy materials so that confidentiality ismaintained within the plan and network.Disease Reporting StatementL.A. Care complies with disease reporting standards as cited by the CaliforniaCode of Regulations, Title 17 (Section 2500), which states that public healthprofessionals, medical providers and others are mandated to reportapproximately 85 diseases or conditions to their local health department. Theprimary objective of disease reporting and surveillance is to protect the health ofthe public, determine the extent of morbidity within the community, evaluate riskof transmission, and intervene rapidly when appropriate. Forms to reportdiseases can be found at www.lapublichealth.org/acd/cdrs.htm and via a link onthe L.A. Care website at www.lacare.org.105

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.0 CREDENTIALING7.1 OVERVIEW7.1.1 L.A. Care’s direct contracted practitioners are required to becredentialed in accordance with L.A. Care’s credentialing criteriaand the standards of the Department of Health Services (DHCS),DMHC, CMS, the Medicare Managed Care Manual, and NCQArequirements.7.1.2 L.A. Care requires that all practitioners who are performing servicesfor L.A. Care members must have a current license at all times toprovide patient care to members and abide by State and Federallaws and regulations. All practitioners must be qualified toparticipate in the Medi-Cal, CMS, and Medicare product lines inorder to participate in all lines of business. Failure to meet Medi-Cal, CMS, and Medicare Managed Care Manual requirements maybe cause for removal from L.A. Care’s network.These requirements include verification of the followingcircumstances:Excluded ProvidersConfirmation that practitioners or other health careproviders/entities are not “excluded providers” on the Office of theInspector General (OIG) sanction list that identifies thoseindividuals found guilty of fraudulent billing, misrepresentation ofcredentials, etc. Organizations employing or contracting with healthproviders have a responsibility to check the sanction list with eachnew issuance of the list, as they are prohibited from hiring,continuing to employ, or contracting with individuals named on thatlist. . Lists of the excluded providers are available at:http://oig.hhs.gov/fraud/exclusions/exclusions_list.asp andhttps://www.epls.gov/.Opt-Out ProvidersIf a practitioner or other practitioner opts out of Medicare, thatpractitioner or other practitioner may not accept Federalreimbursement for a period of 2 years. The only exception to thatrule is for emergency and urgently needed services. Payment mustbe made for emergency or urgently needed services furnished byan “opt-out” practitioner or practitioner to a member, but paymentshould not be made otherwise to opt-out providers. Information onproviders who opt-out of Medicare may be obtained from the local106

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMedicare Part B carrier. This list must be checked on a regularbasis.7.1.3 Participating Practitioner Groups (PPGs) will establish standards,requirements and process for the evaluation of practitioners, nonpractitionerhealth care professionals and health deliveryorganizations that comply with CMS requirements who areperforming services for L.A. Care members to ensure that thesepractitioners and health delivery organizations are qualified toperform the services, and are licensed and/or certified consistentwith State laws and regulations. These standards, requirementsand processes are applicable whether or not credentialing and recredentialingactivities (herein after referred to as “credentialing”)are delegated.7.1.4 The acceptance of a practitioner into the L.A. Care network iscontingent upon successfully completing the credentialing reviewprocess. The re-credentialing process is implemented every three(3) years in accordance with CMS, the Medicare Managed CareManual letter and NCQA requirements. Continuation ofparticipation with L.A. Care is dependent upon successfullycompleting the re-credentialing process.7.1.5 L.A. Care’s Board of Governors has delegated the responsibility tothe Credentialing/Peer Review Committee, to review and makerecommendations on practitioner initial credentialing and recredentialingapplications for participation in the L.A. Care network.7.2 DELEGATION OF CREDENTIALING7.2.1 L.A. Care is responsible for monitoring all contracted PPGs,credentialing, and re-credentialing activities. A PPG must pass theL.A. Care Credentialing department’s pre-delegation credentialingaudit in order to be delegated the credentialing responsibility.Otherwise, L.A. Care’s Credentialing department is responsible fora PPG’s credentialing activities. Regardless of a PPG’scredentialing delegation status, L.A. Care retains the right toapprove new practitioners and sites, and to terminate or suspendindividual practitioners, based on credentialing issues at all times.7.2.2 Definition of Delegation: Delegation is a formal process by which anorganization gives another entity the authority to perform certainfunctions on its behalf. Although the organization can delegate theauthority to perform such a function, it cannot delegate theresponsibility for assuring that those functions are performedappropriately.107

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.2.3 If the PPG delegates any credentialing and re-credentialingactivities, there is evidence of oversight of the delegated activity.The PPG is accountable for credentialing and re-credentialing itspractitioners, even if it delegates all or part of these activities.There must be annual evidence that a delegation agreement hasbeen agreed to by both the PPG and the delegate.7.2.4 When delegates have access to the PPG's protected healthinformation (PHI) on members or practitioners, or create suchinformation in the course of their work, the mutually agreed-upondocument must ensure that the information will remain protected.This is not applicable if there is no delegation arrangement, or if thedelegation arrangement does not involve the use, creation ordisclosure of protected health information.7.2.5 If the delegation arrangement does not include the use of PHI inany form, an affirmative statement to that fact in the delegationagreement is sufficient, but is not required; the PPG may documentthe lack of PHI in a delegation arrangement in other manners.7.2.6 Prior to delegation, L.A. Care’s Credentialing Department audits thePPG (the potential delegated entity) to determine if the PPG meetsL.A. Care’s criteria for delegation. The Credentialing Departmentevaluates the potential delegated entity’s ability to perform thedelegated activities, which will include all activities related tocredentialing and re-credentialing in accordance with the standardsof NCQA, CMS, State and L.A. Care. Using a modified version ofthe Standardized Audit Tool in accordance with L.A. Care andNCQA standards, the Credentialing Department will evaluatedelegated entitiy’s performance.7.2.7 Types of Delegation Status7.2.7.1 After completion of the pre-delegation audit, the audit toolis scored and recommendations regarding delegation arepresented to the Credentialing/Peer Review Committeeand the Quality Oversight Committee (QOC) as follows:7.2.7.1.1 Delegation – PPG group scores between 80%to 100% on the pre-delegation audit. Acorrective action plan must be successfullycompleted if score is below 100%.7.2.7.1.2 Full delegation – PPG scores 100%. No CAPrequired.7.2.7.1.3 Full delegation – PPG scores between 80-99%. CAP required. A corrective action mustbe successfully completed.108

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.2.7.1.4 Provisional Delegation – PPG scoresbetween 70%-79% on the pre-delegationcredentialing audit. A corrective action planmust be successfully completed and a re-auditperformed after ninety (90) days.7.2.7.1.5 Denial of Delegation – PPG chooses not topursue delegation of credentialing, or itreceives less than a 70% on the pre-delegationcredentialing audit. PPG has a Non-Delegatedcredentialing status for a minimum of one year.The credentialing of PPG’s practitioners isperformed by L.A. Care’s Credentialingdepartment.7.2.7.2 Following recommendations by the Credentialing/PeerReview Committee, delegation letters will be sent to thePPG’s scoring 80% or above, and Delegation Agreementsfor credentialing will be executed.7.2.8 Levels of Delegation7.2.8.1 Partial – Some credentialing activities have beendelegated to the PPG, and some activities have beenretained by L.A. Care. The Delegation Agreement willidentify in detail exactly what functions have beendelegated to the PPG.7.2.8.2 Full – All credentialing activities have been delegated toeither the PPG or a combination of a hospital and medicalgroup. The Delegation Agreement will identify in detailexactly what functions have been delegated to the PPG.7.2.9 Delegation Oversight7.2.9.1 The PPG agrees, upon delegation, to make available toL.A. Care the credentialing and re-credentialing status onthe PPG’s participating practitioners/practitioners, andrequested data, documents and reports quarterly, asappropriate.7.2.9.2 Credentialing and recredentialing files will be reviewedaccording to the following file pull methodology: A roster ofpractitioners credentialed and recredentialed within theaudit period will be requested. Using the Excelrandomization function the roster of practitioner names willbe sorted and the first 30 credentialing and the first 30recredentialing files identified for review. NCQA’s 8/30methodology will be used in evaluating files. The minimumfiles reviewed will be eight (8) initial files and eight (8)109

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrecredential files. If any element should fall out of the 8/30Rule, then the deficient element(s) will be reviewed for theremaining files, up to a maximum of 30 initial credentialingand 30 recredentialing files.7.2.9.3 L.A. Care’s oversight audit will include a review of thePPG’s credentialing policies and procedures, Committeemeeting minutes, application(s), file review, and otherrelated documentation of PPG’s credentialing and recredentialingprocess in accordance with NCQA guidelines,State and L.A. Care requirements.7.2.9.4 Results of L.A. Care’s oversight audit will be reported tothe PPG, including corrective action plan if deficiencies arenoted. The PPG will implement such corrective action planwithin the time period stated and will permit a re-audit byL.A. Care or its agent, if requested. If PPG fails toadequately correct the deficiencies within the required timeperiod, L.A. Care may de-delegate credentialing andassume responsibility for all or part of credentialingfunctions.7.2.9.5 The Credentialing Department works collaboratively withthe delegate when deficiencies have been identifiedthrough the oversight process. The delegate is given aCorrective Action Plan (CAP) and asked to respond within30 days. If no response is received within 30 days, theRegulatory Affairs and Compliance (RAC) Departmentsends a second letter requesting a response within 14days and advising that failure to respond may be cause forrevocation of the delegation agreement.7.2.9.6 PPG that receives a rating of “excellent”, “commendable”,or “accredited” from NCQA, will be deemed to meet L.A.Care’s requirements for credentialing. These PPGs will beexempt from the L.A. Care audit of credentialing inelements for which they are accredited or certified. L.A.Care retains overall responsibility for ensuring thatcredentialing requirements are met and will requiredocumentation from PPG to establish proof of NCQAaccreditation status. Elements not listed in the NCQAaccreditation documentation will require further validationthrough annual or pre-delegation audits.110

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.2.10 Delegation Revocation7.2.10.1 At L.A. Care’s discretion, or in the event that L.A. Caredetermines that significant deficiencies are occurringrelated to performance by the delegate and are withoutremedy, additional on-site audits can be initiated and/orCAPs can be implemented as stipulated in the writtendelegation agreement.7.2.10.2 L.A. Care retains the right to approve new participatingpractitioners and sites (delegated or sub-delegated), and toterminate, suspend, and/or limit participation of PPG’spractitioners who do not meet L.A. Care’s credentialingrequirements.7.3 PPG RESPONSIBILITIES7.3.1 PPG must have policies and procedures to address credentialing ofpractitioners, non-practitioner health care professionals, licensedindependent practitioners and health delivery organizations that fallwithin in its scope of credentialing. PPG must state in policy thatthey do not make credentialing and re-credentialing decisionsbased solely on an applicant's race, ethnic/national identity, gender,age, sexual orientation or the types of procedures (e.g., abortions)or patients (e.g., Medicaid) in which the practitioner specializes.7.3.2 PPG will establish standards, requirements and process for thehealth delivery organizations who are performing services for L.A.Care members to ensure that these practitioners and healthdelivery organizations are qualified to perform the services, and arelicensed and/or certified consistent with State laws, regulations,NCQA, DMHC, CMS and Medicare requirements. Thesestandards, requirements and processes are applicable whether ornot credentialing and re-credentialing activities are delegated.7.3.3 PPG's policies must explicitly define the process used to ensurethat the information provided in member materials, includingpractitioner directories, is consistent with the information obtainedduring the credentialing process. Specifically, any practitionerinformation regarding qualifications given to members should matchthe information regarding practitioner's education, training, andcertification and designated specialty gathered during thecredentialing process. "Specialty" refers to an area of practice,including primary care disciplines.7.3.4 PPG will establish a peer review process by designating aCredentialing Committee that includes representation from a range111

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALof participating practitioners. The credentialing process canencompass separate review bodies for each specialty (e.g.,practitioner, dentist, and psychologist) or a multidisciplinarycommittee with representation from various types of practitionersand specialties.7.3.5 PPG must notify the practitioner, in writing, of any adverse actionsto the practitioner and send a copy of the notification letter to L.A.Care.7.3.6 L.A. Care reserves the right, pursuant to the ParticipatingPractitioner Group Services Agreement, to coordinate, consolidate,and participate in any PPG participating practitioner disciplinaryhearing, conducted in accordance with L.A. Care Policy andProcedures, and California Business and Professions Code Section805.7.3.7 PPG will advise L.A. Care of any changes to its credentialing andre-credentialing policies and procedures, processes, delegation orsub-delegation, and criteria within thirty (30) days of the change. IfL.A. Care deems the changed items not in compliance with L.A.Care, CMS, or NCQA credentialing requirements, L.A. Care shallnotify PPG immediately. PPG will have 45 days to be incompliance, and, if not in compliance, L.A. Care may de-delegatecredentialing and assume responsibility for all or part of thecredentialing functions.7.3.8 PPG will provide quarterly reports to L.A. Care following the end ofeach report month (May 15th, August 15th, November 15th,February 15th) with accurate and complete PPG practitioner data.PPG must provide Board certification status and Board expirationdate when adding a practitioner to L.A. Care’s network and anyupdates.7.3.9 Using the standardized ICE format and Excel grid will include thefollowing:7.3.9.1 Number of adds/deletes of PCPS (i.e. MDS, DOS andDDSS)7.3.9.2 Number of adds/deletes of SCPS (i.e. MDS, and DOS)7.3.9.3 Numbers of adds/deletes of independent practitioners (i.e.chiropractor, podiatrist)7.3.9.4 Any new or revised policies and procedures, additions of acomputer system, CVO7.3.9.5 Practitioners termed for quality issues112

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.3.10 PPG will submit profiles of new practitioners/practitioners sites thatwere credentialed and approved by the committee at each meeting.PPG will submit with profile documented evidence of PCP’s (i.e.,general practitioners, family practice, pediatrics, internal medicine,and OB/GYNs serving as PCPs). Practitioners who treat members0-16 must be CHDP certified. Internists treating members 14 yearsand above must be CHDP certified. The PPG will be responsible tomanage the CHDP certification process within their network.7.3.11 PPGs must submit profiles of new practitioners/practitioner sitesthat were credentialed and approved by the committee at eachmeeting that meet the L.A. Care hospital requirements.Practitioners/ practitioners who do not have hospital privileges witha L.A. Care contracted hospital, may use the PPGs admitting panelor have a direct agreement with a practitioner who has admittingprivileges at a L.A. Care contracted hospital. This agreement mustcapture responsible for the provisions of and coordination of care,when patients are discharged from the hospital, referral of patientsback to PCP with a hospital discharge summary, and coordinate aseven day week, 24-hour call coverage utilizing the practitionersthat are contracted with the PPG.7.3.12 PPG will notify L.A. Care within thirty (30) days of any changes inthe status of any of the PPG’s participating practitioners, including,but not limited to, termination, resignation, and changes inprivileges, accusation, probation, or other disciplinary action ofpractitioners.7.3.13 If the PPG delegates any or all of the credentialing functions to aCredentials Verification PPG (CVO) or affiliated hospital, the PPGwill provide L.A. Care with evidence or a written description of thedelegated activity, pre-contractual and annual oversight of thedelegated activity, and allow L.A. Care access to audit results.7.3.14 PPG will ensure that practitioners and all of their contracted sitesare reviewed in accordance with the requirements described in theCMS Medicare Managed Care Manual. All Practitioners musthave a current (i.e., within 3 years of the date of initialcredentialing/re-credentialing) full scope site review at the time ofinitial credentialing/re-credentialing.7.3.15 PPG’s Board of Governors (Board), or the group or committee towhom the Board has formally delegated the credentialing function,reviews and approves the credentialing policies and procedures onan annual basis.113

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.3.16 Pending DecisionsIf the initial committee review results in a “Pending” status for apractitioner, there must be a final review and decision when thecommittee evaluates all credentials at the same time. If a result of adelayed decision is that some information in the practitioner file nolonger meets CMS and NCQA timeliness requirements, the PPGmust re-verify the noncompliant information before presenting it tothe committee for a final decision.7.2.16 Provisional CredentialingThe PPG may conduct provisional credentialing (in compliance withthe Medicare Manage Care Manual) of practitioners who completedresidency or fellowship requirements for their particular specialtyarea within the 12 months before the credentialing decision.7.4 CREDENTIALS COMMITTEE7.4.1 The Credentials Committee will consist of not less than three (3)participating practitioners in good standings with state and federalagencies in order to ensure accurate representation of medicalspecialties.7.4.2 Administrative support staff may attend at the request of the Chair butare not entitled to vote.7.4.3 A quorum should consist of three (3) practitioner committee members.Any action taken upon the vote of a majority of members present at aduly held meeting at which a quorum is present shall be an act of thecommittee.7.4.4 Meetings and Reporting7.4.4.1 The Credentials Committee shall meet at least quarterlybut as frequently necessary to demonstrate follow-up on allfindings and required action; and maintain a permanentrecord of its proceedings and actions. The activities,findings, recommendations, and actions of the committeemust be reported to the governing body or designee inwriting on a scheduled basis.7.4.4.2 Additional meetings of the credentials committee may becalled by the committee chairperson on an as-needed.7.4.5 Committee Decisions7.4.5.1 In some cases, a review board or governing body reviewsa decision after the Credentials Committee, but NCQA andL.A. Care considers the decision made by the CredentialsCommittee to be final. The committee may not approve apractitioner if the credentials it receives and reviews are114

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALnot within the verification time limits specified by CMS andNCQA.7.4.5.2 The PPG's credentialing policies and procedures mustinclude a time frame for notifying applicants ofcredentialing decisions, not to exceed sixty (60) calendardays from the committee's decision.7.4.6 Participation of Medical Director or other DesignatedPractitioner7.4.6.1 The PPG must have a practitioner (medical director ordesignated practitioner) who has overall responsibility forthe credentialing process. Credentialing policies andprocedures must clearly indicate the practitioner directlyresponsible for the credentialing program and must includea description of his or her participation.7.4.7 Committee Functions7.4.7.1 Review and evaluate the qualifications of each practitionerapplying for initial appointment, and reappointment andconsider the recommendations to the appropriateCommittee/Board;7.4.7.2 Submit required reports and information on the qualification ofeach practitioner applying for membership.7.4.7.3 Investigate, review and report on matters referred by theMedical Director or his/her designee or the Board regardingthe qualifications, conduct, professional character orcompetence of any applicant or practitioner, and;7.4.7.4 Submit periodic reports to the appropriate Committee and/orBoard on its activities and the status of pending applications.7.4.7.5 Review annually policies and procedures relevant to thecredentialing process, and make revision as necessary tocomply with current standards, regulations and practices.7.4.7.6 The Credentials Committee must review practitionercredentials and give thoughtful consideration to thecredentialing elements before making recommendationsabout a practitioner's ability to deliver care. At a minimum, theCredentials Committee must receive and review thecredentials of practitioners who do not meet the PPG'sestablished criteria.7.4.7.7 The Credentialing Committee must document in its minutes115

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALthe thoughtful consideration of credentials discussed during itsmeetings.7.4.7.8 When the credentialing function is not delegated to the PPG,L.A. Care’s Credentialing department will verify practitionerinformation in-house.7.4.7.9 The L.A. Care Credentialing/Peer Review Committee mayterminate, suspend or modify participation for thosepractitioners/practitioners who fail to meet eligibility criteria.The decisions to terminate, suspend, or modify participation ofa contracted practitioner/practitioner as a result of a reportablequality of care issue shall be subject to an appeals process bythe practitioner/practitioner.7.4.8 Credentials Committee File Review7.4.8.1 The PPG's policies and procedures must describe theprocess used to determine and approve clean files. Theymust identify the Medical Director as the individual with theauthority to determine that a file is "clean" and to sign offon it as complete, clean and approved. With regard toclean files, the practitioner may not provide care tomembers until the final decision of the CredentialingCommittee or the Medical Director or his or her designee.7.4.8.1.1 (NCQA uses the date of the Credentialing Committeemeeting to determine the timeliness of allrequirements for credentialing). To meet NCQAstandards, credentials must be valid at the time of theCredentialing Committee review and verified withinthe specified time limits.7.4.8.2 PPG's credentialing and re-credentialing policies mustexplicitly define the process used to reach a credentialingdecision.7.5 RECREDENTIALING7.5.1 Participating practitioners must satisfy re-credentialing standardsrequired for continued participation in the network. Recredentialingis completed three years from the month of initialcredentialing and every three (3) years thereafter.7.5.2 A facility site review does not need to be repeated as part of the recredentialingprocess if the site has a current passing score (thisapplies to PCPs). A passing site review survey will be considered“current” if it is dated within the last three (3) years (with use of newtool) of the re-credentialing date, and does not need to be repeateduntil the due date of the next scheduled site review survey or whendetermined necessary through monitoring activities by the Plan.116

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.6 CONFIDENTIALITY AND PRACTITIONER RIGHTS7.6.1 PPG's credentialing policies and procedures must clearly state theconfidential nature of information obtained in the credentialingprocess. The PPG must also describe the mechanisms in effect toensure confidentiality of information collected in this process. ThePPG must ensure that information obtained in the credentialingprocess is kept confidential and, ensure that practitioners canaccess their own credentialing information, as outlined in Right toreview information, below.7.6.2 During the credentialing process, all information that is obtained isconsidered confidential. All Committee meeting minutes andpractitioner/practitioner files are to be securely stored and can onlybe seen by an appropriate Medical Director or his/her designee,and the Credentials Committee members. Documents in these filesmay not be reproduced or distributed, except for confidential peerreview and credentialing purposes consistent with Section 1157 ofthe State of California Evidence Code and Section 1370 of theHealth and Safety Code of the State of California.7.6.3 PPG's policies and procedures must state that practitioners arenotified of their right to review information obtained by the PPG toevaluate their credentialing application. The evaluation includesinformation obtained from any outside source (malpracticeinsurance carriers, state licensing boards, etc.).7.6.4 PPG must have written policies and procedures for notifying apractitioner in the event that credentialing information obtained fromother sources varies substantially from that provided by thepractitioner. The policies and procedures must clearly identifytimeframes, methods, documentation and responsibility fornotification.7.6.5 PPG is not required to reveal the source of information if theinformation is not obtained to meet PPG credentialing verificationrequirements or if disclosure is prohibited by law.7.6.6 Policies and procedures must also state the practitioner's right tocorrect erroneous information submitted by another source. Thepolicy must clearly state:117

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Timeframe for changes• Format for submitting corrections• The person to whom corrections must be submitted• Receipt of documented corrections• How practitioners are notified of their right to correcterroneous information (avenues identified under Right toreview information, above, are appropriate).7.6.7 PPG’s credentialing policies and procedures must state thatpractitioners have a right to be informed of the status of theirapplications upon request, and must describe the process forresponding to such requests, including information that the PPGmay share with practitioners. This element does not require thePPG to allow a practitioner to review references, recommendationsor other peer-review protected information7.7 APPEAL AND FAIR HEARING7.7.1 Delegated PPG, or if not delegated, L.A. Care must have amechanism for fair hearing and appeal process for addressingadverse decisions that could result in limitation of a practitioner’sparticipation based on issues of quality of care and/or service, inaccordance with all applicable statutes. The process shouldinclude the scheduling of hearing requests, followed by theprocedures hearings, the composition of the hearing committee andthe agenda for the hearing.7.7.2 The PPG must have an appeal process for instances in which itchooses to alter the conditions of a practitioner’s participationbased upon issues of quality of care and/or service. Except asotherwise specified in this manual, any one or more of the followingactions or recommended actions taken for a medical disciplinarycause or reason shall be deemed actual or potential adverse actionand constitute grounds for a hearing:7.7.2.1 The following actions entitle the practitioner the opportunityto appear before a Peer Review Committee to presentrebuttal evidence before a final determination is made.The following actions also entitle the practitioner theopportunity for a hearing before the Plan PerformanceCommittee in the event that the final determination of aPeer Review Committee is adverse to the practitioner,unless the right to a hearing has been forfeited asdescribed below. The actions to which this section appliesare:118

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Denial of initial panel appointment• Denial of reappointment to panel• Suspension of panel appointment (except asdescribed below)• Revocation of panel appointment• Other adverse restrictions on panel appointment(except as described below)7.7.3 A Peer Review Committee has the right to recommend suspensionof a practitioner’s panel appointment for up to fourteen (14)calendar days while an investigation is being conducted todetermine the need for peer review action, without the practitionerhaving a right to the rebuttal and/or fair hearing process set forthbelow.7.7.4 A Peer Review Committee has the right to recommend immediatesuspension or restriction of a practitioner’s panel appointment if thecommittee reasonably believes that the health of any individualwould be jeopardized by the continued participation of thepractitioner. In the case of such an immediate suspension orlimitation on privileges (summary action), the practitioner has theright to notice, opportunity to present rebuttal information and fairhearing, in accordance with the procedure described in L.A. Care’sFair Hearing Policy and Procedure (602.1), but those rights applysubsequent to the summary action, rather than prior to it.7.7.5 Required Reporting7.7.5.1 PPG must file a Section 805 report with the Medical Boardof California and a report with the National PractitionerData Bank/Healthcare Integrity Protection Data Bank withinfifteen (15) calendar days after the effective date of theaction, if any of the following events occur:7.7.5.1.1 The practitioner’s application for participationstatus (credentialing) is denied or rejected for amedical disciplinary cause or reason.7.7.5.1.2 The practitioner’s participation status isterminated or revoked for a medical disciplinarycause or reason.7.7.5.1.3 Restrictions are imposed or voluntarily acceptedfor a cumulative total of thirty (30) days or morefor any 12-month period, for a medicaldisciplinary cause or reason.119

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL7.7.5.1.4 The practitioner resigns or takes a leave ofabsence from participation status followingnotice of any impending investigation based oninformation indicating medical disciplinary causeor reason.7.7.5.2 The practitioner must be notified of any adverse actions inwriting, and if credentialing is delegated to a PPG, a copyof the notification letter must be submitted to L.A. Care.7.7.6 Ongoing Monitoring of Sanctions, Complaints, and QualityIssues7.7.6.1 PPG must implement a process for monitoring practitionersanctions, complaints and the occurrence of adverseevents between re-credentialing cycles. The PPG mustconduct ongoing monitoring of all practitioners who fallwithin the scope of credentialing. The PPG must be fullycompliant with NCQA Standard CR9 and use the approvedsources of sanction information.7.7.6.2 PPG develops and implements policies and procedures forongoing monitoring of practitioner sanctions, complaintsand quality issues between re-credentialing cycles, andtakes appropriate action against practitioners when itidentifies occurrences of poor quality. PPG identifies and,when appropriate, acts on important quality and safetyissues in a timely manner during the interval betweenformal credentialing.7.7.7 EXPIRED LICENSE7.7.7.1 Failure to RenewThe license to practice medicine in California must berenewed every two (2) years. Practitioners/practitionerscontracted with L.A. Care shall be licensed or certified bytheir respective board or agency, where licensure orcertification is required by law.7.7.7.2 If any practitioner/practitioner fails to renew their license bythe expiration date, the following steps will be initiated byL.A. Care.7.7.7.2.1 If the identified practitioner(s) has memberenrollment:120

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALoooooClose provider’s panel to new membersupon notification of license expirationNotify PPG of expiration and possiblereassignment of membersRemove assigned members fromunlicensed practitioner/practitioner 5business days following license expiration,if not renewedReassign members to a qualified licensedcredentialed practitionerRemove unlicensed practitioner fromnetwork7.7.7.2.2 If the identified practitioner(s) has no memberenrollment:o Close practitioner’s panel to new memberso If practitioner/practitioner has not renewedby the 5 th business day following theexpiration date, the unlicensedpractitioner/practitioner will be removedfrom the network.121

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL8.0 PROVIDER NETWORK OPERATIONS (PNO)8.1 SPECIFIC AREAS8.1.1 Provider ContractingThe Provider Network Contracting team is responsible fordeveloping and negotiating financially sound contracts withphysicians, Participating Physician Groups (PPGs), hospitals,ancillary providers and other health professionals in order tomaintain a comprehensive network of health care providers for theprovision of health care services to covered members.8.1.2 Provider Relations8.1.2.1 Provider Relations Manager and Provider NetworkRepresentatives are responsible for the following:8.1.2.1.2 Serving as key contacts for PPGs, hospitals,and other providers to resolve all operationaland ongoing service issues.8.1.2.1.3 Coordinating closely with Provider Contracting,Provider Information Management, MemberServices, Claims, Utilization Management, andPPGs when necessary to resolve issues.8.1.2.1.4 Training PPG personnel to ensure L.A. Careprocedures and requirements are understoodand followed.8.1.2.1.5 Conducting Joint Operations Meetings toensure that administrators and staff are keptinformed of policy and procedure changes.8.1.2.1.6 Provider grievance resolution.8.1.3 Provider Network Research & Analysis UnitThe Provider Network Research & Analysis Unit (PNRA) hasprogram responsibility over multifaceted, highly technical functionsthat bring together the services of information technology, providernetwork information, and statistical studies and reporting. In thiscapacity, PNRA has oversight responsibility for the management,accessibility, and usability of provider information. PNRA is alsoresponsible for conducting comprehensive provider related studiesas mandated by the Centers for Medicare & Medicaid Services(CMS) and other governing agencies/bodies. Other key functions ofthe PNRA unit are the production of L.A. Care’s provider directories122

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALand the entry/updating of contractual terms/rates into L.A. Care’stransaction system for our directly contracted PPGs, hospitals,ancillary providers, and individual providers for claim paymentpurposes.8.2 PROVIDER TRAINING AND EDUCATION8.2.1 Provider education is implemented by L.A. Care and its PPGs.Goals, objectives, curricula, and implementation guidelines areestablished by L.A. Care. The PPGs are responsible for conductingprovider training and orientation. L.A. Care provides additionalresources and opportunities for provider education.8.2.2 L.A. Care provides special training and workshops for traditionaland safety net providers. These workshops encompass focusedclinical competence training, product line workshops, and otherrelated clinical practice management issues along with the HealthPromotion Services department.8.2.3 Ultimately, the goal of provider training and education is to improvethe delivery of services to members by providing appropriateforums for providers to:8.2.3.1 Be better informed about products offered by L.A. Careand its systems and processes.8.2.3.2 Understand the needs of L.A. Care members.8.2.3.3 Improve clinical, patient interaction, and administrative/management skills.8.2.4 A training and education curriculum will be developed andimplemented by the PPGs with collaborative oversight, guidance,and approval of L.A. Care or it will be provided directly by L.A.Care. L.A. Care’s Health Promotion Services department and PNOshare responsibility for L.A. Care’s involvement in this process.8.3 TRAINING AND EDUCATION MATERIALS AND METHODSAll provider training and education materials produced and distributed byPPGs must be approved by L.A. Care prior to distribution. The followingprovider training and education materials must be used by the PPGs:8.3.1 Provider ManualsEach PPG must distribute a provider manual to its contractednetwork within Los Angeles County that includes information aboutL.A. Care’s contracted programs.123

