Provider Manual
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Medicaid Managed Care
- Product Overview
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Benefit Information
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Clinical Trials and Related Routine ServicesDental and Oral SurgeryHome Health Care ServicesNever EventNon-covered ServicesNurse On-Call and Telemonitoring ProgramsPersonal Care ServicesSkilled Nursing FacilitySterilization - Hysterectomy CoverageSterilization - Tubal Ligation or Vasectomy CoverageTransportation ServicesUrgent Care & Emergency RoomVision care
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Care Management
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Additional ProgramsChronic Care ManagementHealth AssessmentNational Committee for Quality AssurancePotentially Preventable Readmission programPrenatal Care Coordination ServicesPreventive Service GuidelinesPrograms for membersQuality Improvement - Utilization Management Program Overview Security Health Plan ProtocolsWellness and Health Promotion
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyBilling claims for dates that span a change of enrollmentClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsOutput ReportsProvider Appeal and Grievance PolicyProvider Validation for Claims ProcessingProvider Remittance Advice StatementReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessReference outside Laboratory Billing ProtocolSubrogationSurgery InformationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- ForwardHealth
- Fraud, Waste and Abuse
- HealthCheck
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Provider Directory
- Provider resources for Program Integrity Training
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Rights and Responsibilities
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Access StandardsDHS Subcontract requirementsImproper billing of Medicaid Managed Care membersMedical PoliciesPrimary Care - Specialty Care Provider RoleProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider Response Requirements for Member ComplaintsProvider System Outages and or Material BreachProviders' Expectations of Security Health PlanSecurity Health Plans Expectations of Providers
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Utilization Management
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Continuity and Care CoordinationeviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh end imaging - radiation servicesHome HealthHospital admissions - Pre-certificationHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNavihealth-Skilled Nursing Facility CareNorthwood DMENursing Facility Care/Skilled Nursing Facility CarePhysical, Speech and Occupational Therapy - OutpatientPre-certification Notification and Concurrent Review GuidePrior authorizationPrior Authorization for Non-affiliated ProvidersProvider Appeal and Grievance PolicySecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSleep managementSterilization: Hysterectomy CoverageTechnology AssessmentUtilization management general informationUtilization management for behavior healthUtilization management for timeliness standards
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Family Health Center
- Program Overview
- Benefit Information
- Care Management
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Claims Processing and Policies and Procedures
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Anatomical Modifier Requirement PolicyClaims Coding ResourceClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessLimitation of LiabilityModifier InformationNational Drug Code RequirementsOutput ReportsProvider Appeal and Grievance PolicyProvider Remittance Advice StatementReference Outside Laboratory Billing ProtocolReimbursement Recovery ProcessSubrogationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB 04 Instructions and Sample Claim FormUnlisted CodesWorkers Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Pharmacy
- Rights and Responsibilities
- Utilization Management
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Group & Direct Pay
- Product Overview
- Benefit Information
- Care Management
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityModifier InformationNational Drug Code RequirementsNew Code PricingNon-covered Services and Experimental/InvestigativeOffice Infusion ProtocolOutput ReportsPrior Authorization Required for Office Based Procedures in ASC or Hospital Outpatient SettingProvider Appeal and Grievance PolicyProvider Reimbursement NotesProvider Remittance Advice StatementReference (Outside) Laboratory Billing ProtocolReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessSubrogationSurgery InformationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 InstructionsUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- HCC - Risk Adjustment/Government Programs
