Provider Manual

• Medicaid Managed Care
  • Product Overview
    Overview
  • Benefit Information
    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
  • Care Management
    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
  • Claims Processing Policies and Procedures
    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
    Clinical Practice Guidelines
  • Contact Information
    Contact information
  • Documentation Requirements
    Telehealth Documentation RequirementsDocumentation of CareMedical Record Documentation
  • ForwardHealth
    ForwardHealth
  • Fraud, Waste and Abuse
    Compliance - Fraud, Waste and Abuse
  • HealthCheck
    BillingClinical PCP HealthCheck ReportsCodingExam at Community Based AgenciesExam DocumentationExam Including Prenatal ExamOutreachServicesVerification Card
  • Health Equity and Cultural Sensitivity Awareness
    Accessible Patient Care: Supporting Individuals with DisabilitiesCultural competency and language access awarenessCulturally Responsive Hair Care in Patient CareLanguage ResourcesProvider News Archive
  • Important Disclosures
    Confidentiality StatementNon-discrimination StatementProvider performance dataSuspension of Payment
  • Member Information
    Member HandbookRights and Responsibilities
  • Provider Directory
    Provider Directory
  • Provider resources for Program Integrity Training
    Provider resources for Program Integrity Training
  • Rights and Responsibilities
    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
  • Utilization Management
    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
• Family Health Center
  • Program Overview
    Program Overview
  • Benefit Information
    Ambulance TransportationDental and Oral SurgeryEmergency RoomInpatient, Outpatient and Ambulatory Surgery CenterMental Health and Substance Use DisorderNon-covered servicesPrescription Medications/PharmacySterilizationTobacco Cessation
  • Care Management
    Additional ProgramsPreventive Service GuidelinesQuality Improvement - Utilization Management Program OverviewWellness and Health Promotion
  • Claims Processing and Policies and Procedures
    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
    Clinical Practice Guidelines
  • Contact Information
    Contact Information
  • Documentation Requirements
    Telehealth Documentation RequirementsDocumentation of CareMedical Record Documentation
  • Fraud, Waste and Abuse
    Compliance - Fraud, Waste and Abuse
  • Health Equity and Cultural Sensitivity Awareness
    Accessible Patient Care: Supporting Individuals with DisabilitiesCulturally Responsive Hair Care in Patient CareCultural competency and language access awarenessLanguage ResourcesProvider News Archive
  • Important Disclosures
    Confidentiality StatementNon-discrimination StatementProvider performance data
  • Member Information
    Member information
  • Pharmacy
    Claims ProcessingDrug FormularyFormulary ExceptionGeneral ExclusionsGeneric SubstitutionNetwork PharmaciesPrior AuthorizationStep TherapyTobacco Cessation CoverageUtilization Management
  • Rights and Responsibilities
    Access StandardsFamily Health Center Expectations of ProvidersMedical PoliciesProvider Credentialing ProcessProvider Reporting of Member ComplaintsProvider System Outages and or Material BreachProviders' Expectation of Family Health Center
  • Utilization Management
    High end imaging and radiation servicesHome HealthHospital Admissions - Pre-certificationInpatient Acute Rehabilitation/Long term acute careMedical NecessityNorthwood DMEPrior authorizationsProvider appeal and grievance policySecond OpinionTechnology Assessment
• Group & Direct Pay
  • Product Overview
    Product Overview
  • Benefit Information
    Dental Oral SurgeryEmergency/Urgent Care ServicesHearing AidsNever EventsNon-covered Services and Experimental/InvestigativePreventive benefitsTemporomandibular (TMD) DisorderVision Care
  • Care Management
    Additional ProgramsChronic Care ManagementNational Committee for Quality AssurancePreventive Service GuidelinesPrograms for MembersQuality Improvement - Utilization Management Program OverviewSecurity Health Plan ProtocolsTransition Care ManagementWellness and Health Promotion
  • Claims Processing Policies and Procedures
    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
    Clinical Practice Guidelines
  • Contact Information
    Contact Information
  • Documentation Requirements
    Documentation of CareMedical Record DocumentationTelehealth Documentation Requirements
  • Fraud, Waste and Abuse
    Compliance - Fraud, Waste and Abuse
  • HCC - Risk Adjustment/Government Programs
    HCC - Hierarchical Condition Category Coding
  • Health Equity and Cultural Sensitivity Awareness
    Accessible Patient Care: Supporting Individuals with DisabilitiesCultural competency and language access awarenessCulturally Responsive Hair Care in Patient CareLanguage ResourcesProvider News Archive
  • Important Disclosures
    Confidentiality StatementNondiscrimination StatementProvider performance dataSuspension of Payment
  • Member Information
    ID Card SampleMember HandbookRights and Responsibilities
  • Pharmacy
    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
    Provider Directory
  • Rights and Responsibilities
    Access StandardsMedical PoliciesProvider 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 Providers
  • Utilization Management
    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
• Medicare Advantage
  • Product Overview D-SNP
    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
    Ally Rx D-SNP Model of CareDiscussion of Disenrollment from Medicare Advantage PlansEncounter Data PolicyMedicare Advantage Part D Data SubmissionsMedicare Advantage Part D Reporting RequirementsMedicare Advantage Reporting RequirementsRecipient of Federal Funds Policy
  • Benefit Information
    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
  • Care Management
    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
  • Claims Processing Policies and Procedures
    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
    Clinical Practice GuidelinesMental Health Medication Management
  • Contact Information
    Contact Information
  • Documentation Requirements
    Documentation of CareMedical Record DocumentationTelehealth Documentation Requirements
  • Fraud, Waste and Abuse
    Compliance - Fraud, Waste and Abuse
  • HCC - Risk Adjustment
    HCC - Hierarchical Condition Category Coding
  • Health Equity and Cultural Sensitivity Awareness
    Accessible Patient Care: Supporting Individuals with DisabilitiesCultural competency and language access awarenessCulturally Responsive Hair Care in Patient CareLanguage ResourcesProvider News Archive
  • Important Disclosures
    Confidentiality StatementNondiscrimination StatementProvider performance dataSuspension of Payment
  • Member Information
    Appeal/GrievanceCustomer Service RepresentativesEligibility and Enrollment Evidence of Coverage/Member HandbookID Card SampleMember Rights and Responsibilities
  • Pharmacy
    Appeal ProcessCoverage DeterminationException ProcessFormularyPrior Authorization - Medical PharmacyPrior Authorization - Pharmacy
  • Primary Care Provider
    Anti-kickback StatuteDepression in Primary Care GuidelinesModel of CareThe False Claims Act
  • Provider Directory
    Provider Directory
  • Rights and Responsibilities
    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
  • Utilization Management
    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