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL8.3.2 Orientation Sessions and On-site VisitsProvider orientation sessions and on-site visits will be conducted byPPGs to provide an in-service on their provider manual and toconduct additional training, as needed, for newly contractedproviders and programs within ten (10) calendar days of effectivecontract.8.3.3 Provider Bulletins and NewslettersPPGs should publish and distribute provider newsletters and/orbulletins at least semi-annually. The newsletters should providerelevant and timely information concerning applicable standards,services available to members, quality improvement activities,updates, and other pertinent issues related to the delivery of healthservices to L.A. Care members. Semi-annual general meetingsthat provide updates on health care delivery issues, hosted byPPGs and its providers, will meet the requirement of publishingsemi-annual newsletters/bulletins.8.3.4 Focused Seminars, Workshops and SymposiaL.A. Care and PPGs will work together to conduct focusedseminars, workshops, and symposia on special topics.8.4 PROVIDER DATA MAINTANCE PROCEDURE8.4.1 Adding A New Provider: Prior to adding a new provider record oran additional site for an existing provider into MPD, the ProviderRelations Representative will verify with the Credentialingdepartment that the provider is eligible for inclusion in L. A. Care’sprovider network. The physician must meet all credentialingrequirements and have no sanctions, debarred status, or expiredlicense. All primary care physicians must also receive a passingFacility Site Review score; however, Facility Site Reviews are notrequired for specialty care physicians. Within five (5) days ofreceipt, the Provider Relations representative will, based oninformation contained on the provider profile, enter all eligibleproviders’ data into MPD.8.4.2 Changing Provider Data: Within five (5) days of receiving awritten request via electronic/U.S. mail or fax from a PPG to changea provider’s capacity, specialty, member age parameter, or otherdata element of a provider’s record, the Provider RelationsRepresentative will make the appropriate update in MPD.8.4.3 Changing a Provider’s Address: The Provider RelationsRepresentative will receive written notification, via U.S./electronicmail or fax, from L. A. Care Health Plan’s contracted PPGs advisingthat a provider’s address should be changed. Before the address124

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALchange is made in MPD, the Facility Site Review department mustconfirm a passing score for the new PCP address. No Facility SiteReview is required for a change of address for a specialty careprovider.8.4.4 Closing a Provider’s Panel: The Provider Relationsrepresentative will receive written notification, via U.S./electronicmail or fax, from L. A. Care Health Plan’s contracted PPGs advisingthat a provider’s membership panel should be closed to any newmember assignments. The Provider Relations representative willimmediately close the provider’s panel in MPD.8.4.5 Terminating a Provider: The Provider Relations representativewill receive notification, via U.S./electronic mail or fax, from L. A.Care Health Plan’s contracted PPGs advising that a provider hasbeen terminated from the entity’s network. Prior to terminating aprovider’s record in MPD, the Provider Relations representative willnotify Member Services, via a “Change Form”, that membersassigned to the physician must be moved to a new PCP asdesignated by the PPG. Once the members have received aminimum 30-calendar day prior notification before the provider’stermination effective date and have been re-assigned to the newPCP, Member Services will notify the Provider RelationsRepresentative of the transfer via the “Change Form”. The primarycare physician’s record will then be inactivated in MPD. Themember transfer process is not applicable for specialty careproviders. L.A. Care will make a good faith effort to provide writtennotice of a termination of other contracted providers at least 30calendar days before the termination effective date to all memberswho are patients seen on a regular basis by the provider whosecontract is terminating, irrespective of whether the termination wasfor cause or without cause. Completion of the provider terminationprocess in MPD by the Provider Relations Representative shouldoccur within a 5-day timeframe.8.5 PROVIDER UPLOAD PROCESS8.5.1 It is L.A. Care’s goal to maintain current and accurate data for eachprimary care physician, specialist, mid-level, non-physician andancillary provider associated with L.A. Care’s contracted PPGs.The quarterly provider upload is the process by which this isaccomplished. To ensure that all additions, changes, andterminations are captured in an accurate and timely manner, eachPPG is required to submit, on a quarterly basis, a provider uploadfile that includes all changes to their provider network. Threeweeks prior to each calendar year quarter, each PPG will receive,125

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALvia email, an excel spreadsheet including the PPG’s active providernetwork as it currently resides in L.A. Care’s provider database.The PPG is required to update each provider record, whereapplicable, and electronically submit the spreadsheet to ProviderNetwork Research and Analysis within three weeks of receipt.8.5.2 To assist L.A. Care’s contracted PPGs in submitting provider datarecords that are accurate and complete, an Upload Packageaccompanies each provider upload file. The contents of thissupplemental package are found in Exhibit 11 of the servicesagreement and include the following:• A cover letter that defines the purpose of the upload,instructional information on the correct manner in which toupdate the file, and submission timeframe guidelines.• Data specification tables for each provider type: primary carephysician, specialist, mid-level, non-physician and ancillary.• A current copy of the L.A. Care’s MPD Technical Bulletin tobe used as a reference tool.8.6 PROVIDER DIRECTORIESL.A. Care produces a provider directory for each product line on a regularbasis. The directory includes a listing of all the PPGs, PCPs, hospitalsand pharmacies. Data for the directory will be compiled by L.A. Care fromPPG provider uploads. Upon request, L.A. Care will send a directory tothe requesting party.8.7 MID-LEVEL MEDICAL PRACTITIONERS8.7.1 The use of non-physician practitioners is designed to increasemembers’ access to appropriate primary care and specialty medicalservices, maximize the patient’s health and well-being, andpromote cost-effective care. The delegation of specified medicalprocedures to non-physician practitioners does not relieve thesupervising physician of ultimate responsibility for the welfare of thepatient or the actions of the non-physician practitioner.8.7.2 Physicians may supervise up to four mid-level medical practitionersaccording to the following ratios of a full-time equivalent physiciansupervisor to mid-level medical practitioners:8.7.2.1 One physician to four nurse practitioners8.7.2.2 One physician to three certified nurse midwives8.7.2.3 One physician to two physician assistants8.7.2.4 Four non-physician practitioners in any combination thatdoes not include more than three certified nurse midwives126

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALor two physician assistants and maintain the full-timeequivalence limits.8.7.3 A single non-physician practitioner can potentially increase thesupervising physician’s capacity by 1,000 members. However,when all practitioners are added, the physician cannot beresponsible for more than 5,000 patients in total. The nonphysicianpractitioner may only provide those medical services thathe/she is competent to perform and that are consistent with thepractitioner’s education, training and experience, the terms of whichmust be delineated in writing by the supervising physician. Thestipulated scope of practice must be in full compliance withstandards set forth by the Physician Assistant ExaminingCommittee of the Medical Board of California, California Board ofNursing, the Nursing Practice Act, DMHC the California Code ofRegulations, the California Administrative Code, the CaliforniaBusiness and Professions Code, and the requirements of any otherapplicable professional licensing body, law and regulations.8.7.4 A scope of practice agreement which is signed by the nonphysicianpractitioner and the supervising physician, as well asstandardized procedures, must be filed and maintained at themedical practice site. The scope of practice agreement mustaddress the following elements:8.7.4.1 Delegated responsibilities8.7.4.2 Disciplinary policies8.7.4.3 Method and frequency of physician supervision8.7.4.4 Monitoring and evaluation of the non-physician practitioner8.7.4.5 Chart review requirements8.7.4.6 Term of the agreement/contract8.7.5 The following requirements must be included within thestandardized procedures for mid-level medical practitioners, andreflected in written agreements as indicated above:8.7.5.1 The supervision or back-up physician must be available inperson or through electronic means at all times when thenon-physician practitioner is caring for patients.8.7.5.2 The supervising physician must review on a continualbasis tasks delegated to the non-physician practitioners forcompetency.8.7.5.3 Medical record documentation by the non-physicianpractitioner must be reviewed and counter-signed by thesupervising physician within thirty (30) calendar days of thedate care was provided.127

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL8.7.6 Each PPG must set and implement credentialing elements for midlevelmedical practitioners and ensure that they are consistent withthe criteria and scope of practice requirements set forth in thismanual and any other policies, procedures, and directives issuedby L.A. Care. As part of the credentialing process, the appropriatecredentialing committee, prior to the provision of care by mid-levelmedical practitioners, must verify that a signed scope of practiceagreement, a signed set of procedures by the supervising provider,and appropriate license(s) are present. L.A. Care will audit thePPG’s credentialing verification process.8.8 ELIGIBILITY LISTS8.8.1 Monthly Eligibility lists (E-lists) are provided to PPGs by or on thetenth (10 th ) business day of each month. The E-list containscurrent information through the last day of the previous month formembers assigned to PCPs with each PPG. Daily eligibility can beverified by L.A. Care’s IVR system or by using L.A. Care Connect.8.8.2 Medicare Advantage–SNP E-lists will follow the same process asoutlined in section 8.9.1 above except they will contain that month’scurrent member eligibility information.8.8.3 Please call L.A. Care’s Provider Information Line at 1-866-LACARE6 or your assigned Provider Network Representative if youhave any questions about your eligibility lists.8.9 PROCEDURE FOR HANDLING PROVIDER QUESTIONS &CONCERNS8.9.1 CommunicationProviders can communicate their questions and concerns to theirPPG or to L.A. Care directly. Providers may communicate with L.A.Care by telephone, in person, in writing, or by e-mail.8.9.2 Resolution8.9.2.1 Provider Network Representatives from the PPG or L.A.Care will be able to answer most provider questions andresolve provider concerns immediately. Any question orconcern, which suggests a quality of care issue, will behandled as a clinical grievance. Any question regardingPart “D” benefits will be forwarded to the L.A. Care HealthPlan Part “D” hotline. [What is the Part D hotline and wheredoes it go?]8.9.2.2 The provider network representative will answer theprovider’s question and inform the provider of his/her right128

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALto file an informal complaint or formal grievance if desired.If the provider asks a question over the telephone or inperson, the answer will be provided orally. If the providerwrites a letter, the answer will be provided in writing withinseven (7) business days.8.10 PROVIDER GRIEVANCESProvider administrative grievances will be handled as specified below.8.10.1 Communication of Formal Grievances8.10.1.1 Providers must communicate their formal grievancesdirectly to their PPG. This communication may be over thetelephone, in person or in writing.8.10.1.2 If the provider wishes to file a formal grievance, theProvider Network Representative will give the providerdetailed instructions for filing a grievance. The ProviderNetwork Representative will assist providers in filinggrievances, including assistance with completing agrievance form, if applicable.8.10.1.3 The Provider Network Representative will record thegrievance on the provider grievance log. Regardless of themethod of filing of the provider’s grievance, the providernetwork representative will send an acknowledgment letterto the provider within five (5) working days.8.10.1.4 If a provider contacts L.A. Care directly with a grievance,the L.A. Care Provider Network Representative will recordthe information on the provider grievance log, contact theprovider’s PPG, and send an acknowledgement letterwithin five (5) business days. The PPG will be responsiblefor resolving the grievance within thirty (30) calendar daysand informing L.A. Care of the resolution/disposition. L.A.Care will be responsible for informing the provider of theresolution/disposition in this case.8.11.2 Resolution8.11.2.1 All grievances will be resolved within thirty (30) calendardays.8.11.2.2 Extensions to grievances will be requested to the ProviderRelations Manager. A fifteen (15) or thirty (30) calendarday extension may be granted. If an extension is granted,129

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALa letter to the grieving provider will be sent with appropriatereasons for the extension.8.11.2.3 The PPG and/or L.A. Care will provide written notice ofgrievance resolution/disposition and deliver each letter byway of certified mail.8.11.3 Dispute Resolution8.11.3.1 A provider has the right to file an appeal. The providermust submit a detailed written grievance, including thedesired resolution and all supporting documentation andcorrespondence to the PNO Director at L.A. Care. L.A.Care will respond with an acknowledgement letter withinfive (5) business days.8.11.3.2 A Provider Relations Subcommittee will convene withinthirty (30) calendar days of receipt of the dispute to decidewhether the committee has authority to address the issue.The grieving party will have the opportunity to address theissue in front of the committee if L.A. Care’s committee hasdeemed it applicable. A resolution will be made by thecommittee with notification to the provider within seven (7)business days of the decision.8.11.3.3 All providers have the right to file a grievance with theDepartment of Managed Health Care (DMHC). The tollfreetelephone number is (800) 400-0815. If you have agrievance against L.A. Care Health Plan, contact L.A. Careand use our grievance process.130

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL9.0 HEALTH PROMOTION & EDUCATIONHealth promotion and education is the process of providing health information,skill training, and support to individuals to enable and empower them to modifytheir behaviors and improve their health status. In order to ensure effectiveness,health promotion and education activities should be well-planned and continuallyevaluated.L.A. Care places a high priority on the provision of health promotion andeducation services for its members. The Health Promotion Servicesdepartment’s goal is to provide guidelines for the implementation and provision ofmember health education services. These requirements are designed to providedirect contract Participating Physician Groups (PPGs) with guidelines to developand enhance quality health education programs. L.A. Care’s Health PromotionServices department will provide resource information, educational material andother program resources to assist PPGs in providing effective health educationservices for L.A. Care members.STAFFINGL.A. Care Health Plan PPGs must designate at least one staff personresponsible to serve as a liaison at L.A. Care Health Plan biannual healtheducation meetings. The designated individual(s) are responsible forcoordinating, monitoring, tracking and reporting health education activitiesand resources. The roles and responsibilities of this staff person must beincluded in organizational documents such as job description(s) andpolicies and procedures.PROGRAM DESCRIPTIONPPGs are required to develop a health education program description.The program description details the structure and responsibilities of thedepartment. The document should be reviewed and, if necessary, revisedannually to reflect changes and improvements to the health educationprogram. The program description must be available for review at sitevisits and upon request. The program plan must include:• Organizational structure and accountability• Identification of health education staff• Description of staff responsibilities• Scope of services and overview of the health education programWORK PLAN(January 31 st Deadline)PPGs are required to develop an annual health promotion and educationwork plan. The work plan should outline the activities that will beimplemented throughout the year in order to enhance the PPG healthpromotion and education program. The work plan must be submitted to131

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL.A. Care’s Health Promotion Services department by January 31st ofeach year for review. A template will be provided for use; however, otherformats may be used. The PPG should review the work plan and revise ifnecessary, in order to ensure that activities are carried out according tothe established timeframes. An evaluation should be conducted at theend of the year to determine if all activities were completed. The workplan shall contain the following elements:• Goals• Objectives• Timeline (expected completion dates)• Person(s) responsible• Evaluation methodL.A. Care Health Plan Delegation and Monitoring of HealthEducation ServicesL.A. Care Health Plan’s HPS Department operates on a shared model ofdelegation for our direct product lines.The following delegation matrix details the responsible party for key healtheducation functions.CriteriaHealth Education Program Description &WorkplanOversight and Monitoring of DelegatedSucontractorsFunction becomes a PPG responsibility if thePPG delegates out the responsibility for healtheducation.Health Education ServicesProvision of health education services in allrequired topics and languages; breastfeedingeducation; diabetic self management programs.Health Education Services ReferralReferral process for coordinating healtheducation services, attendance follow-up anddocumentation.Promotion of Health Education Services tomembers; methods may include, but are notlimited to: newsletters, flyers, direct/targetingmailings, web postings, etc.Health Education MaterialsAvailability of materials in all required topics andResponsibilityL.A. PPG SharedCareX XXXXXX132

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCriterialanguages, ordering and distribution processMaterials Review ProcessReview of materials to ensure compliance withreading level, medical accuracy and cultural andlinguistic appropriateness; completion of thematerials review form. Function becomes aPPG responsibility if the PPG utilizes materialsnot previously approved by L.A. Care HealthPlan.Provider EducationCommunication of health educationrequirements and resources to providersDocumentation and Reporting of HealthEducation Utilization and MaterialsDistributionMonitoring and tracking of health educationreferrals/encounters and materials distribution;quarterly report submissionImplementation of “Staying Healthy”Behavioral AssessmentProvision and implementation of assessmentforms and additional resources, provision of ongoingtraining and education, ordering anddistribution processGroup Needs AssessmentsDevelopment, implementation and evaluation ofhealth education and cultural and linguisticgroup needs assessments on L.A Caremembers according to contractual requirements;incorporation of GNA findings in thedevelopment of health education programs.XXResponsibilityL.A. PPG SharedCareXXXXPROVISION OF HEALTH EDUCATION SERVICESDelivery MethodsHealth promotion and education services can be carried out in oneof the following formats: one-on-one counseling, classes, or supportgroups. Health education services must be provided at no cost tomembers.Individual CounselingA health educator, physician, nurse, community healthworker/promotora, or other staff who is trained to instruct on133

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALthe specific health issue being addressed may provide oneon-onecounseling in person or by telephone. The one-ononecounseling session should be conducted as a separatesession in addition to brief counseling provided during officevisits.ClassesClasses may be taught by a health educator, physician,nurse, community health worker/promotora, or otherindividual who is trained on the specific health issue beingaddressed. Health promotion and education classes can besingle or multiple sessions.Support Group SessionA health educator, physician, nurse, community healthworker/promotora, or other individual trained as a facilitatorfor the specific health issue being addressed may leadsupport group sessions. Sessions are usually one to twohours in duration and provide emotional and social supportfor patients.ContentHealth promotion and education programs should take into accountage, education level, cultural beliefs, language, and learning styles.Health promotion and education programs must include thefollowing regardless of delivery method or topic:• General overview of the disease or condition. Generalinformation includes the basic definition, cause of disease,signs and symptoms, modes of disease transmission, effect,impact of behavior and preventive health guidelines• Methods of primary, secondary and tertiary prevention asappropriate• Skills needed to achieve desired outcome/management• Patient identification of barriers to achieving desiredoutcomes• Referral to community resources for additional support asneeded• Action plan to achieve goalOutlines and CurriculumAll health promotion and education programs offered to membersshould have a written outline and/or curricula. PPGs should have acopy of the program outline and/or curriculum on site and availablefor review upon request by L.A. Care. If a PPG refers members toa hospital or community-based health education program, the PPGshould obtain a class outline or curriculum for the program prior toreferral. Outlines and curricula should include the following:• Measurable goals and objectives• Content outline• Copy of evaluation tool134

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALTopics/Threshold LanguagesPPGs, with assistance from L.A. Care must ensure all L.A. Caremembers have at minimum the following program topics andthreshold languages. This list is subject to change.Health Education Topics Threshold LanguagesAnticipatory GuidanceEnglishAsthmaSpanishBreastfeedingArmenianDental HealthChineseDiabetesFarsiExerciseKhmerFamily PlanningKoreanHIV/STD PreventionRussianHypertensionTagalogImmunizationsVietnameseInjury PreventionNutritionParentingPerinatal / PregnancySubstance AbuseTobaccoPrevention/CessationWeight ManagementReferral ProcessPPG has evidence of a systematic process and mechanism forreferring L.A. Care Health Plan members to Health Educationservices. This process begins with a provider or self referral andconcludes with documentation in the member’s medical recordverifying attendance and needed follow-up. Documentation ofreferral process includes, but is not limited to:o Referral formo Referral logo Policy and procedureo Provider manualo Health Education program descriptionDocumentation/Documentation ReviewAll relevant educational encounters must be documented in themember’s medical record and the PPG’s health promotion andeducation program utilization records. Documentation shouldinclude the date, the health promotion and education activityrendered (one-on-one, class, or support group session), and healthpromotion and education resources provided (brochure, newsletter,videotape, audiotape) and initialed by the health professional135

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALproviding the education. This documentation in the patient’smedical record will be verified during L.A. Care’s annual facility sitereview.Program EvaluationAll programs must conclude with an opportunity for members tocomplete a written participant evaluation. Evaluation forms shouldassess the overall satisfaction of the program including the qualityof the instructor, quality of the content presented, whetherparticipant expectations were met, location, room, time of day, andprogram recommendations. Evaluation forms should also be madeavailable for participants receiving one-on-one counseling. Copiesof completed participant evaluations must be available for review.PROVISION OF HEALTH EDUCATION RESOURCES AND MATERIALSL.A. Care has available at least one approved health educationmaterial for each health topic. Many of the samples are camerareadyand can be used to make photocopies. PPGs/providers mayuse the L.A. Care health education materials order form to requestfree copies.Health promotion and education resources and materials must beprovided at no cost to individuals. Health materials and resourcesare meant to supplement, not replace, health promotion andeducation services such as one-on-one counseling, classes, andsupport group sessions. Materials and resources can assistindividuals in the learning process. Some examples of materialsand resources include brochures, videos, audiotapes and membernewsletters. Because each individual learns differently, using acombination of these tools can further enhance the effectiveness ofhealth education activities. Member health education materials(printed) are often re-read or used as a reference after a healtheducation activity. DVDs and audiotapes can be used during aclass or in a support group session to help illustrate concepts.Material Review FormMember health education materials provided by L.A. Care will meetlanguage, minimum 12 pt. font size, reading level, culturalcompetency, medical accuracy and program topic requirements.Material Review Forms will be kept on file in the Health PromotionServices department.Reading LevelAll member health education materials must be reviewed prior todistribution to members to assure quality, effectiveness, and bewritten at a maximum of a 6 th grade reading level. The Fry ReadingTest is recommended; however, other tests may be used. Health136

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALeducation materials distributed at providers offices andsubcontracted health education agencies shall comply with thereading level requirements.Medical AccuracyAll member health education materials shall be reviewed formedical accuracy. Individuals qualified to review member healtheducation materials are registered nurses, physicians or specialistsin the field appropriate for topic.PPG Material ReviewIt is the responsibility of PPGs to review materials that are notprovided by L.A. Care Health Plan or its Plan Partners.In the event a PPG chooses to use a material not previouslyreviewed and approved by L.A. Care, the PPG must conduct areview using L.A. Care Health Plan’s current Materials ReviewForm. PPG must submit a completed Material Review Form, alongwith sample material, to L.A. Care Health Plan’s Health PromotionServices Department prior to distribution to members. Copies ofMaterial Review Forms must be kept on file by the PPG for reviewduring L.A. Care Health Plan site visits or annual audits.L.A. Care Health Plan Health Promotion Services is available toprovide technical assistance on the materials review process.REPORTINGPPGs must submit reports summarizing member referrals to andutilization of health education programs and materials distribution toproviders and members. Report templates are available for use; however,groups may use other reporting forms. All reports should be faxed or e-mailed to L.A. Care’s Health Promotion Services department. See tablebelow for schedule:Quarterly Reporting Schedule:QuarteMonthsDue Dater1 January/February/March April 252 April/May/June July 253 July/August/September October 254 October/November/December January 25137

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALHealth Education Referrals ReportPPGs are responsible for reporting health education referrals byL.A. Care MCLA members. The report will include the followinginformation:• Health issues addressed• Number of patient referrals to each health educationprogram• Number of patients that attended each health educationprogram• Type of service, i.e., one-on-one counseling, class, supportgroup• Language in which service was provided or requestedMaterials Distribution ReportMaterials distribution reports shall include a list of all memberhealth education materials distributed to providers and members.Information requested includes:• Date of distribution• Title of material• Number of copies distributed• Language in which materials requested• Names of provider or member requesting/receiving thematerialsINDIVIDUAL HEALTH EDUCATION BEHAVIORAL ASSESSMENT TOOL –“STAYING HEALTHY”PPGs are responsible for ensuring the use of the Individual HealthEducation Behavioral Assessment (also called “IHEBA” or “StayingHealthy”) by contracted physicians. The goals of the IHEBA are to:• Identify high-risk behaviors of plan members.• Prioritize individual health education needs related to lifestyle,environment, and cultural and linguistic background.• Assist physicians in initiating and documenting focused healtheducation intervention and follow-up.PPGs must ensure the “Staying Healthy” Behavioral Assessment Tool isadministered to all new L.A. Care members as part of the Initial HealthAssessment within 120 calendar days of effective enrollment, and to allexisting members who present for a scheduled visit.PPGs are responsible for the distribution of the assessment tool to theircontracted providers. Assessment forms and educational tip sheets maybe obtained from L.A. Care by using the Materials Order Form oraccessing L.A. Care’s website at www.lacare.org.138

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALPPGs share the responsibility with L.A. Care for provider educationactivities related to the “Staying Healthy” Behavioral Assessment Tool.Each contracted physician should have access to necessary resources toprovide targeted health education to members such as tip sheets,brochures, pamphlets and other health education resources. L.A. CareHealth Promotion Services department is available to provide training andtechnical assistance to help PPGs meet this requirement.Methods of educating providers about “Staying Healthy” include, but arenot limited to classes, newsletters, faxes, provider manuals and targetedmailings. PPGs must maintain documentation, such as agendas, meetingminutes and sign-in sheets, for all provider education sessions related tothe “Staying Healthy” Behavioral Assessment Tool. The PPG shouldmaintain copies of all correspondence regarding “Staying Healthy.”PROVIDER EDUCATIONPPG must use a minimum of two educational strategies to educateproviders on L.A. Care health education requirements and availablemember health education resources. Health education resourceinformation should include types of health education services andprograms offered in available threshold languages, location and frequencyof health education services, and contact information to request additionalinformation.Provider education includes, but is not limited to:• FORMAL TRAININGS• PRESENTATIONS AT PROVIDER MEETINGS• INDIVIDUAL PROVIDER IN-SERVICES• INFORMATION PROVIDED IN NEWSLETTERS,MEMOS, BLAST-FAXES, MAILINGS, ETC.Supporting documentation of provider education must be available for reviewand should include:• Copies of program handouts or correspondence• Sign-in sheets• Agenda/Training Outline• Meeting MinutesOVERSIGHT AUDITSOversight audits of L.A. Care Health Plan’s directly contracted PPGs areconducted during the due diligence process, and thereafter annually to monitorPPG compliance with Health Promotion Services Department policies andprocedures, and state and national regulatory requirements. Wherever possiblethese audits may be done in conjunction with other L.A. Care Health Plandepartments to improve efficiencies and decrease duplication. The oversightaudit consists of document review and staff interviews to verify compliance withand implementation of policies, procedures and processes.139

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL10.0 CULTURAL & LINGUISTIC SERVICESCultural and linguistic competence is an on-going learning process thatprofoundly impacts the diverse communities within Los Angeles County.The direct relationship between culture, language and health is complexand inextricably linked to the health status of individuals and subsequentlycommunities. For this reason, it is essential that L.A. Care andParticipating Provider Groups (PPGs) strive to ensure culturally andlinguistically competent healthcare services to members.PPGs' Cultural & Linguistic Services Program must be consistent with L.A.Care Health Plan’s Cultural & Linguistics Program and meet State andFederal requirements and regulations.10.1 STAFFINGPPGs must designate at least one staff person who is responsible for thecoordination and tracking of cultural and linguistic services. To encouragecollaboration and coordination of services, the designated individual shallparticipate in L.A. Care cultural and linguistic liaison meetings, heldquarterly with L.A. Care Cultural & Linguistic Services Department staff.PPGs must ensure that the roles and responsibilities of the designatedcultural and linguistic staff member are included in organizationaldocuments, including, but not limited to, job description and policies andprocedures.10.2 INTERPRETATION SERVICESPPGs are required to make available interpretation services, including inAmerican Sign Language, to L.A. Care members at all times. PPGs mayaccess these services via L.A. Care’s contracted agency, or may contractwith agencies that provide interpretation services. Interpretation servicesshould be provided by a qualified interpreter who is either on-site atprovider facilities or available by telephone. Interpretation services to L.A.Care members must be provided at no cost to all L.A. Care members.PPGs and their network providers cannot require members to provide theirown interpreters. However, friends and family members may be used asinterpreters, if requested by the member after being informed of their rightto free professional interpretation. Member refusal of the use of aninterpreter must be documented in the member’s medical records. Minorsare not permitted to interpret except under the most extraordinarycircumstances, such as a medical emergency.Providers are also required to document member language preference,including American Sign Language in the medical record.To ensure clarity regarding interpretation services, PPGs are required todevelop, implement and monitor policies and procedures for both theirown organization and their subcontracted provider network. PPGs are also140

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrequired to educate their staff and provider network about interpretationservices available through L.A. Care.10.3 ACCESSING INTERPRETATION AND AMERICAN SIGN LANGUAGE(ASL) SERVICESIt is required that provider facilities post interpretation services signagetranslated in L.A. Care threshold languages. The signage must be visibleto members and clearly state the members’ right to request freeinterpretation services.If PPGs do not have a contract with an interpretation service agency, theymay access L.A. Care’s interpretation services for telephonic and face-tofaceinterpretation as well as ASL. To ensure the availability of aninterpreter, provider requests for face-to-face interpretation and ASL mustbe made to L.A. Care's Cultural & Linguistics Services Departmentthrough the Interpretation Project Coordinator at least seven (7) businessdays prior to the member’s appointment. For telephonic interpretationservices, providers can access services by using the following steps:Step 1: Call L.A. Care Health Plan’s Member Services line at 1-888-839-9909 24-hours a day.Step 2: Prepare to give the following information to member servicesrepresentative:• Access code• Language needed• Caller’s name• Patient’s program• Member ID number• Provider Site number10.4 ACCESSING CALIFORNIA RELAY SERVICE (CRS) FOR MEMBERSWITH HEARING OR SPEECH LOSSPPGs and network providers can call the CRS directly for members withhearing or speech loss. The statewide access for voice orTeletypewriter/Telecommunications Device for the Deaf (TTY/TDD) is 1-888-877-5379 voice (SPRINT) or 1-800-735-2922 voice (MCI).California Relay Service (CRS) is an exchange service that can be used tocontact a member. A member can also use the service to contact his/herprovider. CRS enables a person using a TTY to communicate with aperson who does not use a TTY by phone. The service also works inreverse by allowing a non-TTY user to call a TTY user. Trained relayoperators are on-line to relay the conversation as it takes place.*Note: Many older deaf people or grassroots community members maynot recognize the term TDD, it is recommended to use TTY or TTY/TDD.141

