Care Improvement Plus! This provider manual

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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: 30
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 12: and data may be submitted to CMS. B
Page 13 and 14: • Obtain authorizations as approp
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: Other HIPAA Administrative Simplifi
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 69 and 70: APPENDIX H - Filing Claims with CIP
Page 71: Address 351 W. Camden Street, Suite

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