Care Improvement Plus! This provider manual

careimprovementplus.com

Care Improvement Plus! This provider manual

2012

Care Improvement Plus

Provider

Manual


Care Improvement Plus

Contact Information

PROVIDER SELF-SERVICE CENTER……………………………..…... www.careimprovementplus.com

For eligibility verification, claims status and payment information

PROVIDER RELATIONS……………………………………………………………………1-866-679-3119

Claims Questions………………………………………………………... provider@careimprovementplus.com

Credentialing……………………………………………………….. credentialing@careimprovementplus.com

Contract/Address Updates

Non-delegated and Delegated groups………………... cipcontractupdates@careimprovementplus.com

Contracting…………………………………………….. providerrelations@careimprovementplus.com

ELIGIBILITY VERIFICATION………………………………………………….……….....1-866-679-3119

Secure Provider Portal………………………………..https://providerportal.careimprovementplus.com

UTILIZATION MANAGEMENT……………………….…………………………………...1-888-625-2204

For services requiring authorization or prior authorization

MEDICAL CLAIMS…………………………………………………………………………. 1-866-679-3119

Non-Par Provider Dispute Resolution……..www.careimprovementplus.com/providers/nonparpayment.aspx

EDI claims via Emdeon: Payor ID 77082

Paper Medical Claims:

Care Improvement Plus

P.O. Box 488

Linthicum, MD 21090-0488

Attention: Claims Department

Provider@careimprovementplus.com

Medical Claim Appeals....................................................................................................1-800-213-0672

PHARMACY BENEFITS SERVICES……………………………………………………….1-866-673-3561

Provided by Medco Health Solutions

Pharmacy Claims:

Medco Health Solutions, Inc.

P.O. Box 14718

Lexington, KY 40512

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Pharmacy Appeals……....................................................................................................1-866-683-3275

Vision and Dental Claims…..………………………………….................................................1-800-828-9341

Provided by Avesis Third Party Administrators

P.O. Box 7777

Phoenix, AZ 85011

Attention: Claims Department

or electronically www.avesis.com

Mental Health Claims………………………………………………………………………….1-888-751-1235

Optum

P.O. Box 30760

Salt Lake City, UT 84130-0760

or electronically: payor ID is 87726

CASE MANAGEMENT………………………………………………………………………1-866-272-2945

TELEPHONE FOR HEARING IMPAIRED (TTY)……………………………………………………..711

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Table of Contents

TABLE OF CONTENTS ..................................................................................................................................... 3

SECTION A – INTRODUCTION ........................................................................................................................... 4

Welcome ................................................................................................................................................................................... 4

Overview of Care Improvement Plus ....................................................................................................................................... 4

SECTION B – ELIGIBILITY & PLAN DESCRIPTION ...................................................................................... 6

Eligibility Verification Procedure ............................................................................................................................................ 6

Plan Description ....................................................................................................................................................................... 6

SECTION C – PROVIDER REQUIREMENTS .................................................................................................... 7

SECTION D – PROVIDER RIGHTS AND RESPONSIBILITIES ................................................................... 10

SECTION E – BILLING & CLAIMS PAYMENT ............................................................................................... 15

SECTION F – CREDENTIALING PROGRAM .................................................................................................. 17

SECTION G – USE OF ANCILLARY PROVIDERS .......................................................................................... 18

SECTION H – BEHAVORIAL HEALTH SERVICES ........................................................................................ 19

SECTION I – PHARMACY ................................................................................................................................... 19

SECTION L – QUALITY IMPROVEMENT (QI) .............................................................................................. 23

SECTION M – MEMBER RIGHTS AND RESPONSIBILITIES ..................................................................... 24

SECTION N – ADVANCED DIRECTIVE ........................................................................................................... 27

APPENDICES...…………………………………………………………………………………………………………………….37

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SECTION A – INTRODUCTION

Welcome

Welcome to Care Improvement Plus! This provider manual was developed as a guide to assist you and

your office staff with providing services to our members, your patients. We are confident that this

provider manual will be an important resource for your office. The provider manual contains essential

information, and will be updated on a regular basis as policies and procedures are created and/or are

modified and placed online. We encourage you to utilize other tools and information available on our

website www.careimprovementplus.com through our provider services center, specifically designed to

make working with Care Improvement Plus easy for our providers.

Your review and understanding of the provider manual is essential. Any questions, issues, and/or

suggestions concerning the provider manual or our website are encouraged and should be directed to the

Care Improvement Plus Provider Relations department at 1-866-679-3119 or via email at

providerrealtions@careimprovementplus.com.

Once again, thank you for your participation with Care Improvement Plus.

Overview of Care Improvement Plus

Care Improvement Plus is owned by XLHealth, an industry leader in improving the quality of care for

chronically ill and underserved Medicare beneficiaries. Using a combination of specifically designed

coverage options, benefits, services and Care Management programs, our Medicare Advantage plans

are focused on delivering quality healthcare. And our collaborative “team” approach to healthcare

works for members and healthcare providers to achieve better patient outcomes.

The Plan is available to Medicare beneficiaries who are enrolled in Medicare Part A and Medicare

Part B, who reside in our service area, and meet all other eligibility criteria.

We offer a broad range of Medicare Advantage plans including:

• Chronic Conditions Special Needs Plans for Medicare beneficiaries with diabetes and/or heart

failure

• Dual Special Needs plans for beneficiaries who receive both Medicare and full Medicaid

• Medicare Advantage Prescription Drug plans for Medicare beneficiaries who are not eligible for

our Special Needs or Dual Advantage Plans, such as caregivers or spouses of members

• A Medicare Advantage plan for Medicare beneficiaries who reside in select counties in Wisconsin

(no Part D coverage)

In addition to Hospital (Part A), Medical (Part B), and Prescription Drug (Part D) coverage, our plans

feature additional services, including:

• Open-access provider network; no referral required for Medicare-covered services. Members can

go to any Medicare-approved provider who accepts payment from the plan

Care management support including a 24/7 nurse hotline

• Health education

• A HouseCalls program which enables Medicare patients to receive a yearly in-home visit from a

physician or a nurse practitioner who will perform an annual health risk assessment and report

back to the primary care doctor

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• A PharmAssist program which Members receive personalized, private counseling sessions with

specially-trained plan pharmacists.

• Tools to help the member manage and monitor their care

As a sponsor of Medicare Advantage plans, Care Improvement Plus abides by all CMS requirements,

which includes ensuring that payment and incentive arrangements with providers are specified in a

contract, ensuring providers meet all the downstream Medicare Advantage and Medicare Part D

requirements, and ensuring that the plan and its providers follow all laws subject to federal funds,

including fraud, waste, abuse and anti-kickback statutes.

Secure Messaging

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires our electronic

communications that contain Protected Health Information (PHI) to be secure. To comply with this

important and practical security measure, we use ZixCorp to protect our email and ensure all PHI remains

confidential.

When a Care Improvement Plus employee sends you an email that contains PHI, ZixCorp detects the PHI

and protects the email. You will receive an email notification that you have been sent a ZixMail secure

message. The notification tells you who the secure message is from and includes a link to retrieve the

email message. The first time you use the ZixMail message service to retrieve a message, you must create

a password. Thereafter, you can use the same password each time you log into the ZixMessage Center to

retrieve an encrypted email.

Please note – ZixMail secure messages are posted and available for 30 calendar days. If the message is

not opened during that timeframe, the message is removed and the sender is notified.

If you would like more information about ZixCorp, visit their website at www.zixcorp.com.

Care Improvement Plus Programs

With every plan we offer, our members have access to special programs in which they are encouraged to

take advantage of. These personalized programs were created to serve our member’s unique needs and

are at no cost to the member.

HouseCalls

This program allows the member to receive one-on-one services without having to leave his/her home. A

physician or nurse practitioner visits the member annually and evaluates the member’s health. The

physician or nurse practitioner is also available to answer any questions the member might have. The

information collected from this visit is summarized and sent to the members primary care provider.

PharmAssist

A pharmacist will review member’s medications to ensure no drug interactions or side effects will occur

if taken all together. The pharmacist is also able to answer any questions the member has regarding their

prescriptions.

Social Service Coordinators

Care Improvement Plus has partnered with Social Service Coordinators to help our members see if they

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qualify for programs that they may be entitled to. These programs can include: local, state, and federal

assistance programs.

SECTION B – ELIGIBILITY & PLAN DESCRIPTION

Eligibility Verification Procedure

Members should present their Care Improvement Plus ID card (or temporary proof of coverage if they

have not yet received their ID card) upon arrival for services. If a member is enrolled in our Dual

Advantage plan, they will also need to present their State Medicaid card. Providers are encouraged to

validate the identity of the person presenting an ID card by requesting some form of photo

identification, such as a driver’s license, in addition to the ID card. Please see Appendix A for an

example of our ID cards.

Member eligibility may be confirmed by visiting the secure provider self-service center at

www.careimprovementplus.com, or by calling a provider service representative at 1-866-679-3119,

Monday through Friday from 8:00 a.m. to 8:00 p.m.

The ID card does not guarantee eligibility. Member eligibility must be verified at each visit. Failure

to verify eligibility may result in delay or non-payment of claims.

Disease State Verification

Members that wish to enroll in a Care Improvement Plus Chronic Special Needs Plan must have their

disease state verified by a provider within 30 days of enrollment. A Chronic Condition Verification form

will be faxed to your office at the time of the beneficiary enrollment for your completion. See Appendix

I for a sample of this form. If we do not receive a completed form we will make an attempt to contact

your office via telephone.

Secure Provider Portal

The secure provider portal serves as a resource for providers. The portal allows providers to check

member eligibility and claims status as well as other services. To access the provider portal, visit our

website at https://www.careimprovementplus.com/providers/Default.aspx

Plan Description

Care Improvement Plus:

• Has an open access network, which means members may use any Medicare-approved provider

that will accept payment from Care Improvement Plus, however;

o Members that use an out-of-network provider may have higher costs for covered services

o Members in our Dual Advantage plan should use a provider that accepts Medicare and

Medicaid

• Because our Plan is a Regional/Local Preferred Provider Organization, if no contracted

network provider is readily available members can access care at in-network cost-sharing

from an out-of-network provider.

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o Members that use an out of network provider for home health care services, DME, dental

or vision may have additional out-of-pocket expenses

• Does not require referrals for Medicare-covered services

o Dentures require referrals

• Requires preauthorization for elective inpatient hospital admissions, skilled nursing facilities,

home health services, certain Part B medications, and select DME items. Please see Appendix C

for the current list of services requiring preauthorization, or visit our website at

www.careimprovementplus.com to access the Provider Authorization Requirements fact sheet

o No preauthorization is required for emergency services. However, all inpatient admissions

require authorization.

• Does not require a qualifying three (3) day hospital stay before admission to a Skilled Nursing

Facility (as does traditional fee-for-service Medicare). This allows the physician to admit to this

level of care if that is the most appropriate care for the patient

• Covers emergency and urgently-needed services, regardless if the member is in or outside of the

plan service area (as further described in the members Evidence of Coverage)

• Encourages the use of preventive services, including an annual physical exam

• Offers additional benefits, such as transportation, routine vision and routine dental

services

SECTION C – PROVIDER REQUIREMENTS

Providers may include physicians, facilities, and ancillary providers that provide services to Care

Improvement Plus members. In some instances, providers may include Physician Hospital Organizations

and Independent Physician Associations who may subcontract with other Care Improvement Plus

approved Providers to render care to Care Improvement Plus members as well. In all cases, Care

Improvement Plus providers are required to acknowledge and adhere to the following:

Standards of Care

• Providers are required to render medically necessary covered services to members in an

appropriate, timely, and cost effective manner and in accordance with Care Improvement Plus’s

policies and procedures, including adherence to Care Improvement Plus’s appointment wait time

standards. Refer to Appendix H for maximum expected wait times.

• Providers are required to support an open communication relationship with members regarding

appropriate treatment alternatives without regard to cost or benefit coverage.

