integrated home care services, inc. provider manual€¦ · dme quick reference document ......

©Integrated Home Care Services, Inc. 3700 Commerce Parkway Miramar FL, 33025 Phone 844-215-4264 – Fax 844-215-4265

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“PARTNERING FOR PERFORMANCE EXCELLENCE “

Integrated Home Care Services, Inc.

Provider Manual


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Table of Contents:

Introduction------------------------------------------------------------------------------------------6

Company Information, Mission, Vision and Values---------------------------------------6

Accessibility and contact Information---------------------------------------------------------7

Utilization Management Program--------------------------------------------------------------8

Submission and Review Requirements-------------------------------------------------------9

HCPC Procedure Codes Requiring Authorization-----------------------------------------11

Checking the Status of a Prior Authorization of a Referral-----------------------------11

Processing Timelines and Notification-------------------------------------------------------12

Key Contacts----------------------------------------------------------------------------------------13

NOMNC----------------------------------------------------------------------------------------------14

Performance Standards-------------------------------------------------------------------------15

Provider Orientation-----------------------------------------------------------------------------16

Provider Manual-----------------------------------------------------------------------------------17

The Integrated Provider Portal----------------------------------------------------------------18

Provider Credentialing and Quality Management---------------------------------------19


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Table of Contents:

Re-Credentialing-----------------------------------------------------------------------------------20

Coordination of Authorization and Service------------------------------------------------21

Reauthorization Responsibilities--------------------------------------------------------------27

Retroactive Reauthorization Requests------------------------------------------------------29

Utilization Management------------------------------------------------------------------------30

Utilization Management Responsibilities--------------------------------------------------32

Retrospective Claims Review------------------------------------------------------------------33

Appealing a Denied Request-------------------------------------------------------------------34

Service Delivery------------------------------------------------------------------------------------34

The Provider’s Discharge Responsibilities--------------------------------------------------36

Referral, Authorization, Billing and Claims Guidelines----------------------------------37

Home Health Quick Reference Document--------------------------------------------------38

FAQ & Who Do I Call? ---------------------------------------------------------------------------43

Policy and Procedure for Patient Incident Reporting------------------------------------44

Quality Management Program----------------------------------------------------------------46


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Table of Contents:

Request for Visit Sample Form----------------------------------------------------------------47

Nursing Delay of Service Notification Form------------------------------------------------48

Wound Care Supply Order Form--------------------------------------------------------------49

DME Quick Reference Document-------------------------------------------------------------50

FAQ & Who Do I Call? ---------------------------------------------------------------------------55

DME Delay of Service Report------------------------------------------------------------------56

General Claims and Reimbursement Information---------------------------------------57

Claims Process-------------------------------------------------------------------------------------58

Check Reimbursement Status-----------------------------------------------------------------59

Clean Form and Clean Claim Requirements ----------------------------------------------59

Timely Filing---------------------------------------------------------------------------------------64

Utilization Management Issues--------------------------------------------------------------64


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Table of Contents:

Claims Payment Issues---------------------------------------------------------------------------65

Claims Inquires-------------------------------------------------------------------------------------65

Reconsideration-----------------------------------------------------------------------------------66

Appeals-----------------------------------------------------------------------------------------------68

Dispute Resolution--------------------------------------------------------------------------------69

Customer Acknowledgement and Resolution Management--------------------------70

Complaints / Grievances ------------------------------------------------------------------------73

Member Complaints------------------------------------------------------------------------------75

Provider Complaints------------------------------------------------------------------------------79


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Introduction

hank you for your participation with Integrated Home Care Services, Inc. where our goal is

to provide quality services to health plan enrollees we are contracted with. These provider

manual highlights the key points related to billing and claim policies and procedures and is an

extension to your contract. It is intended to be a guideline to facilitate and inform you and your

staff of what the Integrated program is about, what we need from you, and what you can expect

from Integrated Home Care Services, Inc. The guidelines outlined in this provider manual are

designed to assist you in providing caring, responsive service to our health plan enrollees. We

look forward to a long and productive relationship with you and your staff. Should you need

further assistance, please contact your provider contracting representative.

