GA_CAID_Provider_Manual_ENG_2019_R.pdf - 2019 GEORGIA MEDICAID PROVIDER MANUAL WellCare proudly serves the Georgia Medicaid and PeachCare for Kids\u00ae

GA_CAID_Provider_Manual_ENG_2019_R.pdf - 2019 GEORGIA...

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Unformatted text preview: 2019 GEORGIA MEDICAID PROVIDER MANUAL WellCare proudly serves the Georgia Medicaid and PeachCare for Kids® members enrolled in the Georgia Families® program and women enrolled in the Planning for Healthy Babies® program. Partners in Quality Care Partners in Quality Care Dear Provider Partner: Quality Highlights At WellCare we value everything you do to deliver quality care to our members – your patients. Through our combined efforts we ensure that our members continue to trust us to help them in their quest to lead longer and more satisfying lives. Section 3 • Responsibilities of all Providers • Access Standards • Member Rights and Responsibilities We’re committed to quality. That pledge demands the highest standards of care and service. We are constantly investing in people and programs, innovating, and working hard to remove barriers to care. Section 4 • Quality Improvement WellCare’s dedication to quality means that we are also committed to supporting you. We want to make sure that you have the tools you need to succeed. We will work with you and your staff to identify members with outstanding care gaps, and we will reward you for closing those gaps. Section 5 • Prior Authorization • Criteria for Utilization Management Decisions • Access to Care and Disease Management Programs The enclosed provider manual is your guide to working with us. We hope you find it a useful resource, and the areas highlighted to the right are sections of the manual that directly address our mutual goal of delivering quality care. Section 8 • Appeals and Grievances Thank you again for being a trusted WellCare provider partner! Sincerely, Dr. Clarence Davis Medical Director – Georgia, WellCare Health Plans Quality care is a team effort. Thank you for playing a starring role! Section 9 • Cultural Competency Program and Plan Section 11 • Continuity and Coordination of Care Between Medical and Behavioral Providers Section 12 • Preferred Drug List Table of Contents Table of Contents................................................................................................1 Table of Revisions ..............................................................................................6 Section 1: Overview ............................................................................................7 About WellCare .......................................................................................................7 Purpose of this Handbook .......................................................................................7 DCH Fiscal Agent ....................................................................................................8 WellCare’s Medicaid Programs................................................................................9 Telemedicine .........................................................................................................18 Planning for Healthy Babies® .................................................................................19 Family Planning Covered Services ........................................................................20 Provider Services ..................................................................................................24 Interactive Voice Response (IVR) System .............................................................24 Website Resources ...............................................................................................25 Section 2: Georgia Health Information Network (GaHIN) .............................27 Section 3: Provider and Member Administrative Guidelines ........................30 Provider Administrative Guidelines ............................................................................30 Overview ...............................................................................................................30 Excluded or Prohibited Services ............................................................................32 Responsibilities of All Providers.............................................................................32 Members with Special Healthcare Needs ..............................................................33 Access Standards..................................................................................................34 Responsibilities of Primary Care Physicians (PCP) ...............................................35 Role of the Medical Home .....................................................................................36 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) .......................38 Primary Care Offices .............................................................................................39 Closing of Physician Panel ....................................................................................39 Covering Physicians/Providers ..............................................................................40 Termination of a Member.......................................................................................40 Abuse, Neglect, or Exploitation..............................................................................41 Substance Abuse Screening and Depression........................................................41 Smoking Cessation................................................................................................41 Adult Health Screening ..........................................................................................41 Member Administrative Guidelines ............................................................................41 Overview ...............................................................................................................41 Member Handbook ................................................................................................42 Enrollment .............................................................................................................42 Member Identification Cards ..................................................................................42 Eligibility Verification..............................................................................................42 Member Rights and Responsibilities......................................................................44 Assignment of Primary Care Physician..................................................................46 Changing Primary Care Physicians .......................................................................46 Women’s Health Specialists ..................................................................................46 Hearing-Impaired, Interpreter and Sign Language Services ..................................46 Section 4: Quality Improvement ......................................................................47 WellCare Health Plans, Inc. Georgia Medicaid Provider Handbook Provider Services: 1-866-231-1821 Effective: January 23, 2019 Page 1 of 168 Overview ...............................................................................................................47 Provider Participation in the Quality Improvement Program...................................48 Value-Based Purchasing Program.........................................................................48 Member Experience ..............................................................................................49 EPSDT Screening Periodicity Schedule ................................................................49 Clinical Practice Guidelines (CPGs).......................................................................61 HEDIS®..................................................................................................................62 Medical Record Documentation.............................................................................63 Web Resources .....................................................................................................67 Patient Safety Plan....................................................................................................67 Overview ...............................................................................................................67 Quality of Care Issues ...........................................................................................67 Incident Reporting .................................................................................................68 Hospital Patient Safety Program............................................................................69 Hospital Program Overview ...................................................................................70 Hospital Patient Safety Program Requirements .....................................................70 Program Compliance.............................................................................................70 Section 5: Utilization Management (UM), Care Management (CM) and Disease Management (DM) ............................................................................................. 