• Providers are required to accept and render service to members at the same level, scope, and

quality of care rendered to all members and other patients.

• Providers must accept responsibility for the advice and treatment given to members and for the

performance of all medical services in accordance with accepted professional standards.

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• Providers must render service as applicable within the scope of their specialty.

• Providers should make a concerted effort to educate and instruct members about the proper

utilization of the practitioner’s office in lieu of hospital emergency rooms.

• Providers shall not refer or direct members to hospital emergency rooms for non-emergent

medical services at any time.

• Providers must meet all applicable requirements of the Americans with Disabilities Act (ADA),

the Civil Rights Act of 1974, the Age Discrimination Act of 1975 and any other applicable

laws or rules when rendering services to members with disabilities who may request special

accommodations such as interpreters, alternative formats, or assistance with physician

accessibility. Providers must remain professional and keep the member’s needs in mind at all

times.

• Providers shall provide services in a culturally competent manner.

Discrimination

Providers are required to refrain from discriminating against any member on any basis prohibited by law,

by the frequency or extent of services; Providers shall not discriminate because of member’s religion,

race, color, national origin, age, sex, weight, height, marital status, economic status, health status, sexual

preference, or physical handicaps as further prohibited by law. Providers are further required to refrain

from segregating a member or treating a member in a location or manner different from other members or

other patients.

Accessibility

Physician providers are required to provide or arrange for urgent care, including emergency medical

services on a 24-hour per day basis, 7 days per week. Providers are required to have an answering

service set up for after hours to meet these needs.

Medical Records

Every provider is required to create and maintain, consistent with all federal and state laws (including

Medicare Advantage and Medicare Part D laws) and standards of any organization to which the provider

is subject, a health record-keeping system through which a complete and accurate set of all pertinent

information relating to the health care of members is maintained and is readily available to persons

authorized to review these records, including Care Improvement Plus and its designee.

Providers shall maintain confidential medical records consistent with HIPAA regulations and state laws

governing the use and disclosure of Care Improvement Plus members’ information. HIPAA limits the use

and disclosure of Protected Health Information without the individual’s authorization. Providers also

must maintain and safeguard member personal health information and records (including, without

limitation, medical records), consistent with state and federal laws and other standards applicable to

Providers.

License, Certifications and Privileges

Providers are required to maintain all licenses, certifications, permits, and other prerequisites required by

law to render services pursuant to their contracts with Care Improvement Plus, and submitting evidence

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that each is current and in good standing upon the request by Care Improvement Plus, including but not

limited to eligibility and participation in the Medicare Program. Providers are further required, as

applicable, to maintain staff membership and admission privileges in good standing at the network

hospital stipulated in Provider’s credentialed approval.

Any changes in hospital privileges should be reported to Care Improvement Plus’s Credentialing

Department in writing at:

Care Improvement Plus

4350 Lockhill-Selma Road, Suite 300

Shavano Park, TX 78249

Attention: Credentialing Department

credentialing@careimprovementplus.com

Compliance with Medicare Requirements and Care Improvement Plus Policies and Procedures

Providers must comply with all applicable Medicare Advantage and Medicare Part D laws and

regulations, guidance and instructions issued by the Centers for Medicare and Medicaid Services (CMS),

Care Improvement Plus’s contract with CMS to sponsor MA-PD plans, and applicable written policies

and procedures as established and modified by Care Improvement Plus from time to time, which are

available online through our Provider Portal at www.careimprovementplus.com.

Network Providers

Providers are encouraged to utilize Care Improvement Plus’ network hospitals, physicians, and ancillary

providers. A network directory may be found at www.careimprovementplus.com. However, providers

may refer members to any Medicare approved provider as long as the provider agrees to accept payment

from Care Improvement Plus.

Pharmaceutical Prescriptions

Providers are encouraged to prescribe and authorize the substitution of generic pharmaceuticals and

otherwise abide by the Care Improvement Plus Formulary available upon request and found online

at www.careimprovementplus.com.

Advance Directives

Institutional providers are required to give adult members (age 21 and older) written information

about their right to have an advance directive; advance directives are oral or written statements

either outlining a member’s choice for medical treatment or naming a person who should make

choices if the member loses the ability to make decisions.

Non-institutional providers that choose to provide information on Advance Directives should follow the

same provisions listed above. For more information reference Section N.

Reporting and Disclosure/Encounter Data

Providers are required to submit data and other information, including medical records, as needed when

necessary to characterize the content and purpose of each encounter with a member. Providers are

required to certify to the completeness, truthfulness and accuracy of such information. This information

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and data may be submitted to CMS.

Billing of Members

Providers may not bill, charge, collect a deposit from, seek compensation, remuneration, or

reimbursement from or have any recourse against any member for any amount owed by Care

Improvement Plus to Providers. The foregoing does not affect Provider’s obligation to collect

applicable coinsurance, copayments and deductibles as applicable, from members.

Every provider shall indemnify and hold members harmless for any and all debts of provider, amounts

owed to provider by Care Improvement Plus, and any coinsurance, copayments and deductibles owed to

provider by the applicable state Medicaid program.

In order to bill a Care Improvement Plus member for a non-covered service, Providers must inform the

member, and obtain the member’s written acknowledgement that he or she has been informed, in

conformity with the requirements of Section 1879 of the Social Security Act, of the following:

(1) The nature of the non-covered service;

(2) An explanation of why the Provider believes Care Improvement Plus will not cover the service;

and

(3) That the member will be personally and financially liable for payment of the service.

Annual Model of Care Training

As required by CMS, Care Improvement Plus must conduct initial and annual Model of Care training for

our provider network to keep everyone informed about the care management structure and revisions

made based on performance improvement activities. You must satisfy this requirement by completing

the course provided in our learning management system, the University of XLHealth (UXL).

You can access the University of XLHealth at www.xlhealthtraining.com/vendor. Click on the New User

Registration link and complete all required fields. Click the Submit Form button and the Course Catalog

will open displaying all available courses. Select Model of Care 2011 and then the Home tab to launch

the course. Detailed Instructions on how to register can be found in the upper right corner of the home

page, as well as contact information for any questions or issues you may encounter.

SECTION D – PROVIDER RIGHTS AND RESPONSIBILITIES

Primary Care Physician

Care Improvement Plus recognizes the important role that specialists have in the health care needs of our

members. We also recognize the need for a Primary Health Care Provider to coordinate and monitor the

overall clinical care needs of the patient (the physician primarily focuses on clinical aspects related to

their chronic illness). As such, we encourage the member to identify a Primary Care Physician who will

be willing to act in that capacity.

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A Primary Care Physician (PCP) is defined as a physician with a specialty of: family practice, general

practice, internal medicine, or gerontology. When a Provider consents to act as Primary Care Physician

for a member, it is the role of the Primary Care Physician to coordinate all health care and when

medically necessary, refer Care Improvement Plus members to other specialists if needed.

Primary Care Physicians responsibilities include, but are not limited to:

• Notify Care Improvement Plus of all hospital admissions, if aware.

• Discuss and consider requests from members who have chosen that physician as their Primary

Care Physician

• Perform services normally in his or her scope of practice

• Coordinate the provision of covered services to members by: (1) counseling members and their

families regarding members’ medical care needs, including family planning and advance

directives; (2) initiating medically necessary referrals; and (3) monitoring progress, care, and

managing utilization of specialty services

• Render preventive health services; such services shall include, but are not limited to, periodic

health assessments, immunizations, and other measures for the prevention and detection of

disease

• Render immunization services without assessing a co-pay

• Participate and abide by all decisions regarding member complaints, peer reviews, quality

improvement and utilization management

• Give direction and follow-up care to those members who have received emergency services

• Accept and participate in peer review

• Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) medical care

• Provide clinical documentation as requested

Specialty Care Physicians

All specialty care physicians have responsibilities that include, but are not limited to:

• Providing covered specialty care services to members (referrals are not required)

• Confirm member eligibility prior to rendering routine (non-emergent, non-urgent) medical care

• Provide clinical documentation as requested

Facility Providers

All facility providers have responsibilities that include, but are not limited to:

• Providing covered services to members

• Obtain authorizations as appropriate

• Confirm member eligibility prior to rendering routine (non-emergent, non-urgent)

• Provide clinical documentation as requested

Ancillary Providers

All ancillary providers have responsibilities that include, but are not limited to:

• Providing covered services to members

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• Obtain authorizations as appropriate

• Confirm member eligibility prior to rendering routine (non-emergent, non-urgent)

• Provide clinical documentation as requested

*Note: There is an out-of-network cost differential for dental, vision, home health services and DME in

some Care Improvement Plus plans.

Updates to Pertinent Information

Providers must give Care Improvement Plus written notification thirty (30) days prior to any change in:

• Address

• Telephone number

• Tax identification number (including a W-9 form)

• License status

• Certification status

• Medicare certification status

• Professional liability coverage

• National Provider Identifier (NPI)

• Specialties (Primary Taxonomy Code)

• Other information supplied in the credentialing application.

All updates should be directed to:

Non Delegated and Delegated Groups – cipcontractupdates@careimprovementplus.com or by mail:

Care Improvement Plus

4350 Lockhill-Selma Road, Suite 300

Shavano Park, TX 78249

Attention: Credentialing Department

Failure to notify Care Improvement Plus may result in delay of or denial of payment for services

rendered and the provider must hold the member harmless.

Appeals

Providers may appeal claims where Care Improvement Plus has denied all or part of a claim. All appeals

must be submitted within sixty (60) days, or as stipulated in the provider’s contract, from the date that the

provider’s payment was denied in whole or in part. The appeal case will undergo investigation and

review by clinical appeals staff who will work with a licensed physician to review cases for medical

necessity and appropriateness of care. The provider must cooperate in sending all necessary medical

documentation to support the case for the Plan’s review. Care Improvement Plus will send a written

decision within sixty (60) days. If the initial decision is overturned, in whole or in part, a check will be

sent following the decision. In making the decision, Care Improvement Plus follows Medicare coverage

requirements, the benefit package applicable to the member, and Milliman and/or Interqual Guidelines

where needed. The Plan is also guided by the Provider Contract. If Care Improvement Plus upholds the

initial denial, then the contracted provider is notified. At this point the contracted provider’s appeal

process is closed and the member cannot be balanced billed.

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Provider and Member Appeals: Members have appeal rights that begin with plan-level

reconsideration and extend through four (4) additional levels of external review. Providers may

appeal on behalf of a member, but only in the limited circumstances as allowed by federal law, as

follows:

Expedited Appeals: Physicians may request an expedited appeal on behalf of the member.

Expedited appeals (also known as reconsiderations) are cases where denied medical services or

prescription drug(s) are of an urgent nature. That is, a delay in obtaining the medical services or

prescription drug(s) could jeopardize the member’s health, life, or ability to regain maximum

function. Expedited appeals do not have to be in writing and may be initiated by calling 1-800-213-

0672 for medical and 1-866-683-3275 for prescription drug appeals.

Authorized Representative: Providers may serve as the “official” representative of the member by

signing, along with the member, a CMS Form 1696. A letter that includes the same designation of

authority and co-signed with the member may also be used. Once activated, an authorized

representative has the same rights as a member in the Medicare member appeals process.

Except for expedited appeals, all appeals should be in writing and mailed to the following address:

Care Improvement Plus

351 W. Camden Street, Suite 100

Baltimore, MD 21201

Attn: Appeals Department

For more information on how to file an appeal, please call the Compliance Department at

1-800-213-0672; TTY users should call 711.

For prescription drug appeals, please call 1-866-683-3275, or fax to 1-866-683-3272, or send to

the following address:

Care Improvement Plus

351 W. Camden Street, Suite 100

Baltimore, MD 21201

Attention: Pharmacy Appeals

By email: PartDexceptionsandappeals@careimprovementplus.com

Member Solicitation

Providers may announce new affiliations and repeat affiliation announcements for specific plan sponsors

through general advertising (e.g., publicity, radio, television). An announcement to patients of a new

affiliation which names only one plan sponsor may occur only once when such announcement is

conveyed through direct mail and/or email. Additional direct mail and/or email communications from

providers to their patients regarding affiliations must include all plans with which the provider contracts.