Company Information, Mission, Vision and Values

Integrated Home Care Services, Inc. (Integrated) is a for profit, Florida health care quality

improvement, medical cost management and health information technology company providing

a wide range of effective and efficient solutions for our health plan clients. Services include care

coordination, utilization review, and quality improvement, provision of home medical services

inclusive of home health, durable medical equipment/supplies and pharmacy home infusion.

Integrated is committed to assisting our downstream providers to embrace quality standards,

Medicare and Medicaid compliance to maximize and improve the quality of care provided to our

patients/recipients.

T


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Florida

Integrated will serve as your Quality Improvement Organization (QIO) providing diverse

utilization and quality management services for a variety of home care settings. Our main office

is located in the Miramar area.

Note: The current Florida Medicaid Provider Handbooks are posted on the Medicaid fiscal

agent’s Web site at www.mymedicaid-florida.com. Changes to a handbook are issued as

handbook updates. An update can be a change, addition, or correction to policy. An update

may be issued as either replacement pages in an existing handbook or a completely revised

handbook. It is very important that all providers read the updated material. It is the provider’s

responsibility to follow correct policy to obtain correct reimbursement on Medicaid managed

care recipients:

ACCESSIBILITY AND CONTACT INFORMATION Submitting Prior Authorization (Review) Requests

Prior authorization (PA or review) requests are submitted to Integrated through our proprietary,

HIPAA-compliant Web-based system, Integrated, at https://www.ihcscorp.com. The system is

accessible 24 hours a day, seven days a week.

For Information or Assistance

We offer a variety of ways for providers to efficiently obtain the information or assistance you

need. In the following sections, we will identify, by topic or type of assistance needed, useful

resources.


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Questions about the DME, Home Health or Infusion Services

Utilization Management Program For questions or information about the DME, HH or Infusion Services Utilization Management

Program, the following resources are available:

Resources available on our Web site: https://www.ihcscorp.com

DME Provider Manual as well as manuals for the therapy services, inpatient, PPEC and

home health services programs.

Training presentations: Copies of training and education presentations are available

under the “Training/Education” tab.

Frequently Asked Questions (FAQs): The FAQs are under the “Provider Resources” tab.

Integrated’s Provider Relations service staff: Toll free number 844-215-4264

https://www.ihcscorp.com/


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SUBMISSION AND REVIEW REQUIREMENTS On behalf of our health plan partners, Integrated Home Care Services, performs prior and post

authorization (PA or review) for specified DME items and devices. This section provides

summary information about the following authorization requirements:

DME codes subject to review

□ Submitting PA requests

□ Supporting documentation

□ Review request submission timeframes

□ Review completion timeframes

Most DME items or devices that require medical necessity review by Integrated must be prior

authorized (before services are provided). However, per Chapter 2 of the Florida Medicaid

Durable Medical Equipment and Medical Supply Services Coverage and Limitations Handbook,

hospital beds may be provided prior to submitting the request for authorization. Custom

equipment or devices must be prior authorized


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Services Subject to Authorization by Integrated Home Care Services

Applicable Recipients

Integrated’s DME Utilization Management services are applicable for eligible recipients

Essential References

The Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage and

Limitations Handbook provides, comprehensive information about DME and medical supply

services, including authorization requirements.

There are two DME and Medical Supply Services Provider Fee Schedules. The fee schedules

contain information about which DME services are reimbursable by Medicaid, which require prior

authorization and which services must be manually priced before the provider is reimbursed. The

two fee schedules are:

DME and Medical Supply Services Provider Fee Schedule for all Recipients

DME and Medical Supply Services Provider Fee Schedule for Recipients under Age 21

(The Handbook and the fee schedules are available at http://portal.flmmis.com/FLPublic. Select

Provider Support and click on Provider Handbooks or Fee Schedules.) Integrated also provides a

link to the handbooks and fee schedules at our website.


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HCPCS Procedure Codes Requiring Authorization and Pricing by Integrated

The provider fee schedule tables display the Healthcare Common Procedure Coding System

(HCPCS) procedure codes for DME and medical supply services that are reimbursable by

Medicaid. Each fee schedule has a column labeled “PA” (Prior Authorization). DME items that

require authorization by Integrated have “PA” in that column.