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
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Pharmacy
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Claims ProcessingDrug FormularyFormulary Exception RequestsGeneral ExclusionsGeneric SubstitutionOffice/Medical Setting Administered Medications that require prior authorization Over-the-Counter Medication CoveragePharmacy Utilization ManagementPrior AuthorizationSpecialty pharmacyStep TherapyTobacco Cessation Coverage
- Provider Directory
- Rights and Responsibilities
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Utilization Management
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Continuity and Care CoordinationDurable Medical Equipment and Home Respiratory EquipmenteviCoreHigh End Imaging - Cardiac studies and elective heart catheterizationHigh End Imaging - Radiation ServicesHome HealthHome IV Drug TherapiesHospice ProtocolsHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNorthwood DMEOutpatient Therapy Treatment ConcurrentPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider appeal and grievance policyRadiation Oncology ServicesSecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization management general informationUtilization management for Behavior HealthUtilization management for Timeliness Standards
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Medicare Advantage
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Product Overview D-SNP
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Ally Rx D-SNP BasicsAlly Rx D-SNP Model of CareBilling Ally Rx D-SNP MembersDiscussion of Disenrollment from Medicare AdvantageEncounter Data PolicyMedicare Advantage Part D Data SubmissionsMedicare Advantage Part D Reporting RequirementsMedicare Advantage Reporting RequirementsRecipient of Federal Funds PolicyWhat are Medicare Advantage Plans
- Product Overview HMO and D-SNP
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Benefit Information
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Acupuncture for chronic low back painContinuity and Coordination of CareDental BenefitsEmergency and Non-emergency TransportationEmergency and Urgently Needed Care CoverageHearing Services and Hearing AidsHome Health Care ServicesHome INR MonitoringMacular Degeneration Eye InjectionsPlan OverviewsPreventive Care CoverageRenal DialysisSkilled Nursing FacilityVision and Hardware Coverage
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Care Management
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Additional ProgramsAdvance Directive PolicyChronic Care ManagementCoverage DeterminationEnd Stage Renal Disease (ESRD) Care CoordinationHealth Risk AssessmentHospice Care CoordinationNational Committee for Quality AssuranceNotice of Medicare NoncoverageOutpatient Observation Frequently Asked QuestionsPreventive Service GuidelinesPrograms for MembersQuality Improvement/Utilization Management Program OverviewSecurity Health Plan ProtocolsTwo Midnight RuleWellness and Health Promotion
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Claims Processing Policies and Procedures
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Anatomical Modifier Requirement PolicyBilling and ReportingClaims Coding ResourcesClaims Payment CalendarClean Claim and InterestCMS 1500 InstructionsCoding Quick ReferenceCoordination of BenefitsCorrection Adjustment RequestData Security and ConfidentialityDrug Wastage PoliciesElectronic ClaimsElectronic File Submission ProcessGenetic and Molecular Lab TestingLimitation of LiabilityNational Drug Code RequirementsModifier InformationOffice Infusion ProtocolOutput ReportsPayment IssuesProvider Appeal and Grievance PolicyProvider Remittance Advice StatementRate Letters from CMS for CAH, RHC & Swing BedsReference (Outside) Laboratory Billing ProtocolReimbursement for Inappropriate Discharge and ReadmissionReimbursement Recovery ProcessSkilled Nursing Facility (SNF) and Consolidated Billing SubrogationTesting ProceduresTimely Filing for Claim SubmissionTrading Partner for Electronic DataTransaction TermsTransmissionUB-04 Instructions and Sample Claim FormUnlisted CodesWorkers' Compensation
- Clinical Practice Guidelines
- Contact Information
- Documentation Requirements
- Fraud, Waste and Abuse
- HCC - Risk Adjustment
- Health Equity and Cultural Sensitivity Awareness
- Important Disclosures
- Member Information
- Pharmacy
- Primary Care Provider
- Provider Directory
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Rights and Responsibilities
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Access StandardsMedical policiesProhibition of Interference with Health Care Professionals Advice to Medicare Advantage MembersProvider ContractingProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider Response Requirements for Member ComplaintsProvider System Outages and or Material BreachProviders' Expectations of Security Health PlanSecurity Health Plan's Expectations of ProvidersSkilled Nursing Facility Denial of Medicare/Medicaid Payment