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL10.5 LANGUAGE PROFICENCYClinical and non-clinical bilingual staff members who interface with limitedEnglish proficient members are required to be assessed using theEmployee Language Skills Self– Assessment Tool developed by theIndustry Collaboration Effort (ICE). A print ready copy of the tool isavailable from L.A. Care’s Cultural & Linguistic Services Department orfrom the ICE website athttp://www.iceforhealth.org/library/documents/ICE_Booklet.pdf. PPGs arerequired to further document any training completed, as well as thenumber of years served/worked as an interpreter, by bilingual staff.Physicians are required to complete the Employee Language Skills Self–Assessment Tool once every three years; other staff members arerequired to complete the tool annually. Completed assessments arerequired to be on file and available during L.A. Care site visits.10.6 MATERIALS TRANSLATIONAny materials that are translated by PPG or provider staff are required toadhere to L.A. Care's Cultural & Linguistic Services Departmenttranslation process. The process includes translation and second reviewby two separate individuals. PPGs are strongly encouraged to contractwith a qualified translation services vendor. If PPG or provider staff areused for translations, the staff member(s) responsible for translations musthave qualifications on file (such as an ATA membership or formallanguage assessment). Translations done by in-house staff must alsoundergo a second review by a qualified translator. PPGs must track allmaterials translated (either by contracted vendors or by in-house staff),and must keep a copy of the source document, the translated document,and a signed attestation available for review during annual audits.10.7 COMPLAINTS & GRIEVANCESIn accordance with state and federal laws, members have the right to file acompliant or grievance if they have been denied interpretation service or ifmember information was not available in their primary language. Allcomplaints and grievances are filed with L.A. Care’s Member ServicesDepartment and are routed to the appropriate areas within theorganization.10.8 REFERRALS TO CULTURALLY APPROPRIATE SOCIAL SERVICESPPGs and providers are required to refer members to culturally andlinguistically appropriate services and documentation of referrals areforwarded to L.A. Care Health Promotion Service Department on quarterlybases. To facilitate provider referral to community resources, L.A. Caredeveloped and distributed the Community Resources Directory – Health &Social Service Agencies 2008. Providers are required to document allmember referrals to health education and social service agencies in the142

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALmember’s medical record. Member medical records will be monitored forreferral documentation during facility site review.10.9 PROVIDER EDUCATION/TRAININGPPGs are responsible for educating network providers on cultural andlinguistic requirements, programs, and services. PPGs are also required toattend and promote cultural competency trainings and the Health CareInterpretation Training Program made available by L.A. Care.Supporting documentation of provider education must be available forreview and must include:• Copies of program handouts or correspondence• Sign-in sheets• Agenda/ Training Outline• Meeting minutes10.10 MONITORING/COMPLIANCEPPGs are required to develop and distribute policies and procedures thatoutline all cultural and linguistic requirements listed in this providermanual. PPGs are also responsible for provider education and oversightto ensure full compliance with state and federal laws.143

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL11.0 FINANCEUnder contractual agreement, each month L.A. Care and Participating PhysicianGroups (PPGs) accept capitated payments for the provision of health services toL.A. Care members, regardless of how frequently members access services.This section covers guidelines for financial reports and requirements, capitation,and other related issues.11.1 CAPITATION PAYMENTS11.1.1 One-hundred percent (100%) of capitation payments will beremitted to a PPG no later than the tenth (10) calendar days(except as defined in “Financial Security Requirements,” and“Assumption of Financial Risk”). The payments will constitutepayment in full for health care and administration services renderedunder the PPG’s L.A. Care Services Agreement.11.1.2 FOR FURTHER INFORMATION REGARDING PPGCOMPENSATION, PLEASE REFER TO THE CAPITATIONSCHEDULE OF THE L.A. CARE PHYSICIAN CAPITATEDSERVICES AGREEMENT.11.2 CAPITATION STATEMENT REPORT11.2.1 A Capitation Statement Report will be placed in a protected PPGweb site on or before the tenth (10) business day of every month.The Capitation Statement Report will provide a summary of thecapitation payment for each enrolled member assigned to eachPPG, and will include the following information:• Number of current active enrollees (initial eligibles).• Number of retroactive disenrollments (decaps). This numberrepresents the number of retroactive disenrollment monthsprocessed.• Capitation amount.• Capitation total.11.2.2 The Capitation Statement Report is also used to create the GroupCapitation Payment Summary Report.11.3 INSURANCEEach PPG is responsible for total costs, except as provided herein, forcare rendered to members enrolled with that PPG under the terms of itsServices Agreement with L.A. Care. The PPG must maintain adequateinsurance set forth in the following:11.3.1 Professional Liability Insurance. The PPG has, and shallmaintain at its expense throughout the term of this Agreement,Professional Liability Insurance for each Affiliated Provider withlimits of not less than one million dollars ($1,000,000.00) per144

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALoccurrence and three million dollars ($3,000,000.00) in theaggregate for the year of coverage or such other amountacceptable and permitted by Health Plan in writing. PPG shallprovide reasonable prior written notice to Health Plan of a changeof insurance carrier for Health Plan’s prior written approval, whichapproval shall not be unreasonably withheld. PPG shall providecopies of such insurance policies within five (5) business days of awritten request by Health Plan.11.3.2 FTCA Alternative. In lieu of providing Professional LiabilityInsurance as set forth in Section 1.13(a), PPG may provide HealthPlan with evidence of liability protection under the Federal TortClaims Act by the Bureau of Primary Health Care in accordancewith Section 224(h) of the Public Health Service Act, 42 U.S.C.233(h), as amended (“FTCA Coverage”). However, PPG shallensure that only those providers covered pursuant to section1.13(a) or under FTCA Coverage may provide provider services tomembers.11.3.3 Reinsurance/Stop-Loss Insurance. The PPG must maintainadequate stop-loss insurance to cover PPG’s catastrophic cases inan amount reasonably acceptable to L.A. Care, but in no event lessthan thirty thousand dollars ($30,000.00) plus fifty percent (50%) ofany medically necessary billed charges.The cost of the PPG’s reinsurance/stop-loss coverage is the PPG’ssole financial responsibility.11.3.4 General Liability Insurance. The PPG shall maintain generalliability insurance in at least the minimum amounts acceptable toL.A. Care to cover any property loss that is not covered under anylease agreement with the landlord, or contract agreement with themanagement company. The limits of liability shall not be less than$100,000.00 for each claim and $300,000.00 in aggregate undereach policy period.11.3.5 Errors and Omissions Insurance. The PPG shall maintain Errorsand Omissions Insurance in at least the minimum amountsacceptable to L.A. Care to cover the claims made against itsDirectors and Officers. The insurance shall be written on a claimmade basis. The limits of liability shall not be less than$100,000.00 for each claim and $100,000.00 in aggregate undereach policy period.11.3.6 Independent Certified Public Accounting Firm LiabilityInsurance. PPG shall ensure that all independent certified publicaccounting firm conducting audits on PPG’s financial statements145

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALmaintain at its expense throughout the term of this agreement,liability insurance with limits of not less than two hundred and fiftythousand dollars ($250,000.00) in aggregate for the year ofcoverage or such other amount acceptable and permitted byhealthplan in writing. PPG shall provide copies of such insurancepolicies within five (5) business days of a written request byhealthplan.11.4 MINIMUM FINANCIAL SOLVENCY STANDARDS11.4.1 Each PPG must maintain adequate financial resources to meet itsobligations as they become due. PPGs contracted with L.A. Careshall be solvent at all times, and shall maintain the followingminimum financial solvency standards:11.4.1.1 Prepare quarterly financial statements in accordance withGenerally Accepted Accounting Principles (GAAP). Thesefinancial statements must be submitted to the FinancialCompliance department of L.A. Care no later than 45calendar days after the close of each quarter of the fiscalyear.11.4.1.2 Reimburse, contest or deny at least ninety-five percent(95%) of all claims (for all lines of business) consistent withapplicable law, regulation and contractual timelinessrequirements.11.4.1.3 Estimate and document, on a monthly basis, theorganization’s liability for incurred but not reported (IBNR)claims using a lag study, an actuarial estimate, or otherreasonable method as stipulated by Title 28, CaliforniaCode of Regulations, Section 1300.77.2.11.4.1.4 Maintain at all times a positive Working Capital (currentassets net of related party receivables less currentliabilities).11.4.1.5 Maintain at all times a positive Tangible Net Equity (TNE)as defined in Title 28, California Code of Regulations,Section 1300.76(e).11.4.1.6 Maintain a “Cash to claims ratio” (cash, readily availablemarketable securities and receivables, excluding all riskpool, risk-sharing, incentive payment program and pay-forperformancereceivables, reasonably anticipated to becollected within 60 days divided by the organization’sunpaid claims (claims payable and incurred but notreported (IBNR) claims) liability as listed per SB 260 Title146

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL28, California Code of Regulations, Section 1300.75.4.2.Maintain at all times a “cash to claims ratio” of .60 as ofJanuary 1, 2006, .65 as of July 1, 2006 and .75 as ofJanuary 1, 2007.11.4.1.7 On an annual basis, submit to the Financial Compliancedepartment of L.A. Care, financial statements audited byan independent Certified Public Accounting Firm within 150calendar days after the close of the fiscal year.11.4.2 Each PPG must actively monitor its providers to measure theirfinancial stability. Copies of all reports, including findings,recommendations, corrective action plans, and other informationregarding these reviews must be provided to L.A. Care uponrequest.11.4.3 On a discretionary basis, the Financial Compliance department ofL.A. Care will have the right to periodically schedule audits toensure compliance with the above requirements, CMSrequirements and all regulations per SB 260 Title 28, CaliforniaCode of Regulation requirements. Since the financial solvencystandards apply to the entity as a whole, the audits will beconducted for all books of business, not only for the line(s) ofbusiness contracted with L.A. Care. Representatives of the PPGsshall facilitate access to records necessary to complete the audit.11.5 REIMBURSEMENT SERVICES AND REPORTS11.5.1 In accordance with the provisions of PPG’s Subcontracts, the PPGwill provide all normal reimbursement services, including thoserelating to the payment of capitation, processing and payment ofany claims on a fee-for-service basis, administration of any stoplossand risk-sharing programs, and any other paymentmechanisms. Claims processing may be delegated to PPGs incases where utilization management is delegated.11.5.2 Upon request, the PPG will provide to L.A. Care a copy of paymentrecords, summaries and reconciliations with respect to L.A. Caremembers, along with any other payment compensation reportswhich the PPG customarily provides to its providers.11.6 RECORDS, REPORTS, AND INSPECTION11.6.1 Records Each PPG will maintain all books, records, and otherpertinent information that may be necessary to ensure the PPG’scompliance with its L.A. Care Services Agreement, and therequirements of CMS for a period of 10 years from the final date ofthe contract period or from the date of completion of any audit,whichever is later These books, records, and other information147

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALmust be maintained in accordance with generally acceptedaccounting principles, applicable state law and regulations, andCMS and DMHC requirements.11.6.2 These books and records will include, without limitation, all physicalrecords originated or prepared pursuant to the performance underthis contract including but not limited to:• Working papers• All reports submitted to DMHC• Financial records• All books of account• Encounter data• All medical records• Hospital discharge summaries• Medical charts and prescription files• Any other documentation pertaining to medical and nonmedicalservices rendered to members• Records of Emergency Services and other information asreasonably requested by L.A. Care and DMHC to disclosethe quality, appropriateness, and/or timeliness of health careservices provided to members under the PPG’s PhysicianCapitated Services Agreement• PPG subcontracts• Reports from other contracted and non-contracted providers• Any reports deemed necessary by L.A. Care, CMS andDMHC to ensure compliance by L.A. Care with theregulatory requirements.11.6.3 Each PPG will maintain all books and records necessary todisclose how the PPG is fulfilling and discharging its obligationsunder their L.A. Care Services Agreement, and their responsibilitiesas defined by CMS and DMHC. These books and records will bemaintained to disclose the following:• Quantity of covered services provided.• Quality of those services.• Method and amount of payment made for those services.• Persons eligible to receive covered services.• Method in which the PPG administered its daily business.• Cost of administering its daily business.11.6.4 Inspection of RecordsPPGs will allow L.A. Care, DMHC, DHHS, the Comptroller General,or their designees and any other authorized state and federalagencies to inspect, evaluate, and audit any and all books, records,and facilities maintained by the PPG and its providers as they148

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALpertain to services rendered under the PPG’s Physician CapitatedServices Agreement, at any time during normal business hours,subject to the confidentiality restrictions discussed in the PPG’sPhysician Capitated Services Agreement.The PPG also agrees to require all related entities, contractors, orsubcontractors, and downstream entities to agree that:• DHHS, the Comptroller General, or their designees have the right to inspect,evaluate, and audit any pertinent contracts, books, documents, papers,and records of the related entity(s), contractor(s), or subcontractor(s), anddownstream entities involving transactions related to the L.A. Care’sMedicare Advantage – SNP line of business;• DHHS', the Comptroller General's, or their designee's right to inspect,evaluate, and audit any pertinent information for any particular contractperiod will exist through 10 years from the final date of the contract periodor from the date of completion of any audit, whichever is later.11.6.5 Records Retention TermMedicare Advantage-SNP Line of Business - The PPG’s books andrecords must be maintained for a minimum of ten (10) years fromthe end of the fiscal year in which the PPG’s contract with L.A. Careexpires or is terminated.11.6.6 Financial StatementsAs required by Section 11.8 above, each PPG must provide L.A.Care with a copy of its Quarterly Financial Statements and AnnualAudited Financial Statements. If requested, these financialdocuments, as well as any other reports required by DMHC, will bemade available to DMHC, CMS and any other regulatory agencies.149

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALThis section is subject to change pursuant to receipt ofsupplemental regulations under Title 10.150

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL12.0 Claims – Medicare Advantage-SNP Line of BusinessThis section covers guidelines for claims process and other claims related issuesfor Participating Providers with respect to L.A. Care’s Medicare Advantage-SNPline of business.12.1 RESPONSIBILITY OF PARTICIPATING PROVIDERSParticipating Physician Groups (PPGs), and hospitals contracted with L.A.Care are responsible to perform certain tasks for claims under the terms oftheir agreement in the L.A. Care Medicare Program. After reviewing thissection, please refer to the “Division of Responsibility” in the agreementbetween the PPG, and L.A. Care to determine what entity is responsiblefor specific claims. The “Division of Financial Responsibility,”specifies which health care services are the financial responsibility of L.A.Care, and which are the financial responsibility of the PPG. The PPG isresponsible for handling all claims for those services it is financiallyresponsible.12.2 COLLECTION OF CHARGES FROM MEMBERSNeither the PPG nor any of its providers will in any event submit a claim todemand or otherwise collect reimbursement from an L.A. Care member orpersons acting on behalf of a member for any services provided pursuantto the PPG’s L.A. Care Services Agreement, except to collect anyauthorized co-payments.12.3 Coordination Of Benefits (COB)DEFINITION OF COB:A. Coordination of Benefits (COB) is the procedure to determine the order ofpayment responsibility when a Member is covered by more than onehealth plan or insurer.B. COB is applied in accordance with state and federal law governing COBincluding the Order of Determination of payment.C. LA CARE and PPGs are responsible for identifying other health plans thatare primary to LA CARE and must coordinate benefits for Members inaccordance with state and federal law.D. LA CARE and PPGs must make reasonable efforts to appropriatelydetermine payment of claims for covered services rendered to anyMember who is fully or partially covered for the same service under anyother state or federal program, or other entitlement such as a privategroup or indemnification program.151

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALE. Medicare may be the secondary payer under certain rules as delineatedunder Title 42, Chapter 7 of the Social Security Act and LA Care’sMedicare - Coordination Of Benefits Policy.PROCEDURE FOR COB RECOVERY :A. LA CARE pays PPGs capitation rates as outlined in the LA CARECapitated Agreement, for all Members assigned to them regardless ofother insurance coverage.B. Since all L.A. Care Medicare Advantage SNP members have bothMedicare and Medi-Cal (Medi-Medi) the claim is processed with Medicareas the primary and Medi-Cal as the secondary, following the policies andprocedures outlined in the LA CARE Medi-Cal Provider Manual,“Coordination of Benefits”.C. If the Member has other health coverage in addition to Medicare andMedi-Cal, Medicare may be secondary under certain rules for coordinationof benefit, as outlined below.D. If the Member has other primary health care coverage, the claim isadjudicated at the lesser of the Medicare allowable or the primary payerallowable. LA CARE adjudicates covered services as primary if they arenot covered by the other health coverage. The provider of service mustsubmit such claims with a denial letter or explanation of benefits from theother health coverage.The COB claim determination period is based on the period of time theMember is enrolled with LA CARE. If the Member is not enrolled with LACARE on the date of service, COB is not applicable.LA CARE has the right to obtain and release COB information and may doso without the Member’s or Authorized Representative’s consent.Members must provide an insurer with any information needed to makeCOB determinations and to pay claims.When coordinating benefits, the following Order of Benefits Determinationrules are applied except where Medicare Secondary Payer rulessupersede these guidelines: [I recommend using the same language as inthe Medicare COB policy CLM 004.]E. Medicare Secondary Payer rules supersede other federal and state lawgoverning the coordination of benefits.F. Providers retain any monies collected through COB, in addition to anycapitation received.152

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL12.4 Third-Party Liability (TPL)This policy applies to all LA CARE Medicare Advantage Members. PPGs maymake a claim for recovery of the value of covered services rendered to aMedicare Advantage Member in cases involving the tort liability of a third party orcasualty liability insurance, including Workers’ Compensation awards anduninsured motorist’s coverage.PROCEDURE FOR TPL RECOVERY:A. If the Payer determines that there is reasonable evidence of third partyliability (TPL), the Payer must investigate the claim and request theprovider of service to submit the claim with an EOB/RA showing theamount of payment from the third party.B. If the Payer becomes aware of a claim involving Third Party Liability(TPL), the Payer must pursue recovery of any monies paid in accordancewith state and federal guidelines.C. The Payer must notify the primary insurance payer and/or attorney ofrecord of its intent to recover. Additionally, the Payer must provide copiesof all related claims with its notification.D. The Payer should regularly communicate and follow-up with all involvedparties every 30 days until resolution is complete.12.5 CLAIMS SUBMISSIONSubmitted claims must be completed with all required information toensure timely processing and payment as stipulated in the provider’scontract.12.5.1 BillingAll paper claims must be submitted on CMS 1500 form forprofessional services and UB-04 forms for facility services.12.5.2 Claim Filing LimitThe provider shall bill using appropriate forms and in a manneracceptable to L.A. Care or the PPG within the filing limit specified inthe provider’s contract.12.5.2.1 In general, physician and ancillary service claims for MA-SNP members will be submitted to the PPG. Inpatienthospital claims and claims for ancillary services for MA-SNP members will be submitted to L.A. Care. In order todetermine who is responsible for paying a claim, please refer toExhibit B, the Division of Financial Responsibility, in yourcompany’s contract with L.A. Care. The Division of Financial153

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALResponsibility specifies what entity is responsible for paying aclaim.12.5.2.2 If you have a question about where to send a claim, pleasecall L.A. Care’s Provider Information Line. You will accessour Interactive Voice Recognition (IVR) system that willguide you to one of our Provider Network Representativesthat can assist.12.5.2.3 For all claims for which L.A. Care is financially responsible,please mail the claims to:L.A. Care Health PlanAttn: Claims Dept.P.O. Box 712129Los Angeles, CA 9007112.5.3 Claim Status InquiriesPlease be advised that you may inquire about the status of a claim,including the date of receipt, for which L.A. Care is financiallyresponsible by calling 1-866-LACARE6.12.6 CLAIMS PROCESSINGA. All claims must be processed (paid or denied) and disclosures made inaccordance with all federal and state laws and regulations and the LACARE contract.B. All PPGs are delegated the responsibility of claims processing for theservices identified as PPG’s responsibility in the Division of FinancialResponsibility exhibit of the L.A. Care Service Agreement and are subjectto review by LA CARE. LA CARE provides oversight of the PPGs bymonitoring, reviewing and measuring claims processing systems andpayment appeals to ensure timely and accurate claims processing andappeal resolution.C. Contracted providers of service are required to submit claims inaccordance with the provisions outlined in their contract with the Payer. Ifthe contract is silent on a timeframe for submission, or the provider ofservice is non-contracted, the provider of service has 27 months from thedate of service to submit a claim.D. Misdirected claims must be forwarded to the appropriate financiallyresponsible entity within 10 working days of receipt.E. PPGs must pay 95% of clean claims for non-contracted providersrendering services to Medicare Members within 30 calendar days of154

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALreceipt of the claim. All other claims for non-contracted providers must bepaid or denied within 60 calendar days. Claims for contracted providersmust be paid within contractual timeframes.F. If the Payer pays clean claims from non-contracted providers after 30days, it must pay interest in accordance with federal guidelines andinterest rates as published by the United States Treasury.G. PPGs are expected to identify and recover overpayments resulting from apayment error or when it has been determined that the provider of serviceor Member was liable for the services, in accordance with federalregulations.H. PPGs must establish and maintain a process that addresses the receipt,handling and disposition of a payment appeal in accordance with federalor state regulations and contractual guidelines. All payment appeals mustbe resolved within 60 calendar days of receipt of the appeal.12.7 PROCEDURE FOR MEDICARE CLAIMS PROCESSING:A. PPGs must have written procedures for claims processing that areavailable for review. In addition, PPGs must disclose claims filingdirections, fee schedules and payment appeal processes via contract,written notification, Explanation of Benefits (EOB) or Remittance Advice(RA) at the time of payment, denial or adjustment, and/or via a website, asapplicable. These written procedures and disclosures must comply withstate, federal and LA CARE contractual standards and requirements.Such disclosures must also be made available upon request to providersof service, LA CARE or a regulatory agency.B. PPGs’ claims processing systems must identify and track all claims andpayment appeals by line of business and/or program and be able toproduce claims and appeals related reports as outlined in Section 12.7.10,“Initial Claims Payment Appeals.”C. Contracted providers of service must be given no less than the timeframestipulated in the contract to submit a claim.D. Non-contracted providers of service and contracted providers of servicewhose contract is silent on a submission timeframe are allowed up to 27months from the month of service to submit a claim.1. Claims received after 27 months from the month of service shouldbe denied.2. Claims received after the filing deadline are reconsidered forpayment only when the provider of service has submitted anexplanation of the circumstances surrounding the late filing, or LACARE or the PPG.is responsible due to an administrative error.155

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL3. If a claim is denied for untimely filing, the provider of service mayfile an appeal as outlined in Section 12.7.10,, “Initial ClaimsPayment Appeals” and the claim may be reconsidered for paymentupon proof of and demonstration of good cause for the delay.E. PPGs must redirect claims that are not their financial responsibility to theappropriate responsible party within 10 working days of receipt.1. If the Member cannot be identified or the financially responsibleentity is not affiliated with the Payer’s network, the claim may bedenied and/or returned to the provider of service advising the billingprovider to verify eligibility assignment and to bill the appropriateresponsible party.2. All redirected claims must be tracked and reported as outlined in“Claims and Payment Appeal Reporting.”F. Clean claims are those claims and attachments or other documentationthat include all reasonably relevant information necessary to determinePayer liability and in which no further information is required from theprovider of service or a third party to develop the claim. To be considereda clean claim the claim should be prepared in accordance with theNational Uniform Billing Committee standards and should include, but isnot limited to the following information:1. A claim form that contains:a. A description of the service rendered using valid CPT, ICD9,HCPCS, and/or Revenue codes, the number of days or unitsfor each service line, the place of service code, the type ofservice code and charge for each listed service.b. Other claim specific information as dictated by Medicare forprovider of service type (i.e., Hospital, lab, etc.).c. Member (patient) demographic information, which must at aminimum include the Member’s last name and first nameand date of birth.d. Provider of service name, address, state license number, taxidentification number; Medicare Health Insurance ClaimNumber (HICN), and Providers NPI.e. Information pertaining to existence of another Payer, ifapplicable.f. Date(s) of service.g. Amount billed.h. Signature of Member or person authorized to sign on behalfof Member.i. Signature of person submitting claim.156

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL2. Other documentation necessary to adjudicate the claim, such asmedical or emergency room reports, claims itemization or detailedinvoice, medical necessity documentation, other insurance paymentinformation and referring provider information (or copy of referral)as applicable.3. Proof of Member eligibility on the date(s) services were rendered.4. Prior authorization documentation, such as an authorizationnumber on the claim, a copy of the authorization form or referralform attached to the claim for services in which authorization isrequired.G. If a claim is missing required information, as defined in Procedure above,or requires additional information in order to complete the claim, the claimmust be developed as follows:1. The Payer must send a written notice to the provider of servicerequesting the missing information or other reasonably relevantinformation necessary to determine Payer liability within 30calendar days after the date of receipt. If the Payer is requestingadditional reasonably relevant information, the Payer must includea written explanation of the necessity for the request.2. If the Payer does not receive the requested information from aprovider of service within 45 calendar days after it receives theclaim, the Payer must review the claim and make a decision to payor deny the claim based on available information. That payment ordenial must be issued within 60 calendar days of original receipt ofthe claim.3. Upon receipt of the requested information, the Payer must pay ordeny the claim within 30 calendar days from receipt of theadditional information from a non-contracted provider, or withincontractual timeframes if a contracted provider of service.4. If the Payer denies a claim on the basis of a failure to submitrequested medical records or other information reasonablynecessary to determine Payer liability, as outlined in ProcedureF(2)-(4), the Payer must process any appeal from the denial ofsuch claim in accordance with the appeals process outlined in“Initial Claims Payment Appeals”.5. If the Provider fails to submit requested required information asdefined in Procedure G(1), or the information is invalid orincomplete, the claim can be rejected or denied.H. PPGs must establish administrative processes for claim determination andreimbursement for the following covered services rendered to a MedicareMember by a non-contracted provider of service:157

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL1. Ambulance services dispatched through 911 or its local equivalentwhere other means of transportation may endanger the Member’sHealth.2. Emergency services3. Urgently needed services4. Post-stabilization care services5. Renal dialysis services6. Covered services that the Payer denied through the appealsprocess that were determined to be services to which the Memberwas entitled.I. PPGs must coordinate benefits and follow Medicare as Secondary Payerrules as outlined in the “Coordination of Benefits” Section. Claimssubmitted for secondary payment must follow the submission timeframesstated in Procedure D, from the date the primary Payer’s notice ofpayment or denial is received by the provider of service in order to beconsidered timely.J. Claims received from contracted providers of service must beappropriately paid or denied within contractual timeframes. Clean claimsfrom non-contracted providers of service rendering services to MedicareMembers must be paid within 30 calendar days of receipt, or 60 calendardays for all other claims.1. This standard is based on the timeframe from the initial date ofreceipt of the claim (e.g., date stamp) until the check or denial ismailed to the provider of service, regardless of when the check isdated.2. The payment date used to meet timeliness standards is the actualdate the check is mailed, deposited into the provider of service’saccount or transferred electronically, regardless of the date on thecheck.3. The date of receipt is the date the claim is first received by an entitywithin the plans’s network even if that party is not financiallyresponsible for that particular claim as indicated by its date stampon the claim. In cases of a misdirected claim, the date of receipt isthe date the claim is first received by the responsible entity.Claims with multiple date stamps should be deemed priorityand processed immediately.4. “All other claims” are denied claims or those claims that requireinvestigation or additional information from the provider of serviceto develop the claim. This includes but is not limited to requests foradditional information from the physician/supplier or other externalsource such as routine data omitted from the claim, medicalinformation, or information to resolve discrepancies.158

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALK. If the PPG fails to pay a clean claim from a non-contracted provider ofservice within 30 calendar days after receipt, the PPG must pay interest atthe rate used for such late payments, as stated in federal regulations.1. Interest rates change every 6 months on January 1 and July 1.2. The interest is due on the first calendar day following 30 calendardays from the date of receipt.. Interest accrues from that date untilthe date the check is mailed.3. Interest is paid at the prevailing rate as published by the USTreasury.L. Denial Letters must be mailed to the provider of service within timeframes statedin Procedure J for paying or denying a claim,PPG should access the MedicareAdvantage Pre-Service Denial Reason Matrix from INDUSTRYCOLLABORATION EFFORT (ICE). The date of denial notification is the datethe denial notice is actually mailed to the provider of service.1. Any claim that is denied must include an accurate and clear writtenexplanation of the actions taken. Both the provider of service andMember must be notified of the denial if there is member liability forthe claim or a portion of the claim.2. All denial notifications and the EOB and/or RA to the provider ofservice must include mandated language and be properly formattedin accordance with Medicare specifications. At a minimum, thedenial notification must:a. Use approved notice language in a readable andunderstandable formatb. State the specific reason for the denialc. Inform the Member of his or her right to reconsideration ofthe payment determinationd. For payment denials, the standard reconsideration processas well as the rest of the appeal process as outlined in “InitialClaims Payment Appeals,” “2 nd Level Claims PaymentAppeals” and “Member Appeal Resolution Process(Standard and Fast Track)”e. Comply with any other notice requirements specified byCMS.3. The denial notification must incorporate appropriate denial reasonlanguage.M. If a Payer determines that a claim has been overpaid, the Payer mustattempt to recover the overpayment and send a written notice to theprovider of service.159

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL1. Individual overpayments are those overpayments resulting fromincorrect payment to the provider for physician/supplier services,including but not limited to duplicate payments, payments to thewrong provider of service, processing errors.2. The written notice must clearly identify the claim, the name of theMember, the date of service and a clear explanation of the basisupon which the Payer believes the amount paid was in excess ofthe amount due, including interest and penalties.3. Providers of service must respond to the request with a correctedbilling, an appeal or a refund in accordance with federal guidelineswithin 30 days of the date of the request. Interest begins accruingon any overpayments, refunds received after 30 days.4. PPGs may retract the overpayment in certain circumstancesoutlined in federal guidelines, provided there has been claimsactivity within 60 days from the date the overpayment wasidentified.5. If there is no claims activity for 60 days following identification of theoverpayment the Payer must send a written request and continueto follow-up with the provider of service to recover the money, untilsuch time as either a corrected billing is sent or there is claimsactivity in which to recover the money.6. Under no circumstances may overpayments be recovered afterDecember 31 of the third calendar year in which the overpaymentwas identified.N. PPGs must establish processes that address the receipt, handling anddisposition of a payment appeal in accordance with federal or stateregulations and contractual guidelines, as outlined in “Initial ClaimsPayment Appeals”.O. LA CARE’s Claims Department is available from 8:00am - 5:00pm,Monday through Friday at (866) 522-2736 to assist and answer anyquestions related to claims processing.P. The responsibility for claims payment as outlined above continues until allclaims have been paid/denied for services rendered during the timeframea Capitated Agreement existed.Q. Capitated PPGs must appropriately pay clean claims for non-contractedproviders of service within 30 calendar days from original receipt. All othernon-contracted providers of service claims must be paid or denied within60 calendar days. Contracted providers are paid in accordance withcontractual requirements. This standard is based on the timeframe fromthe initial date of receipt of the claim until the check or denial letter ismailed to the provider of service.160