A provider will be required to log into the Integrated website provider portal with your username

and password. Once successfully authenticated, you will be able to view information for claims

that were either paid or denied based on date of service. Pended claims will not be shown. In

order to view status information, the NPI on your account must match the billing NPI on the

claim.

Checking the Status of a Prior Authorization or Referral

Before checking the status of a prior authorization or referral, please review the processing

timelines and notification information below on how requests are processed.


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Processing Timelines and Notification

Routine prior authorization and referral requests are processed within 2–5 business days

of receiving the request form the provider.

Urgent requests are processed in an expedited manner for care that needs to be delivered

within 72 hours.

Requests are processed using the clinical information submitted by the provider.

Processing time for both routine and urgent requests may be delayed if sufficient

information is not provided

Determination letters for routine requests will be delivered to beneficiaries within 7–10

business days after the request has been processed


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KEY CONTACTS Register for Provider Portal & EDI

Register for the Provider Portal Provider Portal

Register for EDI (Electronic Claims Submission)

TBD

Support

Portal Support 844-215-4264 ext. 1534

EDI Support TBD

Initial Authorization Requests (844)215-4264 ext. 1533

Fax # (844) 215-4265

Authorization Status https://apps.ihcscorp.com/medtrac/

Re-Authorization Requests (844)215-4264 ext. 1533

https://apps.ihcscorp.com/medtrac/ Add-On Services https://apps.ihcscorp.com/medtrac/

Authorization Contact (844)215-4264 ext. 1533

Claims

Claims Questions Claims Questions, Appeal Status and Claim Support Team – (844)215-4264 ext. 1532 / 1534

Claims Status (844)215-4264 ext. 1532

Appeal Status (844) 215-4264 ext. 1532 / 1534

Claim Support Team (844) 215-4264 ext. 1532 / 1534

Contract/Provider Operations

Compliance

Mark Gilchrist 844-215-4264 ext. 7495

Patient Financial Accounts

Nicole Falconer 844-215-4264 ext. 1534

Donna Gale 844-215-4264 ext. 7494

Customer Service 844-215-4264 ext. 1530

https://apps.ihcscorp.com/medtrac/




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Compliance with CMS Notice of Medicare Non-Coverage Requirement

N O M N C

Providers are required to comply with applicable state and federal laws. With respect to

Medicare patients who are discharged from home health care, CMS requires Providers to

timely issue a Notice of Medicare Non-Coverage (NOMNC) to the patient. The following are

some steps Providers should take to ensure compliance with this NOMNC requirement:

Prior to discharging a patient from home health services, determine whether the

patient is a Medicare Advantage member.

If the patient is a Medicare Advantage member, provide the patient with a

NOMNC letter at least 48 hours prior to discharge. Please note that the patient

or the patient’s authorized representative must sign and date the notice.

Utilize the approved CMS NOMNC letter template and complete the template letter

as directed by CMS.


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PERFORMANCE STANDARDS

As a participant in the Integrated network of Providers, you are required to:

Provide high quality, compassionate care to patients.

Submit timely written notice to Integrated of changes in your organization as required in your Provider contract and this Provider Manual.

Maintain 24 hour on-call coverage 7 days per week and respond to patient and/or Integrated contacts within 30 minutes of call, including weekends, evenings and holidays, unless otherwise specified by contract.

Submit billing for authorized services and/or products to Integrated at least monthly and within timely filing requirements at the designated address for claims and submit no billing to the primary Health Plan for services/products unless directed to do so by Integrated in writing.

Not bill the patient/member for covered services or for services where payment is denied because you did not comply with your Provider Agreement or this Provider Manual.

Not otherwise bill the patient/member for any covered services.

Not, under any circumstance, tell the patient/member that they are not responsible for any co-pays, coinsurance or deductibles. Providers are paid for authorized covered services in accordance with their contract rates. Although the patient is not responsible to pay copays, coinsurance or deductibles to the Provider since the Provider has been paid in full, the patient is responsible for remitting those amounts to Integrated.