Provider affiliation banners, displays, brochures, and/or posters located on the premises of the provider

must include all plan sponsors with which the provider contracts. Any affiliation communication

materials that describe plans in any way (e.g., benefits, formularies) must be approved by CMS.

Providers may feature Special Needs Plans (SNPs) in a mailing announcing an ongoing affiliation. This

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mailing may highlight the providers’ affiliation or arrangement by placing the SNP affiliations at the

beginning of the announcement and may include specific information about the SNP. This includes

providing information on special plan features, the population the SNP serves or specific benefits for

each SNP. The announcement must list all other plans with which the provider is affiliated.

Provider Based Activities

Providers contracted with Care Improvement Plus may:

• Provide the names of plan sponsors with which they contract and/or participate;

• Provide information and assistance in applying for the low income subsidy;

• Provide objective information on ALL plan sponsors’ specific plan formularies, based on a

particular patient’s medications and health care needs;

• Provide objective information regarding ALL plan sponsors’ specific plans being offered, such as

covered benefits, cost sharing, and utilization management tools;

• Make available and/or distribute plan marketing materials for all plans with which the provider

participates (including PDP enrollment applications, but not MA or MA-PD enrollment

applications);

• Refer their patients to other sources of information, such as the SHIPS, plan marketing

representatives, their State Medicaid Office, local Social Security Office, CMS’s website at

http://www.medicare.gov/ or calling 1-800-MEDICARE; and

• Print out and share information with patients from CMS’s website.

Providers contracted with Care Improvement Plus may not:

• Direct, urge or attempt to persuade, any prospective enrollee to enroll in a particular Plan or to

insure with a particular company based on financial or any other interest of the provider;

• Offer sales/appointment forms;

• Collect enrollment applications;

• Mail marketing materials on behalf of plan sponsors;

• Offer inducements to persuade beneficiaries to enroll in a particular plan or organization;

• Offer anything of value to induce Plan enrollees to select them as their provider;

• Expect compensation in consideration for the enrollment of a beneficiary; and

• Expect compensation directly or indirectly from the Plan for beneficiary enrollment activities.

Suspension or Termination of Contract

In the event Care Improvement Plus suspends or terminates a Provider’s contract to provide health care

services to members, Care Improvement Plus will provide the Provider written notice of the suspension

or termination, including the basis for Care Improvement Plus’s action, the right to appeal the action, and

the process and timing for requesting a hearing regarding Care Improvement Plus’s action. Suspensions

and terminations resulting from deficiencies in the quality of care furnished by the Provider will be

reported to the applicable licensing or disciplinary bodies or other appropriate authorities as required by

Medicare Advantage regulation.

Termination without cause of a Provider’s contract with Care Improvement Plus, if permitted by the

terms of the contract, may be effective no earlier than sixty (60) calendar days after notice of termination

is provided.

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SECTION E – BILLING & CLAIMS PAYMENT

Billing

Care Improvement Plus follows Medicare payment policies and guidelines as directed in the

Medicare Advantage Payment Guide. Providers must submit their claim on the current and

appropriate Medicare billing form, with all required fields and documentation complete.

Claims Payment

Care Improvement Plus accepts both paper and electronically submitted claim forms from providers.

Care Improvement Plus encourages providers to submit claims electronically whenever possible. There

are many advantages to submitting claims electronically. Elimination of paper and associated expenses,

more timely claims payment by Care Improvement Plus, and the ability to track submitted claims are just

a few of the benefits. If you are filing a claim with Care Improvement Plus and a State Medicaid System

for a Dual Advantage Plan member, please review Appendix G at the end of this manual. Care

Improvement Plus coordinates benefits with State Medicaid for members in the Dual Advantage plan.

All claims and encounter data must be submitted on either a form CMS 1500 or UB-04, or on electronic

media in an approved HIPAA compliant format.

Care Improvement Plus utilizes Emdeon as our clearinghouse. The unique Electronic Payor ID is: 77082.

Call 1-866-369-8805 for more information on Emdeon Business Services EDI Solutions. Refer to

Appendix B for more information.

For more detailed information regarding Care Improvement Plus claims payment policies, please go online to

www.careimprovementplus.com to our provider self-service center and access the quick links for more

information.

For claims status information, you can visit us at www.careimprovementplus.com and log into the

secure provider self-service center, or call Provider Relations at 1-866-679-3119.

Medical Claims may also be submitted via paper to:

Care Improvement Plus

P.O. Box 488 Linthicum, MD 21090-0488

Attention: Claims Department

or

Electronic payor ID is 77082

Dual Advantage Provider Reimbursement

The Dual Advantage plan is a Dual Special Needs plan designed for beneficiaries that have their A/B cost

sharing covered by State Medicaid. Members are not responsible for paying any Medicare Part A or Part

B cost sharing in this plan. Refer to Appendix G for additional, state specific claims information.

Arkansas-Department of Human Services

1.800.482.5431 or (local) (501) 682.8501

P.O. Box 1437, Slot S410, 112 W. Main Street

15


Little Rock, AR 72203

http://www.arkansas.gov/dhs/homepage.html

Georgia-Department of Human Resources Division of Family & Children Services

1-800-869-1150

2 Peachtree Street, NW Suite 18-486

Atlanta, GA 30303

http://dfcs.dhr.georgia.gov/portal/site/DHS-DFCS/

Iowa Medicaid Enterprise

1-800-338-8366

P.O. Box 36510

Des Moines, IA 50315

http://www.ime.state.ia.us/index.html

Indiana Medicaid

1-866-408-6131

P.O. Box 7269

Indianapolis, IN 46207-7269

http://www.indianamedicaid.com/

Missouri Department of Social Services

1-800-392-2161

615 Howerton Court, P.O. Box 6500

Jefferson City, MO 65102

http://www.dss.mo.gov/

South Carolina-Department of Health and Human Services

1-888-549-0820

P.O. Box 8206

Columbia, SC 29202

http://www.dhhs.state.sc.us/medicaid.asp

Texas Health and Human Services Commission

1-800-252-8263

4900 N. Lamar Blvd.

Austin, TX 78751-2316

http://www.hhsc.state.tx.us/medicaid/index.html

Mental Health and Substance Abuse Claims via paper to:

Optum

P.O. Box 30760

Salt Lake City, UT 84130-0760

or

Electronic payor ID is 87726

Pharmacy Claims may be submitted via paper to:

Medco Health Solutions, Inc.

PO BOX 14718

Lexington, KY 40512

16


Dental and Vision Claims may be submitted via paper to:

Avesis Third Party Administrators

P.O. Box 7777 Phoenix, AZ 85011

Attention: Claims Department

www.avesis.com

Explanation of Payment

An explanation of payment (EOP) will be generated for all claims processed by Care Improvement Plus.

The EOP will be mailed regardless of payment amount, and will be accompanied by a claim check when

applicable. For questions or concerns about the EOP, visit the provider self-service center at

www.careimprovementplus.com or contact Provider relations at 1-866-679-3119; TTY users should call

711. A copy of the EOP can be found in Appendix E.

Provider Refunds

Georgia and South Carolina

Care Improvement Plus of the Southeast Inc

P.O. Box 822657

Philadelphia, PA 19182-2657

Missouri and Arkansas

Care Improvement Plus South-central Insurance Company Inc

P.O. Box 822660

Philadelphia, PA 19182-2660

Texas, New Mexico, Illinois, Iowa, Indiana, and New York

Care Improvement Plus of Texas Insurance Company Inc

P.O. Box 822663

Philadelphia, PA 19182-2663

Wisconsin

Care Improvement Plus Wisconsin Insurance Company

P.O. Box 824460

Philadelphia, PA 19182-4444

SECTION F – CREDENTIALING PROGRAM

Program Overview

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Care Improvement Plus maintains a comprehensive credentialing program; developed in accordance

with CMS and the National Committee for Quality Assurance (NCQA) standards. The credentialing

process involves several steps including application, primary source verification, Credentialing

Committee review and provider notification.

All providers applying to the Care Improvement Plus network have the right to:

• Review information obtained in support of their credentialing application except for

references, recommendations or other information peer review protected by law.

• Respond to information obtained during the credentialing process that is discrepant with

the information submitted on their credentialing application.

• Correct erroneous information that may have been submitted.

• Be informed of the status of their credentialing or re-credentialing application upon

request.

The credentialing program is periodically reviewed by the Credentialing Committee and revised

when necessary. All information obtained during the credentialing process is held in the strictest

confidence. All providers shall be notified in writing of any denial, suspension or termination.

Re-Credentialing

Providers are re-credentialed every three (3) years of the date of their last credentialing cycle. The basic

process is the same as the initial credentialing process. Additional criteria that may be used during the recredentialing

process include, but are not limited to:

• Compliance with health plan policies and procedures.

• Sanctions related to utilization management, administrative or quality of care issues.

• Member complaints

• Member satisfaction survey results

• Participation in quality improvement activities

SECTION G – USE OF ANCILLARY PROVIDERS

Ancillary Services

Laboratory Services

Any Medicare certified laboratory provider may be used. Physicians may do limited lab work in their

offices – some services will be considered “bundled charges” and will not be paid in addition to an office

visit. For a listing of contracted laboratory facilities in your area, search our online provider directory or

contact our Provider Relations department.

Radiology Services

Any Medicare certified radiology provider may be used. For a listing of contracted radiology

facilities in your area, search our online provider directory or contact our Provider Relations

department.

Physical Therapy

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Any Medicare certified therapy provider may be used. For a listing of contracted physical therapy

facilities in your area, search our online provider directory or contact our Provider Relations

department.

Home Health and Durable Medical Equipment

Any Medicare certified licensed Home Health and/or DME supplier may be used; however Care

Improvement Plus members may have additional out-of-pocket expenses if an out-of-network provider is

used. Select DME items require preauthorization. For a listing of contracted Home Health and DME

suppliers in your area, search our online provider directory or contact our Provider Relations department.

Please refer to Appendix C for the specific DME which require prior authorization.

SECTION H – BEHAVORIAL HEALTH SERVICES

Program Overview

Care Improvement Plus recognizes that members with chronic medical illness may also have

symptoms requiring behavioral health services for psychiatric or substance abuse treatment. Clinical

staff will assist in accessing providers and facilities for treatment (both inpatient and outpatient)

when these needs are identified.

Members and providers can make requests for this assistance by calling Optum at 1-877-751-1235.

Emergency care needs should always be directed to the nearest Emergency Department or Local

Hospital.

Mental Health and Substance Abuse Claims may be submitted via paper to:

Optum

PO Box 30760

Salt Lake City, UT 84130-0760

or

Electronic payor ID is 87726

SECTION I – PHARMACY

List of Prescriptions/Medications

The Care Improvement Plus Formulary:

• Contains at least two (2) drugs from each class;

• Provides a framework and relative cost information for the management of drug costs;

• Requires generic drug prescription usage whenever possible. These drugs are listed with the

generic name on the Formulary. If a member requests a brand name drug when a generic drug is

available, the member may be responsible for additional charges;

• Includes quantity, form, dosage and preauthorization restrictions for certain drugs

19


(Clinical and/or coverage determinations); and

• Will be updated, reprinted and distributed to physician offices upon request.

Physician offices needing additional copies of the list should contact Care Improvement Plus Provider

Relations at 1-866-679-3119. The formulary and any recent changes are also available online at

www.careimprovementplus.com.

Preauthorization

Some medications as noted on the Care Improvement Plus Formulary require preauthorization from

Care Improvement Plus (clinical (PA), step therapy (ST), quantity limit (QL) or Part B/D coverage

determination (B/D)). Prescriptions requiring preauthorization should be called in to 1-800-753-2851

(TTY: 711).

