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
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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
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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:
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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
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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:
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• 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
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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.
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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
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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:
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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