Promptly return to Integrated any overpayments for services provided under your Provider Agreement.

For services where payment is denied because the services are not medically necessary or are not otherwise covered under the member’s plan, not charge the member for such services unless, in advance of the provision of the services, the member agrees in writing to accept the financial responsibility for the services.


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Submit medical records, quality assessment, quality improvement, clinical outcomes, program evaluation, and other reports upon request of Integrated personnel and cooperate fully with any audits conducted by Integrated. Requested records must be provided to Integrated at no charge to Integrated and within the timeframes requested by Integrated. If Provider fails to timely provide records requested by Integrated in order to substantiate services billed, payments on the claims that are the subject of the record request may be reversed and recovered through a refund request or offset. Integrated further reserves the right to impose a penalty of $50 per day for each day that the Provider fails to provide records within the requested timeframes.

Participate in Integrated Quality initiatives as requested.

Notify patients of FDA recalls impacting them and facilitate the repair, replacement and/or resolution of the recall according to the guidelines issued by the manufacturer in the FDA notification

Adhere to all other principles, practices and procedures found in the Provider Agreement, Integrated Provider Manual, and contractual relationships between Integrated and its Health Plan customers

Provider Orientation

In keeping with our commitment to support our Network Providers, we have a variety of

Provider orientation and training communications and opportunities.


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Provider Orientation

Our Provider Relations team provides important information on Provider responsibilities and

Integrated operational procedures as outlined in this manual. If you are a new provider, our

Provider Relations Department will contact you to set a date and time for an orientation

conference call or meeting. Network Providers may also request an orientation to give a

refresher of this manual’s contents. Providers should review this manual prior to the call

to obtain the most benefit from their participation.

Provider Manual

Our Provider Manual is intended to inform our providers of their responsibilities as an

Integrated Network Provider. This Manual also serves as an ongoing reference that is

updated periodically.

Providers have a responsibility to ensure they are following the most up to date policies and

procedures implemented by Integrated. Providers must check the Integrated Provider Portal

(https://apps.ihcscorp.com/medtrac/) frequently for any information updates, including updates

to this manual. Changes may include:

A change in policy, process and/or procedure that impacts the Provider and/or Provider

operations.

A change in the expectations or conditions of contract(s) with Integrated customers.

New carrier contracts which the Provider may service.



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The Integrated Provider Portal

The Integrated Provider Portal (https://apps.ihcscorp.com/medtrac/) is the best place to find

the most up to date information about how to work with Integrated. In addition to providing

educational resources, our Provider Portal gives you access to several self-service tools.

When you access our Provider Portal, you can:

• Request an authorization or re-authorization

• Edit an authorization request

• Upload clinical documentation

• Look up claim and authorization status

• Submit a claims inquiry*

• Submit a request for reconsideration and/or appeal*

• Enroll in EDI (Electronic Claims Submission)

• Access self-guided Provider education tools on several topics

Integrated Communication to Providers



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PROVIDER CREDENTIALING AND QUALITY MANAGEMENT

Credentialing:

Our credentialing process requires, but is not limited to, the following:

Completed Integrated Credentialing Application. The application must contain a current

signature of the CEO, Administrator or other appropriate designated representative,

attesting that all information provided in conjunction with the application is true,

correct, and complete.

Copies of current licensure as required by applicable law.

Proof of professional and general liability insurance. Required limits are generally one

million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in

aggregate and a copy of a current fidelity bond for fifty thousand dollars ($50,000)

or other crime and theft coverage in an amount satisfactory to Integrated.

Five year malpractice history.

1. Copies of current accreditation or certification. For non-accredited, non-certified Providers, Integrated will perform a site visit. QA/QI program description - The quality program must address patient care in general detail, including the overall steps that are taken to maintain quality control over internal processes as they relate to patient care. Quality Improvement Plans should contain the following:

2. The implementation of the plan, analysis and progress on QI initiatives.

3. The purpose, goals, objectives, and scope of the quality improvement program.

4. The organizational authority, organization of responsibility, general methodology and quality improvement methodology.