Exceptions

Members may request an exception when they wish to receive a drug that is not on the formulary or to

receive a drug at a lower coinsurance/copay/tier. The Care Improvement Plus Pharmacy department

reviews the request and may contact the prescriber to obtain information necessary to approve or deny

the request. The decision to approve or deny the request will be made within seventy-two (72) hours of

receiving complete information for a standard request or within twenty-four (24) hours of receiving

complete information for an expedited request. Members may request a re-determination of any denial of

coverage (See Section M- Members Rights and Responsibilities, page 26 for more detailed information

on pharmacy appeals, including the right to an expedited appeal). More information on requesting an

exception (including provider and member forms to request an exception) is available online at

www.careimprovementplus.com.

Transition

All new enrollees may receive a one-time refill of any non-formulary medication for up to a ninety (90)

day period after enrollment. This includes formulary medications requiring prior authorization and step

therapy under Care Improvement Plus’ utilization management rules. Medications that are excluded by

Medicare and those that require a Part B/D coverage termination are not eligible for a transition fill.

Providers and patients should consider switching to a formulary option in advance to the next refill of

medication. A notification will be sent to the member regarding the need to transition to a formulary

medication.

Four-Tier Copay Structure

Care Improvement Plus has a four-tier formulary. Most drugs are covered (with the exception of

exclusions as listed in the member’s Certificate of Insurance). Copayments vary depending on the tier in

which the prescription drug falls.

To access a copy of our formulary or to access our online formulary search tool, go to

www.careimprovementplus.com, select the appropriate state from the Provider Portal dropdown list, and

click Submit. Once inside the Provider Portal, select Medicare Part D from the left-hand navigation.

Tiers include:

20


Generic (Tier 1) Generic drugs rated AB products by the FDA. Care Improvement

Plus covers all generics (including those not listed on the printed

formulary) that are not excluded by Medicare.

Preferred Brand Agents approved by the FDA as safe and effective, not available

(Tier 2) as AB rated generics. These drugs have been reviewed by the

Pharmacy and Therapeutic Committee as drugs that are standards

of care to be used for reasons of increased safety, efficacy and

cost-effectiveness over other available FDA approved drugs.

Non-Preferred Brand Non-Preferred brand drugs process at a higher copay level than

(Tier 3)

preferred brand medications.

Specialty Drugs They are often injectable or infused medications, but may also

(Tier 4) include oral agents. CMS defines specialty medications as

medications that may cost at least $600 per month.

Preauthorization Some medications as noted on the Care Improvement Plus

Formulary require pre-authorization from Care Improvement Plus

(clinical (PA), quantity limit (QL) or Part B/D coverage

determination (B/D)). Preauthorization may be requested by

calling Medco Health Solutions Preauthorization Department at 1-

800-753-2851.

Exceptions Members may request an exception when they wish to receive a

drug that is not on the formulary or to receive a drug at a lower

coinsurance/co-pay/tier. The Care Improvement Plus Pharmacy

department reviews the request and may contact the prescriber (as

necessary) to obtain information necessary to make a coverage

decision. The decision to approve or deny the request will be

made within seventy-two (72) hours of receiving complete

information for a standard request or within twenty-four (24)

hours of receiving complete information for an expedited request.

Members may request a re-determination of any denial of

coverage (See Section M- Members Rights and Responsibilities,

page 26 for more detailed information on pharmacy appeals,

including the right to an expedited appeal). More information on

requesting an exception (including provider and member forms to

request an exception) is available at

www.careimprovementplus.com.

Transition All new enrollees may receive a one-time refill of any nonformulary

medication for up to a ninety (90) day period after

enrollment. This includes formulary medications requiring prior

authorization and step therapy under Care Improvement Plus

utilization management rules. Medications that are excluded by

Medicare and those that require a Part B/D coverage

determination are not eligible for a transition fill. Providers and

patients should consider switching to a formulary option in

advance of the next refill of the non-formulary medication. A

notification will be sent to the member regarding the need to

transition to a formulary medication. Members who are

experiencing a level of care change to or from a long term care

facility may be eligible for additional transition supplies after the

21


initial ninety (90) day period.

SECTION J – VISION AND DENTAL COVERAGE

Care Improvement Plus covers medical services for vision care as well as routine vision screening services

that are typically not covered by Medicare through Avesis. Care Improvement Plus offers routine eye exams

and a materials benefit to purchase frames, lenses or contacts. A list of contracted routine vision service

providers is located in the provider directory. Care Improvement Plus also offers a routine dental benefit,

which includes cleaning, exam, x-rays, and denture adjustments. Some plans offer comprehensive coverage as

well. Plans that cover dentures will require a referral. A list of contracted routine dental service providers

is located in the provider directory. This is a general description only. Please refer to the members’ Evidence

of Coverage and summary of benefits for benefit information. In the event of any conflict between the

Evidence of Coverage and this provider manual, the Evidence of Coverage shall prevail.

For assistance, members and providers may call Avesis at 1-800-828-9341 or visit their website,

www.avesis.com

Providers may also submit Dental and Vision Claims via paper to:

Avesis Third Party Administrators

P.O. Box 7777

Phoenix, AZ 85011

Attention: Claims Department

SECTION K– UTILIZATION AND CASE MANAGEMENT (UM)

Note: Authorization is based on a determination that services are medically necessary but is not a

guarantee of payment. Payment for services is subject to member eligibility and benefits limitations.

Case Management

Care Improvement Plus’ Case Management program is a customized/case-specific approach to

managing complex, resource-intensive cases, and provides education and counseling for our members.

Our Case Managers develop and implement proactive care plans designed to reduce or eliminate barriers

to care, especially those in the realm of psychosocial or socioeconomic barriers. Our goal is to maximize

participation with the chronic care management approaches proven to be successful in enhancing health

outcomes. Care Managers collaborate with Primary Care Physicians, discharge planners, social

workers, community outreach programs, family and caregivers. We encourage providers to make

referrals to our Case Management Department at 1-866-272-2945, Monday -Friday, 8:00 a.m. - 5:00

p.m. EST. To make referrals after hours, Providers can leave a message at 1-888-625-2204.

Chronic Care Management

Care Improvement Plus offers fully integrated chronic care management programs for high

prevalence, high cost conditions that encompass the full continuum of disease management

interventions from low-risk through high-risk. We take a comprehensive focus on care issues

surrounding diabetes, heart failure, chronic obstructive pulmonary disease and end stage renal

22


disease. The programs are proactive, criteria and risk-based with targeted clinical outcomes, focused

on meeting the health needs of members.

Utilization Review

Utilization Management staff will perform review services telephonically and/or onsite and review the

member’s admissions, services and continued stays for medical necessity and appropriateness of the level

of care. Utilization Management staff may also screen for quality and/or risk management issues,

participate in and coordinate the discharge planning process, and identify member’s post-discharge

needs. Care Improvement Plus’ Medical Director may, from time to time, ask to speak with a member’s

provider to discuss a plan of care or institutional stay.

Services Requiring Prior Authorization

Services requiring preauthorization can be found in Appendix C of this manual. In addition, certain Part

B Drugs provided in the physician’s office require an administrative authorization as noted on the

website, www.careimprovementplus.com, as well as in Appendix D of this manual.

SECTION L – QUALITY IMPROVEMENT (QI)

QI Program Overview

Care Improvement Plus’s Quality Improvement program aims to ensure that timely, efficient and quality

clinical care and services are rendered to our members. We participate in all CMS reporting and survey

requirements, including the annual HEDIS, NCQA, CAHPS, and HOS surveys. The program seeks to

demonstrate value and improve quality through the elimination of over, under, and misuse of services by:

• Measuring, assessing, and coordinating the quality of clinical care across Care Improvement Plus

delivery system.

• Promoting members’ health through health promotion, disease management, and condition

pathways.

• Assisting members to engage in healthy behaviors and encourage active self-management.

• Implementing interventions to improve the safety, quality, availability and accessibility of, and

member satisfaction with, care and services.

Care Improvement Plus has a long-term commitment to quality improvement initiatives that encompass the

full spectrum of care and services provided to our members. The Quality Improvement Program is dedicated

to fulfilling that commitment by working with the provider community to establish evidence-based clinical

guidelines and service standards. The guidelines and measures are used to develop tools for the purpose of

providing feedback to members and providers, to encourage improvement.

Care Improvement Plus will disclose to CMS as required, from time to time, information and data relating to

efforts and initiatives to achieve satisfactory health outcomes and other performance indicators.

Clinical Practice Guidelines

23


The Chief Medical Officer (CMO) and clinical leadership team are responsible for identifying appropriate

nationally recognized clinical guidelines for use in Care Improvement Plus clinical programs. All guidelines

are evidence-based so as to achieve optimum, high-quality health outcomes. The complete set of guidelines

is reviewed annually by Care Improvement Plus Medical Advisory Board comprised of community based

physicians and clinical experts.

Preventive Services Guidelines

When providers consistently offer preventive services, patients are able to maintain or improve their health,

while avoiding more costly and invasive medical procedures. With prevention, everybody wins. These

guidelines are evidence-based, offering only recommendations that are well supported in the medical

literature. Every year the guidelines are reviewed and updated as needed.

Health Plan Employer Data and Information Set (HEDIS)

Care Improvement Plus is required by CMS to submit data annually for HEDIS reporting that measures the

quality of clinical care provided to our members and health plan performance. At various times throughout

the year and especially during annual HEDIS preparation, Care Improvement Plus may request medical

files, including lab results, blood pressures and other clinical data which will be reviewed for adherence

with HEDIS clinical performance indicators. The HEDIS quality indicators may be viewed on the National

Committee for Quality Assurance website at: www.ncqa.org.

Medical Records

Care Improvement Plus requires all affiliated providers to abide by the medical record standards established

by Care Improvement Plus policy as well as state and federal regulations. These standards are based on the

requirements of NCQA, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and other

regulatory bodies. Care Improvement Plus’s Quality Improvement department routinely audits provider

documentation for medical record-keeping practices during the credentialing process and re-credentialing

process, when applicable.

Model of Care Training

As a Special Needs Plan, Care Improvement Plus must implement a model of care consistent with CMS

standards. Requirements include conducting initial and annual Model of Care training for employees,

contracted personnel and the provider network to keep everyone informed about the care management

structure and revisions made based on performance improvement activities. Providers satisfy this

requirement by completing the presentation provided on our learning management system (LMS) website

and passing a short test. Instructions to access the LMS are distributed annually.

SECTION M – MEMBER RIGHTS AND RESPONSIBILITIES

Member Rights

Care Improvement Plus members have the right to understand their health conditions and to

participate in health care decisions. To ensure that members attain the maximum benefits, we

encourage members to exercise their rights, including but not limited to:

24


• Receive considerate and respectful care, regardless of nationality, race, creed, color, age,

economic status, sex, lifestyle or severity of illness

• Be treated with respect and to have their dignity and personal privacy recognized

• Obtain complete and current information about their treatment alternatives without regard to cost

or benefit coverage

• Understand their health conditions and to participate in health care decisions

• Receive all information needed to give informed consent prior to the start of any procedure or

treatment including an explanation of procedures and any potential risks

• Be informed of the Care Improvement Plus affiliated providers available to deliver medical care

• Access to complete and current information about Care Improvement Plus, its services,

practitioners and providers

• Receive prompt treatment in an emergency

• Voice an opinion or to file a grievance or appeal

Member Responsibilities

Care Improvement Plus is committed to treating its members in a manner that respects their rights and

addresses their responsibility for cooperating with Care Improvement Plus staff and Care Improvement

Plus affiliated practitioners and providers. Member responsibilities include but are not limited to:

• Make a full and complete disclosure of their medical history and symptoms before and during the

course of treatment

• Follow the agreed upon plan and instruction from their health care provider

• Treat Care Improvement Plus staff, Care Improvement Plus affiliated providers and their

personnel, and other Care Improvement Plus members or patients respectfully and courteously

• Keep scheduled appointments or give adequate notice of delay or cancellation of appointments.

Notify their health care provider of any unexpected health changes. Understand and follow Care

Improvement Plus policies and procedures. Provide pertinent information to Care Improvement

Plus and its affiliated providers in order to render health care benefits and health care services.