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALR. In the event the Payer fails to meet LA CARE claims processing standardsas indicated above, LA CARE may elect to pay these claims on behalf ofthe Payer by deducting such payment from the Provider’s next monthlycapitation check.S. The 14-Day letter process is applied when there are unpaid claims and/orclaims inquiries.12.7.1 PROCEDURE FOR ISSUING 14 DAY LETTER:A. The 14-Day letter is a tool used by LA CARE to facilitate inquiriesfrom providers of service related to claims issues involving allegedlack of payment or denial from the payer.B. LA CARE’s 14-Day letter process is available to providers ofservice under the following circumstances:1. A provider of service (both contracted and non-contracted)notifies LA CARE that no status has been provided on aclaim submitted to the appropriate payer for over 60 days, or2. LA CARE identifies a claim that has not been paid within theclaims processing timeframes.C. The 14-Day letter process is available for unpaid and/orunresponded to claims inquiries. Providers may avail themselvesto the 14-Day letter process for up to 1 year and 60 days after thedate of service.D. Providers of service must submit a cover letter and the claim, alongwith documentation proving an attempt to obtain payment from thepayer, including but not limited to: copies of claim tracers indicatingdate tracers were sent, phone logs that include phone numbercalled and date and time the call was made and who the provider ofservice spoke to, as applicable.E. Upon receipt of the claim LA CARE verifies Member eligibility onthe date of service and ensures that the claim was sent to theappropriate payer. If the Member is not eligible with LA CARE forthe date of service, the request is rejected and a denial letter isissued to the provider of service explaining the reason for therejection. If the claim was sent to the incorrect payer LA CAREreturns the claim to the provider of service advising them to re-billthe correct payer.161

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALF. LA CARE mails a 14-Day letter to the Payer. The 14-Day letterrequests information on the status of the claim, as outlined inProcedure G below. The Payer must complete this form and returnit to LA CARE within 14 days from the date of the certified letter. Acopy of the claim from the provider of service is included with the14-Day letter sent by LA CARE to the Payer.G. Providers must provide LA CARE the following information in theirresponse regarding the claim: the date the claim was originallyreceived, if it was paid or denied, the date paid or denied, theamount paid, check number and/or the reason for the denial.H. The following are examples of unacceptable responses to the 14-day letter:1. Not Payer’s Delegated Responsibility (LA CARE confirmsfinancial responsibility prior to 14-day notification).2. Member Not Eligible (LA CARE confirms eligibility prior to14-day notification).3. Not Authorized (it is inappropriate to deny a claim due to “NoAuthorization” as medical review must be performed prior todenial).I. In the event the Payer fails to provide an acceptable writtenresponse to LA CARE within 14 days or the requested informationis returned incomplete, LA CARE pays the provider of servicedirectly using the prevailing Medicare fee schedule outlined belowand deducts the amount paid from the Payer’s monthly capitationcheck.1. The Medicare limiting charge for unassigned claims by nonparticipatingproviders.2. Non-par amounts for assigned claims by non-participatingproviders.3. The par amount for participating providers.J. Claims capitation deductions are outlined on a detail report that issent with the capitation payment.12.7.2 PROCEDURE FOR INITIAL CLAIM APPEALS:A. Inquiries regarding the status of a claim or requests for interventionby LA CARE on behalf of the billing provider in an attempt to get aninitial adjudication decision (payment or denial) made on a claim by162

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALthe Payer are not considered appeals and are handled inaccordance with the procedure outlined in “14-Day Letters”Section.B. Payment appeals relate to the initial determination of a paymentdecision or denial and are primarily complaints concerning anadverse organizational determination denying a request forpayment.1. Any appeal involving PCP P4P reimbursements should be filedin accordance with the guidelines provided in “Pay ForPerformance”.2. Any provider appeal not involving payment should be filed inaccordance with the guidelines provided in “AppealResolution Process for Providers of Service: Initial AppealResolution”.3. Grievances and appeals are separate and distinct. If thedocumentation submitted is considered to be a grievance,PPGs must resolve it in accordance with their grievancepolicies and procedures as outlined in “Appeal ResolutionProcess for Providers of Service: Initial Appeal Resolution”or using the “Member Grievance Resolution Process”.C. Members, their authorized representative or providers of serviceacting on behalf of a Member and non-contracted providers ofservice must submit all payment appeals in writing to the Payerwithin 60 calendar days from the date of a denial or other adversepayment determination from the Payer. The denial may be in theform of a written adverse determination from the Payer or anExplanation of Benefits (EOB) or Remittance Advice (RA)Justification and supporting documentation must be provided withthe written appeal, as outlined in Procedure F below.D. Non-contracted providers of service may file an appeal on his orher own behalf if the provider of service furnished a coveredservice to the Member and completes a waiver of liability statementthat states that the provider of service will not bill the Member forcovered services regardless of the outcome of the payment appeal.E. Payers may accept a request for reconsideration of an appeal filedafter 60 calendar days if the Member, the Member’s authorizedrepresentative or non-contracted provider of service submits awritten request for an extension of the timeframe for good cause.F. Written payment appeals must be submitted to the Payer inaccordance with the appeal process guidelines issued by thePayer.163

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL1. For payment appeals involving LA CARE as the Payer,appeals must be sent to:Grievance and Appeals Coordination UnitP.O. Box 712489Los Angeles, CA 900712. Written payment appeals to L.A. Care must include:a) A copy of the Member’s eligibility statusb) The Medicare health insurance claim numberc) Specific service(s) and/or item(s) for whichreconsideration is being requested and the specificdate(s) of serviced) The name and signature of the party or therepresentative of the party filing the appeale) A clear explanation of why the appealing partydisagrees with Payer’s initial determination andshould include supporting documentation theappealing party feels should be considering whenmaking the reconsideration:1) If the appeal involves a denied emergencyclaim, the documentation should include acopy of the Member’s emergency roomrecords, notification of the emergency roomvisit and a copy of the notice of determinationor EOB.2) If the appeal involves an ambulance claim, thedocumentation should include a copy of thetransport record, a copy of the Member’semergency room or hospitalization recordsrelating to the ambulance trip, includingrecords from the triage or medical departmentsas applicable and a copy of the notice ofdetermination or EOB.3) If the appeal involves co-payment charges orco-payment reimbursement, the supportingdocumentation should include a copy of theMember’s medical record from thecorresponding hospital, emergency room orprovider of service office, a copy of theutilization records if the Member was admitted,164

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALa copy of the notification of the emergencyroom visit or admission, and a copy of thenotice of determination or EOB.3. If supporting documentation is not available or the Payerdoes not have enough information to make a determinationon the appeal, the Payer may send a request for additionalinformation to the provider of service. If the provider ofservice fails to provide requested information within 5calendar days of the request, the Payer must make adetermination on the information available.G. Payers must research the appeal and if it meets the criteria for apayment appeal, the Payer must send a written acknowledgementletter, an authorization for release of protected health information,and a self-addressed stamped envelope to the Member, theauthorized representative or non-contracted provider of service whosubmitted the request, within 5 working days of the request.H. Payers must make every effort to investigate and take intoconsideration all information on file or received from the provider ofservice. The Payer may request additional information or discussthe issue with the involved provider of service as needed to make adetermination.I. PPGs must send written notice of the resolution, including pertinentfacts and an explanation of the reason for the determination, within60 calendar days of the receipt of the payment appeal. Thenotification must be sent to both the Member and appealing party,with a copy to LA CARE.1. Written notification of affirmative (uphold) determinations,whether in whole or in part, must be written in a mannereasily understood by the Member and include:a. A clear statement indicating the extent to which thereconsideration is favorable or unfavorable;b. A summary of the facts, including, as appropriate, asummary of the clinical or scientific evidence used inmaking the re-determination;c. An explanation of how pertinent laws, regulations,coverage rules and CMS policy applies to the facts ofthe case;d. A summary of the rationale for the re-determination inclear, understandable language;e. The procedures for obtaining additional informationconcerning determinations, such as specificprovisions of the policy, manual or regulation used in165

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALmaking the determinationf. Any other requirements specified by CMS.2. Failure to respond to the request for reconsideration with adetermination within the specified timeframe must considerthe failure as an affirmation of the adverse decision and thePayer must forward the request to the CMS IndependentReview Entity (IRE) for review in accordance with Medicarerequirements, within 60 calendar days after receiving therequest for reconsideration.J. If the written determination results in payment, payment must bemade within 60 calendar days of receipt of the payment appeal,which is concurrently with the written determination. There is nointerest due on payments made as a result of an appeal.K. If the determination is to affirm or uphold the initial paymentdetermination, the Payer must send a written determination to theMember and appealing party informing them of the decision andimmediately forward the appeal and determination and supportingdocumentation to the IRE for final review in accordance withMedicare guidelines.1. The information must be forwarded to the IRE within 5calendar days of the determination, or within 60 calendardays of receipt of the appeal from the appealing party,whichever occurs first.2. The IRE will make a decision on the payment appeal inaccordance with is CMS contracted timeframes.3. The IRE may request additional information, and uponreceipt of such information, LA CARE and/or the Payer mustmake every effort to provide the requested information withinthe timeframe specified by the IRE.4. If the IRE upholds the original adverse determination, theIRE will notify the Member and other parties to the appeal inwriting of such decision following CMS guidelines.5. If the IRE reverses or partially reverses the original adversedetermination, the IRE notifies the Payer and LA CARE. Thepayer in turn must notify the Member and the provider ofservice of the decision, with a copy to LA CARE.6. If payment is required as a result of the IRE, the IRE notifiesthe Payer of the requirement to pay the claim. Payment mustbe issued within 30 calendar days of receipt of the decisionby the IRE. No interest is due on favorable paymentdeterminations made by the IRE.166

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL. If the appealing party is not satisfied with the decision of the IRE,and the projected value of the disputed service afterreconsideration meets or exceeds the minimum requirementsprovided in the IRE’s decision, the appealing party may request areview by an Administrative Law Judge (ALJ) within 60 calendardays of receipt of the decision from the IRE, as outlined in “MemberAppeal Resolution Process (Standard and Fast-Track”).M. Subsequently, any party dissatisfied with the outcome of theAdministration Law Judge Hearing, may request a MedicareAppeals Council review as outlined in “Member Appeal ResolutionProcess If still dissatisfied with the outcome, any party may requestjudicial review as outlined in “Member Appeal Resolution Process(Standard and Fast-Track)”.N. If LA CARE receives an initial payment appeal directly for whichanother Payer is financially responsible, LA CARE will forward theappeal or grievance to the Payer for resolution, as applicable andnotify the involved parties.O. At any point in the process, the appealing party may bypass LACARE or the Payer and submit an appeal directly to the IRE, inaccordance with CMS guidelines. Additionally, any party to theappeal may withdraw the appeal at any point in the appeal process.P. Members or providers of service not satisfied with the initialdetermination by the Payer where the determination is related tomedical necessity, utilization management or pre-service referraldenials or modifications may submit a written appeal to LA CAREwithin 60 calendar days, for review as outlined in LA CARE Policy #UM-041, “Appeals or Reconsideration”.Q. No retaliation can be made against a Member or provider of servicewho submits an appeal in good faith.R. Copies of all appeals and related documentation must be retainedfor at least ten years. A minimum of the last two years must beeasily accessible and available within five days of request from LACARE or regulatory agency.S. Payers must track and report all appeals received in accordancewith “Claims and Payment Appeals Reporting.”T. LA CARE tracks, trends and analyzes appeals data, taking intoaccount information from all other sources, including PPGs, andpresents such information to the LA CARE Governing Board withrecommendations for intervention, as appropriate.167

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL12.7.2.1 Grievance disposition letters issued by PPGs must fully describethe grievance and grievance appeal process. This must include adescription of timelines as well as higher levels of consideration,including L.A. Care.Grievance and Appeals Coordination UnitP.O. Box 712489Los Angeles, CA. 9007112.7.3 Disputes Between Contracted RelationshipsA. IPA’s, PCPs and/or LA CARE are responsible for authorizingmedical care.B. In the event that a particular service is not available at the assignedHospital the PPG must coordinate with the Hospital, if capitated, orLA CARE for contracted non-capitated Hospitals, to provide carefor the Member at a mutually agreed upon facility.C. In the event of an emergency the PPG must inform the Hospital, ifcapitated, or LA CARE for contracted non-capitated Hospitals, thatcare is being rendered at another facility.D. Members cannot be transferred when admissions are due to lack ofspecialty coverage, access standard timeframe issues or when theMember refuses to be transferred.PROCEDURE FOR DISPUTE RESOLUTION:A. In the event an authorization for Hospital services is provided by a PPGrepresentative that is in breach of the above policy, the following mayoccur:1. Hospital/LA CARE reviews its incoming claims and identifies PPGcontract violations that do not meet the above criteria such as:A. Authorized hospital services provided at a non-contractedfacility.B. Authorized hospital services provided at another contractedfacility that could have been provided at the assigned facility.C. Authorized ER services for non-emergent care.Appropriately licensed medical staff must perform review formedical appropriateness.2. If the Hospital, or LA CARE as applicable, was not notified or notamenable to these arrangements, the Hospital or LA CARE maydeny payment of these authorized services.168

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL3. Upon denial, the Hospital or LA CARE must send a copy of theclaim to the PPG for payment with a denial letter explaining thereasons for the denial. If denied by the Hospital a copy of thedenial letter, claim, records and all supporting documentationshould also be sent to LA CARE at the following address:LA Care Health PlanAttention: Claims DepartmentP.O. Box 712129Los Angeles, CA 900714. Hospitals may send the provider of service a letter informing themthat the claim has been forwarded to the IPA for payment, howevera denial should not be sent to the practitioner.5. The IPA must pay the claim for these hospital services unless theIPA feels the services provided were emergent or that the servicewas justified. In the event of the latter the IPA should submit theclaim with the appropriate supporting documentation to LA CARE atthe above address with a letter of appeal explaining their position.The appeal must be submitted to LA CARE within 60 days of thedenial or payment.6. LA CARE will follow the procedures outlined in Section 12.7.10,“Initial Claims Payment Appeals,” in determining theappropriateness of the appeal and whose financial responsibility itis to pay the claim.7. Payment will be issued by the responsible party as outlined in“Initial Claims Payment Appeals.”169

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALClaims Attachment{Provider Name}{Provider Mailing Address}Member: {Member Name}Member No: {Sub ID – Suffix}Date of Service: {From – To Service Dates}Claim No: {Claim ID}Claim Amount: {Charged Amount}Dear {Provider Name}:NOTICE OF DENIAL OF PAYMENTWe have received your claim for the above-referenced member. This claim has been denied forthe following reason:A) Contracted providers(1) Medical Records Requested – not received/ Contracted Prov – CONT 06Medical records requested were not received. In order to determine financial liability or medicalnecessity, medical records are required to assist in a clinical determination. As these records havenot been received, this claim in not payable by L. A. Care Health Plan. You are a contractedprovider with (PMG / IPA) and you are not allowed to balance bill the member for these services.THE MEMBER IS NOT RESPONSIBLE FOR PAYMENT OF THIS CLAIM.(2) Outpatient Services (Office visits, lab and diagnostic imaging) – CONT-01According to our records, there is no authorization for the services rendered. Contracted providersare required to provide documentation or other evidence that the member was advised prior to theservices being rendered that they may be financially responsible for such services. You are acontracted provider with (PGM / IPA) and you are not allowed to balance bill the member for theseservices. THE MEMBER IS NOT RESPONSIBLE FOR PAYMENT OF THIS CLAIM.(3) Contracted Hospital or Provider Services (non-emergent – no triage call) – CONT-02Emergency services are services needed immediately due to sudden illness, injury, or prudentlayperson perception, and additional time spent to reach (PMG / IPA) would have meant risk ofpermanent damage to the member's health. The services you provided do not meet this definitionand therefore required that you obtain prior authorization or provide documented proof the memberwas advised prior to services being rendered that they may be financially liable for such services.170

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAs a contracted provider, you are precluded from billing the member for these services. THEMEMBER IS NOT RESPONSIBLE FOR THE PAYMENT OF THIS CLAIM.(4) Contracted Facility (delay in care resulted in unnecessary days) CONT -03Medical Management has reviewed the care provided and determined that a delay in servicesprovided resulted in unnecessary inpatient days listed above. As a contracted provider, you arenot allowed to balance bill the member for these non-covered services. THE MEMBER IS NOTRESPONSIBLE FOR PAYMENT OF THIS CLAIM.(5) –In – area Emergency Services (non-emergent) – (presenting circumstances fail test) – ERIA -01Medical records do not support that the presenting symptoms meet the below definition ofemergency. An emergency service is a service needed immediately due to acute symptoms(including pain) which a prudent layperson feels could result in serious jeopardy to their health.Additional time spent to reach an HMO provider would mean risking permanent damage to yourhealth.(6) Required Claim Data missing or Spoiled – (A required data element or one of the nine specifieddata emoluments is missing or Spoiled and the Contracted provider has not responded to thePlan’s request for the missing data) - CONT- 04 & CONT -05The information submitted to us was missing one or more essential items of information requiredunder 42 CFR 422.257(d) paragraphs (1) and (4). You have not responded to our request(s) forthat information. Because the federal time limit for us to obtain that information has expired, weremain unable to process the claim and must send you this notice. BY CONTRACTUALAGREEMENT, YOU MAY NOT BILL THE MEMBER.Unless otherwise specified, the missing or deficient items include one or more of the followingitems listed below this paragraph that is not to the highest level of specificity or in accordance withcurrently valid Medicare codes. If you submit a complete claim to us that includes the informationrequested not later than the one- to two-year time limit allowed under Medicare law andregulations, we will process this claim.[CMS -1500: CONT-04] [or] [UB-04: CONT-05] .Patient's Name (2) Patient Name (12)Sex (3) Sex (15)Birth Date (3) Birthdate (14)I.D. No. (HIC or SSN) (1a) HIC or SSN (60)Dates of Service (24A) From and Through Dates (6)Diagnosis Code (24E) Principal Diagnosis Code (67)Procedure, Service,HCPCS/CPT Procedure CodeSupply Code (24D)(44) (Outpt.)Days or Units (24G)Service Units (46) (Outpt.)Place of Service (24B)Admission Date (17) (Inpt.)Anesthesia/Oxygen Type of Bill (4)Min. (varies) (if applic.)Provider State License Principle Procedure Code (80)171

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALor UPIN (24K)Date of Service (45)(Outpt.)B) Non- Contracted Provider Denial language -(1) Missing required data –missing or Spoiled (Medicare guidelines)[This page presents an approach to developing these problem claims when they are received fromnon-contracting providers. Please note that unlike for contracting provider claims on the precedingpage, non-contracting provider claims cannot initially be denied for lack of complete, correct CMSrequired encounter data elements. CMS required data elements includes submission of a completeclaim including complete diagnosis coding required for submission of risk adjustment information toCMS. Such incomplete claims from non-contracted providers are defined as non- clean andshould be developed for up to 60 calendar days. If the claim data remains incomplete afterrequesting complete information, the claim should be denied on day 60 for incomplete information.]Medicare requires us to report more complete information than you provided on this claim. Your claim assubmitted is missing one or more essential items of information or has codes that are not sufficiently specific ordo not conform to national standards (e.g., are incomplete, invalid or out of date). 42 CFR 422.257(d)paragraphs (1) and (4) require Medicare Advantage organizations to submit complete, conforming encounterdata from paid claims. Unless otherwise specified, the missing or deficient items include one or more of theitems listed below this paragraph that is not to the highest level of specificity or in accordance with currentlyvalid Medicare codes. Until you provide us with the requested information, THE MEMBER IS NOTRESPONSIBLE FOR PAYMENT OF THIS INCOMPLETE CLAIM and should not be billed.(2) In-Area Emergency Services (non-emergent) (presenting circumstances fail test) – ERIA -04(cc: member)Medical records do not support that the presenting symptoms meet the below definition ofemergency. An emergency service is a service needed immediately due to acute symptoms(including pain) which a prudent layperson feels could result in serious jeopardy to their health.Additional time spent to reach an HMO provider would mean risking permanent damage to yourhealth. Use of non-Plan providers in non-emergency situations is not payable by L. A. Care HealthPlan.(3) Medical Records requested and not received -NON -01 (cc: Member)Medical records requested were not received. In order to determine financial liability or medicalnecessity, medical records are required to assist in a clinical determination. As these records havenot been received, this claim is not payable by L. A. Care Health Plan.C) Contracted and non-contracted providers denial language (Could be utilized by both)C1) Eligibility(1) Provider Eligibility with Plan –ELIG -01The date you received medical services on the above claim was prior to your effective date ofeligibility with L. A. Care Health Plan. Please submit your claim to Medicare or the HMO withwhom you were eligible as of the date services were rendered.172

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL(2) In-between Eligibility – ELIG-04The date of service is between your eligibility for L. A. Care Health Plan.Please submit your claim to Medicare or the HMO with whom you were eligible as of the dateservices were rendered.(3) Postdates Eligibility with Plan – Elig-02The date you received medical services on the above claim was after your effective date ofdisenrollment with L. A. Care Health Plan. Please submit your claim to Medicare or the HMO withwhom you were eligible as of the date services were rendered(4) Service Postdates Member’s death – ELIG-03Our records show the date of service was after the date of death.C2) Emergency and Urgently Needed Services(5) In-Area Emergency Services (records not received) – ERIA-02Medical records requested were never received. An emergency service is a service neededimmediately due to acute symptoms (including pain) which a prudent layperson feels could result inserious jeopardy to their health. Additional time spent to reach an HMO provider would meanrisking permanent damage to your health. The services received and circumstances do not meetthese requirements based on the information available.(6) In-area (Partial denial of inappropriate services) ERIA-03Services delivered as emergency care were not consistent with presenting symptoms oremergency diagnosis(7) Out-of-area Emergency and Urgently Needed Services (not urgently needed) –EROA-01Emergency/urgent services are covered outside of the service area if necessary to preventdeterioration of health due to unforeseen illness while temporarily out of the service area. Theservices received were not emergent/urgent and were not authorized.(8) Out-of-Area Emergency and urgently needed Services (records not received) –EROA-02Emergent / urgent services are covered outside of the service area if necessary to preventdeterioration of health due to unforeseen illness while temporarily out of the service area. Medicalrecords requested were never received. The services received cannot be determined to meetthese requirements based on the information available.C3) Maximum Allowable Benefit(10) Inpatient Psychiatric – MAPY-01Inpatient psychiatric care is covered according to Medicare guidelines and is limited to 190 daysper lifetime in a Medicare certified psychiatric hospital. Our records indicate you reached 190lifetime days on {date}.(11) Podiatry (non-Medicare covered) – MAPO-01173

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALThe maximum calendar year additional podiatry benefit is {#} visits per year. Our records indicateyou reached that limit on {date}. The maximum benefit was paid at that time.(12) Prescription Drugs (non-Medicare covered) – MARX-01The maximum calendar year benefit allowance for outpatient prescription drugs is ${______}. Ourrecords indicate you reached that limit on {date}. The maximum benefit was paid at that time.(13) Skilled Nursing Facility – MASN-01Skilled Nursing Facilities are covered by L. A. Care Health Plan up to 100 days per benefit period.Our records indicate that on {date}, you reached your 100 day benefit maximum for this benefitperiod.(14) Miscellaneous – MAMI-01Insert other specific benefits with annual maximums.C4) Not a covered Benefit(15) Ambulance (not medically necessary) –NCAM-01Ambulance transportation is covered if you could not have used another means of transportationwithout endangering your health. The transport you received does not meet this criterion.(16) Ambulance (no patient transport) – NCAM-02As you were not transported by ambulance, the services are not covered by Medicare or L. A. CareHealth Plan.(17) Assistant Surgeon (Medicare guidelines) – NCAS-01Medicare does not pay for an assistant surgeon for this procedure/surgery. Payment for theassistant surgeon is denied by L. A. Care Health Plan. The member has no financial responsibilityfor these services.(18) Bundling (Medicare Guidelines) – NCBU-01Medicare does not pay separately for this service. Payment is included in another service themember has received. The member has no financial liability and should not be billed for theseservices.(19) Chiropractic (Medicare guidelines) NCCH-01Medicare coverage for chiropractic care requires that you be diagnosed with subluxation of thespine. The services received do not meet this criterion and are not covered by Medicare or L. A.Care Health Plan.(20) Cosmetic – NCCO-01The procedure you received is considered a cosmetic procedure. Cosmetic procedures are not abenefit covered by Medicare or L. A. Care Health Plan for post accident repair/reconstruction.Please refer to your Health Plan's member materials for benefit guidelines.(21) Dental Services – NCDS-01174

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALDental services are not a benefit covered under Medicare or L. A. Care Health Plan except forsurgery related to the jaw or any structure related to the jaw or any facial bone. Please refer toyour Health Plan's member materials for benefit guidelines.(22) DME- Durable Medical Equipment (does not meet Medicare DME criteria) – NCDM-01Medicare defines durable medical equipment as an item that is medical in nature, can withstandrepeated use, and is used in the home. The item received does not meet these requirements andis not payable by Medicare or L. A. Care Health Plan.(23) DME- Durable Medical equipment (not authorized) –NCDM-02The durable medical equipment received was not prescribed/authorized by your primary carephysician. Services not authorized, unless emergent or urgently needed out of the area, are notpayable by L. A. Care Health Plan.(24) Hearing Aids – NCHA-01Hearing Aids are not a benefit covered under Medicare or L. A. Care Health Plan.(25) Home Health (does not meet skilled guidelines) –NCHH-01Home health services must include intermittent skilled care (skilled nursing, PT, or speech therapy)to qualify under Medicare guidelines. The services received were not skilled care and are notpayable by Medicare or L. A. Care Health Plan.(26) Home Health (member not homebound) – NCHH-02Home health care must meet Medicare guidelines, which require that you are confined to yourhome. You are not homebound and consequently the home health services received are notpayable by Medicare orL. A. Care Health Plan}.(27) Home Health (not authorized) – NCHH-03The home health services you received were not authorized by your primary care physician.Services not authorized, unless emergent or urgently needed out of the area, are not payable by L.A. Care Health Plan.(29) Non Medicare/FDA Approved Drugs or Devices – NCRX-02{_________} is not approved by Medicare/the FDA and is excluded from coverage by L. A. CareHealth Plan. Please refer to your Health Plan's member materials for benefit guidelines.(30) Not Authorized In-Area (if ER/Emergent, use emergency denial message) – NCNA-01When you enrolled in a Medicare Advantage Plan, you selected a Primary Care Physician tocoordinate/authorize your medical care. The services received were not authorized and are notpayable by {L. A. Care Health Plan}.(31) Over the counter Drugs – NCRX-03The drugs/medication received is available over the counter without a prescription and are not abenefit covered by {L. A. Care Health Plan}. Please refer to your Health Plan's member materialsfor benefit guidelines.175

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL(32) Personal comfort items – NCPC-01The {______} you were provided is considered a personal comfort item and is not a coveredbenefit under Medicare or {L. A. Care Health Plan}. Please refer to your Health Plan's membermaterials for benefit guidelines.(33) Podiatry – NCPO -01Podiatry services for routine foot care, such as toe nail trimming, or corn/callus removal are not abenefit covered under Medicare or {L. A. Care Health Plan}. Please refer to your Health Plan'smember materials for benefit guidelines.(34) Shoe Orthotics – NCSO-01Shoe orthotics, including inserts and modifications, are only covered by Medicare or {L. A. CareHealth Plan} for diabetics or when the shoe is an integral part of a leg brace. Please refer to yourHealth Plan's member materials for benefit guidelines.(35) Skilled Nursing Facility – (custodial care or not daily SNF care) – NCSN-01Medicare guidelines require that skilled nursing facility care be needed daily, as certified by yourphysician. The services received were custodial in nature and/or not required daily. They are notcovered by Medicare or {L. A. Care Health Plan}.(36) Skilled Nursing Facility (not authorized) – NCSN-02The skilled nursing facility services you received were not authorized by your primary carephysician. Services not authorized, unless emergent or urgently needed out of the area, are not acovered benefit under {L. A. Care Health Plan}.(37) Miscellaneous – NCMI-01{SPECIFIC Item(s)} is not a Medicare covered benefit and excluded from coverage under {L. A.Care Health Plan}. Please refer to your Health Plan's member materials for benefit guidelines.C5) Coordination of Benefits(1) Requested information not received from member –COB-01Our records indicate that you may have other insurance coverage. Coordination of benefitsinformation (primary insurance carrier information) was requested from you and has not beenreceived. In order to determine financial liability this information is required. As this information hasnot been received, this claim in not payable by [Health Plan}.If you believe this determination is incorrect, you have the right to request for reconsideration. Youmust submit your request in writing within 60 days from the date of this notice, include theadditional information which will substantiate your request for reconsideration to:Sincerely,L. A. Care Health PlanAppeals and Grievance DepartmentP. O. Box 712489Los Angeles, CA 90071Fax# (213) 623-8974176

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL13.0 MARKETING – Medicare Advantage-SNP Line of Business13.1 PURPOSE:The purpose of this Policy & Procedure is to ensure that allMedicare Marketing materials used by L.A. Care Health Plan, andour contracted Providers, have been approved by the Centers forMedicare and Medicaid Services (CMS).13.2 POLICY:L.A. Care Health Plan shall establish Marketing standards bywhich L.A. Care Health Plan and its Providers may engage inMarketing Activities related to L.A. Care Health Plan’s MedicareAdvantage product in accordance with the Centers for Medicare &Medicaid (CMS) marketing guidelines set forth in the MedicareManaged Care ManualL.A. Care may impose sanctions on a Provider in accordance withthe terms of this policy or the contracted Provider agreement forany violation of this policy or the marketing guidelines set forth inthe Medicare Managed Care Manual.Nothing in this policy shall affect a Provider’s obligation tocommunicate with L.A. Care or a member pursuant to contractual,statutory, regulatory, or L.A. Care policy requirements.13.3 DEFINITION(S):CMS – Centers for Medicare & Medicaid, the oversight agencygoverning the Medicare program, including marketing.Co-Branding – Co-branding is defined as a relationship betweentwo or more separate legal entities, one of which is an organizationthat sponsors a Medicare plan. The organization displays thename(s) or brand(s) of the co-branding entity or entities on itsmarketing materials to signify a business arrangement. Cobrandingarrangements allow an organization and its co-brandingpartner(s) to promote enrollment into the plan. Co-brandingrelationships are entered into independently from the contract thatthe organization has with CMS.177

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALProvider Promotional Activities – Activities that a provider mayperform to educate potential enrollees or to assist potentialenrollees in enrollment.Marketing - Steering, or attempting to steer, an undecided potentialenrollee towards a plan, or limited number of plans, and for which theindividual or entity performing marketing activities expects compensationdirectly or indirectly from the plan for such marketing activities.“Assisting in enrollment” and “education” do not constitute marketing.Marketing activities are limited to those activities permitted in theMedicare Marketing Guidelines.Marketing Materials – Marketing materials include any informationalmaterials that perform one or more of the following actions:a. Promote an organization.b. Provide enrollment information for an organization.c. Explain the benefits of enrollment in an organization.d. Describe the rules that apply to enrollees in an organization.e. Explain how Medicare services are covered under anorganization, including conditions that apply to suchcoverage.f. Communicate with the individual on various membershipoperational policies, rules, and procedures.Member – Medicare beneficiary, either enrolled in Managed Careor not.Provider – Physicians, physician groups, clinics, hospitals andothers.13.4 PROCEDURE/S:13.4.1 Promotional ActivitiesL.A. Care Health Plan, or a contracted Provider may engage inPromotional Activities related to L.A. Care Health Plan’sMedicare Advantage product in accordance with the terms andconditions of this policy and the CMS Marketing guidelines setforth in the Medicare Managed Care Manual:In accordance to the CMS Marketing Guidelines set forth in theMedicare Managed Care Manual, certain communications are NOTconsidered Promotional Activities including, but not limited to:178