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Re-Credentialing

Integrated Network Providers are re-credentialed every two to three years (as determined by

applicable law or plan requirements). However, a Provider’s credentialing status may be

evaluated by Integrated at any time during the two to three year credentialed period,

including when a Provider adds a new service category, or malpractice or quality of

care/service issues are brought to the Committee’s attention. In addition, if a Provider adds

or acquires a new location, subsidiary or affiliate, that location or entity must be credentialed.

The standard re-credentialing process begins approximately six (6) months before the

credentialing anniversary. Our re-credentialing process requires, but is not limited to, the

following:

Completion of re-credentialing application

Copies of current licensure.

Proof of professional and general liability insurance. Required limits are generally one

million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in

aggregate; a copy of current fidelity bond for fifty thousand dollars ($50,000) or other

crime and theft coverage in an amount satisfactory to Integrated.

Three year malpractice history.

Copies of current accreditation or certification. For non-accredited, non-certified

Providers, Integrated will perform a site visit.

QA/QI program description and program evaluation.


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COORDINATION OF AUTHORIZATION AND SERVICE

Integrated Providers may receive referrals for new patients as follows:

A primary referral source, a physician, hospital or skilled nursing facility; discharge planner,

other Provider, etc., contacts Integrated with the referral. Initial orders/referrals must be faxed

to Integrated at (844)215-4265 for processing. Integrated digitizes the physician orders and

routes them to the network provider. Integrated will provide your initial administration

authorization. In all cases, subject to patient choice, Integrated reserves the right to select an

alternative Provider to service the referral.

Integrated Receives Referral from Referral Source The required information generally includes, but is not limited to, the following:

A. Patient first and last name

B. Patient date of birth

C. Patient insurance company and insurance subscriber ID number

D. Patient physical address (not PO Box) including zip code

E. Patient phone number

F. Patient gender

G. Diagnosis

H. If recently discharged from hospital or other inpatient setting, facility name and full

address

I. Ordering and primary physician first and last name, full address and telephone number

J. Medical necessity justification for the service or item requested

K. Confirmation that physician orders exist for services for which authorization is being requested


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If the Provider does not submit all of the required information, the request will not be

accepted by Integrated.

The type of review applied to a request for authorization depends on the patient’s Health

Plan. For example, an item or service may be reviewed for medical necessity under one

Health Plan but not another. In addition, the type of review may change from time to time.

Receipt of an authorization from Integrated does not guarantee that the service was

reviewed for medical necessity. If medical necessity is later determined not to exist, the

Provider’s claim for service may be denied or payments may be recouped.

Reauthorization requests submitted via the Portal will be processed within 72 hours. The

Provider receives an electronic notification of authorization.

Some requests require verification of administrative information or clinical review. These

requests are submitted to our utilization management team for processing. Reasons for

routing include, but are not limited to:

1. Other insurance

2. Medical necessity review

3. Obtaining authorization from the Health Plan


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Once any necessary verification is completed or when a request is automatically processed

and approved, an authorization is generated and an Authorization

Form (SAF) is faxed to the Provider. Authorization details are posted on the Integrated

Provider Portal for Providers to retrieve.

Providers must verify eligibility and benefits with the patient’s Health Plan prior to providing

any service, equipment or supply item. It is recommended that providers maintain

evidence of verification of eligibility and benefits. Please remember that eligibility and benefit

verification and service authorization are not a guarantee of payment for services such as, but

not limited to, items provided when the member is not eligible or there is no available benefit.

Providers are responsible for ensuring that they maintain, and have available upon request,

all documentation necessary to support the services rendered, including but not limited to, the

medical necessity of such services.

Requests for the initial start of care or reauthorization for continued care, must be requested

prior to the service being. If a Provider fails to request an authorization or reauthorization prior

to services, those services performed may not be reimbursable and are not billable to the

patient. Exceptions may exist for certain Plans that do not require initial or reauthorization

from Integrated.


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Integrated Receives Referral from Provider

Provider staffing is the process of identifying a Provider to meet the needs of a specific patient.