Out of Area Services

Emergency and urgently needed services are covered regardless of whether a member is within or

outside the applicable Care Improvement Plus plan service area. Renal dialysis services are covered

when a member is out of the applicable Care Improvement Plus plan service area temporarily. Care

Improvement Plus also covers ambulance services for medical emergencies.

Additional coverage for members who permanently move from the applicable Care Improvement Plus

plan service area into a designated continuation area may be available. More information is available by

contacting Care Improvement Plus.

Primary Care Physician Selection

All members are encouraged to identify a Primary Care Physician (PCP), and Care Improvement Plus’s

Member Services department will assist with that process if needed. The process begins with a new

member’s enrollment application. A member may identify their PCP at enrollment into Care

Improvement Plus, or Members can also select a PCP by contacting Care Improvement Plus’s telephone

25


line, or going online at www.careimprovementplus.com.

Provider Terminations

While Care Improvement Plus does not require members to be assigned to a Primary Care Physician

(PCP), when known, we will notify affected members thirty (30) days before the effective date of a

Primary Care Physician termination. The notification will include information that will assist the

member in selecting a new PCP, if requested. It will also identify resources for additional physician

selection assistance. Reasons for terminations will remain confidential.

Grievance Procedures

The purpose of the member grievance process is to provide a mechanism by which a Care Improvement

Plus member who is dissatisfied with any aspect of the health plan may file a formal grievance and have

the complaint investigated. A grievance is any complaint other than an adverse decision with regard to a

service or claim (e.g., denied authorizations and denied claims are appeals, not grievances). Timeframes

for responding to grievances are as follows:

• Thirty (30) days for regular grievance, but may extend fourteen (14) calendar days if additional

information is required

• Twenty-four (24) hours for an expedited grievance

Member Appeals

Members or their authorized representatives may request in writing an appeal of a denied service, such as

a disapproved authorization or admission, or a denied claim. The member has sixty (60) days from the

date of the denial to file an appeal. Care Improvement Plus conducts these reconsiderations, or first level

appeals, according to Medicare Advantage and Medicare Part D requirements. There are standard

timeframes for medical appeals and claims appeals. There also are expedited appeals for medical

services. The timeframes are as follows:

• Standard medical reconsiderations: Up to thirty (30) calendar days, with a possible extension of

fourteen (14) calendar days

• Expedited reconsiderations: seventy-two (72) hours or less based on need, with a possible

extension of fourteen (14) calendar days

• Medical claim reconsiderations: No more than sixty (60) days

With the prescription drug benefit, there are also appeals, or “redeterminations.” Appeals related to the

drug benefit may occur when a formulary drug is denied, a member’s drug claim is denied, a request for

an exception to the tiering structure of the formulary is rejected, a request for an exception to a drug

utilization management tool is rejected, or a request for a non-formulary drug is denied (See Section I:

Pharmacy Services). As with medical services, there are expedited appeals in addition to the standard

timeframes:

• Standard drug redeterminations: Up to seven (7) days

• Expedited drug redeterminations: Seventy-two (72) hours or less

There are several sources of information on how an enrollee may file an appeal, such as in their

26


Evidence of Coverage, on the plan website, and on denial notices. Additional questions may be directed

to Provider Relations at 1-866-679-3119.

If Care Improvement Plus upholds Part C denial, the case is then sent to an external, Independent Review

Organization (Maximus). The enrollee may keep appealing through two (2) additional levels of federal

review and ultimately seek Judicial Review.

Providers are expected to participate in member appeals.

SECTION N – ADVANCED DIRECTIVE

Every competent adult and emancipated minor has the right to execute an Advance Directive. The

Patient Self-Determination Act requires that “a provider of services” must document in the individual’s

medical record whether or not the individual has executed an Advance Directive. Institutional

participating providers must demonstrate compliance with all applicable state and federal laws and

regulations. If a non-institutional provider chooses to discuss advance directives, they must document it

in their patient’s medical charts.

Care Improvement plus routinely provides information on Advance Directives to members upon

enrollment. Provider Relations may conduct provider staff education on Advance Directives along with

regular updates and reminders. Providers seeking information on Advance Directives and/or forms can

contact the Provider Relations Department at Care Improvement Plus.

SECTION O – HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA) RESPONSIBILITIES

To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability

and Accountability Act of 1996 (HIPAA), Public Law 104-191, included Administrative Simplification

provisions that required the United States Health and Human Services Department (HHS) to adopt

national standards for electronic health care transaction code sets, unique health identifiers, and security.

At the same time, Congress recognized that advances in electronic technology could erode the privacy of

health information. Consequently, Congress incorporated HIPAA provisions that mandated the adoption

of Federal privacy protections for individually identifiable health information.

HHS published a final Privacy Rule in December 2000, which was later modified in August 2002. This

Rule set national standards for the protection of individually identifiable health information by three

types of covered entities: health plans, health care clearinghouses, and health care providers who conduct

the standard health care transactions electronically. Compliance with the Privacy Rule was required as of

April 14, 2003 (April 14, 2004, for small health plans).

HHS published a final Security Rule in February 2003. This Rule sets national standards for protecting

the confidentiality, integrity, and availability of electronic protected health information. Compliance with

the Security Rule was required as of April 20, 2005 (April 20, 2006 for small health plans).

The Office of Civil Rights administers and enforces the Privacy Rule and Security Rule.

27


Other HIPAA Administrative Simplification Rules are administered and enforced by the Centers for

Medicare & Medicaid Services (CMS), and include:

Electronic Transactions and Code Sets Standards

Employer Identifier Standard

National Provider Identifier Standard

The Enforcement Rule provides standards for the enforcement of all the Administrative Simplification

Rules.

All of the HIPAA Administrative Simplification Rules are located at 45 CFR Parts 160, 162, and 164.

HIPAA Privacy and Security Standards and information can be found at:

https://www.cms.gov/HIPAAGenInfo/ and Office of Civil Rights (OCR) at:

http://www.hhs.gov/ocr/hipaa/

Care Improvement Plus has processes, policies and procedures to comply with the Health Insurance

Portability and Accountability Act of 1996 (HIPAA).

Privacy Rule

The Privacy Rule regulates who has access to a Member’s/Patient’s protected health information (PHI),

whether in written, verbal or electronic form. In addition, this regulation affords individuals the right to

keep their PHI confidential, and in some instances, from being disclosed.

The Office for Civil Rights enforces the HIPAA Privacy and Security Rules, which sets national

standards for the security of electronic protected health information; and the confidentiality provisions of

the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events

and improve patient safety.

In compliance with the Privacy Regulations, Care Improvement Plus (CIP) has provided each CIP

Member with a Notice of Privacy Practices, which describes how Care Improvement Plus can use and

disclose a Member’s health records, and how the Member can get access to the information. In addition,

the Notice of Privacy Practice informs the Member of their health care privacy rights, and explains how

these rights can be exercised.

A copy of Care Improvement Plus’s Notice of Privacy Practices is included as Attachment F.

As a Provider, if you have any questions about Care Improvement Plus’s privacy practices, please contact

the Compliance and HIPAA Department at 1-800-210-3312.

Members should be directed to Care Improvement Plus Member Services with any questions about the

Privacy Regulations at 1-800-204-1002.

Security Rule

28


The HIPAA Security Rule establishes national standards to protect individuals’ electronic protected

health information (ePHI) that is created, received, used or maintained by Care Improvement Plus. The

Security Rule requires appropriate administrative, physical and technical safeguards to ensure

confidentiality, integrity, and security of electronic protected health information.

The Security Rule is located at 45 CFR Part 160 and Subparts A and C of Part 164.

Breach Notification Rule

Interim final breach notification regulations, issued October 2009, found at 45 CFR 164.400, et seq

(Subpart D – Notification in Case of Breach of Unsecured Protected Health Information), implement

section 13402 of the Health Information Technology for Economic and Clinical Health (HITECH) Act

by requiring Care Improvement Plus and their business associates to provide notification following a

breach of unsecured protected health information. Care Improvement Plus will provide notice of any

breach of unsecured protected health information to affected individuals, the Secretary and, in certain

circumstances, the news media.

Similar breach notification provisions implemented and enforced by the Federal Trade Commission

(FTC), apply to vendors of personal health records and their third party service providers, pursuant to

section 13407 of the HITECH Act.

Care Improvement Plus has additional obligations to notify CMS of security incidents. Those obligations

are in addition to the HITECH requirements and include additional incidents not reportable under

HITECH.

Transactions and Code Sets Regulations

Transactions are activities involving the transfer of health care information for specific purposes. Under

HIPAA, if Care Improvement Plus or a health care provider engages in one of the identified transactions,

they must comply with the standard for it, which includes using a standard code set to identify diagnoses

and procedures. The Standards for Electronic Transactions and Code Sets, published August 17, 2000

and since modified, adopted standards for several transactions, including claims and encounter

information, payment and remittance advice, and claims status. Any health care provider that conducts a

standard transaction also must comply with the Privacy Rule.

HIPAA Required Code Sets

The HIPAA Code Sets regulation requires that all codes utilized in electronic transactions are

standardized, utilizing national standard coding.

Only national standard codes can be used for electronic claims and/or authorization services.

Code Sets

The HIPAA final rule also named standards for code sets used to encode data that is sent in the HIPAA-

29


named transactions. Code sets are identified as “medical” or “non-medical”. Medical code sets include

the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9), Current

Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS). “Nonmedical”

code sets are administrative code sets and include ZIP code, state abbreviations, and

administrative billing code sets (e.g. place of service).

HIPAA Designated Medical Code Sets

Standard Code Set Name Code Set Functionality Maintained or Established

by:

International Classification of

Diseases, 9 th revision, Clinical

Modification (ICD-9-CM)

Volumes 1 & 2

International Classification of

Diseases, 9 th revision, Clinical

Modification (ICD-9-CM)

Volume 3

Current Procedure Terminology

Diagnosis National Center for Health

Statistics, Centers for Disease

Control (CDC) within the

Department of Health and

Human Services (HHS)

Inpatient hospital procedures Center for Medicare and

Medicaid Services (CMS)

Physician services/other health American Medical Association

(CPT) codes

services

Health Care Common Procedure Physician services/other health Center for Medicare and

Coding System (HCPCS) services and medical supplies,

orthotics and durable medical

equipment

Medicaid Services (CMS)

Code of Dental Procedures and

Nomenclature (CDT)

Dental Services American Dental Association

National Drug Codes (NDC) Drugs/biologics FDA

1. HCPCS can be purchased from the American Medical Association at 1-800-621-8335. For more

information and resources from the American Medical Association go to: http://www.amaassn.org/

2. To access the complete NDC code set go to:

http://www.fda.gov/Drugs/InformationOnDrugs/ucm142438.htm

International Classification of Diseases, 10 th revision, Clinical Modification ICD-10-CM is the new

diagnosis coding system that was developed as a replacement for ICD-9-CM, Volume 1 & 2.

International Classification of Diseases, 10 th revision, Procedure Coding System ICD-10-PCS is the new

procedure coding system that was developed as a replacement for ICD-9-CM, volume 3. The

compliance date for implementing and adopting ICD-10-CM for diagnosis and ICD-10-PCS for

inpatient hospital procedures is October 1, 2013.

HIPAA Electronic Transactions

There are eight electronic standardized transactions that are mandated by HIPAA regulations:

30


Transaction Transaction Number Utilized by CIP

Health claims or equivalent

encounter information

837 Professional, 837 Institutional Y

Enrollment and disenrollment in a

health plan

834 N

Health plan eligibility solicitations 270 (Request)/ 271 (Response) N

and response

Alternative

Method

Health care payment and

remittance advice

835 Y

Health plan premium payment 820 N

Health claim status 276 (Request)/277 (Response) N

Alternative

Method

Coordination of benefits 837 Professional and Institutional Claims Y

Referral certification and

authorization

278 N

On January 16, 2009, the Department of Health and Human Services (HHS) announced that the updated

version of the HIPAA standards will be required for use starting on January 1, 2012. The updated version

of these standards are referred to as 5010. The compliance date for implementing and adopting 5010

electronic administrative transactions is January 1, 2012. For more information and resources from

the American Medical Association go to: http://www.ama-assn.org/

Though it is standard operating process, Care Improvement Plus does not currently utilize all standard

transaction sets. Functionality equivalent to that which is offered by these transaction sets is made

available to Care Improvement Plus Members and Providers such as online tools.