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALa. Communications from a Provider to a Member who is part ofthe Provider’s current Contracted Membership regardingclinical matters;b. Communication from a Provider to any Member whorequests information or materials regarding a physician’sPhysician Group affiliations; andc. Communications from a Provider to existing patients who areMembers to notify them if and when the physician haschanged Physician Group affiliations or the location at whichhe or she provides Covered Services.L.A. Care shall consider a health education material and wellnesspromotion as Marketing Materials if such material is:a. Used in any way to promote L.A. Care or a Provider;b. Used to explain benefits; orc. Contains any commercial message or beneficiary notificationinformation.L.A. Care shall consider the Internet as both Marketing Materialsand Promotional Activities.1. The Internet consists of, but may not be limited to, electronictransfer, transmittal, dissemination, and distribution throughthe organization’s Web site.2. L.A. Care or a Provider shall follow approval procedures setforth in this policy for all Marketing Materials andPromotional Activities conducted through the internet.13.4.2 Marketing StandardsAll Marketing Materials and Promotional Activities shall meet thefollowing standards.All Marketing Materials and Marketing Activities shall comply withthe CMS Marketing Guidelines set forth in the Medicare ManagedCare Manual. The CMS guidelines pertain to, but are not limited to,the following types of Marketing Materials and PromotionalActivities:a. Advertising and pre-enrollment materials;179

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALb. Post-enrolment materials;c. Outreach to Members;d. Promotional Activities; ande. Other Marketing Activities.Marketing Materials shall not contain false, misleading, orambiguous information. L.A. Care and a Provider should use theCMS “Must Use/Can’t Use/Can Use Chart” found in the MedicareManaged Care Manual in Chapter 11, “Guidelines for PromotionalActivities.”L.A. Care and a Provider shall make every effort to write MarketingMaterials at a reading level no greater than (6 th ) grade and be bothculturally and linguistically appropriate.13.4.3 All Marketing Materials shall clearly labeled with thefollowing:a. The year on which they were last updated;b. The source of any representations, endorsements, orawards referred to in the Marketing Materials; andc. The entity responsible for producing the Marketing Materials.13.4.4 L.A. Care LogoL.A. Care reserves the right to review and ensure correct usage ofthe L.A. care logo including the contents of the material thatcontains the L.A. Care logo.L.A. Care must review and approve the use of the L.A. Care logoprior to publishing.13.5 APPROVAL PROCESSA Provider shall submit all Marketing Materials and Promotional Activitiesto L.A. Care through the Provider Network Relations department forreview and CMS approval at least forty-five (45) calendar days prior tousing such Marketing Materials or engaging in such Promotional Activities.The exception to the 45 days is if Provider uses CMS model languagewithout modification in Marketing Materials, L.A. Care shall submit theMarketing Materials to CMS at least ten (10) calendar days prior to usingthe Marketing Materials.180

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMail or facsimile to:L.A. Care Health PlanAttn: Provider Network Operations Department555 West Fifth Street, 29 th FloorLos Angeles, CA 90013Fax: 213.438.5732Documentation of proposed Marketing Materials and PromotionalActivities shall include:a. A draft in final layout of the proposed Marketing Materials ordescription of the proposed Activities;b. A draft of translated versions of the proposed MarketingMaterials with a letter attesting that the translated materialconveys the same information and level of detail as the Englishmaterial; andc. The total cost of the proposed Marketing Materials orPromotional Activities.If, upon review, L.A. Care does not object to a Provider’s MarketingMaterials and Promotional Activities, L.A. Care shall send a written noticeto the Provider within ten (10) business days after receipt of alldocumentation indicating L.A. Care’s review of the documentation andintent to submit the proposed Marketing Materials and PromotionalActivities to CMS.If, upon review, L.A. Care objects to a Provider’s Marketing Materials orPromotional Activities, L.A. Care shall send a notice to the Provider thatdescribes its objections in detail.a. The Provider may resubmit revisions of the Marketing Materialsor Promotional Activities and all applicable documentation toL.A. Care within five (5) business days after receipt of L.A.Care’s Notice.b. L.A. Care shall review the resubmitted documentation and shallrespond to the Provider within five (5) business days afterreceipt.c. If approved, L.A. Care shall submit the proposed MarketingMaterials or Promotional Activities to CMS.d. If a Provider fails to resubmit revisions of Marketing Materials orPromotional Activities within five (5) working days after receipt181

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALof L.A. Care’s review, the Provider shall submit such materialsas new Marketing Materials or Promotional Activities.A Provider shall NOT use Marketing Materials or engage in PromotionalActivities prior to receipt of L.A. Care’s written notice of CMS approval.L.A. Care shall notify the Physician Group or Provider that proposedMarketing Materials or Promotional Activities have been approved by CMSwithin five (5) working days after receipt of CMS approval.L.A. Care shall consider Marketing Materials and Promotional Activitiesapproved if CMS fails to respond to L.A. Care’s request to approveMarketing Materials or Promotional Activities within 45 working days.13.6 PROHIBITED ACTIVITIES:Engaging in prohibited activities as set forth in the Medicare Managed Caremanual. Use of Marketing Materials or engaging in Promotional Activities withoutprior written approval from L.A. Care and CMS; and use of logos or otheridentifying information used by a government or public agency, including L.A.Care without prior authorization.Failure to ComplyL.A. Care may impose Sanctions on a Provider for any violation of theterms and conditions of this policy and the CMS marketing guidelines setforth in the Medicare Managed Care Manual. L.A. Care may imposeSanctions including, but not limited to:Financial penalties;Immediate suspension of use of all Marketing Materials and PromotionalActivities for a period not to exceed six (6) months;Imposition of an enrollment cap or membership cap and Contracttermination.182

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL14.0 ENCOUNTER DATAParticipating Physician Groups (PPGs) are responsible for gathering,processing, and submitting encounter data on all L.A. Care members.Encounter Data is the primary source of information about the delivery ofservices provided by practitioners to L.A. Care members. When PPGscontracted with L.A. Care submit encounter data that is timely, accurate,and complete, L.A. Care staff is able to track utilized services and analyzethe validity of capitation rates. This is a very important source ofinformation for determining needed changes and improvements in healthrelated programs administered at L.A. Care. L.A. Care will also useencounter data for monitoring and oversight functions including HEDISreporting and meeting various regulatory requirementsL.A. Care has contracted with Diversified Data Design (DDD), a dataclearinghouse company, to assist PPGs with the proper formatting timelyand accurate submission of encounter data. PPGs must submit encounterdata directly to Diversified Data Design.14.1 REQUIREMENTSPPGs are required to submit all requested encounter data, including datafor services provided under the capitated arrangement, for L.A. Caremembers. Encounter data is required to be submitted within sixty (60)business days after the end of the month in which the encounter occurred.The encounter data must be submitted in an electronic format inaccordance with the encounter data specifications established byDiversified Data Design. If the PPG is unable to submit data electronically,a hard copy of the CMS 1500 can be sent to DDD.When a PPG uses Diversified Data Design to process its encounter data,Diversified Data Design will convert the PPG’s encounter data into theappropriate format to meet L.A. Care’s specifications.The PPG must submit encounter data on a monthly basis. Services mustuse current valid CPT codes and ICD9 diagnosis codes.PPGs must use Diversified Data Design’s services under the belowmentioned terms and conditions free of charge. L.A. Care will reimburseDiversified Data Design for services rendered to all contracted PPGs.Listed below is Diversified Data Design’s contact information.Diversified Data Design5875 Green Valley CircleCulver City, CA 90230(310) 973-2880Contact: Noelle Clark Porter or Horace Clark183

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL14.2 USE OF DIVERSIFIED DATA DESIGN SERVICESPPGs are required to:• Submit data to Diversified Data Design within the parametersrequired by Diversified Data Design.• Submit data to Diversified Data Design within timeframes to ensureroutine and timely submission of encounter data to L.A. Care.• Provide a completed encounter data batch cover sheet, which isdesigned to facilitate an accurate accounting of encounter datasubmissions, to Provider Network Operations’ Business Analystconcurrently with the submission to Diversified Data Design.184

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL15.0 COMPLIANCEL.A. Care’s Compliance & Audit Program is designed to ensure theprovision of quality health care services to all L.A. Care members. This isachieved through a variety of compliance activities. L.A. Care’sCompliance & Audit Program activities include:Auditing Oversight of Delegated Responsibilities.Fraud & Abuse Prevention.HIPAA Compliance and Member Rights re Privacy and ConfidentialityOngoing monitoring of quality health care services.Education of PPGs about new legislation and other health carecompliance requirements.15.1 GOAL AND OBJECTIVESGOALThe goal of L.A. Care’s Compliance & Audit Program is to ensure that allL.A. Care health plan members receive appropriate and quality healthcare services through the provider network in compliance with allapplicable California and federal rules and regulations including CMSMedicare requirements as well as L.A. Care contractual requirements.L.A. Care’s Compliance & Audit Program:Provides oversight of delegated responsibilities to provider network –implements corrective actions with PPGs to address deficiencies inprovision of health care services.Identifies and investigates potential fraud & abuse activities – takesappropriate actions to resolve all fraud & abuse activities.Provides education and other available resources to assist PPGs inbecoming compliant with HIPAA requirements and Member Rights rePrivacy and Confidentiality.Conducts ongoing monitoring of provider network to assess quality ofhealth care services provided to health plan members – implementscorrective actions as necessary to address identified deficiencies.Provides new legislation updates to PPGs that specifies required actionsto ensure contract compliance – makes available additional informationon compliance activities and requirements to PPGs on an on-goingbasis.15.2 AUTHORITY AND RESPONSIBILITYL.A. Care’s Compliance & Audit Program ensures compliance with Stateof California and federal rules and regulations, L.A. Care’s payercontracts, and other standards as required by applicable regulatory185

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALagencies. This includes but is not limited to the following requirements asapplicable to each PPG’s contract with L.A. Care:Requirements described in the Medicare Managed Care Manual and asset forth by CMSRules and regulations promulgated by and for the Department of ManagedHealth Care.All applicable federal rules and regulations that apply to the provision ofhealth care services.Federal and State of California governing law and legal rulings.Terms and conditions as set forth in L.A. Care’s contracts with Californiaand federal agencies, private foundations, other payer organizationsfor the provision of health care services.Requirements established by L.A. Care and implemented with PPG asstated in the PPG’s contract with L.A. Care.15.3 DELEGATION OF COMPLIANCE & AUDIT PROGRAML.A. Care does not delegate its Compliance & Audit Programresponsibilities to a PPG. L.A. Care staff works with PPG staff toadminister compliance activities and implement corrective actions torectify deficiencies. PPG staff is encouraged to work with L.A. Carecompliance staff to ensure compliance with all program requirements.15.4 AUDIT & OVERSIGHT ACTIVITIESTo ensure that all L.A. Care health plan members receive quality andappropriate health care services, L.A. Care staff performs an annual auditof contract responsibilities and services delegated by L.A. Care to PPG.L.A. Care’s audit program for delegated PPGs includes but is not limited tothe following activities:Annual on-site visit to delegated PPG to ensure that delegatedresponsibilities and services are in compliance with programrequirements. The annual evaluation will be a comprehensiveassessment of the delegate's performance, including both compliancewith applicable standards and the extent to which the delegate'sactivities promote L.A. Care’s overall goals and objectives for thedelegated function. If any problems or deficiencies are identified, theevaluation will specify any necessary corrective action and includeprocedures for assuring that the corrective action is implemented.Ad-hoc on-site visits to review PPG activities to ensure compliance withprogram requirements.186

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALOngoing monitoring through review of periodic reports and data requiredas outlined in the delegation agreement.PPG shall maintain and provide to L.A. Care, all books and records andinformation as may be necessary for compliance by L.A. Care andPPG with State of California, federal, and contractual requirements.Records include, but are not limited to, financial records and booksof account, all medical records, medical charts and prescription files,and any other documentation pertaining medical and non-medicalservices rendered to members and such other information asreasonably requested by L.A. Care.PPG shall ensure all their related entities, contractors, or subcontractors,and downstream entities involved in transactions related to L.A. Care’sSNP maintain and provide access to all pertinent contracts, books,documents, papers, and records necessary for compliance with state andfederal requirements.15.5 L.A. CARE’S HEALTH CARE FRAUD & ABUSE LINEL.A. Care’s Fraud & Abuse Detection unit was created to help reducefraudulent activities in L.A. Care’s network.Fraud is defined as an intentional deception or misrepresentation that theprovider, member, employee or entity makes knowing that themisrepresentation could result in some unauthorized benefit to the provider,member, employee, entity or some other party.The goal of this unit will be to protect members in the delivery of health careservices through timely detection, investigation and prosecution of suspectedhealth care fraud. Anti-fraud activities will be coordinated between L.A. Careand its PPGs, hospitals and ancillary providers.15.5.1 REPORTING POTENTIALLY FRADULENT ACTIVITIESThe Fraud & Abuse Detection unit is set up to handle all types ofpotentially fraudulent activities. Staff monitors activities ranging fromclaims to health care services provided to members. Written or verbalallegations of fraudulent activities are forwarded to L.A. Care’sRegulatory Affairs & Compliance Department for follow-up.Potentially fraudulent activities can be reported by calling L.A. Care’sFraud and Abuse Hotline at 1-800-400-4889. You may also call L.A.Care’s Compliance Officer directly at 1-213-694-1250, ext. 4292. If, for187

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALwhatever reason, you are not able to report a potential fraud case bycalling these phone numbers, please call L.A. Care’s Provider InquiryLine at 1-866-522-2736.A written letter regarding potentially fraudulent activities can be mailedto L.A. Care at:Compliance Officer, Regulatory Affairs &ComplianceC/o Special Investigative Unit (SIU)555 W. Fifth Street, 29 th FloorLos Angeles, CA 90013If fraud or abuse is found, the fraudulent incident or activity is reportedto the appropriate outside law enforcement and/or regulatory agency.15.5.2 COMMUNICATION OF L.A. CARE’S FRAUD & ABUSEDETECTION EFFORTSL.A. Care uses various means to educate its provider network andmembership about its fraud & abuse detection unit’s efforts.Information about L.A. Care’s Fraud & Abuse Detection unit iscommunicated in some of the following ways: provider bulletins;provider mailings; provider trainings; member newsletters; NewMember Handbook and L.A. Care’s Regional Community AdvisoryCommittee meetings.15.6 THE FEDERAL FALSE CLAIMS ACTThe federal False Claims Act permits a person who learns of fraud againstthe United States Government, to file a lawsuit on behalf of thegovernment against the person or business that committed the fraud. Ifthe action is successful, the person filing the lawsuit or "plaintiff" isrewarded with a percentage of the recovery.Who can be a plaintiff?If the fraud has not previously been publicly disclosed, any person maybring a lawsuit called a "qui tam action" regardless of whether he or shehas "direct" or first-hand knowledge of the fraud. Thus, where there hasbeen no public disclosure, an employee that learns from a colleague offraud the employer or another employee at work may bring a qui tamaction, even if the qui tam plaintiff personally has no first-hand knowledge.188

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALWhat types of fraud qualify?When a person deliberately uses a misrepresentation or other deceitfulmeans to obtain something to which he or she is not otherwise entitled,that person has committed fraud. This usually -- although not always --involves money. However, under the False Claims Act, fraud has a muchwider and more inclusive meaning.Under the Act, the defendant need not have actually known that theinformation it provided to the government was false. It is sufficient that thedefendant supplied the information to the Government either: (i) in"deliberate ignorance" of the truth or falsity of the information; or (ii) in"reckless disregard" of the truth or falsity of the information.Thus, if a defendant should have known that its representations to thegovernment were not true or accurate, but did not bother to check, suchrecklessness may constitute a violation of the Act. Likewise, if a defendantdeliberately ignores information which may reveal the falsity of theinformation submitted to the government, such "deliberate ignorance" mayconstitute a violation of the Act.What protection is there for a plaintiff who brings an action?The False Claims Act provides protection to employees who are retaliatedagainst by an employer because of the employee's participation in a quitam action. The protection is available to any employee who is fired,demoted, threatened, harassed or otherwise discriminated against by hisor her employer because the employee investigates, files or participates ina qui tam action.This "whistleblower" protection includes reinstatement and damages ofdouble the amount of lost wages if the employee is fired, and any otherdamages sustained if the employee is otherwise discriminated against.15.7 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT(HIPAA) FOR MEDI-CAL AND MEDICARE PROGRAMSHIPAA stands for the Health Insurance Portability & Accountability Act of 1996(August 21, 1996), Public Law 104-191. Also known as the Kennedy-Kassebaum Act, the Act included a section re Title II, entitled AdministrativeSimplification, requiring:• Improved efficiency in healthcare delivery by standardizingelectronic data interchange, and• Protection of confidentiality and information security of health datathrough setting and enforcing standards.189

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMore specifically, HIPAA called upon the Department of Health andHuman Services (“DHHS”) to publish rules that ensure:• Standardization of electronic patient health, administrative andfinancial data.• Unique health identifiers for individuals, employers, health plans andhealth care providers.• Privacy and Information Security standards protecting theconfidentiality and integrity of "individually identifiable healthinformation," past, present or future.Overall, HIPAA has meant sweeping changes in most healthcaretransaction and administrative information systems.15.7.1 SECURITY RULEThe Security Rule requires covered entities to ensure the confidentiality,integrity, and availability of all electronic protected health information(“ePHI”) the covered entity creates, receives, maintains, or transmits. Italso requires entities to protect against any reasonably anticipated threatsor hazards to the security or integrity of ePHI, protect against anyreasonably anticipated uses or disclosures of such information that are notpermitted or required by the Privacy Rule, and ensure compliance by theirworkforce. Required safeguards include application of appropriate policiesand procedures, safeguarding physical access to ePHI, and ensuring thattechnical security measures are in place to protect networks, computersand other electronic devices.The Security Standard is intended to be scalable; in other words, it doesnot require specific technologies to be used. Covered entities may electsolutions that are appropriate to their operations, as long as the selectedsolutions are supported by a thorough security assessment and riskanalysis.15.7.2 PRIAVACY RULEThe Privacy Rule is intended to protect the privacy of all individuallyidentifiable health information in the hands of covered entities, regardlessof whether the information is or has been in electronic form. The Privacystandards:• Give patients rights to access their medical records, restrict accessby others, request changes, and to learn how patient’s healthinformation has been accessed.190

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL• Restrict most disclosures of protected health information to theminimum amount of information needed for healthcare treatment,payment and healthcare operations.• Provide the right of all patients to be formally notified of coveredentities' privacy practices.• Enable patients to decide if they will authorize disclosure of theirprotected health information (“PHI”) for uses other than treatment,payment or healthcare operations.• Establish new criminal and civil sanctions for improper use ordisclosure of PHI.• Establish new requirements for access to records by researchersand others.• Establish business associate agreements with business partnersand vendors that safeguard their use and disclosure of PHI.• Implement a comprehensive compliance program, includingo Conducting an impact assessment to determine gapsbetween existing information practices and policies andHIPAA requirements.o Reviewing functions and activities of the organization'sbusiness partners to determine where Business AssociateAgreements are required.o Developing and implementing enterprise-wise privacypolicies and procedures to implement the regulations.o Assigning a Privacy Officer who will administer and overseethe organizational privacy program and enforce compliance.o Training all members of the workforce on HIPAA andorganizational privacy policies.o Updating systems to ensure they provide adequateprotection of patient information data.15.7.3 TRANSACTION AND CODE SETS STANDARDSAccording to CMS, electronic transactions are activities involving the transferof healthcare information for specific purposes. Under the HIPAA regulations,if a health care provider engages in one of the identified transactions, theymust comply with the standard for that transaction. HIPAA requires everyprovider who does business electronically to use the same healthcaretransactions, code sets and identifiers. HIPAA has identified ten standardtransactions for Electronic Data Interchange (“EDI”) for the transmission ofhealthcare data. Claims and encounter information, payment and remittanceadvice, and claims status and inquiry are several diagnosis and clinicalprocedures on claims and encounter forms. The HCPCS, CPT-4 and ICD-9codes with which providers are familiar, are examples of code sets forprocedures and diagnoses.191

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL15.8 GOVERNMENTAL AND HIPAA-RELATED RESOURCES & WEBSITESU.S. Department of Health & Human Services- Office of Civil Rightshttp://www.hhs.gov/ocr/hipaa/Centers for Medicare & Medicaid Services (CMS)http://www.cms.hhs.gov/hipaageninfo/01_overview.asp?California Department of Health Care Serviceshttp://www.privacy.ca.gov/lawenforcement/laws.htmHIPAA Advisoryhttp://www.hipaadvisory.comNational Committee on Vital and Health Statisticshttp://www.ncvhs.hhs.gov/Workgroup for Electronic Data Exchangehttp://www.wedi.orgPortability of Health Coveragehttp://www.dol.gov/dol/topic/health-plans/portability.htmNational Institutes of Healthhttp://privacyruleandresearch.nih.gov/Centers for Disease Control and Prevention Privacy Rulehttp://www.cdc.gov/privacyrule/Health Resources and Services Administrationhttp://www.hrsa.gov/servicedelivery/hipaa.htm192

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL16.0 PHARMACYPART D PRESCRIPTION DRUG COVERAGE – MEDICARE ADVANTAGE-SNPThis chapter describes the key aspects of the Part D Prescription Drug benefitoffered under L.A. Care’s Medicare Advantage-SNP plan.16.1 Pharmacy BenefitsL.A. Care, through its pharmacy benefits manager (PBM), has contractedwith a comprehensive network of pharmacies located throughout theService Area that are staffed by credentialed pharmacists. Additionally,MA-SNP members may fill prescriptions by mail order at significantsavings to themselves and to the Plan. The Plan has made arrangementswith a PBM (Pharmacy Benefit Manager) to manage these pharmacyservices for Plan Members.16.2 Systems Support for L.A. Care and its ProvidersThe PBM has developed sophisticated systems to work efficiently withL.A. Care and its Participating Providers to safeguard the health ofMembers and to facilitate access to appropriate pharmacy and therapeuticservices.a) Member Eligibility, as well as Member identifying information, is verifiedon-line, in real time by the customer services representativesb) Formulary Compliance is monitored and facilitated through theidentification of alternative medications or dosagesc) Drug Interaction(s) with potentially adverse outcomes are noted andbrought to the attention of prescribing Providers16.3 Clinician’s Support for L.A. CareThe PBM dedicates a pharmacist and support staff to work with L.A. Careand its Providers on identifying the best strategies for prescribing anddispensing pharmaceuticals considering quality, cost, and Member needs.a) The PBM’s pharmacist works closely with the Plan’s Pharmacy Directorand Medical Director to:1) Administer the Pharmacy Benefits2) Recommend improvements based on the experience of L,A. Care, aswell as trends and innovations found throughout the managed careindustry193

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUAL16.4 L.A. Care’s Drug Formulary for Part DThe Drug Formulary for Part D represents the efforts by the PBM’sPharmacy and Therapeutics (P&T) Committee to provide physicians andpharmacists with a method for evaluating the various drug productsavailable.The medical treatment of Members is frequently related to the practicalapplication of drug therapy. Due to the vast availability of medicationtherapy and treatment modalities, a reasonable program of drug productselection and drug usage has been developed. The goal of the DrugFormulary is to enhance the physician’s abilities to provide optimal costeffective drug therapy for Members.The development, maintenance, and improvement of this process areevolutionary and require constant attention. This is accomplished by thePBM’s P&T and Formulary Committee. The Formulary is continuouslyreviewed and revised, as a necessary part of a Quality Improvement. Toaccommodate the necessary changes of this document, updates are sentregularly. Additionally, an updated electronic version of this formulary isavailable online at: http://www.LACARE.Com.L.A. Care’s Customer Services Department may also be contactedregarding Formulary updates at (888) 839-9909. As ParticipatingProviders use this Formulary, they are encouraged to review theinformation and provide input to the P&T process.The PBM’s P&T Committees use the following criteria in the evaluation ofdrug selection for the Drug Formulary:a) Drug safety profileb) Drug efficacyc) Comparison of relevant drug benefits to current formulary agents ofsimilar use, while minimizing duplicationsd) Equitable cost and outcomes of the total cost of product and medicalcaree) If drug needs authorization or is not in formulary an exception may berequested. This may be requested on CMS Medicare Part D CoverageDetermination Request form.The Formulary is a list of covered and preferred drug therapies for L.A.Care’s SNP Members. Drugs are listed by their generic names and/ormost common proprietary (branded) name. The Formulary is arranged bytherapeutic drug category and indexed by either generic or proprietaryname. Some branded drugs listed are for reference use only, and do notdenote coverage; covered branded drugs are listed entirely in capitallettering. Any drug not found in this Formulary listing or in any Formularyupdates published by L.A. Care shall be considered a Non-Formularydrug.194

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALL.A. Care’s Formulary does not provide information regarding the specificcoverage and limitations an individual Member may have. Many Membershave specific Benefit inclusions, exclusions, Co-payments, or a lack ofcoverage, which are not reflected in the Formulary.The Formulary applies only to Outpatient drugs provided to Members, andmay not apply to medications used in Inpatient settings or to medicationsthat require special handling and/or administration by a ParticipatingProvider. If a Member has any specific questions regarding their coverage,they should contact L.A. Care at (888) 839-9909.16.5 Medicare Part D Formulary StructureThe Medicare Part D Formulary is based on a two-tier structure, whichincludes Generic drugs (Tier 1) covered at a zero or lower Co-payment,and Brand drugs (Tier 2) at the higher a Co-payment amount. Should aMember need drugs that are restricted by the Formulary, a CMS MedicarePart D Coverage Determination Request Form will need to be filled outand fax or mail to the PBM or L.A. Care.16.6 L.A. Care’s Policies Regarding PrescriptionsIt is the goal of L.A. Care to provide quality care to our members byensuring that medications prescribed by the L.A. Care’s Providers areappropriate for the Member considering his/her health status and theclinical alternatives that are available. Consequently it is the policy of theL.A. Care that:1. Generics will be substituted, unless the name brand is specified by theProvider2. Higher Co-payments apply to name brand drugs than to generics3. PBM’s clinicians administer the Plan’s guidelines4. In instances where the guidelines are not sufficiently specific, L.A. Care’sPharmacy Director or Medical Director will be involved in rendering adecision regarding a specific case for a determination.5. Grievances and Appeals by Members and/or Providers relative topharmacy services, are handled by L.A. Care, as for all other Benefits16.7 Coverage determinationThe Coverage Determination made by L.A.Care is the starting point fordealing with requests members may have about covering or paying for aPart D prescription drug. If the members’ doctors or pharmacists inform195

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALthem that a certain prescription drug is not covered, our members or theirproviders should contact L.A.Care and ask how to obtain a CoverageDetermination. Requests for a Coverage Determination or exception maybe submitted on CMS Medicare Part D Coverage Determination RequestForm via fax or mail.With this Coverage Determination decision, L.A. Care does explainwhether we will provide the prescription drug requested or pay for aprescription drug already received. If L.A. Care denies the request (this issometimes called an “adverse coverage determination”), our memberscan request for a redetermination of the decision within sixty (60) calendardays. If L.A.Care fails to make a timely coverage determination on arequest, it will be automatically forwarded to the independent review entity(IRE) for review.The following are examples of coverage determinations:1. A member requests payment for a prescription drug alreadyreceived. This is a request for a coverage determination aboutpayment. You can call us at 1-888-839-9909 to get help inmaking this request.2. A Part D drug that is not on L.A.Care's list of covered drugs.This is a request for a "formulary exception."3. Exception is requested for prior authorization, dosage limits,quantity limits, or step therapy requirements. Requesting anexception to a utilization management tool is a type of formularyexception.4. A member requests for a non-preferred Part D drug to beprovided at the preferred cost-sharing level. This is a requestfor a "tiering exception.5. Request for reimbursement for a drug obtained at an out-ofnetworkpharmacy. In certain circumstances, out-of-networkpurchases, including drugs provided in a physician’s office,may be covered by the L.A. Care.When L.A.Care makes a coverage determination, we are providingour interpretation of how the Part D prescription drug benefits that arecovered for our members based on that specific situation.16.8 Utilization Management Tools:a. Prior Authorization: L.A. Care requires prior authorization for certaindrugs. This means that a member, their doctor, or authorizedrepresentative will need to get approval from us before filling aprescription. If they don’t get approval, we may not cover the drug.196

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALb. Quantity Limits: For certain drugs, L.A. Care limits the amount ofthe drug that we will cover per prescription or for a defined period oftime. For example, we will provide up to 60 tablets for every 31 dayperiod per prescription for Namenda.c. Step Therapy: In some cases, L.A. Care requires a member to firsttry one drug to treat their medical condition before covering anotherdrug for that condition. For example, if Drug A and Drug B bothtreat their medical condition, L.A. Care may require the provider toprescribe Drug A first. If Drug A does not work for you, then L.A.Care will cover Drug B16.9 Time Frames for Coverage DeterminationsA decision about whether L.A. Care will cover a Part D prescription drugcan be a “standard" coverage determination that is made within thestandard timeframe (typically within 72 hours); or it can be a “fast"coverage determination that is made more quickly (typically within 24hours). A fast decision is sometimes called an “expedited coveragedetermination.”A fast or expedited coverage determination may be requested only if themember or their doctor believes that waiting for a standard decision couldseriously harm a member’s health or ability to function. (Fast decisionsapply only to requests for Part D drugs that a member has not receivedyet. Members cannot get a fast decision if they are requesting paymentfor a Part D drug that was already received.)16.10 Reports on Pharmacy Services UtilizationL.A. Care conducts drug utilization reviews for all of our members to makesure that they are receiving safe and appropriate care. These reviews areespecially important for members who have more than one doctor whoprescribe their medications. These drug utilization reviews occur eachtime a prescription may be filled and on a regular basis by reviewing themember’s pharmacy records. During these reviews, we look formedication problems such as:1. Possible medication errors2. Duplicate drugs that are unnecessary because you are taking anotherdrug to treat the same medical condition3. Drugs that are inappropriate because of your age or gender4. Possible harmful interactions between drugs you are taking5. Drug allergies6. Drug dosage errorsPursuant to its agreement with L.A. Care, the PBM generates reportsabout the utilization of pharmacy services by within the health plan,Participating Providers and selected specialties. This information isanalyzed on a retrospective basis in accordance with general industrytrends and criteria. Consideration of the specific interests of L.A. Care197