All Referrals/orders will initially be sent to the Provider via fax. The referral source has the

option to submit referrals/orders directly via the Integrated Referral Portal

(https://apps.ihcscorp.com/medtrac/) Integrated Referral Portal is Integrated’s electronic

application that allows Referring Providers to submit referrals quickly and entirely on-line.

Providers will obtain information about how to enroll on Integrated’s referral portal, please

contact your Provider Operations Representative. Referrals are based on a variety of factors,

including but not limited to:

The location where the patient will receive service and corresponding location of the Provider

The services/products for which a Provider is credentialed to perform or supply

The lines of business for which a Provider is credentialed (e.g. Medicaid, Medicare)

The Provider’s ability to provide the service or item for the required start of care date

Integrated makes no guarantees on the number of patients that will be referred to a Integrated Network Provider. Integrated reserves the right to direct and/or redirect patients to selected Integrated Network Providers; Furthermore, our health plan partners reserve the right to exclude certain Providers from the network.



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The process for staffing cases is as follows:

A. Integrated receives a request for a service or item from the referral source.

B. The initial referral is either sent out electronically to the network providers via fax or

by telephonic outreach.

i. The Provider accepts the referral.

ii. The Integrated associate generates the authorization and an Authorization

Form (SAF) is faxed to the Provider. For information about how to go paperless,

please contact your Provider Operations Representative.

Providers should verify eligibility and benefit availability with the Health Plan prior to providing

any services, equipment or supply item. Authorization is never a guarantee of payment for

services/items and is subject to factors that include, without limitation eligibility, benefit

coverage, timely and proper claims submission and compliance with the terms of the Provider

Agreement and this Provider Manual. In addition, Providers must carefully consider their ability

to accept every case and only do so when the Provider is confident that the patient’s needs can

be met. The return of referrals can delay the start of care and can cause quality of care and

service issues.

After accepting a referral and receiving an authorization, it is the Provider’s responsibility to

abide by all of the terms of the Provider Agreement and this Provider Manual including, without

limitation, the following:


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Notify Integrated immediately when the start of care/delivery must be delayed or if unable

to continue the case. The Provider should contact the Integrated prior to the start of

care/delivery date to allow Integrated adequate time to secure an alternate provider if

needed. It is also the provider’s responsibility to obtain approval from the patient’s physician

if the start of care/delivery date is delayed.

• Timely notify patients that the services have been authorized when patient notice is

required by law.

• Render no service unless ordered by the appropriate physician.

• Provide after hours (on call) home visits as appropriate and necessary in situations that

cannot be resolved by telephone consultation.

• Notify the Integrated utilization management staff of changes in patient/family status

within 24 hours upon occurrence and/or identification, including:

Illness

Hospitalization

Death

Any other adverse incident or change affecting continued service delivery


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Immediately notify Integrated of complaints made by the patient, family, physician or Health

Plan upon occurrence.

•Except as otherwise provided in this Provider Manual, submit requests for service/product re-

authorization within 72 hours prior to expiration date of the previous authorization. Obtain

authorization for any previously unauthorized emergency or urgent services immediately

following services or the next business day. Integrated provides 24/7 on-call access for

emergency and urgent situations. Provide assessment reports, progress reports, organizational

forms or other organizational documents within 48 hours of request by Integrated.

Respond to grievances/complaints filed against the Integrated Provider within 24 hours and

pursue timely resolution as acceptable by Integrated staff.

Notify Integrated if other insurance or additional sources of reimbursement are identified.

Provide all other documentation and records which may be requested by Integrated, timely

or within the time frames set forth in the request.

Reauthorization Responsibilities

A reauthorization or concurrent review is required to continue service if either

The date span of the authorization will be exceeded, regardless of any remaining units


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The authorized number of visits/units will be exceeded.

Obtaining a re-authorization is the responsibility of the Provider.

Providers must submit requests for reauthorization at least 48 hours prior to the expiration

of the authorization. Provider must submit clinical status and objective reasons for re-

authorization prior to authorization expiration.

Reauthorization should be requested via the Provider Portal at www.Integratedportal.com.