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Utilization Management
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Authorization of Inpatient CareContinuity and Care CoordinationeviCoreHigh End Imaging - Cardiac imaging and elective heart catheterizationHigh End Imaging - Radiation ServicesHome HealthHome IV Drug TherapiesHospice ProtocolsHospital Inpatient Utilization ReviewHospital Urgent/Observation AdmissionInappropriate Discharge and ReadmissionInpatient Acute Rehabilitation/Long Term Acute CareMedical NecessityMusculoskeletal proceduresNavihealth-Skilled Nursing Facility CareNorthwood DMEPharmaceuticals - Specialty Medications (Magellan)Physical, Speech and Occupational Therapy - OutpatientPre-Certification Notification and Concurrent Review GuidePrior authorizationsProvider appeal and grievance policyRadiation Oncology ServicesSecond OpinionServices related to oral appliances - for treatment of obstructive sleep apneaSkilled Nursing Facility AdmissionSleep managementTechnology AssessmentUtilization management general informationUtilization Management for behavior healthUtilization Management for timeliness standards
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Product Overview D-SNP
HealthCheck Exam Documentation
Last Updated on January 24, 2019
There are several components to a HealthCheck exam. Each of the following components should be documented in the patient’s medical record when a HealthCheck exam is billed.
HealthCheck checkup includes:
- Health and developmental history (including anticipatory guidance).
- Unclothed physical examination.
- Vision screening
- Hearing screening
- Dental screening and a referral to a dentist beginning at age one.
- Immunizations appropriate for age (shots)
- Blood and urine lab tests (including blood lead level testing when appropriate for age)
Click here for the ForwardHealth Portal for HealthCheck forms. Scroll down to “HealthCheck” and click on More Information. Click on HealthCheck Forms and select the age specific form needed.
Health and Development History
Identification of any special risk factors or prior conditions/treatments pertinent to future care of the patient. This history should include:
- A nutritional assessment: for instance, number of times breastfeeding/day, and fluoride in water
- Health education/anticipatory guidance: including age-appropriate preventive health education and an explanation of screening findings such as nutrition, safety, normal stages of growth and development.
- Developmental behavior assessment: observed behavior and developmental milestones compared to age-specific norms.
Unclothed Physical Exam and Growth Assessment
Review of body systems, indicating normal or abnormal findings.
- Blood pressure: must be taken on all patients beginning at age 3.
- Growth assessment: height, weight – including weight to length percentile – and head circumference are plotted on growth charts. Head circumference must be completed up to age 2.
- Sexual development: especially on patients who have reached puberty.
Vision Assessment
Use of vision charts must be attempted starting at age 4 and done annually. If attempted but unable to complete due to age, this must be documented. The general guideline is start on the 20/25 line; if unable to read, go up one level. If the child misses one letter on a line, he/she passes. If the child misses two or more in one row, he/she fails. Record vision at the previous level.
If the child wears glasses, vision assessment is not necessary. Document that the child wears glasses, and when he/she was last seen by an optometrist/ophthalmologist for an eye exam. If last optometrist/ ophthalmologist visit is more than one year ago, or if concerns are expressed, reassess vision.
Hearing Assessment
- Infancy and childhood: This should include otoscopic exam and/or tympanometric measurement for detection of chronic/recurrent otitis media.
- Puretone audiometric screening must be attempted on all children ages 3 – 8 years, and then every four years to age 16, also, if children are older than 8 years and have excessive exposure to noise, delayed speech/language development, or it is their first HealthCheck. Document if screening is attempted but unable to complete due to age. (General guideline: test at the 20dB level at the following frequencies: 1000, 2000, 4000, 500. If unable to hear at 20dB level, go to the 25dB level.)
If the child wears a hearing aid, a hearing assessment is not necessary. Document that the child wears a hearing aid and when he/she was last seen by an audiologist for an exam. If the last audiologist visit is more than one year ago, or if concerns are expressed, reassess hearing.