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALrelative to the health status of its unique membership base and the relatedprescribing practices of network Providers are also taken into account.Such reports will be reviewed by the L.A. Care’s Pharmacy andTherapeutics Committee. L.A. Care will share drug utilization reports withthe Physician Groups on a periodic basis as part of its QualityImprovement process.16.11 Reimbursement for Pharmacy ServicesReimbursement for pharmacy services is a responsibility of L.A. Care andhas budgeted funds based on the actuarial assumptions regarding suchcosts for the target population.16.12 Additional Pharmacy Services for Medicare MembersMail Order PrescriptionsAs a convenience to our Members, they have the option of obtaining anextended 90-day supply of covered Part D medications through L.A.CareHealth Plan’s mail-order program. To receive medications through ourmail-order service, they simply complete one of our mail-order forms andmail it in with the doctor’s prescription to the address on the form. If youneed forms contact L.A. Care’s Member Services.Transition PolicyNew members in to L.A. Care may be taking drugs that are not on ourformulary, or that are subject to certain restrictions, such as priorauthorization or step therapy. Members should talk to their doctors todecide if they should switch to an appropriate drug that we cover orrequest a formulary exception (which is a type of coverage determination)in order to get coverage for the drug. The exception process is describedbelow. While these new members might talk to their providers todetermine the right course of action, we may cover the non-formulary drugin certain cases during the first 90 days of new membership.For each of the drugs that are not on our formulary or that have coveragerestrictions or limits, we will cover a temporary 90-day supply (unless theprescription is written for fewer days) when the new member goes to aparticipating network pharmacy (and the drug is otherwise a “Part Ddrug”). After the first 30-day supply, we will provide refills up to 90 days.After 90 days L.A. Care will not pay for these drugs.If the new member is a resident of a long-term care facility, L.A. Care willcover a temporary 31-day transition supply (unless you have aprescription written for fewer days). We will cover more than one refill ofthese drugs for the first 90 days for a new member of our plan. If a newmember needs a drug that is not on our formulary or subject to otherrestrictions, such as step therapy or dosage limits, but the new member is198

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALpast the first 90 days of new membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewerdays) while the new member pursues a formulary exception.Medication Therapy Management (MTM) programsL.A. Care offers Medication Therapy Management (MTM) programs at noadditional cost for our members who have multiple medical conditions,who are taking many prescription drugs, or who have high drug costs.These MTM programs were developed to help us provide better coveragefor our members. For example, these programs help us make sure thatour members are using appropriate drugs to treat their medical conditionsand help us identify possible medication errors. We offer MTM programsfor members that meet specific criteria. L.A. Care may contact memberswho qualify and their providers for these MTM programs. If we contactyou, we hope you will encourage your members to join so that we canhelp manage their medications. Members do not need to pay anythingextra to participate.If members are selected to join a medication therapy managementprogram, we will send information about the specific program, includinginformation about how to access the program.Drug exclusionsBy law, certain types of drugs or categories of drugs are not covered byMedicare Prescription Drug Plans. These drugs are not considered PartD drugs and may be referred to as “exclusions” or “non-Part D drugs.”These drugs include:Nonprescription drugsDrugs when used for anorexia, weight loss, orweight gainDrugs when used to promote fertility Drugs when used for cosmetic purposes or hairDrugs when used for the symptomatic reliefof cough or coldsOutpatient drugs for which the manufacturerseeks to require that associated tests ormonitoring services be purchasedexclusively from the manufacturer as acondition of salegrowthPrescription vitamins and mineral products,except prenatal vitamins and fluoridepreparationsBarbiturates and BenzodiazepinesNOTE: Due to a change in Medicare regulation, most Medicare Part D Plans willno longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra, andCaverject after January 1, 2007.In addition, a Medicare Prescription Drug Plan cannot cover a drug that would becovered under Medicare Part A or Part B199

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALTable 1. L.A. Care’s Medicare Advantage-SNP plan FormularyAcidifying AgentsAcidifying Agentsammonium chloride (Ammonium Chloride) 2 solnAdrenalsAdrenalscortisone acetate (Cortisone Acetate) 1 tabsDEPO-MEDROL 2 susp; 20mg/mldexamethasone (Decadron) 1 elix, tabsENTOCORT EC 2 cp24FLOVENT DISKUS 2 aepbFLOVENT HFA 2 aerofludrocortisone acetate (Florinef) 1 tabshydrocortisone (Cortef) 1 tabshydrocortisone sodium (A-hydrocort) 1 solrsuccinatemethylprednisolone (Medrol) 1 tabsmethylprednisoloneacetate(Depo-medrol) 1 susp; 40mg/ml,80mg/mlmethylprednisolonesodium succinate(Solu-medrol) 1 solr; 40mg,125mg, 500mg,1000mgprednisolone anhydrous (Millipred) 1 syrp, tabsprednisolone sodium (Pediapred) 1 liqd, solnphosphateprednisone (Prednisone) 1 tabsprednisone (Prednisone) 2 solnAlkalinizing AgentsPREDNISONE INTENSOL 2 concPULMICORT FLEXHALER 2 inhaQVAR 2 aersSOLU-MEDROL 2 solr; 2gmSOLU-MEDROL ACT-O- 2 solr; 500mgVIALSYMBICORT 2 aeroAlkalinizing Agentspotassium citrate (Urocit-K) 1 tbcrsodium bicarbonate (Sodium Bicarbonate) 1 solnsodium lactate (Sodium Lactate) 1 soln200

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAlpha-Adrenergic Blocking AgentsAlpha-Adrenergic Blocking Agentsdoxazosin mesylate (Cardura) 1 tabsprazosin hydrochloride (Minipress) 1 capsterazosin hcl (Hytrin) 1 capsAmmonia DetoxicantsAmmonia DetoxicantsBUPHENYL 2 powd, tabslactulose (Enulose) 1 solnLITHOSTAT 2 tabsAnalgesics and AntipyreticsNon-Steroidal Anti-inflammatory AgentsCELEBREX 2 QL, ST capsdiclofenac potassium (Cataflam) 1 tabsdiclofenac sodium (Voltaren) 1 tb24, tbecdiflunisal (Dolobid) 1 tabsetodolac (Lodine) 1 caps, tabs, tb24fenoprofen calcium (Nalfon) 1 tabsflurbiprofen (Ansaid) 1 tabsibuprofen (Motrin) 1 susp, tabsindomethacin (Indocin) 1 caps, cpcrketoprofen (Orudis) 1 caps, cp24ketorolac tromethamine (Toradol) 1 QL soln, tabsmeclofenamate sodium (Meclomen) 1 capsmeloxicam (Mobic) 1 susp, tabsnabumetone (Relafen) 1 tabsnaproxen (Naprosyn) 1 susp, tabs, tbecnaproxen sodium (Anaprox) 1 tabs, tb24oxaprozin (Daypro) 1 tabspiroxicam (Feldene) 1 capsPREVACID NAPRAPAC 2 ST kitsulindac (Clinoril) 1 tabstolmetin sodium (Tolectin) 1 caps, tabsVOLTAREN 2 gelOpiate Agonistsacetaminophen andbutalbital and caffeineand codeine phosphate(Fioricet/codeine) 1 caps201

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALacetaminophen andcaffeine anddihydrocodeinebitartrateacetaminophen andcodeine phosphateacetaminophen andhydrocodone bitartrateacetaminophen andoxycodone hydrochlorideacetaminophen andpropoxyphenehydrochlorideacetaminophen andpropoxyphene napsylateacetaminophen andtramadol hclaspirin and butalbitaland caffeine and codeinephosphate(Panlor SS) 1 caps, tabs(Tylenol/codeine #3) 1 soln, tabs(Vicodin ES) 1 caps, soln, tabs(Percocet) 1 caps, tabs(Acetaminophen andPropoxyphene Hydrochloride)1 tabs(Darvocet-n 100) 1 tabs(Ultracet) 1 tabs(Fiorinal/codeine #3) 1 capsDOLOPHINE HCL 1 tabsfentanyl (Duragesic) 1 PA, QL pt72fentanyl citrate (Actiq) 1 PA, QL lpopfentanyl citrate (Actiq) 1 solnFENTORA 2 PA, QL tabshydrocodone bitartrateand ibuprofenhydromorphonehydrochlorideibuprofen and oxycodonehydrochloride(Vicoprofen) 1 tabs(Dilaudid) 1 soln, tabs(Combunox) 1 tabsKADIAN 2 ST cp24LEVO-DROMORAN 1 tabslevorphanol tartrate (Levo-dromoran) 1 tabsLORTAB 2.5 1 tabs; 500mg,2.5mgmeperidine(Demerol) 1 soln, tabshydrochloridemethadone(Dolophine) 1 conc, soln, tabshydrochloridemethadone(Methadone Hydrochloride) 2 solnhydrochloridemorphine sulfate (MS Contin) 1 soln, tabs, tb12NARVOX 1 tabs; 500mg, 10mgORAMORPH SR 1 tb12202

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALoxycodone hydrochloride (Oxycodone Hydrochloride) 1 QL tb12; 10mg, 20mg,40mg, 80mgoxycodone hydrochloride (Roxicodone) 1 tabsOXYCONTIN 2 QL tb12; 10mg, 15mg,20mg, 30mg,40mg, 60mg,80mgPERLOXX 1 tabs; 300mg,2.5mgpropoxyphene(Darvon) 1 capshydrochloridetramadol hcl (Ultram) 1 tabsVANACET 1 tabs; 500mg, 5mgOpiate Partial Agonistsacetaminophen and (Talacen) 1 tabspentazocinehydrochlorideBUPRENEX 2 solnbuprenorphinehydrochloride(BuprenorphineHydrochloride)2 solnbutorphanol tartrate (Stadol) 1 solnnaloxone hydrochlorideand pentazocinehydrochloride(Talwin Nx) 1 tabsAndrogensSUBOXONE 2 sublSUBUTEX 2 sublAndrogensANDRODERM 2 PA, QL pt24ANDROGEL 2 PA, QL gel; 25mg/2.5gm,50mg/5gmANDROGEL PUMP 2 PA, QL gel; 1%ANDROID 1 capsdanazol (Danocrine) 1 capsfluoxymesterone (Halotestin) 1 tabsMETHITEST 2 tabsoxandrolone (Oxandrin) 1 tabstestosterone cypionate (Depo-testosterone) 1 PA oiltestosterone enanthate (Delatestryl) 1 PA oilTESTRED 1 capsAnorexigenics, Respiratory, Cerebral StimulantsAmphetamines203

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALamphetamine aspartateand amphetamine sulfateand dextroamphetaminesaccharate anddextroamphetaminedextroamphetaminesulfateADDERALL XR 2 cp24(Adderall) 1 tabs(Dexedrine) 1 cp24, tabsAnorexigenics, Respiratory, Cerebral Stimulants, MiscellaneousCONCERTA 2 tbcr; 18mg, 27mg,36mg, 54mgdexmethylphenidatehydrochloride(DexmethylphenidateHydrochloride)1 tabsmethylphenidatehydrochlorideAnthelminticsMETADATE ER 1 tbcr; 20mg(Ritalin) 1 tabs, tbcrPROVIGIL 2 PA, QL tabsAnthelminticsALBENZA 2 tabsBILTRICIDE 2 tabsmebendazole (Vermox) 1 chewSTROMECTOL 2 tabsAntiallergic AgentsAntiallergic AgentsALAMAST 2 solnASTELIN 2 solnASTEPRO 2 solnPATADAY 2 ST soln; 0.2%PATANOL 2 ST soln; 0.1%AntibacterialsAminoglycosidesamikacin sulfate (Amikin) 1 solngentamicin sulfate and (Gentamicin Sulfate and 1 solnsodium chloride Sodium Chloride)kanamycin sulfate (Kanamycin Sulfate) 1 solnneomycin sulfate (Neomycin Sulfate) 1 soln, tabstobramycin sulfate (Nebcin) 1 soln, solrAntibacterials, Miscellaneousbacitracin (Bacitracin) 1 solr204

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALclindamycin(Cleocin) 1 capshydrochlorideclindamycin phosphate (Cleocin Phosphate) 1 solncolistimethate sodium (Coly-mycin-m) 2 solrCUBICIN 2 solrdextrose (anhydrous) (Dextrose (anhydrous) and 2 solnand vancomycinhydrochlorideVancomycin Hydrochloride)PYLERA 2 capsSYNERCID 2 solrVANCOCIN HCL 2 capsvancomycin(Vancomycin Hydrochloride) 2 solr; 500mg,hydrochloridevancomycinhydrochloride1000mg(Vancomycin Hydrochloride) 1 solr; 10gm,5000mgZYVOX 2 soln, susr, tabsCephalosporinscefaclor (Ceclor) 1 caps, susrcefaclor monohydrate (Ceclor) 1 tb12cefadroxil hemihydrate (Cefadroxil Hemihydrate) 1 capscefadroxil monohydrate (Duricef) 1 susr, tabscefazolin sodium (Ancef) 1 solrcefdinir (Omnicef) 1 caps, susrcefepime hydrochloride (Maxipime) 1 solr; 1gm, 2gmCEFIZOX IN DEXTROSE 5% 2 solncefotaxime sodium (Claforan) 1 solrcefpodoxime proxetil (Vantin) 1 susr, tabscefprozil (Cefzil) 1 susr, tabsceftazidime (Fortaz) 1 solr; 1gm, 2gm,6gmceftriaxone sodium (Rocephin) 1 solrceftriaxone sodium and (Ceftriaxone Sodium and 1 solndextrose (anhydrous) Dextrose (anhydrous))CEFTRIAXONE/DEXTROSE 2 solrcefuroxime axetil (Ceftin) 1 susr, tabscefuroxime sodium (Zinacef) 1 solrcephalexin (Keflex) 1 capscephalexin monohydrate (Cephalexin Monohydrate) 1 tabsFORTAZ 2 solr; 500mgFORTAZ 2 solnMAXIPIME 2 solr; 1gm, 2gm,500mgChloramphenicolROCEPHIN IN ISO-OSMOTIC DEXTROSE2 soln205

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALchloramphenicol sodium (Chloromycetin) 2 solrsuccinateMacrolidesazithromycin (Zithromax Z-pak) 1 pack, solr, susr,tabsclarithromycin (Biaxin) 1 susr, tabs, tb24ERYTHROCIN 2 solr; 1000mgERYTHROCIN2 solr; 500mgLACTOBIONATEerythromycin (Eryc) 1 cpeperythromycin and (Pediazole) 1 susrsulfisoxazoleerythromycin(Erythromycin Ethylsuccinate) 2 tabsethylsuccinateERYTHROMYCIN2 solr; 500mgLACTOBIONATEerythromycin stearate (Erythromycin Stearate) 2 tabsKETEK 2 ST tabsZMAX 2 susrMiscellaneous B-Lactam Antibioticscefotetan disodium (Cefotetan) 1 solrcefoxitin sodium (Mefoxin) 1 solr; 2gmDORIBAX 2 solrINVANZ 2 solrMEFOXIN 1 solr; 10gmMEFOXIN ADD-VANTAGE 1 solr; 1gm, 2gmMERREM 2 solrPRIMAXIN I.M. 2 solr; 500mg,500mgPRIMAXIN IV 2 solr; 250mg,250mg, 500mg,500mgPRIMAXIN IV ADD-VANTAGE2 solr; 250mg,250mg, 500mg,500mgPenicillinsamoxicillin (Amoxil) 1 caps, chew, susr,tabsamoxicillin and (Augmentin) 1 chew, susr, tabsclavulanic acidamoxicillin and (Augmentin ES-600) 1 susr, tabspotassium clavulanateampicillin (Ampicillin) 1 caps, susrampicillin sodium (Ampicillin Sodium) 1 solr206

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALampicillin sodium and (Unasyn) 1 solrsulbactam sodiumBICILLIN C-R 2 suspBICILLIN L-A 2 suspdicloxacillin sodium (Dynapen) 1 capsnafcillin sodium (Unipen) 1 solrpenicillin g potassium (Penicillin G Potassium) 1 solrpenicillin g sodium (Penicillin G Sodium) 1 solrpenicillin v potassium (Veetids) 1 solr, tabspiperacillin sodium (Piperacillin Sodium) 1 solrTRIMOX 1 capsVEETIDS 1 tabsZOSYN 2 solrZOSYN 2 solnQuinolonesAVELOX 2 solnAVELOX 2 tabsAVELOX ABC PACK 2 tabsciprofloxacin (Cipro I.V.) 1 solnciprofloxacin and (Cipro XR) 1 tb24ciprofloxacin hclciprofloxacin and (Cipro I.V. in D5W) 1 solndextrose (anhydrous)ciprofloxacin hcl (Cipro) 1 tabsLEVAQUIN 2 soln; 5%, 750mg/150mlLEVAQUIN 2 soln, tabsLEVAQUIN LEVA-PAK 2 tabsLEVAQUIN PREMIX 2 soln; 5%, 250mg/50mlofloxacin (Floxin) 1 tabsSulfonamides (Systemic)GANTRISIN PEDIATRIC 2 suspsulfadiazine (Sulfadiazine) 1 tabssulfamethoxazole andtrimethoprim(Bactrim) 1 soln, susp, tabssulfasalazine (Azulfidine) 1 tabs, tbecTRIMETHOPRIM/1 tabsSULFAMETHOXAZOLE DSTetracyclinesdemeclocyclinehydrochloride(Declomycin) 1 tabsdoxycycline hyclate (Vibramycin) 1 caps, cpep, solr,tabs207

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALdoxycyclinemonohydrateminocyclinehydrochloridetetracyclinehydrochloride(Adoxa) 1 caps, susr, tabs(Minocin) 1 caps, tabs(Tetracycline Hydrochloride) 1 capsTYGACIL 2 solrVIBRAMYCIN 2 syrpVIBRAMYCIN 2 susrAnticholinergic AgentsAntimuscarinics/Antispasmodicsatropine sulfate (Atropine Sulfate) 1 solnATROVENT HFA 2 aersCANTIL 2 tabsdicyclomine(Bentyl) 1 caps, soln, tabshydrochlorideglycopyrrolate (Robinul) 1 tabsmethscopolamine (Pamine) 1 tabsbromidepropantheline bromide (Pro-Banthine) 1 tabsSPIRIVA HANDIHALER 2 capsAnticonvulsantsAnticonvulsants, MiscellaneousBANZEL 2 tabscarbamazepine (Tegretol) 1 chew, susp, tabsCARBATROL 2 cp12DEPAKOTE 2 tbecDEPAKOTE ER 2 tb24DEPAKOTE SPRINKLES 2 cpspdivalproex sodium (Depakote) 1 cpsp, tb24, tbecFELBATOL 2 susp, tabsgabapentin (Neurontin) 1 caps, tabsGABITRIL 2 tabsKEPPRA 2 soln, tabs; variousstrengths areavailableLAMICTAL STARTER/NOT 2 kit; 25mg-100mgTAKING CARBAMAZEPINELAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE2 kit; 25mg-100mg208

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALLAMICTAL STARTER/ 2 kit; 25mgTAKING VALPROATElamotrigine (Lamictal) 1 tabs, tbdplevetiracetam (Keppra) 1 soln, tabs; 100mg/ml, 250mg,500mg, 750mg,1000mgLYRICA 2 PA, QL capsmagnesium sulfate, (Magnesium Sulfate,1 solnheptahydrateHeptahydrate)NEURONTIN 2 solnoxcarbazepine (Trileptal) 1 tabsTEGRETOL-XR 2 tb12TOPAMAX 2 tabsTOPAMAX SPRINKLE 2 cpspTRILEPTAL 2 susp, tabsvalproate sodium (Depacon) 1 soln, syrpvalproic acid (Depakene) 1 capszonisamide (Zonegran) 1 capsBarbiturates (Anticonvulsants)primidone (Mysoline) 1 tabsHydantoinsDILANTIN 2 caps; 30mgDILANTIN INFATABS 2 chewfosphenytoin sodium (Cerebyx) 1 solnPEGANONE 2 tabsPHENYTEK 2 caps; 200mg,300mgphenytoin (Dilantin) 1 suspphenytoin sodium (Dilantin) 1 caps; 100mgphenytoin sodium (Phenytoin Sodium) 2 solnSuccinimidesCELONTIN 2 capsethosuximide (Zarontin) 1 caps, solnAntidiabetic AgentsAlpha-Glucosidase Inhibitorsacarbose (Precose) 1 tabsGLYSET 2 tabsAmylinomimeticsSYMLIN 2 soln; 600mcg/mlSYMLINPEN 120 2 soln; 1000mcg/mlSYMLINPEN 60 2 soln; 1000mcg/mlBiguanidesmetformin hydrochloride (Glucophage) 1 tabs, tb24209

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALDipeptidyl Peptidase-4 (dpp-4) InhibitorsJANUMET 2 ST tabsJANUVIA 2 ST tabsIncretin MimeticsBYETTA 2 QL, ST solnInsulinsHUMALOG 2 solnHUMALOG KWIKPEN 2 solnHUMALOG MIX 50/50 2 susp; 50%, 50%HUMALOG MIX 50/50 2 susp; 50%, 50%KWIKPENHUMALOG MIX 50/50 PEN 2 susp; 50%, 50%HUMALOG MIX 75/25 2 susp; 25%, 75%HUMALOG MIX 75/25 2 susp; 25%, 75%KWIKPENHUMALOG MIX 75/25 PEN 2 susp; 25%, 75%HUMALOG PEN 2 solnHUMULIN 50/50 2 susp; 50%, 50%HUMULIN 70/30 2 susp; 30%, 70%HUMULIN 70/30 PEN 2 susp; 30%, 70%HUMULIN N 2 suspHUMULIN N U-100 PEN 2 suspHUMULIN R 2 soln; 100 unit/mlHUMULIN R U-5002 soln; 500 unit/ml(CONCENTRATED)LANTUS 2 solnLANTUS FOR OPTICLIK 2 solnLANTUS SOLOSTAR 2 solnLEVEMIR 2 solnLEVEMIR FLEXPEN 2 solnNOVOLIN 70/30 2 susp; 30%, 70%NOVOLIN 70/30 INNOLET 2 susp; 30%, 70%NOVOLIN 70/30 PENFILL 2 susp; 30%, 70%NOVOLIN N 2 suspNOVOLIN N INNOLET 2 suspNOVOLIN N U-100 PENFILL 2 suspNOVOLIN R 2 soln; 100 unit/mlNOVOLIN R INNOLET 2 soln; 100 unit/mlNOVOLIN R U-100 PENFILL 2 soln; 100 unit/mlNOVOLOG 2 solnNOVOLOG FLEXPEN 2 solnNOVOLOG MIX 70/30 2 suspNOVOLOG MIX 70/30PENFILL2 susp210

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMeglitinidesNOVOLOG MIX 70/30 2 suspPREFILLED FLEXPENNOVOLOG PENFILL 2 solnRELION 70/30 2 susp; 30%, 70%RELION 70/30 INNOLET 2 susp; 30%, 70%RELION N 2 suspRELION N INNOLET 2 suspRELION R 2 soln; 100 unit/mlPRANDIMET 2 tabsPRANDIN 2 tabsSTARLIX 2 tabsSulfonylureaschlorpropamide (Diabinese) 1 tabsglimepiride (Amaryl) 1 tabsglipizide (Glucotrol) 1 tabs, tb24glipizide and metformin (Metaglip) 1 tabshydrochlorideglyburide (Micronase) 1 tabsglyburide and metformin (Glucovance) 1 tabshydrochloridetolazamide (Tolinase) 1 tabstolbutamide (Orinase) 1 tabsThiazolidinedionesACTOPLUS MET 2 ST tabsACTOS 2 ST tabsAVANDAMET 2 ST tabsAVANDARYL 2 ST tabsAVANDIA 2 ST tabsDUETACT 2 ST tabsAntidiarrhea AgentsAntidiarrhea Agentsatropine sulfate and (Lomotil) 1 liqd, tabsdiphenoxylatehydrochlorideloperamide(Imodium) 1 capshydrochlorideMOTOFEN 2 tabsAntiemetics5-HT3 Receptor Antagonistsgranisetron hcl (Kytril) 1 PA soln, tabsgranisetron hcl (Kytril) 1 soln, vial211

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALondansetron (Zofran) 1 PA tbdpondansetron hcl (Zofran) 1 PA soln, tabsondansetron hcl (Zofran) 1 soln, vialSANCUSO 2 PA ptchAntiemetics, MiscellaneousCESAMET 2 capsdronabinol (Marinol) 1 capsEMEND 2 PA, QL caps, miscTRANSDERM-SCOP 2 pt72Antihistamines (GI Drugs)ANTIVERT 2 tabs; 50mgmeclizine hydrochloride (Antivert) 1 tabs; 12.5mg,25mgprochlorperazine (Compazine) 1 suppprochlorperazine (Compazine) 1 solnedisylateprochlorperazine (Compazine) 1 tabsmaleatetrimethobenzamidehydrochloride(Tigan) 1 capsAntifungals (Systemic)Allylaminesterbinafinehydrochloride(Lamisil) 1 tabsAntifungals, Miscellaneousgriseofulvin (Grifulvin V) 1 suspGRIS-PEG 2 tabsAzolesdextrose (anhydrous)and fluconazole(Diflucan in Iso-osmotic 1 solnDextrose)fluconazole (Diflucan) 1 susr, tabsfluconazole and sodium (Diflucan in NaCl) 1 solnchlorideitraconazole (Sporanox) 1 capsketoconazole (Nizoral) 1 tabsNOXAFIL 2 suspSPORANOX 2 solnVFEND 2 susr, tabsVFEND IV 2 solrEchinocandinsCANCIDAS 2 solrERAXIS 2 solrPolyenesABELCET 2 PA susp212

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAMBISOME 2 PA susr; 50mgAMPHOTEC 2 PA susr; 50mg, 100mgamphotericin b (Amphocin) 1 PA solrnystatin (Mycostatin) 1 susp, tabsPyrimidinesANCOBON 2 capsAntiglaucoma AgentsAlpha-Adrenergic Agonists (EENT)ALPHAGAN P 2 soln; 0.1%, 0.15%brimonidine tartrate (Brimonidine Tartrate) 1 soln; 0.2%COMBIGAN 2 solnBeta-Adrenergic Blocking Agents (EENT)betaxolol hydrochloride (Betaxolol Hydrochloride) 1 solnBETIMOL 2 solnISTALOL 2 soln; 0.5%levobunolol(Betagan) 1 solnhydrochloridemetipranolol (Optipranolol) 1 solntimolol maleate (Timoptic) 1 solg, solnTIMOPTIC OCUDOSE 2 soln; 0.25%, 0.5%Carbonic Anhydrase Inhibitors (EENT)acetazolamide (Diamox) 1 cp12, tabsacetazolamide sodium (Acetazolamide Sodium) 2 solrAZOPT 2 suspdorzolamide(Trusopt) 1 solnhydrochloridedorzolamide(Cosopt) 1 solnhydrochloride andtimolol maleatemethazolamide (Neptazane) 1 tabsMioticsPHOSPHOLINE IODIDE 2 solrPILOPINE HS 2 gelProstaglandin AnalogsTRAVATAN 2 solnTRAVATAN Z 2 solnXALATAN 2 solnAntihemorrhagic AgentsHemostaticsCYKLOKAPRON 2 soln213

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAntihypoglycemic AgentsGlycogenolytic AgentsGLUCAGEN HYPOKIT 2 solrGLUCAGON EMERGENCYKIT2 kitAnti-infectives (EENT)Antibacterials (EENT)bacitracin (Bacitracin) 1 ointbacitracin zinc and (Bacitracin Zinc and1 ointhydrocortisone acetateand neomycin sulfateand polymyxin b sulfateHydrocortisone Acetate andNeomycin Sulfate andPolymyxin B Sulfate)bacitracin zinc andneomycin sulfate and(Neosporin) 1 ointpolymyxin b sulfatebacitracin zinc andpolymyxin b sulfate(Polycin B) 1 ointBACTROBAN NASAL 2 ointBLEPHAMIDE 2 suspBLEPHAMIDE S.O.P. 2 ointCIPRO HC 2 suspCIPRODEX 2 suspciprofloxacin hcl (Ciloxan) 1 solnCOLY-MYCIN-S 2 susp; 3mg/ml, 1%,5mg/ml, 0.05%CORTISPORIN-TC 2 susp; 3mg/ml,10mg/ml, 3.3mg/ml, 0.5mg/mldexamethasone andneomycin sulfate andpolymyxin b sulfatedexamethasone andtobramycin sulfate(Maxitrol) 1 oint, susp(Tobradex) 1 suspDEXASPORIN 1 suspdoxycycline hyclate (Periostat) 1 tabserythromycin (Erythromycin) 1 ointgentamicin sulfate (Garamycin) 1 oint, solngramicidin and neomycinsulfate and polymyxin bsulfatehydrocortisone andneomycin sulfate andpolymyxin b sulfate(Neosporin) 1 soln(Cortisporin) 1 soln, susp214

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALOCUSULF-10 1 solnofloxacin (Ocuflox) 1 solnOTICIN HC 1 suspPEDIOTIC 2 suspPOLYCIN B 1 ointpolymyxin b sulfate andtrimethoprim sulfate(Polytrim) 1 solnprednisolone sodiumphosphate andsulfacetamide sodiumPOLY-PRED 2 susp(Prednisolone Sodium1 solnPhosphate and SulfacetamideSodium)sulfacetamide sodium (Sulfac) 1 oint, solntobramycin sulfate (Tobrex) 1 solnVIGAMOX 2 solnZYLET 2 suspZYMAR 2 solnAntifungals (EENT)NATACYN 2 suspAntivirals (EENT)trifluridine (Viroptic) 1 solnEENT Anti-infectives, Miscellaneousacetic acid (Vosol) 1 solnacetic acid and (Domeboro) 1 solnaluminum acetateacetic acid and (Vosol HC) 1 solnhydrocortisonechlorhexidine gluconate (Peridex) 1 solnAnti-infectives (Skin and Mucous Membrane)Antibacterials (Skin and Mucous Membrane)BENZACLIN 2 gelbenzoyl peroxide and (Benzamycin) 1 gelerythromycinclindamycin phosphate (Cleocin) 1 crea, gel, lotn,soln, swabERYDERM 1 solnerythromycin (Erygel) 1 gel, pads, solngentamicin sulfate (Gentamicin Sulfate) 1 crea, ointmetronidazole (Vandazole) 1 gelmupirocin (Centany) 1 ointneomycin sulfate and (Neosporin Gu Irrigant) 1 solnpolymyxin b sulfateVANDAZOLE 1 gelAntifungals (Skin and Mucous Membrane)215

