Care Improvement Plus! This provider manual

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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. 7
• 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 8
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: qualify for programs that they may
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 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
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■ Other uses and disclosures of y
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an insurance policy or claim or for
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APPENDIX G - Filing Claims with CIP
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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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