72 Utilization Management .............................................................................................72 Overview ...............................................................................................................72 Medically Necessary Services ...............................................................................72 Criteria for UM Decisions.......................................................................................73 Utilization Management Process ...........................................................................74 Service Authorization Decisions ............................................................................79 Services Requiring No Authorization .....................................................................81 Peer-to-Peer Reconsideration of Adverse Determination.......................................81 WellCare Proposed Actions ...................................................................................81 Second Medical Opinion........................................................................................82 Individuals with Special Healthcare Needs ............................................................82 Emergency/Urgent Care and Post-Stabilization Services ......................................83 Continuity of Care..................................................................................................83 Transition of Care ..................................................................................................84 Limits to Abortion, Sterilization, and Hysterectomy Coverage ................................85 Delegated Entities .................................................................................................87 Care Management Program ......................................................................................88 Overview ...............................................................................................................88 Transitional Care Management and Discharge Care Coordination ........................89 Disease Management Program .................................................................................90 Overview ...............................................................................................................90 Candidates for Disease Management....................................................................91 Access to Care and Disease Management Programs............................................91 Section 6: Claims ..............................................................................................92 Overview ...............................................................................................................92 Updated Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Process ................................................................................................................. 92 Timely Claims Submission.....................................................................................92 Claims Submission Requirements .........................................................................93 WellCare Health Plans, Inc. Georgia Medicaid Provider Handbook Provider Services: 1-866-231-1821 Effective: January 23, 2019 Page 2 of 168 Claims Processing.................................................................................................95 Coordination of Benefits (COB) .............................................................................96 Encounters Data....................................................................................................97 Balance Billing .......................................................................................................98 Provider-Preventable Conditions (PPCs)...............................................................99 Hold Harmless Dual-Eligible Members ................................................................100 Cost Share ..........................................................................................................100 Claims Payment Disputes....................................................................................100 Corrected Claims or Voided Claims .....................................................................101 Reimbursement ...................................................................................................102 Ground Ambulance Transportation ......................................................................102 Surgical Payments...............................................................................................103 Multiple Procedures.............................................................................................103 Assistant Surgeon ...............................................................................................103 Co-Surgeon .........................................................................................................104 Modifier ...............................................................................................................104 Allied Health Providers ........................................................................................104 Overpayment Recovery .......................................................................................104 Benefits during Disaster and Catastrophic Events ...............................................105 Section 7: Credentialing .................................................................................106 Overview .............................................................................................................106 Practitioner Rights ...............................................................................................107 Baseline Criteria ..................................................................................................107 Liability Insurance................................................................................................108 Site Inspection Evaluation (SIE) ..........................................................................108 Covering Physicians ............................................................................................109 Allied Health Professionals ..................................................................................109 Ancillary Healthcare Delivery Organizations ........................................................109 Re-Credentialing..................................................................................................110 Updated Documentation ......................................................................................110 Office of Inspector General Medicare/Medicaid Sanctions Report .......................110 Sanction Reports Pertaining to Licensure, Hospital Privileges or.........................110 Other Professional Credentials ............................................................................110 Participating Provider Appeal through the Dispute Resolution Peer Review Process ............................................................................................................................ 110 Delegated Entities ...............................................................................................112 Section 8: Appeals and Grievances ..............................................................113 Complaint/Grievance/Administrative Review/Administrative Law Hearing/PeachCare for Kids® Committee Review .................................................................................... 113 Provider Complaint Process ....................................................................................113 Member Grievance Process ....................................................................................113 Member Grievance Submission...........................................................................114 Member Grievance Resolution ............................................................................114 Member Appeal Process .........................................................................................115 Member Overview ...............................................................................................118 Provider Overview ...............................................................................................119 Continuation of Benefits while the Member Appeal, Administrative Law Hearing/PeachCare for Kids® Committee Review are Pending ................................ 121 WellCare Health Plans, Inc. Georgia Medicaid Provider Handbook Provider Services: 1-866-231-1821 Effective: January 23, 2019 Page 3 of 168 Administrative Law Hearing/PeachCare for Kids® Formal Appeals Committee Review ................................................................................................................................ 122 Member Right to Hearing (Non-PeachCare for Kids® Members)..............................122 Provider Right to Hearing ....................................................................................123 Section 9: WellCare Compliance Program ...................................................125 Overview .............................................................................................................125 Provider Education and Outreach........................................................................126 Code of Conduct and Business Ethics.....................................................................126 Overview .............................................................................................................126 Fraud, Waste and Abuse (FWA)..........................................................................127 Confidentiality of Member Information and Release of Records...........................128 Disclosure of Information .....................................................................................129 Cultural Competency Program and Plan..................................................................129 Cultural Competency Survey ...............................................................................132 Section 10: Delegated Entities.......................................................................133 Overview .............................................................................................................133 Delegation Oversight Process .............................................................................133 Section 11: Behavioral Health........................................................................134 Overview .............................................................................................................134 Prior Authorization for Services ...........................................................
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