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALbetamethasone (Lotrisone) 1 crea, lotndipropionate andclotrimazoleciclopirox (Ciclopirox) 1 gel, solnciclopirox olamine (Loprox) 1 crea, suspclotrimazole (Mycelex) 1 crea, lozg, soln,troceconazole nitrate (Spectazole) 1 creaEXELDERM 2 crea, solnGYNAZOLE-1 2 creaketoconazole (Kuric) 1 crea, shamKURIC 1 creaLAMISIL 2 solnLOPROX SHAMPOO 2 shammiconazole nitrate (Monistat 3) 1 suppNAFTIN 2 crea, gelNAFTIN-MP 2 creanystatin (Mycostatin) 1 crea, oint, powdnystatin and(Mycolog-II) 1 crea, ointtriamcinolone acetonideterconazole (Terazol 3) 1 crea, suppAntivirals (Skin and Mucous Membrane)DENAVIR 2 creaZOVIRAX 2 crea, ointLocal Anti-infectives, MiscellaneousALCOHOL SWABS 2 padsmetronidazole (Metrogel) 1 crea, gel, lotnselenium sulfide (Selsun Shampoo) 1 lotnsilver sulfadiazine (Silvadene) 1 creasulfacetamide sodium (Klaron) 1 lotnTHERMAZENE 1 creaScabicides and PediculicidesEURAX 2 crea, lotnlindane (Lindane) 1 lotn, shamOVIDE 2 lotnpermethrin (Elimite) 1 creaAnti-inflammatory Agents (EENT)Corticosteroids (EENT)ALREX 2 susp; 0.2%DERMOTIC 2 oildexamethasone sodium (Dexasol) 1 solnphosphateECONOPRED PLUS 1 susp216

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALflunisolide (Nasarel) 1 solnFLUOROMETHOLONE 1 suspFLUOR-OP 1 suspfluticasone propionate (Flonase) 1 suspLOTEMAX 2 susp; 0.5%NASONEX 2 suspprednisolone acetate (Pred Forte) 1 suspprednisolone sodium (Prednisol) 1 solnphosphateEENT Anti-inflammatory Agents, MiscellaneousRESTASIS 2 PA, QL emulEENT Non-Steroidal Anti-inflammatory AgentsACULAR 2 soln; 0.5%ACULAR LS 2 soln; 0.4%ACULAR PF 2 soln; 0.5%diclofenac sodium (Voltaren) 1 solnflurbiprofen sodium (Ocufen) 1 solnNEVANAC 2 suspAnti-inflammatory Agents (GI Drugs)Anti-inflammatory Agents (GI Drugs)APRISO 2 cp24ASACOL 2 tbecbalsalazide disodium (Colazal) 1 capsCANASA 2 suppDIPENTUM 2 capsmesalamine (5-asa) (Rowasa) 1 enemPENTASA 2 cpcrAnti-inflammatory Agents (Respiratory)Leukotriene ModifiersACCOLATE 2 ST tabsSINGULAIR 2 ST chew, pack, tabsZYFLO CR 2 tb12Mast Cell Stablilizerscromolyn sodium (Cromolyn Sodium) 1 solnGASTROCROM 2 concINTAL INHALER 2 aersAnti-inflammatory Agents (Skin and Mucous)Anti-inflammatory Agents (Skin and Mucous)alclometasone(Aclovate) 1 crea, ointdipropionateamcinonide (Cyclocort) 1 crea, lotn, oint217

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALaugmented(Alphatrex) 1 crea, gel, lotn, ointbetamethasonedipropionatebetamethasone (Del-beta) 1 crea, lotn, ointdipropionatebetamethasone valerate (Betamethasone Valerate) 1 crea, lotn, ointclobetasol propionate (Olux) 1 crea, foam, gel,oint, solnCLODERM 2 creaCORDRAN 2 lotnCORDRAN SP 2 creaCORDRAN TAPE 2 tapeCUTIVATE 2 lotnDEL-BETA 1 lotndesonide (Desowen) 1 crea, lotn, ointdesoximetasone (Topicort) 1 crea, gel, ointdiflorasone diacetate (Psorcon) 1 crea, ointfluocinolone acetonide (Synalar) 1 crea, oint, solnfluocinonide (Lidex) 1 crea, gel, oint, solnfluticasone propionate (Cutivate) 1 crea, ointhalobetasol propionate (Ultravate) 1 crea, ointhydrocortisone (Hytone) 1 crea, enem, lotn,ointhydrocortisone acetate (Carmol-HC) 1 creaand urea (carbamide)hydrocortisone butyrate (Locoid) 1 crea, oint, solnhydrocortisone valerate (Westcort) 1 crea, ointmometasone furoate (Elocon) 1 crea, oint, solnprednicarbate (Dermatop) 1 crea, ointtriamcinolone acetonide (Kenalog) 1 crea, lotn, oint,psteTRIDERM 1 ointAntilipemic AgentsAntilipemic Agents, MiscellaneousLOVAZA 2 capsNIASPAN 2 tbcrBile Acid Sequestrantscholestyramine (Questran) 1 pack, powdcolestipol hydrochloride (Colestid) 1 gran, pack, tabsWELCHOL 2 tabsCholesterol Absorption InhibitorsZETIA 2 tabsFibric Acid Derivativesfenofibrate (Lofibra) 1 caps, tabs218

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALgemfibrozil (Lopid) 1 tabsTRICOR 2 tabsHMG-CoA Reductase InhibitorsCRESTOR 2 tabsLIPITOR 2 tabslovastatin (Mevacor) 1 tabspravastatin sodium (Pravachol) 1 tabssimvastatin (Zocor) 1 tabsAntimanic AgentsAntimanic Agentslithium carbonate (Lithobid) 1 caps, tabs, tbcrlithium citrate (Lithium Citrate) 1 syrpAntimigraine AgentsSelective Serotonin AgonistsIMITREX 2 QL soln, tabsIMITREX 2 QL solnIMITREX STATDOSE 2 QL kitREFILLIMITREX STATDOSE 2 QL kitSYSTEMMAXALT 2 QL tabsMAXALT-MLT 2 QL tbdpsumatriptan succinate (Imitrex) 1 QL soln, tabsTREXIMET 2 QL tabsAntimycobacterialsAntimycobacterials, Miscellaneousdapsone (Dapsone) 2 tabsAntituberculosis AgentsCAPASTAT SULFATE 2 solrethambutol(Myambutol) 1 tabshydrochlorideisoniazid (Isoniazid) 2 syrpisoniazid (Nydrazid) 1 soln, tabsisoniazid and rifampin (Rifamate) 1 capsMYCOBUTIN 2 capsPASER 2 packPRIFTIN 2 tabspyrazinamide (Pyrazinamide) 1 tabsrifampin (Rifadin) 1 caps, solrRIFATER 2 tabsSEROMYCIN 2 caps219

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAntineoplastic AgentsTRECATOR 2 tabsAntineoplastic AgentsABRAXANE 2 susrALIMTA 2 solrALKERAN 2 solrARIMIDEX 2 tabsAROMASIN 2 tabsARRANON 2 solnAVASTIN 2 solnBICNU W/DILUENT2 solrABSOLUTEETHANOLbleomycin sulfate (Blenoxane) 1 PA solrBUSULFEX 2 solnCAMPATH 2 solncarboplatin (Paraplatin) 1 solnCASODEX 2 tabsCEENU 2 capscisplatin (Platinol AQ) 1 solncladribine (Leustatin) 1 PA solnCLOLAR 2 solnCOSMEGEN 2 solrcyclophosphamide (Cytoxan) 1 solrcyclophosphamide (Cytoxan) 1 ST tabscytarabine (Cytosar-U) 2 PA solrcytarabine (Cytosar-U) 1 PA solndacarbazine (DTIC-Dome) 2 solr; 100mgdacarbazine (DTIC-Dome) 1 solr; 200mgDACOGEN 2 solrdaunorubicin(Cerubidine) 1 solrhydrochlorideDAUNOXOME 2 injdoxorubicinhydrochlorideDOXIL 2 PA inj(Adriamycin) 1 PA soln, solrDROXIA 2 caps; 200mg,300mg, 400mgELIGARD 2 kit; 7.5mg,22.5mg, 30mg,45mgELOXATIN 2 solnELSPAR 2 solrEMCYT 2 capsepirubicin hcl (Ellence) 1 soln220

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALERBITUX 2 solnETOPOPHOS 2 solretoposide (Vepesid) 1 solnFARESTON 2 tabsFASLODEX 2 solnFEMARA 2 tabsfludarabine phosphate (Fludara) 1 soln, solrfluorouracil (Adrucil) 1 PA solnflutamide (Eulexin) 1 capsGEMZAR 2 solrGLEEVEC 2 tabsHERCEPTIN 2 solrHEXALEN 2 capsHYCAMTIN 2 solrhydroxyurea (Hydrea) 1 caps; 500mgidarubicin hcl (Idamycin) 1 solnifosfamide (Ifex) 1 solrifosfamide (Ifosfamide) 2 solnifosfamide and mesna (Ifex/mesnex Combo Pack) 1 kitIRESSA 2 tabsirinotecan hydrochloride (Camptosar) 2 solnIXEMPRA KIT 2 solrLEUKERAN 2 tabsleuprolide acetate (Lupron) 1 kit, solnLUPRON DEPOT 2 kit; 3.75mg,7.5mg, 11.25mg,22.5mg, 30mgLUPRON DEPOT-PED 2 kit; 7.5mg,11.25mg, 15mgLYSODREN 2 tabsMATULANE 2 capsMEGACE ES 2 suspmegestrol acetate (Megace) 1 susp, tabsmercaptopurine (Purinethol) 1 tabsmethotrexate (Rheumatrex) 1 ST tabsmethotrexate sodium (Methotrexate) 1 solrmitomycin c (Mutamycin) 1 solrmitoxantronehydrochloride(Novantrone) 1 concMUSTARGEN 2 solrMYLOTARG 2 solrNEXAVAR 2 tabsNILANDRON 2 tabsONCASPAR 2 solnONTAK 2 soln221

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALpaclitaxel (Taxol) 1 concpentostatin (Nipent) 1 solrPHOTOFRIN 2 solrPROLEUKIN 2 solrRHEUMATREX 2 ST tabsRITUXAN 2 concSOLTAMOX 2 solnSPRYCEL 2 tabsSUTENT 2 capsTABLOID 2 tabstamoxifen citrate (Nolvadex) 1 tabsTARCEVA 2 tabsTARGRETIN 2 capsTASIGNA 2 capsTAXOTERE 2 concthiotepa (Thioplex) 1 solrTORISEL 2 solnTREANDA 2 solrTRELSTAR LA 2 susr; 11.25mgtretinoin (Vesanoid) 1 capsTREXALL 2 ST tabstriptorelin pamoate (Triptorelin Pamoate) 2 susr; 3.75mgTRISENOX 2 solnTYKERB 2 tabsVANTAS 2 kitVECTIBIX 2 solnVELCADE 2 solrVIDAZA 2 susrvinblastine sulfate (Vinblastine Sulfate) 2 PA soln, solrvincristine sulfate (Oncovin) 1 PA solnvinorelbine tartrate (Navelbine) 1 solnZANOSAR 2 solrZOLINZA 2 capsAntiparkinsonian AgentsAdamantanes (CNS)amantadine(Symmetrel) 1 caps, tabshydrochlorideAnticholinergic Agents (CNS)benztropine mesylate (Cogentin) 1 tabsCOGENTIN 2 solnKEMADRIN 2 tabstrihexyphenidylhydrochloride(Artane) 1 elix, tabs222

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCatechol-O-Methyltransferase (COMT) InhibitorsCOMTAN 2 tabsTASMAR 2 tabsDopamine Precursorscarbidopa anhydrous (Sinemet) 1 tabs, tbcr, tbdpand levodopacarbidopa monohydrateand levodopa(Parcopa) 1 tbdpLODOSYN 2 tabsSTALEVO 100 2 tabs; 25mg,200mg, 100mgSTALEVO 125 2 tabs; 31.25mg,200mg, 125mgSTALEVO 150 2 tabs; 37.5mg,200mg, 150mgSTALEVO 200 2 tabs; 50mg,200mg, 200mgSTALEVO 50 2 tabs; 12.5mg,200mg, 50mgSTALEVO 75 2 tabs; 18.75mg,200mg, 75mgDopamine Receptor AgonistsAPOKYN 2 solnbromocriptine mesylate (Parlodel) 1 caps, tabscabergoline (Dostinex) 1 tabsMIRAPEX 2 tabsropinirole hydrochloride (Requip) 1 tabsMonoamine Oxidase B InhibitorsAZILECT 2 tabsEMSAM 2 pt24selegiline hcl (Eldepryl) 1 caps, tabsZELAPAR 2 tbdpAntiprotozoalsAmebicidesparomomycin sulfate (Humatin) 1 capsAntimalarialschloroquine phosphate (Aralen) 1 tabsDARAPRIM 2 tabsFANSIDAR 2 tabshydroxychloroquinesulfate(Plaquenil) 1 tabsMALARONE 2 tabsmefloquine hcl (Lariam) 1 tabsPRIMAQUINE PHOSPHATE 2 tabs223

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALQUALAQUIN 2 PA capsAntiprotozoals, MiscellaneousMEPRON 2 suspMETRO IV 1 soln; 500mg/100ml, 0.74%metronidazole (Flagyl) 1 caps, tabsmetronidazole andsodium chloride(Flagyl IV) 1 soln; 5mg/ml,0.79%NEUTREXIN 2 solrAntipruritics and Local AnestheticsAntipruritics and Local Anestheticslidocaine and prilocaine (EMLA) 1 crealidocaine hydrochloride (Xylocaine) 1 ointLIDODERM 2 ptchAntithrombotic AgentsAnticoagulantsdextrose (anhydrous)and heparin sodium(porcine)ARIXTRA 2 PA, QL solnCOUMADIN 2 solr(Dextrose (anhydrous) and 1 solnHeparin Sodium (porcine))FRAGMIN 2 QL injheparin sodium (porcine) (Heparin Sodium (porcine)) 2 soln; 2000 unit/ml,20000 unit/ml,25000 unit/mlheparin sodium (porcine) (Heparin Sodium (porcine)) 1 soln; 5000 unit/ml,10000 unit/mlheparin sodium (porcine)and sodium chloride(Heparin Sodium (porcine) andSodium Chloride)2 soln; 50 unit/ml,0.45%, 100 unit/ml, 0.45%heparin sodium (porcine) (Heparin Sodium (porcine) andand sodium chloride Sodium Chloride)INNOHEP 2 PA, QL solnLOVENOX 2 QL solnwarfarin sodium (Coumadin) 1 tabsPlatelet Aggregation Inhibitorscilostazol (Pletal) 1 tabsPLAVIX 2 tabsticlopidine hydrochloride (Ticlid) 1 tabsAntiulcer Agents and Acid SuppressantsHistamine H2-Antagonists1 soln; 2 unit/ml,0.9%224

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALcimetidine (Tagamet) 1 tabscimetidine hydrochloride (Tagamet) 1 solnfamotidine (Pepcid) 1 soln, tabsfamotidine and sodium (Pepcid IV) 1 solnchloridenizatidine (Axid) 1 capsranitidine hydrochloride (Zantac) 1 caps, soln, syrp,tabsProstaglandinsmisoprostol (Cytotec) 1 tabsProtectantsCARAFATE 2 suspsucralfate (Carafate) 1 tabsProton Pump Inhibitorsomeprazole (Prilosec) 1 cpdrpantoprazole sodiumsesquihydrateAntivirals (Systemic)(Protonix) 1 tbecPREVACID 2 ST cpdrPREVACID SOLUTAB 2 ST tbdpPREVPAC 2 miscPROTONIX 2 solrAdamantanesFLUMADINE 2 tabsrimantadine(Flumadine) 1 tabshydrochlorideAntiretroviralsAPTIVUS 2 capsATRIPLA 2 tabsCOMBIVIR 2 tabsCRIXIVAN 2 capsdidanosine (Videx EC) 1 cpdrEMTRIVA 2 caps, solnEPIVIR 2 soln, tabs; 10mg/ml, 150mg, 300mgEPIVIR HBV 2 soln, tabs; 5mg/ml,100mgEPZICOM 2 tabsFUZEON 2 kitINTELENCE 2 tabsINVIRASE 2 caps, tabsISENTRESS 2 tabsKALETRA 2 caps, soln, tabsLEXIVA 2 susp, tabs225

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALNORVIR 2 caps, solnPREZISTA 2 tabsRESCRIPTOR 2 tabsRETROVIR IV INFUSION 2 solnREYATAZ 2 capsSELZENTRY 2 tabsstavudine (Zerit) 1 capsSUSTIVA 2 caps, tabsTRIZIVIR 2 tabsTRUVADA 2 tabsVIDEX 2 solrVIRACEPT 2 powd, tabsVIRAMUNE 2 susp, tabsVIREAD 2 tabsZERIT 2 caps, solrZIAGEN 2 soln, tabszidovudine (Retrovir) 1 caps, syrp, tabsAntivirals, Miscellaneousfoscarnet sodium (Foscavir) 1 PA solnInterferonsALFERON N 2 solnINFERGEN 2 injINTRON-A 2 kit, solnINTRON-A W/DILUENT 2 solrPEGASYS 2 kitPEG-INTRON 2 kitPEG-INTRON REDIPEN 2 kitPEG-INTRON REDIPENPAK 42 kitMonoclonal AntibodiesSYNAGIS 2 solnNeuraminidase InhibitorsRELENZA DISKHALER 2 aepbTAMIFLU 2 caps, susrNucleosides and Nucleotidesacyclovir (Zovirax) 1 caps, susp, tabsacyclovir sodium (Zovirax) 1 PA solrBARACLUDE 2 soln, tabsCYTOVENE 2 PA solrfamciclovir (Famvir) 1 tabsganciclovir (Cytovene) 1 capsHEPSERA 2 tabsREBETOL 2 solnRIBATAB 1 misc, tabs226

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALribavirin (Copegus) 1 caps, misc, tabsTYZEKA 2 tabsVALCYTE 2 tabsVALTREX 2 tabsVISTIDE 2 solnAnxiolytics, Sedatives and HypnoticsAnxiolytics, Sedatives and Hypnotics, Miscellaneousbuspirone hydrochloride (Buspar) 1 tabshydroxyzine(Atarax) 1 soln, syrp, tabshydrochloridehydroxyzine pamoate (Vistaril) 1 capsLUNESTA 2 tabsmeprobamate (Miltown) 1 tabszaleplon (Sonata) 1 capszolpidem tartrate (Ambien) 1 tabsAutonomic Drugs, MiscellaneousAutonomic Drugs, MiscellaneousCHANTIX 2 misc, tabsNICOTROL INHALER 2 inhaNICOTROL NS 2 solnBeta-Adrenergic Blocking AgentsBeta-Adrenergic Blocking Agentsacebutolol hydrochloride (Sectral) 1 capsatenolol (Tenormin) 1 tabsatenolol and(Tenoretic) 1 tabschlorthalidonebendroflumethiazide and (Corzide) 1 tabsnadololbetaxolol hydrochloride (Kerlone) 1 tabsbisoprolol fumarate (Zebeta) 1 tabsbisoprolol fumarate and (Ziac) 1 tabshydrochlorothiazidecarvedilol (Coreg) 1 tabsCOREG CR 2 cp24hydrochlorothiazide and (Lopressor HCT) 1 tabsmetoprolol tartratehydrochlorothiazide and (Inderide) 1 tabspropranololhydrochloridelabetalol hydrochloride (Trandate) 1 soln, tabsmetoprolol succinate (Toprol XL) 1 tb24227

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALmetoprolol tartrate (Lopressor) 1 soln, tabsnadolol (Corgard) 1 tabspindolol (Visken) 1 tabspropranolol(Inderal LA) 1 cp24, tabshydrochloridesotalol hydrochloride (Betapace) 1 tabstimolol maleate (Blocadren) 1 tabsTOPROL XL 2 tb24Calcium Channel Blocking AgentsCalcium Channel Blocking Agents, MiscellaneousCARDIZEM CD 2 cp24diltiazem hydrochloride (Cardizem CD) 1 cp12, cp24, soln,tabsdiltiazem hydrochloride (Diltiazem Hydrochloride) 2 solrverapamil hydrochloride (Calan SR) 1 cp24, soln, tabs,tbcrDihydropyridinesamlodipine besylate (Norvasc) 1 tabsamlodipine besylate andbenazepril hcl(Lotrel) 1 caps; variousstrengths areavailableCARDENE I.V. 2 solnEXFORGE 2 tabsfelodipine (Plendil) 1 tb24isradipine (Dynacirc) 1 capsLOTREL 2 caps; 5mg, 40mg,10mg, 40mgnicardipine hcl (Cardene) 1 capsnifedipine (Procardia XL) 1 caps, tb24nimodipine (Nimotop) 1 capsnisoldipine (Sular) 1 tb24CALORIC AGENTSCaloric Agentsalcohol, usp and (Alcohol, USP and Dextrosedextrose (anhydrous) (anhydrous))AMINOSYN 7%/ELECTROLYTESAMINOSYN 8.5%/ELECTROLYTES1 soln2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailableAMINOSYN 2 PA soln228

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALAMINOSYN 2 PA soln; variousstrengths areavailableAMINOSYN II 3.5%/DEXTROSE 25%AMINOSYN II 3.5%/DEXTROSE 25%AMINOSYN II 3.5%/DEXTROSE 5%AMINOSYN II 4.25%/DEXTROSE 20%AMINOSYN II 5%/DEXTROSE 25%AMINOSYN II 8.5%/ELECTROLYTES2 PA soln; variousstrengths areavailable2 PA soln2 PA soln; variousstrengths areavailable1 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailableAMINOSYN II 2 PA soln; variousstrengths areavailableAMINOSYN II 1 PA soln; variousstrengths areavailableAMINOSYN II M 3.5%/DEXTROSE 5%2 PA soln; variousstrengths areavailableAMINOSYN M 2 PA soln; variousstrengths areavailableAMINOSYN-HBC 2 PA soln; variousstrengths areavailableAMINOSYN-HF 1 PA solnAMINOSYN-PF 7% 2 PA solnCLIMIMIX E 4.25%/DEXTROSE 5%CLINIMIX 2.75%/DEXTROSE 5%CLINIMIX 4.25%/DEXTROSE 5%2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable229

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALdextrose (anhydrous)10%dextrose (anhydrous)and sodium chlorideglycerin andphospholipids andsoybean oilCLINIMIX 5%/DEXTROSE15%CLINIMIX 5%/DEXTROSE20%CLINIMIX 5%/DEXTROSE25%CLINIMIX E 2.75%/DEXTROSE 10%CLINIMIX E 2.75%/DEXTROSE 5%CLINIMIX E 5%/DEXTROSE15%CLINIMIX E 5%/DEXTROSE20%CLINIMIX E 5%/DEXTROSE25%CLINIMIX E 5%/DEXTROSE35%2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable(Dextrose (anhydrous) 10%) 1 PA soln(Dextrose 5%/Sodium1 solnChloride)FREAMINE HBC 6.9% 2 PA soln; variousstrengths areavailableFREAMINE III 3% 2 PA soln; variousstrengths areavailable(Intralipid) 1 PA emul; 2.25%,1.2%, 20%HEPATASOL 1 PA solnINTRALIPID 1 PA emul; variousstrengths areavailableNEPHRAMINE 2 PA soln230

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALPREMASOL 1 PA soln; variousstrengths areavailablePROCALAMINE 2 PA solnPROSOL 2 PA solnRENAMIN 2 PA solnTRAVASOL 2.75%/DEXTROSE 10%TRAVASOL 2.75%/DEXTROSE 5%TRAVASOL 3.5%/ELECTROLYTESTRAVASOL 4.25%/DEXTROSE 10%TRAVASOL 4.25%/DEXTROSE 25%TRAVASOL 5.5%/DEXTROSE 10%TRAVASOL 5.5%/DEXTROSE 20%TRAVASOL 5.5%/ELECTROLYTESTRAVASOL 8.5%/DEXTROSE 10%TRAVASOL 8.5%/DEXTROSE 20%TRAVASOL 8.5%/DEXTROSE 50%TRAVASOL 8.5%/ELECTROLYTES2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln1 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; 44 meq/l, 0 -,10%, 250mg/100ml, 560mg/100ml2 PA soln; 44 meq/l, 0 -,20%, 250mg/100ml, 560mg/100ml2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailable2 PA soln; variousstrengths areavailableTRAVASOL 1 PA soln; variousstrengths areavailable231

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCardiac DrugsTRAVASOL 2 PA soln; variousstrengths areavailableTROPHAMINE 1 PA soln; variousstrengths areavailableAntiarrhythmic Agentsamiodarone hcl (Cordarone) 1 soln, tabsamiodarone hcl (Cordarone) 2 tabsdisopyramide phosphate (Norpace) 1 caps, cp12flecainide acetate (Tambocor) 1 tabslidocaine hydrochloride (Lidocaine Hydrochloride) 1 solnmexiletine hydrochloride (Mexitil) 1 capsprocainamidehydrochloride(Procainamide Hydrochloride) 1 solnPROCANBID 2 tb12PRONESTYL 1 caps; 250mgPRONESTYL 2 caps; 375mgPRONESTYL SR 1 tbcrpropafenone hcl (Rythmol) 1 tabsquinidine gluconate (Quinidine Gluconate) 2 solnquinidine gluconate (Quinidine Gluconate) 1 tbcrquinidine sulfate (Quinidine Sulfate) 1 tabs, tbcrRYTHMOL SR 2 cp12TIKOSYN 2 capsCardiac Drugs, MiscellaneousRANEXA 2 PA tb12Cardiotonic AgentsDIGOXIN 2 soln; 0.05mg/mldigoxin (Lanoxin) 1 soln, tabsLANOXIN 2 soln; 0.1mg/mlCathartics and LaxativesCathartics and LaxativesAMITIZA 2 capspolyethylene glycol (Miralax) 1 powdpolyethylene glycol andpotassium chloride andsodium bicarbonate andsodium chloride(Nulytely) 1 solr232

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALpolyethylene glycol andpotassium chloride andsodium bicarbonate andsodium chloride andsodium sul(Colyte) 1 solrCell Stimulants and ProliferantsCell Stimulants and ProliferantsAVITA 1 creaKEPIVANCE 2 solrtretinoin (Retin-A) 1 crea, gelCentral Nervous System Agents, MiscellaneousCentral Nervous System Agents, MiscellaneousCAMPRAL 2 tbecNAMENDA 2 soln, tabsNAMENDA TITRATION 2 tabsPAKRILUTEK 2 tabsSTRATTERA 2 capsXYREM 2 LA solnCholelitholytic AgentsCholelitholytic Agentsursodiol (Actigall) 1 capsContraceptivesContraceptivesdesogestrel and ethinylestradioldrospirenone and ethinylestradiolethinyl estradiol andethynodiol diacetateethinyl estradiol andferrous fumarate andnorethindrone acetateethinyl estradiol andlevonorgestrelethinyl estradiol andnorethindroneBREVICON-28 1 tabs; 35mcg,0.5mg(Ortho-cept-28) 1 tabs(Yasmin 28) 1 tabs; 3mg, 0.03mg(Demulen 1/35-28) 1 tabs(Loestrin Fe 1/20) 1 tabs(Seasonale) 1 tabs(Ovcon-35/28) 1 tabs; variousstrengths areavailable233

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALethinyl estradiol and (Loestrin 1/20-21) 1 tabsnorethindrone acetateethinyl estradiol and (Ortho Tri-cyclen) 1 tabsnorgestimateethinyl estradiol and (Ovral) 1 tabsnorgestrelmestranol and(Norinyl 1+50) 1 tabsnorethindronenorethindrone (Nor-qd) 1 tabsNOR-QD 1 tabsNUVARING 2 ringORTHO EVRA 2 ptwkPLAN B 2 tabsYAZ 2 tabs; 3mg, 0.02mgDepigmenting and Pigmenting AgentsDepigmenting AgentsBENOQUIN 2 creaPigmenting Agents8-MOP 2 capsOXSORALEN ULTRA 2 capsUVADEX 2 solnDevicesDevicesDigestantsDigestantsDIABETIC SUPPLIES, MISC 2 misc, insulinsyringe (disp) u-100 1 mlDIABETIC SUPPLIES, MISC 2 misc, insulinsyringe (disp) u-100 1/2 mlDIABETIC SUPPLIES, MISC 2 misc, insulinsyringe (disp) u-100 0.3 mlDIABETIC SUPPLIES, MISC 2 misc, insulin penneedleDIABETIC SUPPLIES, MISC 2 , insulin safetysyringeCREON 5 2 cpep; 16600 unit,5000 unit, 18750unit234

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCREON 10 2 cpep; 33200 unit,10000 unit, 37500unitCREON 20 2 cpep; 66400 unit,20000 unit, 75000unitDYGASE 1 caps; 30000 unit,2400 unit, 30000unitENZYMAX 2 tabs; 12500 unit,1000 unit, 12500unitKU-ZYME HP 2 caps; 30000 unit,8000 unit, 30000unitLAPASE 1 caps; 15000 unit,1200 unit, 15000unitLIPRAM 4500 1 cpep; 20000 unit,4500 unit, 25000unitLIPRAM-PN10 1 cpep; 30000 unit,10000 unit, 30000unitLIPRAM-PN16 1 cpep; 48000 unit,16000 unit, 48000unitLIPRAM-PN20 1 cpep; 56000 unit,20000 unit, 44000unitLIPRAM-UL12 1 cpep; 39000 unit,12000 unit, 39000unitLIPRAM-UL18 1 cpep; 58500 unit,18000 unit, 58500unitLIPRAM-UL20 1 cpep; 65000 unit,20000 unit, 65000unitPALCAPS 10 1 cpep; 33200 unit,10000 unit, 37500unitPALCAPS 20 1 cpep; 66400 unit,20000 unit, 75000unit235

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALPANCREASE MT 4 2 cpep; 12000 unit,4000 unit, 12000unitPANCRECARB MS-16 2 cpep; 52000 unit,16000 unit, 52000unitPANCRECARB MS-4 2 cpep; 25000 unit,4000 unit, 25000unitPANCRECARB MS-8 2 cpep; 40000 unit,8000 unit, 45000unitPANCRELIPASE 1 cpep, tabsPANCRELIPASE MST-16 1 cpep; 48000 unit,16000 unit, 48000unitPANCRON 10 1 cpep; 33200 unit,10000 unit, 37500unitPANCRON 20 1 cpep; 66400 unit,20000 unit, 75000unitPANGESTYME CN 10 1 cpep; 33200 unit,10000 unit, 37500unitPANGESTYME CN 20 1 cpep; 66400 unit,20000 unit, 75000unitPANGESTYME EC 1 cpep; 20000 unit,4500 unit, 25000unitPANGESTYME MT 16 1 cpep; 48000 unit,16000 unit, 48000unitPANGESTYME UL 12 1 cpep; 39000 unit,12000 unit, 39000unitPANGESTYME UL 18 1 cpep; 58500 unit,18000 unit, 58500unitPANGESTYME UL 20 1 cpep; 65000 unit,20000 unit, 65000unitPANOCAPS 1 cpep; 20000 unit,4500 unit, 25000unit236