Care Improvement Plus currently offers an alternative through the online web tool using Care

Improvement Plus’s secure Provider Portal for the following transactions:

ASC X12 270 Health Plan Eligibility Solicitations

ASC X12 271 Response

ASC X12 276 Health Claim Status Request

ASC X12 277 Health Claim Status Response

National Provider Identifier (NPI)

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA)

Administrative Simplification Standard. The NPI is a unique identification number for covered health

care providers. Covered health care providers and all health plans and health care clearinghouses must

use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10position,

intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry

other information about health care providers, such as the state in which they live or their medical

specialty. The NPI must be used in lieu of legacy provider identifiers in all electronic HIPAA standards

transactions.

31


As outlined in the Federal Regulation, covered providers must also share their NPI with other providers,

health plans, clearinghouses, and any entity that may need it for billing purposes.

All Care Improvement Plus providers must attest a valid NPI upon application for network participation.

For any questions about NPI, please contact Provider Relations at: 1-866-679-3119.

SECTION P – LEGAL NOTICES

Subrogation

If we make any payment to you or on your behalf for covered services, we are entitled to be fully

subrogated to any and all rights you have against any person, entity, or insurer that may be responsible

for payment of medical expenses and/or benefits related to your injury, illness, or condition. We are

entitled to exercise the same rights of subrogation and recovery that are accorded to the Medicare

Program under the Medicare Secondary Payer rules.

Once we have made a payment for covered services, we shall have a lien on the proceeds of any

judgment, settlement, or other award or recovery you receive, including but not limited to the following:

1. Any award, settlement, benefits, or other amounts paid under any workers’ compensation law or

award;

2. Any and all payments made directly by or on behalf of a third-party tortfeasor or person, entity, or

insurer responsible for indemnifying the third-party tortfeasor;

3. Any arbitration awards, payments, settlements, structured settlements, or other benefits or

amounts paid under an uninsured or underinsured motorist coverage policy;

4. Any other payments designated, earmarked, or otherwise intended to be paid to you as

compensation, restitution, or remuneration for your injury, illness, or condition suffered as a result

of the negligence or liability of a third party.

You agree to cooperate with us and any of our representatives and to take any actions or steps necessary

to secure our lien, including but not limited to:

1. Responding to requests for information about any accidents or injuries;

2. Responding to our requests for information and providing any relevant information that we have

requested; and

3. Participating in all phases of any legal action we commence in order to protect our rights,

including, but not limited to, participating in discovery, attending depositions, and appearing and

testifying at trial.

In addition, you agree not to do anything to prejudice our rights, including, but not limited to, assigning

any rights or causes of action that you may have against any person or entity relating to your injury,

illness, or condition without our prior express written consent. Your failure to cooperate shall be deemed

a breach of your obligations, and we may institute a legal action against you to protect our rights.

Reimbursement

32


We are also entitled to be fully reimbursed for any and all benefit payments we make to you or on your

behalf that are the responsibility of any person, organization, or insurer. Our right of reimbursement is

separate and apart from our subrogation right, and is limited only by the amount of actual benefits paid

under our plan. You must immediately pay to us any amounts you recover by judgment, settlement,

award, recovery, or otherwise from any liable third party, his or her insurer, to the extent that we paid out

or provided benefits for your injury, illness, or condition during your enrollment in our plan.

Antisubrogation rules do not apply

Our subrogation and reimbursement rights shall have first priority, to be paid before any of your other

claims are paid. Our subrogation and reimbursement rights will not be affected, reduced, or eliminated by

the "made whole" doctrine or any other equitable doctrine. We are not obligated to pursue subrogation or

reimbursement either for our own benefit or on your behalf. Our rights under Medicare law and this

Evidence of Coverage shall not be affected, reduced, or eliminated by our failure to intervene in any legal

action you commence relating to your injury, illness, or condition.

33


APPENDIX A – Sample Care Improvement Plus Member Identification Cards

Care Improvement Plus Chronic Special Needs Plans (CSNP)

Care Improvement Plus Medicare Advantage Plans (MA-PD)

Care Improvement Plus Dual Special Needs Plans (DSNP)

34


APPENDIX B – Electronic Claims (EDI) Information

35


APPENDIX C – Utilization Management Authorization Rules

36


APPENDIX C – Utilization Management Authorization Rules

37


APPENDIX C – Utilization Management Authorization Rules

38


APPENDIX C – Utilization Management Authorization Rules

39


APPENDIX C – Utilization Management Authorization Rules

40


APPENDIX C – Utilization Management Authorization Rules

41


APPENDIX C – Utilization Management Authorization Rules

42


APPENDIX C – Utilization Management Authorization Rules

43


APPENDIX C – Utilization Management Authorization Rules

44


APPENDIX C – Utilization Management Authorization Rules

45


APPENDIX C – Utilization Management Authorization Rules

46


APPENDIX C – Utilization Management Authorization Rules

47


APPENDIX C – Utilization Management Authorization Rules

48


APPENDIX C – Utilization Management Authorization Rules

49


APPENDIX C – Utilization Management Authorization Rules

50


APPENDIX C – Utilization Management Authorization Rules

51


APPENDIX C – Utilization Management Authorization Rules

52


APPENDIX C – Utilization Management Authorization Rules

53


APPENDIX D – Part B Drug Authorization Rules

Prior Authorizations for Medications Given in the Doctor’s Office

Care Improvement Plus requires you (or your physician) to get prior authorization for certain drugs that

are given in the doctor’s office. This means that you will need to get approval for certain medications

before you can receive your medication at the doctor’s office. If you don’t get approval, Care

Improvement Plus may not cover the drug. You or your doctor will need to call 1-800-204-1002 (TTY:

711) to receive authorization for your medication. The following drugs need prior authorization in

2012:

Y0072_OE12_5617

File and Use 08222011

IVIG products (Immune Globulin)

Botox (Botulinum Toxin A)

Rituxan (Rituximab)

Remicade (Infliximab)

Intron A (Interferon Alfa-2b)

Ventavis (Iloprost Inhalation Solution )

Flolan (Epoprostenol)

Veletri (Epoprostenol)

Tyvaso (Treprostinil) Inhalation Solution)

Zemaira (Alpha1-proteinase inhibitor)

Remodulin (Treprostinil)

Provenge (Sipuleucel-T)

54


APPENDIX E – Sample Explanation of Payment (EOP)

55


Notice of Privacy

Practices

Effective Date July 25, 2011

THIS NOTICE DESCRIBES HOW MEDICAL

AND FINANCIAL INFORMATION ABOUT YOU

MAY BE USED AND DISCLOSED AND HOW

YOU CAN GET ACCESS TO THIS

INFORMATION. PLEASE REVIEW IT

CAREFULLY.

Our legal duty

This notice describes our privacy practices,

which include how we may use, disclose (share

or give out), collect, handle and protect our

members’ protected health information. Care

Improvement Plus is required by State and/or

Federal law to maintain the privacy of your

protected health information. We also are

required to give you this notice about our privacy

practices, our legal duties and your rights

concerning your protected health information. We

must follow the privacy practices that are

described in this notice while it is in effect.

We reserve the right to change our privacy

practices and the terms of this notice at any time,

as long as law permits the changes. We reserve

the right to make the changes in our privacy

practices and the new terms of our notice

effective for all protected health information that

we maintain, including protected health

information we created or received before we

made the changes. If we make a material change

in our practices, we will distribute a revised notice

to you within 60 days by direct mail or email if

requested and post it on our website at:

http://careimprovementplus.com/PrivacyPolicy.as

px

You may request a copy of our notice at any

time. For more information about our privacy

practices, or for additional copies of this notice,

please contact us using the information listed at

the end of this notice.

Primary uses and disclosures of protected

health information:

APPENDIX F – Notice of Privacy Practices

Care Improvement Plus primarily uses and

discloses your health information for purposes of

health care operations and payment.

■ Payment: We may use, disclose, and/or

obtain your protected health information for

purposes of payment. For example, we might

use, disclose, and/or obtain your protected health

information to pay claims for services provided to

you by doctors, hospitals, pharmacies and others

that are covered by your health plan. We also

may use your information to determine your

eligibility for benefits, coordinate benefits with

other payers, examine medical necessity, obtain

premiums and issue explanations of benefits.

■ Health care operations: We may use,

disclose, and/or obtain your protected health

information for purposes of health care

operations. For example, we may use, disclose,

and/or obtain your protected health information to

determine our premiums for your health plan,

conduct quality assessment and improvement

activities, engage in care coordination or case

management, and to manage our business.

■ Treatment: We may disclose your protected

health care information to your doctors, hospitals

and other health care providers for their

provision, coordination or management of your

health care and related services – for example,

for coordinating your health care or for referring

you to another provider for care.

■ Business Associates: In connection with our

payment, treatment and health care operations

activities, we contract with individuals and entities

(called “Business Associates”) to perform various

functions on our behalf or to provide certain types

of services (such as member service support,

utilization management, or pharmacy benefit

management). To perform these functions or to

provide the services, our Business Associates

will receive, create, maintain, use or disclose

protected health information, but only after the

Business Associates agree in writing to contract

terms designed to appropriately safeguard your

information.

Other possible uses and disclosures of

Effective Date: July 25, 2011 Notice of Privacy Practices Page 1


protected health information: The following is a

description of other possible ways in which we

may (and are permitted to) use, disclose and/or

obtain your protected health information:

■ Disclosures to the Secretary of the U.S.

Department of Health and Human Services:

We are required to disclose your protected health

information to the Secretary of the U.S.

Department of Health and Human Services

(DHHS) when the Secretary is investigating or

determining our compliance with the federal

Privacy Regulations.

■ To family and friends: In addition, we may

disclose health care information to a family

member, a friend or other persons who are

involved in your care or payment for your care,

when you are not present or are incapacitated, if,

in the exercise of professional judgment, we

believe the disclosure is in your best interest.

For example, we may disclose information to a

family member who is trying to help you

understand our payment for services. However,

as noted below, you may request a restriction on

disclosures of health information to your family

members or other persons identified by you. If

you are present, we will give you the opportunity

to object before we disclose your health care

information to these persons.

■ Health oversight activities: We might

disclose your protected health information to a

health oversight agency for activities authorized

by law, such as: audits, investigations,

inspections, licensure or disciplinary actions, or

civil, administrative or criminal proceedings or

actions. Oversight agencies seeking this

information include government agencies that

oversee: (i) the health care system, (ii)

government benefit programs, (iii) other

government regulatory programs and (iv)

compliance with civil rights laws.

■ Abuse or neglect: We may disclose your

protected health information to appropriate

authorities if we reasonably believe that you

might be a possible victim of abuse, neglect,

domestic violence or other crimes.

APPENDIX F – Notice of Privacy Practices

■ To prevent a serious threat to health or

safety: Consistent with certain federal and state

laws, we may disclose your protected health

information if we believe that the disclosure is

necessary to prevent or lessen a serious and

imminent threat to the health or safety of a

person or the public.

■ Research: We may disclose your protected

health information to researchers when an

institutional review board or privacy board has:

(1) reviewed the research proposal and

established protocols to ensure the privacy of the

information and (2) approved the research.

■ Required by law: We may use, disclose,

and/or obtain your protected health information

when we are required to do so by law. For

example, we must disclose your protected health

information to DHHS upon their request for

purposes of determining whether we are in

compliance with federal privacy laws.

■ Legal process and proceedings: We may

use, disclose, and/or obtain your protected health

information in response to a court or

administrative order, subpoena, discovery

request or other lawful process, under certain

circumstances. Under limited circumstances,

such as a court order, warrant or grand jury

subpoena, we may disclose your protected

health information to law enforcement officials.

