Care Improvement Plus! This provider manual

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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 11
• 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. 12
Page 1 and 2: 2012 Care Improvement Plus Provider
Page 3 and 4: Pharmacy Appeals…….............
Page 5 and 6: SECTION A - INTRODUCTION Welcome We
Page 7 and 8: qualify for programs that they may
Page 9 and 10: • Providers must render service a
Page 11: and data may be submitted to CMS. B
Page 15 and 16: mailing may highlight the providers
Page 17 and 18: Little Rock, AR 72203 http://www.ar
Page 19 and 20: Care Improvement Plus maintains a c
Page 21 and 22: (Clinical and/or coverage determina
Page 23 and 24: initial ninety (90) day period. SEC
Page 25 and 26: The Chief Medical Officer (CMO) and
Page 27 and 28: line, or going online at www.careim
Page 29 and 30: Other HIPAA Administrative Simplifi
Page 31 and 32: named transactions. Code sets are i
Page 33 and 34: As outlined in the Federal Regulati
Page 35 and 36: APPENDIX A - Sample Care Improvemen
Page 37 and 38: APPENDIX C - Utilization Management
Page 55 and 56: APPENDIX D - Part B Drug Authorizat
Page 57 and 58: Notice of Privacy Practices Effecti
Page 59 and 60: ■ Other uses and disclosures of y
Page 61 and 62: an insurance policy or claim or for
Page 63 and 64:
APPENDIX G - Filing Claims with CIP
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
APPENDIX H - Filing Claims with CIP
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Address 351 W. Camden Street, Suite
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