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALDiureticsPANOCAPS MT 16 1 cpep; 48000 unit,16000 unit, 48000unitPANOCAPS MT 20 1 cpep; 56000 unit,20000 unit, 44000unitPANOKASE 1 tabs; 30000 unit,8000 unit, 30000unitPANOKASE-16 1 tabs; 60000 unit,16000 unit, 60000unitPLARETASE 8000 1 tabs; 30000 unit,8000 unit, 30000unitULTRACAPS MT 20 1 cpep; 65000 unit,20000 unit, 65000unitULTRASE 2 cpep; 20000 unit,4500 unit, 25000unitVIOKASE 2 powdLoop Diureticsbumetanide (Bumex) 1 tabsfurosemide (Lasix) 1 soln, tabstorsemide (Demadex) 1 tabsPotassium-Sparing Diureticsamiloride hydrochloride (Midamor) 1 tabs(anhydrous)amiloride hydrochloride (Moduretic 5-50) 1 tabs(anhydrous) andhydrochlorothiazideDYRENIUM 2 capshydrochlorothiazide and (Dyazide) 1 caps, tabstriamtereneThiazide Diureticschlorothiazide (Diuril) 1 tabshydrochlorothiazide (Microzide) 1 caps, tabsmethyclothiazide (Enduron) 1 tabsThiazide-Like Diureticschlorthalidone (Hygroton) 1 tabsindapamide (Lozol) 1 tabsmetolazone (Zaroxolyn) 1 tabs237

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALEENT Drugs, MiscellaneousEENT Drugs, Miscellaneouscarteolol hcl (Ocupress) 1 solnipratropium bromide (Atrovent) 1 solnLACRISERT 2 instEmollients, Demulcents, and ProtectantsBasic Lotions and Linimentsammonium lactate (Ammonium Lactate) 1 lotnlactic acid (Lac-hydrin) 1 lotnEnzymesEnzymesADAGEN 2 solnALDURAZYME 2 solnARALAST 2 solr; 400mg,800mgCEREDASE 2 solnCEREZYME 2 solrELAPRASE 2 solnELITEK 2 solrFABRAZYME 2 solrMYOZYME 2 solrNAGLAZYME 2 solnPROLASTIN 2 solr, susrSUCRAID 2 solnZEMAIRA 2 solr; 1000mgEstrogens and AntiestrogensEstrogen Agonist-AntagonistsEVISTA 2 tabsEstrogensALORA 2 pttw; variousstrengths areavailableCLIMARA 2 ptwkCOMBIPATCH 2 pttwESTRACE 2 creaESTRADERM 2 pttw; 0.05mg/24hr,0.1mg/24hrestradiol (Climara) 1 ptwk, tabs238

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALestradiol and(Activella) 1 tabsnorethindrone acetateestradiol valerate (Delestrogen) 1 oilestropipate (Ogen) 1 tabs; 0.75mg,1.5mg, 3mgGYNODIOL 1 tabsORTHO-EST 1 tabs; 0.75mg,1.5mgPREMARIN 2 solr, tabsPREMARIN W/2 creaAPPLICATORPREMPHASE 2 tabs; 0.625mg,5mgPREMPRO 2 tabs; variousstrengths areavailableVIVELLE-DOT 2 pttw; variousstrengths areavailableFirst Generation AntihistaminesEthanolamine Derivativescarbinoxamine maleate (Pediox) 1 liqdclemastine fumarate (Tavist Allergy) 1 syrp, tabsdiphenhydramine (Benadryl) 1 caps, elix, solnhydrochlorideFirst Generation Antihistamine Derivatives, Miscellaneouscyproheptadinehydrochloride(Periactin) 1 syrp, tabsPhenothiazine Derivativesphenylephrinehydrochloride andpromethazinehydrochloridepromethazinehydrochloridePropylamine Derivativesdexchlorpheniraminemaleate(Phenylephrine Hydrochlorideand PromethazineHydrochloride)1 syrp(Phenergan) 1 soln, supp, syrp,tabs(DexchlorpheniramineMaleate)Genitourinary Smooth Muscle Relaxants1 syrpGenitourinary Smooth Muscle RelaxantsDETROL 2 tabsDETROL LA 2 cp24flavoxate hydrochloride (Urispas) 1 tabs239

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALoxybutynin chloride (Ditropan) 1 syrp, tabs, tb24VESICARE 2 tabsGI Drugs, MiscellaneousGI Drugs, MiscellaneousLOTRONEX 2 tabsRELISTOR 2 PA, QL kit, solnGold CompoundsGold CompoundsRIDAURA 2 capsGonadotropinsGonadotropinsgonadotropin, chorionic (Novarel) 1 solrSYNAREL 2 solnHeavy Metal AntagonistsHeavy Metal AntagonistsCHEMET 2 capsCUPRIMINE 2 capsDEPEN TITRATABS 2 tabsEXJADE 2 tbsoSYPRINE 2 capsHematopoietic AgentsHematopoietic AgentsARANESP ALBUMIN FREE 2 PA, QL soln; 25mcg/0.42ml, 25mcg/ml,40mcg/0.4ml,40mcg/ml, 60mcg/ml, 100mcg/ml,150mcg/0.3ml, 150ARANESP ALBUMIN FREESURE2 PA, QL soln; 60mcg/0.3ml,100mcg/0.5ml,300mcg/0.6mlEPOGEN 2 PA, QL solnLEUKINE 2 soln, solrNEULASTA 2 solnNEUPOGEN 2 solnPROCRIT 2 PA, QL soln240

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALHemorrheologic AgentsHemorrheologic Agentspentoxifylline (Trental) 1 tbcrHypotensive AgentsCentral Alpha-Agonistsclonidine hydrochloride (Catapres) 1 tabsguanabenz acetate (Wytensin) 1 tabsguanfacine hcl (Tenex) 1 tabshydrochlorothiazide and (Aldoril) 1 tabsmethyldopamethyldopa (Methyldopa) 1 tabsmethyldopate(Methyldopate Hydrochloride) 1 solnhydrochlorideDirect Vasodilatorshydralazine(Apresoline) 1 soln, tabshydrochlorideminoxidil (Loniten) 1 tabsPROGLYCEM 2 suspHypotensive Agents, MiscellaneousINVERSINE 2 tabsPeripheral Adrenergic Inhibitorsreserpine (Serpasil) 1 tabsIon-Removing AgentsPhosphate-Removing Agentscalcium acetate (Phoslo) 1 capsRENAGEL 2 tabsRENVELA 2 tabsPotassium-Removing Agents(Kayexalate) 1 powd, suspsodium polystyrenesulfonateIrrigating SolutionsIrrigating Solutions(Tis-u-sol) 1 solncalcium (+2) andchloride ion andpotassium (+1) andsodium (+1)LACTATED RINGER'SIRRIGATION2 soln241

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALPHYSIOLYTE 1 solnsodium chloride (Sodium Chloride 0.9%) 1 solnTIS-U-SOL 1 solnTIS-U-SOL VIAFLEX 1 solnwater, sterile (Water, Sterile) 1 solnLocal Anesthetics (EENT)Local Anesthetics (EENT)lidocaine hydrochloride (Xylocaine Jelly) 1 gel, solnproparacainehydrochloride(Ophthetic) 1 solnLocal Anesthetics (Parenteral)Local Anesthetics (Parenteral)lidocaine hydrochloride (Xylocaine) 1 solnMiscellaneous Therapeutic AgentsMiscellaneous Therapeutic AgentsACTIMMUNE 2 solnACTONEL 2 QL, ST tabsACTONEL WITH CALCIUM 2 QL, ST tabsalendronate sodium (Fosamax) 1 tabsallopurinol (Zyloprim) 1 tabsallopurinol sodium (Aloprim) 1 solramifostine (Ethyol) 1 solranagrelidehydrochloride(Agrylin) 1 capsANTABUSE 2 tabsARCALYST 2 solrATGAM 2 injAVODART 2 capsAVONEX 2 kitazathioprine (Imuran) 1 PA tabsazathioprine sodium (Imuran) 1 PA solrBETASERON 2 solrBONIVA 2 ST kitBONIVA 2 QL, ST tabsBOTOX 2 solrCELLCEPT 2 PA caps, susr, tabsCELLCEPT INTRAVENOUS 2 PA solrCIMZIA 2 kitcolchicine (Colchicine) 1 tabsCOPAXONE 2 kitcyclosporine (Neoral) 1 PA caps, soln242

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALcyclosporine (Neoral) 2 PA capsCYSTADANE 2 powdCYSTAGON 2 capsdexrazoxane (Totect) 1 solrELMIRON 2 capsENBREL 2 kit, solnENBREL SURECLICK 2 solnETHYOL 2 solretidronate disodium (Didronel) 1 tabsfinasteride (Proscar) 1 tabsFLOMAX 2 cp24fluoride prepartion (Fluoride Prepartion) 2fomepizole (4-methylpyrazole)(Antizol) 2 solnFOSAMAX 2 QL solnFOSAMAX PLUS D 2 QL tabsHUMIRA 2 kitHUMIRA PEN 2 kitHUMIRA PEN-CROHNS 2 kitDISEASEKINERET 2 solnKUVAN 2 PA tbsoleflunomide (Arava) 1 tabsleucovorin calcium (Leucovorin Calcium) 2 solr, tabsleucovorin calcium (Leucovorin Calcium) 1 soln, solr, tabslevocarnitine (Carnitor) 1 soln, tabsmesna (Mesnex) 1 solnMESNEX 2 tabsMYFORTIC 2 PA tbecMYOBLOC 2 solnNEUMEGA 2 solroctreotide acetate (Sandostatin) 2 solnORENCIA 2 solrORFADIN 2 capsORTHOCLONE OKT3 2 PA injpamidronate disodium (Aredia) 1 soln, solrPROGRAF 2 PA caps, solnPROMACTA 2 PA tabsRAPAMUNE 2 PA soln, tabsREBIF 2 soln; 22mcg/0.5ml,44mcg/0.5mlREBIF TITRATION PACK 2 soln; 8.8mcg/0.2ml-22mcg/0.5mlREMICADE 2 PA solr243

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALMucolytic AgentsREVLIMID 2 LA capsSANDOSTATIN LAR2 kitDEPOTSENSIPAR 2 tabsSIMULECT 2 PA solrSOMATULINE DEPOT 2 solnTHALOMID 2 capsTHIOLA 2 tabsTHYMOGLOBULIN 2 solrTYSABRI 2 LA concZAVESCA 2 capsZENAPAX 2 PA concZOMETA 2 concMucolytic Agentsacetylcysteine (Mucomyst) 1 solnMultivitamin PreparationsMultivitamin Preparationsprenatal with folic acid(greater than .8mg)(Prenatal With Folic Acid(Greater than .8mg))2MydriaticsMydriaticsdipivefrin hydrochloride (Propine) 1 solnMYDRAL 1 solntropicamide (Mydriacyl) 1 solnOpiate AntagonistsOpiate Antagonistsnaloxone hydrochloride (Narcan) 2 solnnaltrexone hydrochloride (Revia) 1 tabsOXYTOCICSOxytocicsMETHERGINE 2 tabsParasympathomimetics (Cholinergic Agents)Parasympathomimetics (Cholinergic Agents)ARICEPT 2 tabsARICEPT ODT 2 tbdpbethanechol chloride (Urecholine) 1 tabsEVOXAC 2 caps244

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALEXELON 2 pt24EXELON 2 caps, solngalantamine(Razadyne) 1 cp24, tabshydrobromideguanidine hydrochloride (Guanidine Hydrochloride) 1 tabsMESTINON 2 syrpMESTINON TIMESPAN 2 tbcrMYTELASE 2 tabspilocarpine(Salagen) 1 tabshydrochloridepyridostigmine bromide (Mestinon) 1 tabspyridostigmine bromide (Mestinon) 2 solnParathyroidParathyroidcalcitonin,salmon (Miacalcin) 1 soln; 200 unit/actFORTEO 2 solnFORTICAL 2 solnMIACALCIN 2 soln; 200 unit/mlPharmaceutical AidsPituitaryPharmaceutical AidsDIABETIC SUPPLIES, MISC 2 padsPituitarydesmopressin acetate (DDAVP) 1 soln, tabsGENOTROPIN 2 PA solr; 5.8mg,13.8mgGENOTROPIN MINIQUICK 2 PA solr; variousstrengths areavailableHUMATROPE 2 PA solr; 12mg, 24mgHUMATROPE 2 PA solr; 6mgHUMATROPE COMBO 2 PA solr; 5mgPACKNORDITROPIN2 PA soln; 5mg/1.5ml,CARTRIDGENORDITROPINNORDIFLEX PEN15mg/1.5ml2 PA soln; 5mg/1.5ml,10mg/1.5ml,15mg/1.5mlNUTROPIN 2 PA solr; 5mg, 10mgNUTROPIN AQ 2 PA soln; 10mg/2ml245

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALProgestinsNUTROPIN AQ PEN 2 PA soln; 10mg/2ml,20mg/2mlOMNITROPE 2 PA soln, solrSAIZEN 2 PA solr; 5mg, 8.8mgSAIZEN CLICK.EASY 2 PA solr; 8.8mgSEROSTIM 2 PA solr; 4mg, 5mg,6mgSTIMATE 2 solnTEV-TROPIN 2 PA solr; 5mgZORBTIVE 2 PA solr; 8.8mgProgestinsDEPO-PROVERA 2 susp; 400mg/mlDEPO-SUBQ PROVERA 104 2 susp; 104mg/0.65mlmedroxyprogesterone (Provera) 1 susp, tabsacetatenorethindrone acetate (Aygestin) 1 tabsPROCHIEVE 2 gelPROMETRIUM 2 capsProkinetic AgentsProkinetic Agentsmetoclopramidehydrochloride(Reglan) 1 soln, tabsPsychotherapeutic AgentsAntidepressantsamitriptyline(Elavil) 1 tabshydrochlorideamitriptyline(Limbitrol) 1 tabshydrochloride andchlordiazepoxideamitriptyline(Triavil) 1 tabshydrochloride andperphenazineamoxapine (Asendin) 2 tabs; 150mgamoxapine (Asendin) 1 tabs; 25mg, 50mg,100mgbupropion hcl (Wellbutrin) 1 tabs, tb12, tb24citalopram(Celexa) 1 soln, tabshydrobromideclomipramine hcl (Anafranil) 1 caps246

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALCYMBALTA 2 cpepdesipramine(Norpramin) 1 tabshydrochloridedoxepin hydrochloride (Sinequan) 1 caps, concEFFEXOR XR 2 cp24fluoxetine hcl (Prozac) 1 caps, soln, tabsfluvoxamine maleate (Luvox) 1 tabsimipramine(Tofranil) 1 tabshydrochlorideimipramine pamoate (Tofranil-PM) 1 capsLEXAPRO 2 soln, tabsLUVOX CR 2 cp24maprotilinehydrochloride(Ludiomil) 1 tabsMARPLAN 2 tabsmirtazapine (Remeron) 1 tabs, tbdpNARDIL 2 tabsnefazodone(Serzone) 1 tabshydrochloridenortriptyline(Pamelor) 1 caps, solnhydrochlorideparoxetine hydrochloride (Paxil) 1 susp, tabs, tb24PRISTIQ 2 tb24protriptylinehydrochloride(Vivactil) 1 tabsRAPIFLUX 1 tabssertraline hydrochloride (Zoloft) 1 conc, tabsSURMONTIL 2 caps; 100mgtranylcypromine sulfate (Parnate) 1 tabstrazodone hydrochloride (Desyrel) 1 tabstrimipramine maleate (Surmontil) 1 caps; 25mg, 50mgvenlafaxine hcl (Effexor) 1 tabsAntipsychotic AgentsABILIFY 2 QL soln, tabsABILIFY DISCMELT 2 QL tbdpchlorpromazine (Thorazine) 1 soln, tabshydrochlorideclozapine (Clozaril) 1 QL tabs; 25mg, 50mg,100mgclozapine (Clozaril) 2 QL tabs; 200mgFAZACLO 2 QL tbdpfluphenazine decanoate (Prolixin Decanoate) 1 solnfluphenazinehydrochloride(Prolixin) 1 conc, elix, soln,tabsGEODON 2 QL solr247

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALGEODON 2 QL capsHALDOL 2 solnHALDOL DECANOATE-100 2 soln; 100mg/mlHALDOL DECANOATE-50 2 soln; 50mg/mlhaloperidol (Haldol) 1 tabshaloperidol decanoate (Haldol Decanoate) 1 soln; 50mg/ml,100mg/mlhaloperidol lactate (Haloperidol Lactate) 1 conc, solnINVEGA 2 QL, ST tb24loxapine succinate (Loxitane) 1 capsMOBAN 2 tabsNAVANE 2 caps; 20mgORAP 2 tabsperphenazine (Trilafon) 1 tabsRISPERDAL 2 QL solnRISPERDAL CONSTA 2 susrRISPERDAL M-TAB 2 QL tbdprisperidone (Risperdal) 1 QL soln, tabsSEROQUEL 2 QL tabsSEROQUEL XR 2 QL tb24thioridazine(Mellaril) 1 tabshydrochloridethiothixene (Navane) 1 caps; 1mg, 2mg,trifluoperazinehydrochloride5mg, 10mg(Stelazine) 1 tabsZYPREXA 2 QL solr, tabsZYPREXA ZYDIS 2 QL tbdpRenin-Angiotensin-Aldosterone System InhibitorsAngiotensin II Receptor AntagonistsCOZAAR 2 tabsDIOVAN 2 tabsDIOVAN HCT 2 tabsHYZAAR 2 tabsAngiotensin-Converting Enzyme Inhibitorsbenazepril hcl (Lotensin) 1 tabsbenazepril hcl and (Lotensin HCT) 1 tabshydrochlorothiazidecaptopril (Capoten) 1 tabscaptopril and(Capozide) 1 tabshydrochlorothiazideenalapril maleate (Vasotec) 1 tabsenalapril maleate andhydrochlorothiazide(Vaseretic) 1 tabs248

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALfosinopril sodium (Monopril) 1 tabsfosinopril sodium and (Monopril HCT) 1 tabshydrochlorothiazidehydrochlorothiazide and (Zestoretic) 1 tabslisinoprilhydrochlorothiazide and (Uniretic) 1 tabsmoexipril hydrochloridehydrochlorothiazide and (Accuretic) 1 tabsquinapril hcllisinopril (Zestril) 1 tabsmoexipril hydrochloride (Univasc) 1 tabsquinapril hcl (Accupril) 1 tabsramipril (Altace) 1 capstrandolapril (Mavik) 1 tabsMineralocorticoid (Aldosterone) Antagonistseplerenone (Inspra) 1 tabshydrochlorothiazide and (Aldactazide) 1 tabsspironolactonespironolactone (Aldactone) 1 tabsRenin InhibitorsTEKTURNA 2 ST tabsTEKTURNA HCT 2 ST tabsReplacement PreparationsReplacement Preparationscalcium (+2) andchloride ion anddextrose (anhydrous)and lactate anion andpotassium (+1)calcium (+2) andchloride ion andpotassium (+1) andsodium (+1)chloride ion anddextrose (anhydrous)and lactate anion andmagnesium (+2) andphosphatechloride ion anddextrose (anhydrous)and lactate anion andphosphate and potassium(+1)(Calcium (+2) and ChlorideIon and Dextrose (anhydrous)and Lactate Anion andPotassium (+1))(Calcium (+2) and ChlorideIon and Potassium (+1) andSodium (+1))(Chloride Ion and Dextrose(anhydrous) and Lactate Anionand Magnesium (+2) andPhosphate)(Chloride Ion and Dextrose(anhydrous) and Lactate Anionand Phosphate and Potassium(+1))1 soln1 soln2 soln; 24 meq/l, 5%,23 meq/l, 3 meq/l,3 meq/l2 soln; 48 meq/l, 5%,20 meq/l, 15 meq/l,35 meq/l249

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALdextrose (anhydrous)and potassium chloridedextrose (anhydrous)and potassium chlorideand sodium chloride(Dextrose (anhydrous) andPotassium Chloride)(KCl 0.075%/D5W/NaCl0.45%)1 soln1 solnIONOSOL-B/DEXTROSE 5% 2 soln; 49 meq/l, 5%,25 meq/l, 5 meq/l,13 meq/lIONOSOL-MB/DEXTROSE5%2 soln; 22 meq/l, 5%,23 meq/l, 3 meq/l,3 meq/lIONOSOL-T/DEXTROSE 5% 2 soln; 40 meq/l, 5%,20 meq/l, 15 meq/l,35 meq/lISOLYTE-H/DEXTROSE 5% 2 soln; 17 meq/l, 39meq/l, 5%, 3 meq/l, 13 meq/lISOLYTE-P/DEXTROSE 5% 2 solnISOLYTE-S 2 solnISOLYTE-S PH 7.4 2 solnISOLYTE-S/DEXTROSE 5% 2 soln; 30 meq/l, 98meq/l, 5%, 23meq/l, 3 meq/lKLOTRIX 1 tbcrK-TABS 1 tbcrNORMOSOL -R 1 solnNORMOSOL-M IN D5W 1 soln; 16 meq/l, 40meq/l, 5%, 3 meq/l, 13 meq/lNORMOSOL-R 2 solnPLASMA-LYTE 56 2 solnPLASMA-LYTE A 2 solnPLASMA-LYTE-148 2 solnPLASMA-LYTE-148/D5W 2 soln; 27 meq/l, 98meq/l, 5%, 23meq/l, 3 meq/lPLASMA-LYTE-56/D5W 2 soln; 16 meq/l, 40meq/l, 5%, 3 meq/l, 13 meq/lpotassium chloride (K-Dur) 1 cpcr, soln, tbcrpotassium chloride and (Potassium Chloride and 1 solnsodium chloride Sodium Chloride)sodium chloride (Sodium Chloride) 1 soln250

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALRespiratory Smooth Muscle RelaxantsRespiratory Smooth Muscle Relaxantsaminophylline (Aminophylline) 1 tabsTHEOCHRON 1 tb12theophylline (Uniphyl) 1 elix, tb12, tb24Respiratory Tract Agents, MiscellaneousRespiratory Tract Agents, MiscellaneousXOLAIR 2 PA, QL solrSecond Generation AntihistaminesSecond Generation AntihistaminesALLEGRA-D 12 HOUR 2 tb12ALLEGRA-D 24 HOUR 2 tb24fexofenadine(Allegra) 1 tabshydrochlorideXYZAL 2 soln, tabsSerumsSerumsCARIMUNE2 PA solrNANOFILTEREDCARIMUNENANOFILTERED2 PA solr; 1gm, 3gm,6gmFLEBOGAMMA 2 PA solnGAMASTAN S/D 2 PA injGAMMAGARD LIQUID 2 PA solnGAMUNEX 2 PA solnIVEEGAM EN 2 PA solr; 5gmOCTAGAM 2 PA solnPANGLOBULIN NF 2 PA solr; 6gmPANGLOBULIN NF 2 PA solrPOLYGAM S/D 2 PA solrVIVAGLOBIN 2 PA solnSkeletal Muscle RelaxantsCentrally-Acting Skeletal Muscle Relaxantsaspirin and carisoprodol (Soma Compound) 1 tabsaspirin and carisoprodol (Soma Compound/codeine) 1 tabsand codeine phosphatecarisoprodol (Soma) 1 tabschlorzoxazone (Parafon Forte DSC) 1 tabs251

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALcyclobenzaprine (Flexeril) 1 tabshydrochloridemethocarbamol (Robaxin) 1 tabsSKELAXIN 2 tabstizanidine hydrochloride (Zanaflex) 1 tabsDirect-Acting Skeletal Muscle Relaxantsdantrolene sodium (Dantrium) 1 capsGaba-Derivative Skeletal Muscle Relaxantsbaclofen (Lioresal) 1 tabsSkeletal Muscle Relaxants, Miscellaneousaspirin and caffeine and (Norgesic) 1 tabsorphenadrine citrateorphenadrine citrate (Norflex) 1 soln, tb12Skin and Mucous Membrane Agents, MiscellaneousSkin and Mucous Membrane Agents, MiscellaneousALDARA 2 PA, QL creaAMEVIVE 2 solrcalcipotriene (Dovonex) 1 solnCARAC 2 crea; 0.5%DOVONEX 2 creaEFUDEX OCCLUSION 2 kitPACKELIDEL 2 creaFLUOROPLEX 2 crea; 1%fluorouracil (Efudex) 1 crea, solnisotretinoin (Accutane) 1 capsPANRETIN 2 gelpodofilox (Condylox) 1 solnPROTOPIC 2 PA ointRAPTIVA 2 kitREGRANEX 2 PA gelSANTYL 2 ointSOLARAZE 2 gelTARGRETIN 2 gelTAZORAC 2 crea, gelSomatotropin Agonists and AntagonistsSomatotropin AgonistsINCRELEX 2 solnIPLEX 2 solnSomatotropin AntagonistsSOMAVERT 2 solr252

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALSympatholytic Adrenergic Blocking AgentsSympatholytic Adrenergic Blocking Agentscaffeine and ergotamine (Cafergot) 1 supp, tabstartrateDIBENZYLINE 2 capsdihydroergotamine (D.H.E. 45) 1 soln; 1mg/mlmesylateERGOMAR 2 sublergot alkaloids, (Ergot Alkaloids,1 tabshydrogenated (mesylate) Hydrogenated (mesylate))MIGRANAL 2 soln; 4mg/mlSympathomimetic (Adrenergic) AgentsAlpha- and Beta-Adrenergic Agonists(Adrenalin) 1 solnepinephrinehydrochlorideEPIPEN 2-PAK 2 devi; 1 :1000EPIPEN-JR 2-PAK 2 devi; 1 :2000TWINJECT 2 deviAlpha-Adrenergic Agonistsmidodrine hcl (Proamatine) 1 tabsBeta-Adrenergic AgonistsADVAIR DISKUS 2 miscADVAIR HFA 2 aeroalbuterol sulfate (Proventil) 1 nebu, syrp, tabs,tb12BRETHINE 2 solnCOMBIVENT 2 aeroFORADIL AEROLIZER 2 capsmetaproterenol sulfate (Alupent) 1 nebu, syrp, tabsPROAIR HFA 2 aersPROVENTIL HFA 2 aersSEREVENT DISKUS 2 aepbterbutaline sulfate (Brethine) 1 soln, tabsVENTOLIN HFA 2 aersThyroid and Antithyroid AgentsAntithyroid Agentsmethimazole (Tapazole) 1 tabspropylthiouracil (Propylthiouracil) 1 tabsThyroid AgentsCYTOMEL 2 tabs253

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALlevothyroxine sodium (Synthroid) 1 tabs; variousstrengths areavailableliothyronine sodium (Triostat) 1 solnUNITHROID 1 tabs; 137mcgToxoidsToxoidsADACEL 2 susp; 15.5mcg/0.5ml, 2 lf/0.5ml, 5lf/0.5mlBOOSTRIX 2 susp; 18.5mcg/0.5ml, 2.5 lf/0.5ml,5 lf/0.5mlDAPTACEL 2 susp; 10mcg/0.5ml, 15 lf/0.5ml,5 lf/0.5mlDECAVAC 2 inj; 2 lfu, 5 lfuDIPTHERIA/TETANUSTOXOIDPEDIATRIC2 inj; 6.7 lfu/0.5ml, 5lfu/0.5mlINFANRIX 2 susp; 58mcg/0.5ml, 25 lfu/0.5ml, 10 lfu/0.5mltetanus toxoid adsorbed (Tetanus Toxoid, Adsorbed) 1 PA solnTETANUS/DIPHTHERIA 2 suspTOXOIDS-ADSORBEDADULTTRIHIBIT 2 kitTRIPEDIA 2 susp; 46.8mcg/0.5ml, 6.7 lfu/0.5ml, 5 lfu/0.5mlUricosuric AgentsUricosuric Agentscolchicine and (Col-Benemid) 1 tabsprobenecidprobenecid (Benemid) 1 tabsUrinary Anti-infectivesUrinary Anti-infectivesFURADANTIN 2 suspmethenamine hippurate (Hiprex) 1 tabsMONUROL 2 pack254

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALnitrofurantoin(Macrodantin) 1 capsmacrocrystallinenitrofurantoin(Macrobid) 1 capsmonohydratemacrocrystalsPRIMSOL 2 solntrimethoprim (Proloprim) 1 tabsUREX 1 tabsVaccinesVaccinesACTHIB 2 solrATTENUVAX 2 PA injCOMVAX 2 suspENGERIX-B 2 PA inj, susp; 10mcg/0.5ml, 20mcg/mlGARDASIL 2 suspHAVRIX 2 PA suspHIBTITER 2 solnIMOVAX RABIES2 PA inj(H.D.C.V.)IPOL INACTIVATED IPV 2 injJE-VAX 2 solrMENACTRA 2 inj; 4mcg/0.5mlMENOMUNE-A/C/Y/W-135 2 inj; 50mcg/0.5mlMERUVAX II W/DILUENT 2 inj10 DOSEM-M-R II W/DILUENT 10 2 injDOSPEDIARIX 2 suspPEDVAX HIB 2 solnPROQUAD 2 injRABAVERT 2 PA susrRECOMBIVAX HB 2 PA inj, susp; 5mcg/0.5ml, 10mcg/ml,40mcg/mlROTATEQ 2 suspTWINRIX 2 suspTYPHIM VI 2 solnVAQTA 2 PA injVARIVAX 2 injVIVOTIF BERNA 2 cpdrYF-VAX 1 injZOSTAVAX 2 solr255

L.A CARE MEDICARE ADVANTAGE SPECIAL NEEDS PLANPROVIDER MANUALVasoconstrictorsVasoconstrictorsnaphazolinehydrochloride(Albalon) 1 solnTYZINE 2 soln; 0.1%TYZINE PEDIATRIC2 soln; 0.05%NASAL DROPSVASODILATING AGENTSNitrates and NitritesISMO 1 tabsISOCHRON 1 tbcrisosorbide dinitrate (Isordil) 1 subl, tabs, tbcrisosorbide mononitrate (Imdur) 1 tabs, tb24nitroglycerin (Nitro-dur) 1 pt24, solnNITROLINGUAL2 solnPUMPSPRAYNITROSTAT 2 sublPhosphodiesterase InhibitorsREVATIO 2 tabsVasodilating Agents, MiscellaneousAGGRENOX 2 cp12dipyridamole (Persantine) 1 tabsLETAIRIS 2 tabsREMODULIN 2 PA solnTRACLEER 2 LA tabsVITAMIN DVitamin Dcalcitriol (Rocaltrol) 2 solncalcitriol (Rocaltrol) 1 caps, solnHECTOROL 2 caps, soln256