Peach State Provider Office Manual - Peach State Health Plan ...

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Utilization review notes signed and dated physician’s orders, physician’s discharge summary, inhalationtherapy notes, and operative notes. Utilization review notes must indicate the severity of illness/intensity ofservice (SI/IS) that was met for medical necessity of the hospital stay. Failure to document the SI/IS criteriain the utilization review notes may result in the denial of your DRG outlier request. Only requireddocumentation should be submitted. If the entire medical record is submitted, the request may be denied.In some cases more information is required to complete the review process. When additional informationnot identified above is requested, it must be received within thirty (30) days of the date of request. If notreceived by the due date, the request for outlier payment will be denied. Please ensure that the request isclearly marked Outlier Appeal Consideration Request and mailed to:Peach State Health PlanP.O. Box 3030Farmington, MO 63640-3812Claims auditsPeach State uses claims audits to ensure accuracy of the claims payment process.Provider ComplaintsPeach State’s provider complaint system permits providers to dispute Peach State’s policies,procedures, or any aspect of Peach State administrative functions (including the process bywhich Peach State handles Proposed Actions and Explanation of Payment ), other than thespecific claims and administrative review matters described above.Provider complaints must be submitted in writing (or via the Peach State website) to the PeachState Appeals and Grievances Coordinator at the address below:3200 Highlands ParkwaySuite 300Smyrna, GA 30082CLAIM PAYMENT AUDITSPeach State audit review nurses will perform retrospective review of claims paid to providers toensure accuracy of the payment process. If a claim is found to be overpaid, the amount will berecouped against future claim payments. A letter will be sent to the provider notifying them of thereason for the recoupment and the amount.POST PROCESSING CLAIMS AUDITBackgroundPeach State Health Plan (Peach State) is contractually obligated to have procedures in place todetect waste, fraud, and abuse. This is achieved through:• Claims editing• Post-processing review of claims• Provider profiling and credentialing• Quality control• Utilization managementProvider Services1-866-874-063302/22/201195
As accountable and fiscally responsible stewards of public funds, we take the prevention anddetection of waste, fraud, and abuse very seriously. Peach State has a management contractwith its parent organization, Centene Corporation (Centene) in which Centene conducts routinepost-processing claims audits on behalf of Peach State. These audits are designed to ensurethat billing codes and practices are correct and that Peach State has paid health care providersappropriately. In addition to provider reviews, Centene also investigates members who appear tobe abusing the Medicaid and PeachCare for Kids programs.Post Processing Claims AuditA post-processing claims audit consists of a review of clinical documentation and claimssubmissions to determine whether the payment made was consistent with the services rendered.To start the audit, Centene Auditors request medical records for a defined review period.Providers have two weeks to respond to the request; if no response is received, a second andfinal request for medical records is forwarded to the provider. If the provider fails to respond tothe second and final request for medical records, or if services for which claims have beenpaid are not documented in the medical record, Peach State will recover all amounts paidfor the services in question.Centene Auditors review cases for potential unbundling, upcoding, mutually exclusiveprocedures, incorrect procedures and/or diagnosis for member’s age, duplicates, incorrectmodifier usage, and other billing irregularities. They consider state and federal laws andregulations, provider contracts, billing histories, and fee schedules in making determinations ofclaims payment appropriateness. If necessary, a clinician of like specialty may also reviewspecific cases to determine if billing is appropriate. Auditors issue an audit results letter to eachprovider upon completion of the audit, which includes a claims report which identifies all recordsreviewed during the audit. If the Auditor determines that clinical documentation does not supportthe claims payment in some or all circumstances, Peach State will seek recovery of alloverpayments.Depending on the number of services provided during the review period, Peach State maycalculate the overpayment using an extrapolation methodology. Extrapolation is the use ofstatistical sampling to calculate and project overpayment amounts. It is used by MedicareProgram Safeguard Contractors, CMS Recovery Audit Contractors, and Medicaid Fraud ControlUnits in calculating overpayments, and is recommended by the OIG in its Provider Self-Disclosure Protocol (63 Fed. Reg. 58,399; Oct. 30, 1998). To ensure accurate application of theextrapolated methodology, Centene uses RAT-STATS 2007 Version 2, the OIG’s statisticalsoftware tool, to select random samples, assist in evaluating audit results, and calculate projectedoverpayments.Providers who contest the overpayment methodology or wish to calculate an exact overpaymentfigure may request a full, on-site chart audit of all services rendered during the review period. Afull chart audit may take four to eight weeks to complete. On-site audits are performed by PeachState’s contracted vendor, HMS. Per the terms of your contract, you may be liable for the cost ofan on-site audit.Audit findings are reported to the Department of Community Health and may also be reported tothe Georgia Healthcare Fraud Control Unit.Additional information regarding Peach State’s Waste, Fraud, and Abuse program may be foundin the Provider Manual. To report wasteful, abusive, or fraudulent activity, please contact PeachState’s Confidential Hotline at 1-866-685-8664.Provider Services1-866-874-063302/22/201196
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CHRONIC AND COMPLEX CONDITIONS.....