■ Law enforcement: We may disclose to a law

enforcement official limited protected health

information of a suspect, fugitive, material

witness, crime victim or missing person. We

might disclose protected health information

where necessary to assist law enforcement

officials to capture an individual who has

admitted to participation in a crime or has

escaped from lawful custody.

■ Treatment Alternatives, Reminders and

Other Health Related Benefits. We may use

your health care information to provide you with

appointment reminders, information about

treatment alternatives, or other health related

benefits provided by Care Improvement Plus.

Effective Date: July 25, 2011 Notice of Privacy Practices Page 1


■ Other uses and disclosures of your

protected health information: Other uses and

disclosures of your protected health information

that are not described above will be made only

with your written authorization. If you provide us

with such an authorization, you may revoke the

authorization in writing, and this revocation will

be effective for future uses and disclosures of

protected health information. However, the

revocation will not be effective for information

that we already have used or disclosed in

reliance on your authorization or if the

authorization is to permit disclosure of PHI to an

insurance company, as a condition of obtaining

coverage, to the extent that other laws allow the

insurer to contest claims coverage.

State law limitations on the disclosure of

health care information: In instances in which

state law is more protective of your privacy rights

than Federal law; Care Improvement Plus

complies with State Law. For example, certain

states place additional limitations on the use and

disclosure of health care information concerning

HIV, substance abuse, and mental health. Care

Improvement Plus restricts its uses and

disclosures to those allowed under state law and

this privacy notice.

Individual rights:

■ Access: You have the right to look at, or get

copies of, the protected health information

contained in a designated record set, with limited

exceptions. You may request that we provide

copies in a format other than photocopies. We

will use the format you request unless we cannot

reasonably do so. You may request access by

sending a letter to the Care Improvement Plus

address at the end of this notice. If you request

copies, we might charge you a reasonable fee for

each page and postage if you want the copies

mailed to you. If you request an alternative

format, we might charge a cost-based fee for

providing your protected health information in

that format. If you prefer, we will prepare a

summary or an explanation of your protected

health information, but we might charge a fee to

do so.

APPENDIX F – Notice of Privacy Practices

We may deny your request to inspect and copy

your protected health information in certain

limited circumstances. Under certain conditions,

our denial will not be reviewable. If this event

occurs, we will inform you in our denial that the

decision is not reviewable. If you are denied

access to your information and the denial is

subject to review, you may request that the

denial be reviewed. A licensed health care

professional chosen by us will review your

request and the denial. The person performing

this review will not be the same person who

denied your initial request.

■ Disclosure accounting: You have a right to

request and receive an accounting of our

disclosures of your medical information that you

did not specifically authorize, except when those

disclosures are made for treatment, payment or

health care operations, or the law otherwise

restricts the accounting. If you request this list

more than once in a 12-month period, we may

charge you a reasonable, cost-based fee for

responding to these additional requests.

You may request an accounting by submitting

your request in writing using the Care

Improvement Plus address listed at the end of

this notice. Tell us the time period that you want

to know about. Your request may be for

disclosures made up to six years before the date

of your request.

■ Restriction requests: You have the right to

request that we place additional restrictions on

our use or disclosure of your protected health

information. We are not required to agree to

these additional restrictions, but if we do, we will

abide by our agreement (except in an

emergency). Any agreement that we might make

to a request for additional restrictions must be in

writing and signed by a person authorized to

make such an agreement on our behalf. We will

not be liable for uses and disclosures made

outside of the requested restriction unless our

agreement to restrict is in writing. We are

permitted to end our agreement to the requested

restriction by notifying you in writing. Federal law

allows you to restrict disclosures to your family

members, other relatives, or close personal

Effective Date: July 25, 2011 Notice of Privacy Practices Page 1


friends or other persons identified by you, of

health information directly relevant to such

person’s involvement with your care or payment

related to your care.

You may request a restriction by submitting your

request in writing to us using the Care

Improvement Plus address listed at the end of

this notice. In your request tell us: (1) the

information of which you want to limit our use and

disclosure and (2) how you want to limit our use

and/or disclosure of the information.

■ Confidential communication: If you believe

that a disclosure of all or part of your protected

health information may endanger you, you have

the right to request that we communicate with

you in confidence about your protected health

information. This means that you may request

that we send you information by alternative

means, or to an alternate location. As part of your

request, we ask that you specify the alternative

means or alternate location, and how payment

issues (premiums and claims) will be handled.

You may request a confidential communication

by writing to us using the information listed at the

end of this notice.

■ Amendment: You have the right to request

that we amend your protected health information.

Your request must be in writing, and it must

explain why the information should be amended.

We may deny your request if we did not create

the information you want amended or for certain

other reasons. If we deny your request, we will

provide you with a written explanation. You may

respond with a statement of disagreement to be

appended to the information you wanted

amended. If we accept your request to amend

the information, we will make reasonable efforts

to inform others, including people you name, of

the amendment and to include the changes in

any future disclosures of that information.

� Breach. You have the right to be notified

in the event that we (or one of our Business

Associates) discovers a breach of your

unsecured protected health information that

poses a significant risk of harm to you. Notice of

any such breach will be made in accordance with

Federal requirements.

APPENDIX F – Notice of Privacy Practices

■ Electronic notice: Even if you agree to

receive this notice on our Web site or by

electronic mail (e-mail), you are entitled to

receive a paper copy as well. Please contact us

using the information listed at the end of this

notice to obtain this notice in written form. If the

e-mail transmission has failed, and Care

Improvement Plus is aware of the failure, then we

will provide a paper copy of the notice to you.

Collection of Personal Financial Information

We may collect personal financial information

about you from many sources, including:

■ Information you provide on enrollment

applications or other forms, such as your name,

address, social security number, salary, age and

gender.

■ Information about your relationship with Care

Improvement Plus, our affiliates and others, such

as your policy coverage, premiums and claims

payment history.

■ Information as described above that we obtain

from any of our affiliates.

■ Information we receive about you from other

sources such as your employer, your provider,

your broker and other third parties.

■ Information we receive about you when you

log on to our Web site. We have the capability

through the use of “cookies” to track certain

information, such as finding out if members have

previously visited the Care Improvement Plus

Web site or to track the amount of time visitors

spend on the Web site. These cookies do not

collect personally identifiable information and we

do not combine information collected through

cookies with other personal financial information

to determine the identity of visitors to its Web

site. We will not disclose cookies to third parties.

How your information is used

We use the information we collect about you in

connection with underwriting or administration of

Effective Date: July 25, 2011 Notice of Privacy Practices Page 1


an insurance policy or claim or for other purposes

allowed by law. At no time do we disclose your

financial information to anyone outside of Care

Improvement Plus unless we have proper

authorization from you or we are permitted or

required to do so by law. We maintain physical,

electronic and procedural safeguards in

accordance with federal and state standards that

protect your information.

In addition, we limit access to your financial

information to those Care Improvement Plus

employees, business partners, providers, benefit

plan administrators, brokers, consultants and

agents who need to know this information to

conduct Care Improvement Plus business or to

provide products or services to you.

Disclosure of your financial information

In order to protect your privacy, third parties that

are either affiliated or nonaffiliated with Care

Improvement Plus are also subject to strict

privacy laws. Affiliated entities are companies

that are part of the Care Improvement Plus

corporate family and may include, third party

administrators, health insurers, long term care

insurers and insurance agencies. In some

situations related to our insurance transactions

involving you, we will disclose your personal

financial information to a nonaffiliated third party

that helps us to provide services to or for you.

When we disclose information to these third

parties, we require them to agree to protect your

financial information and to use it only for its

intended purpose, and to comply with all relevant

laws.

Changes in our privacy policy

Care Improvement Plus periodically reviews its

policies and reserves the right to change them. If

we change the substance of our privacy policy,

we will continue our commitment to keep your

financial information secure — it is our highest

priority. Even if you are no longer a Care

Improvement Plus customer, our privacy policy

will continue to apply to your records.

Information on Care Improvement Plus

privacy practices. You may request a copy of

APPENDIX F – Notice of Privacy Practices

our notices at any time. If you want more

information about our privacy practices, if you

would like additional copies of this notice, or have

questions or concerns, please call the Member

Services number on your ID card or contact the

Care Improvement Plus Privacy Officer using the

information below.

Filing a complaint: If you are concerned that

we might have violated your privacy rights, or you

disagree with a decision we made about your

individual rights, you may use the contact

information listed at the end of this notice to

complain to us or you may complain to the U.S.

Department of Health and Human Services

(DHHS). Complaints made to the Secretary must

be in writing (whether paper or electronic), must

identify Care Improvement Plus as the entity

about which the complaint is being made, must

describe the situation that gives rise to the

complaint, and must be filed within 180 days of

the date when the complainant knew, or should

have known, of the event that gives rise to the

complaint. We will provide you with the contact

information for DHHS upon request.

We support your right to protect the privacy of

your protected health and financial information.

We will not retaliate in any way if you choose to

file a complaint with us or with DHHS.

Contact Information:

Care Improvement Plus

Compliance and HIPAA Department

351 W. Camden Street, Suite 100

Baltimore, Maryland 21201

Telephone: 1-800-210-3312

Fax Number: 1-866-447-7868

Effective Date: July 25, 2011 Notice of Privacy Practices Page 1


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October, 2011

Filing Claims with Care Improvement Plus & Arkansas State Medicaid for Dual

Advantage Plan Members

Care Improvement Plus is contracted with Arkansas Medicaid to coordinate benefits for members enrolled in our Dual

Advantage plan. The Dual Advantage plan is a Dual Special Needs (D-SNP) plan designed for beneficiaries with full

Medicaid (QMB or QMB+) and Medicare benefits.

Benefits are coordinated with providers when services are billed to Care Improvement Plus for reimbursement. At the time of

processing, providers are reimbursed for the services rendered under the benefit plan less any cost share that would normally be

due from the member. Providers should send their claims to Care Improvement Plus at:

Care Improvement Plus, PO Box 488, Linthicum, MD 21090-0488, Attn: Claims Department Or file electronically with

EDI: Payor ID 77082

If a patient has both Medicare & Medicaid

coverage, how do I file the claim?

Bill Care Improvement Plus first. Then, once Care Improvement Plus pays part of the

claim, bill the balance to Medicaid as a "crossover" claim through PES software. Or

you can submit a paper crossover invoice (sample on the right, from the Provider

Assistance Center) to:

CLAIMS

HP Enterprise Services

PO BOX 8034

Little Rock, AR 72203

For provider enrollment in the Arkansas Medicaid electronic billing system go to:

https://www.medicaid.state.ar.us/InternetSolution/provider/ enroll/enroll.aspx.

NOTE: In Arkansas, claims for full dual members in the Silver Rx plan and the

Dual Advantage plan follow this process.

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance, call

Provider Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com Claims questions can be emailed

to Provider@careimprovementplus.com


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October, 2011

Filing Claims with Care Improvement Plus & Georgia State Medicaid for Dual

Advantage Plan Members

Care Improvement Plus is contracted with the Georgia Department of Community Health (DCH) to coordinate benefits for

members enrolled in our Dual Advantage plan. The Dual Advantage plan is a Dual Special Needs (D-SNP) plan designed for

beneficiaries with full Medicaid (QMB or QMB+) and Medicare benefits.

Benefits are coordinated with providers when services are billed to Care Improvement Plus for reimbursement. At the time of

processing, providers are reimbursed for the services rendered under the benefit plan less any cost share that would normally be

due from the member. Providers should send their claims to Care Improvement Plus at:

Care Improvement Plus

PO Box 488

Linthicum, MD 21090-0488

Attn: Claims Department

or File Electronically using EDI:

Payor ID 77082

If a patient has both Medicare & Medicaid coverage, how do I file the claim?