The Provider Portal identifies the information required in order to complete your request for

reauthorization. That information includes, but is not limited to, the following:

i. Intake ID

ii. Patient’s Last Name

iii. HCPCS Code and modifier needing reauthorization

iv. Number of requested units, start and stop date of requested authorization

v. Medical necessity for the service requested

vi. Physician orders for all services for which authorization is requested for

If the Provider does not submit all of the required information, the request will not be accepted

by Integrated.

http://www.carecentrixportal.com/


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Retroactive Reauthorization Requests

Providers must submit requests for authorization of service/items prior to the service/item being provided or delivered. If a Provider fails to request a reauthorization and continues to provide services, those services performed prior to receiving authorization may not be reimbursed and are not billable to the patient.

Reauthorization request type

Patient Insurance Information

Disciple requested/authorized

Service code (Integrated code)

Description of HCPCS code

From and To dates

Request status

Approved

Cancelled

Denied

o Denied by the Health Plan

In process – elevated to the Health Plan

In process – pending additional information

In process – under review

o Authorization Number/ if authorized

Name of Provider receiving authorization (if authorized)

Number of units for HCPCS code authorized

Unit of Measure for HCPCS code authorized

Authorization From and To dates


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UTILIZATION MANAGEMENT

The Integrated Utilization Management Process

Utilization Management is the evaluation of the appropriateness, medical necessity and

efficiency of healthcare services according to established criteria or guidelines under the

provisions of the patient’s benefit plan. When Integrated is responsible for conducting a review

of the medical necessity of a proposed service, the following is our standard medical necessity

definition:

Appropriate and consistent with the diagnosis of the treating Provider and the

omission of which could adversely affect the eligible Member’s medical condition;

Compatible with the standards of acceptable medical practice in the community;

Provided in a safe, appropriate, and cost-effective setting given the nature of the

diagnosis and the severity of the symptoms;

Not provided solely for the convenience of the Member or the convenience of the

Health Care Provider or hospital; and

Not primarily custodial care unless custodial care is a covered service or benefit under the

Member’s evidence of coverage.


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The above definition is subject to the requirements of the applicable payer and plan and

applicable law (for example, the mandated definition for medical necessity for Medicare and

Medicaid plans will apply to patients covered under such plans; a state mandated definition

for medical necessity for insured commercial plans will apply to patients covered under such

plans). Medical necessity reviews can be conducted for both initial and reauthorization

requests and can be required for all types of service. Providers may request a copy of the

utilization review criteria that Integrated used in making an authorization decision.

Under the Integrated Utilization Management Program:

Utilization Management decisions are made independently and impartially and based

solely on the appropriateness of care and service and the existence of coverage.

Integrated decisions regarding hiring, compensation, termination, or promotions of

Utilization Management personnel are not based on the likelihood that the individual will

support the denial of benefits.

Performance of associates who make Utilization Management decisions is measured

based on the consistent and appropriate application of the approved coverage criteria to

the clinical situation presented. Performance is not measured based on redirection rates

or denial recommendation rates.

Integrated does not specifically reward practitioners or others for issuing

recommendation for denials of coverage, and financial incentives for Utilization

Management decision makers do not encourage decisions.


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Utilization Management Responsibilities

Providers have the following Utilization Management responsibilities:

Provide and maintain appropriate documentation to establish the existence of medical necessity.

Obtain authorization prior to beginning services/products. Services/products performed without authorization may be denied for payment, and any such denial of payment is not billable to the patient by the Provider.

Verify the information on the Authorization Form (service codes, HCPCS, modifier, number of units, start and stop date, Provider name and location) upon receipt. While the Integrated utilization management staff work to assure the accuracy of the information on the Authorization Form, mistakes can occur. Should you identify an error, call Integrated within 24 hours to correct the error.

• Notify Integrated immediately if, when the services or equipment are delivered, the

diagnosis is determined to be different than the diagnosis information obtained from Integrated.

• Notify Integrated if the services ordered will not meet the needs of the patient. You may

be asked to assist in identifying alternatives and discussing with Integrated and the ordering physician.