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Description of GeorgiaFamiliesGeorg
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have any questions about Peach Stat
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Provider ResponsibilitiesPRIMARY CA
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Planning for Healthy BabiesWaiver P
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Tubal Ligation(Sterilization)• St
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Additional InformationProviders see
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83655 Lead Effective: 11/2010 Submi
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PROVIDER VISIT - WAITING TIMES• S
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Medical Management/Case Management1
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• Notification of all newborn del
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PROVIDER ASSISTANCE WITH PUBLIC HEA
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competency begins with self-awarene
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• Unresolved problems from previo
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• Member’s name, ID number• P
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Peach State may shorten the period
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Provider Services1-866-874-063302/2
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Notification is required to track i
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Members, a member’s representativ
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• HIV / AIDS• Children with Spe
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the member. The Peach State Medical
Page 45 and 46: Provider Services1-866-874-063302/2
Page 47 and 48: • A plan physician with privilege
Page 49 and 50: • In order to reimburse providers
Page 51 and 52: • Influence a member to choose on
Page 53 and 54: Covered Services andBenefits for Pe
Page 55 and 56: If you have any questions about the
Page 57 and 58: HEALTH CHECKGEORGIA HEALTH CHECK SE
Page 59 and 60: Health Check (EPSDT) Billing Requir
Page 61 and 62: Vaccine Codes must be billed with m
Page 63 and 64: Interperiodic Vision Only and Heari
Page 65 and 66: BLOOD LEAD SCREENINGPhysicians are
Page 67 and 68: General BillingInformation and Guid
Page 69 and 70: Peach State dental claims should be
Page 71 and 72: IMAGING REQUIREMENTSPeach State use
Page 73 and 74: PROCEDURES FOR FILING A CLAIM/ENCOU
Page 75 and 76: medical necessity. Peach State may
Page 77 and 78: Example: CPT 42820 submitted for a
Page 79 and 80: Procedure 99213 is submitted within
Page 81 and 82: Example: CPT 69436 billed with a 50
Page 83 and 84: BILLING CODESIt is important that p
Page 85 and 86: -Charge information and units• Se
Page 87 and 88: UB 04 CLAIM INSTRUCTIONSPeach State
Page 89 and 90: EMERGENCY DEPARTMENT HOSPITAL CLAIM
Page 91 and 92: Peach State Health PlanATTN: Peach
Page 93 and 94: Inquiry, Claims Adjustmentsand Prov
Page 95: selected, unless the plan and the p
Page 99 and 100: CredentialingCREDENTIALING REQUIREM
Page 101 and 102: CREDENTIALING OF HEALTH DELIVERY OR
Page 103 and 104: Quality ImprovementTHE PEACH STATE
Page 105 and 106: PROVIDER REVIEWThe Peach State Qual
Page 107 and 108: AUTHORITY AND RESPONSIBILITYThe Pea
Page 109 and 110: Provider Services1-866-874-063302/2
Page 111 and 112: Member ServicesPeach State is commi
Page 113 and 114: • Income• Health Status• Arre
Page 115 and 116: • To keep all your appointments.
Page 117 and 118: • An Administrative Law Hearing d
Page 119 and 120: The staff often answers questions a
Page 121 and 122: PharmacyThe Peach State preferred d
Page 123 and 124: • Experimental drugs• Nutrition
Page 125 and 126: The member or provider, acting with
Page 127 and 128: Pharmacy ProgramPeach State Health
Page 129 and 130: Gender LimitsSome medications on th
Page 131 and 132: Cyclosporine, Digoxin, Disopyramide
Page 133 and 134: SPECIALTY MEDICATIONPRIOR AUTHORIZA
Page 135 and 136: Common Brand Name(s) Product Descri
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Common Brand Name(s) Product Descri
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