Provider Manual

TABLE OF CONTENTS

Section I: Introduction

• Welcome
• Background, History and Goals of the HealthChoices – SW Program
• Program Overview
• Contact Us

Section II: Getting Started

• Referral Process
• Verifying Member Eligibility

Section III: Utilization Management

• Authorization Requirements
• Confidentiality
• Drug and Alcohol Services
• Emergency & Urgent Care Authorization Procedures Updated
• Grievance Process
• Group Therapy
• Information Required for Service Authorization (Documentation Guidelines for Inpatient, Documentation Guidelines for Continued Stay Reviews, Documentation Guidelines for Discharge)
• Inpatient and Alternative Levels of Care
• Medical Necessity Criteria
• Peer Review Process
• Prevention, Education and Outreach
• Priority Populations
• Provider Covered Services Grid – HIPAA Compliant
• Purpose and Scope
• Records Retention
• Requests for Authorizations/Retro-authorizations
• Special Procedures (Electro-Convulsive Therapy, Psychological Testing and Methadone Services)
• Utilization Management Staff

Section IV: Participating Provider Responsibilities

• Advance Directives
• Americans with Disabilities Act (ADA)
• Appendix AA
• Appendix H
• Assessments / Evaluations
• Compliance with Quality Improvement and Utilization Management Programs
• Confidentiality
• Coordination of Care
• Cultural Competence
• E-Commerce Requirements
• Limited English Proficiency
• Member Right to Continuing Course of Treatment
• Member’s Right to File a Complaint, Grievance or DHS Fair Hearing
• Member’s Rights and Responsibilities
• National Provider Identifier (NPI)
• Notification of Change in Access to Services
• Notification of Change in Practice Status
• Notifying Carelon of Reportable Events
• Notifying Members of Authorized Services
• Obligation to Report / Duty to Warn
• Professional Standards
• Prohibition of Member Billing
• Prohibition of Billing While Operating a Motor Vehicle
• Provider Preventable Conditions
• Site Visits
• Treatment Record Reviews
• Treatment Record Standards

Section V: Network Management

• Administrative Complaints
• Credentialing and Recredentialing
• Fair Hearing Process
• National Credentialing Committee (NCC)
• Network Management Functions
• Non-renewal of Provider Agreement
• Practitioner and Facility Agreements
• Provider Appeals Related to Credentialing, Sanctions or Termination
• Provider Contracting
• Provider Recruitment
• Provider Sanctions
• Provider Training

Section VI: Claims Payment

• Assistance with Claims Questions
• Claim Filing Requirements
• Claims Adjustments
• Claims Submission
• Current Procedural Terminology (CPT^®)
• E-Commerce Requirements
• Fraud and Abuse
• Going Online with Carelon
• Online Services Account Request Form
• Online Services Intermediary Authorization Form
• Overpayment Recovery
• Prohibition of “Balance Billing”
• Summary Voucher / Electronic Remittance Advice (ERA)
• Third Party Liability (TPL)

Section VII: Quality Management Program

• Confidentiality
• Organizational Structure, Roles and Responsibilities
• Purpose and Scope
• Quality Management Activities
• Quality Management Work Plan
• Work Plan Evaluation and Update Process