Bill Care Improvement Plus first. Then, once Care Improvement Plus pays part of the claim, bill the balance to DCH as a COB

claim with information showing how Care Improvement Plus processed the claim. DCH will coordinate the payment, if any,

with the Medicaid maximum allowable amount for the service. If Care Improvement Plus paid more than the maximum

allowable amount, no additional payment will be made by DCH. If Care Improvement Plus paid less, in most cases DCH will

pay the difference. Paper claims are billed by completing the appropriate form and attaching the required documentation and

send to:

CMS 1500 Claims HPES PO BOX 105202 Tucker, Georgia 30085-5202

UB04 Claims HPES PO BOX 105204 Tucker, Georgia 30085-5204

Although paper claims are accepted, DCH encourages providers to submit claims electronically through the Provider Electronic

Solution (PES). The Provider Enrollment Unit can assist providers with enrolling in this tool at

www.mmis.georgia.gov .

Note: In Georgia, claims for full dual members (QMB or QMB+) in the Silver Rx plan and

the Dual Advantage plan follow this process.

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance, call Provider

Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com

Claims questions can be e-mailed to Provider@careimprovementplus.com


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October, 2011

Filing Claims with Care Improvement Plus & Missouri State Medicaid for Dual

Advantage Plan Members

Care Improvement Plus is contracted with Missouri HealthNet Division (MHD) Medicaid to coordinate benefits for members

enrolled in our Dual Advantage plan. The Dual Advantage plan is a Dual Special Needs (D-SNP) plan designed for

beneficiaries with full Medicaid (QMB & QMB+) and Medicare benefits.

Benefits are coordinated with providers when

services are billed to Care Improvement Plus for

reimbursement. At the time of processing,

providers are reimbursed for the services rendered

under the benefit plan less any cost share that

would normally be due from the member.

MHD will pay one-hundred percent (100%) of the Care Improvement Plus cost sharing* for MO HealthNet participants who

are QMB or QMB+ participants. (*Includes Silver Rx & Dual Advantage plans)

Eligibility can be verified by either of the following methods:

• � Access the “Verify Participant Eligibility” link at

www.emomed.com, or

• Access the Interactive Voice Response (IVR) at 1-573-635-

8908. After entering the participant’s ID number and date of

service, you will hear eligibility information.

Under the eligibility response from emomed, a participant with Care

Improvement Plus coverage will be indicated by an eligibility/benefit

segment with an Insurance Type "HN-Health Maintenance Organization

(HMO) Medicare Risk".

Claims should be sent to Care Improvement Plus at:

PO Box 488, Attn: Claims Department, Linthicum, MD 21090-

0488 or file electronically with EDI: payor 77082

Providers should send their Medicaid claims to MHD at:

http://www.dss.mo.gov/mhd/providers/pdf/bulletin30-

53_2008may05.pdf

Care Improvement Plus does not forward electronic crossover claims to

MHD. Therefore, providers must submit crossover claims through the

MHD online internet billing system at: www.emomed.com.

For non-QMB MO HealthNet participants enrolled in a Medicare

Advantage/Part C Plan, MHD will process claims in accordance with the

established MHD coordination of benefits policy. The policy can be viewed in

Section 5.1.A of the MO HealthNet Provider Manual at

http://manuals.momed.com.

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance, call Provider

Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com

Claims questions can be e-mailed to Provider@careimprovementplus.com


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October, 2011

Filing Claims with Care Improvement Plus & South Carolina State Medicaid for

Dual Advantage Plan Members

Care Improvement Plus is contracted with the South Carolina Department of Health and Human Services (SCDHHS) to

coordinate benefits for members enrolled in our Dual Advantage plan. The Dual Advantage plan is a Dual Special Needs (D-

SNP) plan designed for beneficiaries with full Medicaid (QMB or QMB+) and Medicare benefits.

Benefits are coordinated with providers when services are billed to Care Improvement Plus for reimbursement. At the time of

processing, providers are reimbursed for the services rendered under the benefit plan less any cost share that would normally be

due from the member. Providers should send their claims to Care Improvement Plus at:

Care Improvement Plus

PO Box 488

Linthicum, MD 21090-0488

Attn: Claims Department

or

File Electronically using EDI:

Payor ID 77082

If a patient has both Medicare & Medicaid coverage, how do I file the claim?

Bill Care Improvement Plus first. Then, once Care Improvement Plus pays part of the claim, bill the balance to Medicaid

through the SCDHHS web portal. Or you can submit a paper claim to SCDHHS at:

Medicaid Claims receipt, PO Box 1412, Columbia, SC 29202-1412

SCDHHS provides a free web tool, which allows providers to submit claims (UB and CMS-1500), query Medicaid eligibility,

check claim status, and offers providers electronic access to their remittance packages. To learn more about this tool and how to

access it, visit the SC Medicaid provider website at: www.scmedicaidprovider.org or contact the SC Medicaid EDI Support

Center via the SCDHHA Provider Service Center at 1-888-289-0709

Note: In South Carolina, claims for full dual members (QMB or QMB+) in the Silver Rx plan and

the Dual Advantage plan follow this process.

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance, call Provider

Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com Claims questions can be e-mailed to

Provider@careimprovementplus.com


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October 2011

Filing Claims with Care Improvement Plus & Texas

State Medicaid for Dual Advantage Plan Members

Care Improvement Plus is contracted with Texas Health and Human Services to coordinate benefits

for members enrolled in our Dual Advantage plan. The Dual Advantage plan is a Dual Special

Needs (D-SNP) plan designed for beneficiaries with full Medicaid (QMB, QMB+ or SLMB+) and

Medicare benefits.

Benefits are coordinated with providers when services are billed to Care Improvement Plus for

reimbursement. At the time of processing, providers are reimbursed for the services rendered under

the benefit plan and for any cost share that would normally be due from the member. Providers

should send their claims to Care Improvement Plus at:

Care Improvement Plus

P.O. Box 488

Linthicum, MD 21090-0488

Attention: Claims Department

Or file electronically with EDI Payor ID 77082

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance,

call Provider Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com

Claims questions can be e-mailed to Provider@careimprovementplus.com


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October, 2011

Filing Claims with Care Improvement Plus & Iowa State Medicaid for Dual

Advantage Plan Members

Care Improvement Plus is contracted with the Iowa Department of Human Services Medicaid Program (IME) to coordinate

benefits for members enrolled in our Dual Advantage plan. The Dual Advantage plan is a Dual Special Needs (D-SNP) plan

designed for beneficiaries with full Medicaid (QMB or QMB+) and Medicare benefits.

Benefits are coordinated with providers when services are billed to Care Improvement Plus for reimbursement. At the time of

processing, providers are reimbursed for the services rendered under the benefit plan less any cost share that would normally be

due from the member. Providers should send their claims to Care Improvement Plus at:

Care Improvement Plus

PO Box 488

Linthicum, MD 21090-0488

Attn: Claims Department

or

File Electronically using EDI:

Payor ID 77082

If a patient has both Medicare & Medicaid coverage, how do I file the claim?

Bill Care Improvement Plus first. Then, once Care Improvement Plus pays part of the claim, bill the balance to IME as a

“crossover” claim with information showing how Care Improvement Plus processed the claim. Care Improvement Plus does

not forward electronic crossover claims to IME. Paper claims are processed by completing the appropriate crossover claim form

found at http://www.ime.state.ia.us/Providers/claims.html and attaching the required documentation and send to:

Medicaid Claims, PO Box 150001, Des Moines, IA 50315

Although paper claims are accepted, IME encourages providers to submit claims electronically through the Total Onboarding

System (TOB) by EDISS at www.edissweb.com/med/.

Note: In Iowa, claims for full dual members (QMB or QMB+) in the Silver Rx plan and

the Dual Advantage plan follow this process.

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance, call Provider

Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com Claims questions can

be e-mailed to Provider@careimprovementplus.com


APPENDIX G – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

October, 2011

Filing Claims with Care Improvement Plus & Indiana State Medicaid for Dual

Advantage Plan Members

Care Improvement Plus is contracted with Indiana Medicaid to coordinate benefits for members enrolled in our Dual

Advantage plan. The Dual Advantage plan is a Dual Special Needs (D-SNP) plan designed for Beneficiaries with full Medicaid

(QMB or QMB+) and Medicare benefits.

Benefits are coordinated with providers when services are billed to Care Improvement Plus for reimbursement. At the time of

processing, providers are reimbursed for the services rendered under the benefit plan less any cost share that would normally be

due from the member. Providers should send their claims to Care Improvement Plus at:

Care Improvement Plus

PO Box 488

Linthicum, MD 21090-0488

Attn: Claims Department

If a patient has both Medicare & Medicaid coverage, how do I file the claim?

Bill Care Improvement Plus first. Then, once Care Improvement Plus pays part of the claim, bill the balance to Indiana

Medicaid claim through the Indiana Web Interchange portal at:

https://interchange.indianamedicaid.com/Administrative/logon.aspx

Or you can submit a paper claim to Indiana Medicaid at:

HP Institutional /UB-04 Inpatient Hospital, Home Health, Outpatient, and Nursing Home Claims

P.O. Box 7271 Indianapolis, IN 46207-7271

HP CMS-1500 Claims, single and attachment claims

P.O. Box 7269 Indianapolis, IN 46207-7269

or

File Electronically using EDI:

Payor ID 77082

Indiana Medicaid provides a free web tool, which allows providers to submit claims, query Medicaid eligibility, check claim

status, and offers providers electronic access to their remittance packages. To learn more about this tool and how to access it,

visit the Indiana Medicaid provider website at: http://provider.indianamedicaid.com/provider-home.aspx.

Note: In Indiana, claims for full dual members (QMB or QMB+) in the Silver Rx plan and

the Dual Advantage plan follow this process.

For additional information about joining our network, member eligibility inquiries, or any other issues that require assistance, call Provider

Relations at: 1-866-679-3119 or email us at providerrelations@careimprovementplus.com

Claims questions can be e-mailed to Provider@careimprovementplus.com


APPENDIX H – Filing Claims with CIP & State Medicaid for Dual Adv Plan Members

Maximum Expected Waiting Times:

• Appointment/Waiting Time - Usual and customary not to exceed thirty (30) calendar days for regular

appointments and forty eight (48) hours for urgent care

• In-Office Waiting Time - Members with appointments shall not routinely be made to wait longer than

one (1) hour

• Emergency Care - Emergency care must be provided as the situation dictates. In general, emergency

care must be given in accordance to the time frame dictated by the nature of the emergency, at the

nearest available facility, twenty-four (24) hours a day, seven (7) days a week, regardless of contracts.

All emergency care must be provided on an immediate basis at the nearest facility available, regardless

of contracting arrangements

• Urgent Care - Triage and appropriate treatment shall be provided on the same or next day

• Non-Urgent Problems and Routine Primary Care - Appointments for non-urgent care and routine

primary care shall be provided within three (3) weeks of participant request

• Specialty Care - Referral appointments to specialists, except for specialists providing mental health and

substance abuse services (e.g., specialty physician services, hospice care, home health care and certain

rehabilitation services, etc.), shall not exceed thirty (30) calendar days for routine care or forty eight

(48) hours for urgent care

• General Optometry Services - Plan Providers must have a system in place to document compliance

with the following appointment scheduling time frames listed below. PHP monitors compliance with

appointment/waiting time standards as part of the required surveys and monitoring requirements

• Transport Time - Transport time will be the usual and customary, not to exceed one (1) hour, except in

areas where community access standards and documentation will apply

• Pharmacy Services - Plan Providers must have a system in place to document compliance with the

following appointment scheduling time frames listed below. PHP monitors compliance with

appointment/waiting time standards as part of the required surveys and monitoring requirements

• Lab and X-Ray Services - Plan Providers must have a system in place to document compliance with

appointment scheduling time frames. PHP monitors compliance with appointment/waiting time

standards as part of required surveys and monitoring requirements

• All Other Services - All other services not specified here shall meet the usual and customary standards

for the community


APPENDIX I – Chronic Condition Disease State Verification Form


Address

351 W. Camden Street, Suite 100

Baltimore, MD 21201

Provider Relations

1-866-679-3119

providerrelations@careimprovementplus.com

Visit us on the web www.careimprovementplus.com

2012

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