• Participate in case conferences • Respond to all requests for contact from Integrated within 24 hours • Respond to all requests for contact from the Health Plan case manager within 1 business

day. In most cases, Integrated will act as a liaison when a Health Plan case manager


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requests information. Providers should not initiate contact with a Health Plan case manager

unless directed to do so by Integrated.

If requested by Integrated, provide assessment reports, progress reports, organization

forms or other organization documents within 48 hours of request.

Verify all initial physician orders with the physician and obtain physician orders for

additional services/products as necessary.

Provide all other documentation and records which may be requested by Integrated

from time to time, within the time frames set forth in the request.

Retrospective Claims Review

Paid claims can be subject to retrospective audits, and Providers have the obligation to

maintain and

make available documentation to support the medical necessity of services rendered and billed.

Such documentation must be made available to Integrated and/or the applicable Health Plan

at no cost to

Integrated or the Health Plan and within the timeframes requested. Integrated may recover

any payment for services determined not to meet medical necessity or benefit

requirements, including recovery through recoupment.


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Appealing a Denied Request

If services/products have been escalated to the Health Plan for recommended denial in their

entirety and new and/or additional information is obtained, the Provider should contact the

Integrated utilization management staff to relay the new information and have the

authorization request reviewed. If services/products have been denied by the Health Plan in

their entirety and there is no new information available, the patient or physician may

submit an appeal to the patient’s Health Plan in accordance with the Health Plan’s appeals

process.

SERVICE DELIVERY

To help ensure seamless patient care and timely and accurate payment, it is important that

a Provider clearly understand the responsibilities for service/product delivery and the

discharge of patients from service.

The Provider’s Responsibility

For service/product delivery, a Provider must:

Verify physician’s orders and obtain physician signature within the time specified by state

regulations and licensure.

Meet the start of care date as ordered by the primary referral source. Any delays in services

provided outside of the times set in the service standards MUST be communicated to


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Integrated by faxing the Delay in Service form to 855-801-9771. Form also needs to be faxed to Primary Care Physician. Form is found in the manual on page.

Notify Integrated immediately if unable to continue service delivery to the patient. Notify Integrated within 24 hours if the information obtained during Integrated registration process has changed or was incorrect. The utilization management staff will review the authorization to determine if a change to the authorization is required.

Bill Integrated only for services/products that have been ordered by an appropriate physician, meet medical necessity and benefit requirements and are authorized by Integrated

Report unusual occurrence or variance in providing patient care, products or services that result in injury or potential harm to the patient.

Report complaints and problems with services/products to Integrated within 24 hours of occurrence.

Comply with state and federal licensing requirements and other applicable laws.

Conduct and document discharge planning on an on-going basis during the care and document that discharge needs were met upon discharge.

Not auto ship supplies. Medical necessity must be confirmed and documented with each supply shipment.

Not provide equipment without first confirming medical need.

Not deliver or ship supplies unless, in advance of delivery or shipment, you have verified with the patient or their treating physician that the patient needs additional supplies.

Discharge the patient to a Provider who is in-network with the applicable Health Plan if the patient requires ongoing services not covered by Provider.


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The Provider’s Discharge Responsibilities

Providers are required to notify Integrated prior to discharging a patient in the following

circumstances:

The Provider cannot provide the services/products ordered and authorized because of

lack of staffing or expertise.

The patient relocates outside of the geographic service area.

The patient completes the Plan of Care.

The patient and/or family are capable of assuming care. The patient’s physician should

be notified of the patient/family’s request before stopping services/picking up

equipment.

The patient no longer wishes to receive services/products.

The patient’s physician should be notified of the patient/family’s request before

stopping services/picking up equipment.


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The patient/family refuses to comply or is incapable of compliance.

The physician does not provide the needed orders.

The patient is institutionalized.

The patient expires.

Home care is no longer appropriate due to risk factors.

As applicable, Providers are required to cooperate and assist in transitioning a discharged patient’s

care to another Provider in order to ensure continuity of care.

REFERRAL, AUTHORIZATION, BILLING, AND CLAIMS GUIDELINES SPECIFIC TO PROVIDER SPECIALTY

This section outlines the guidelines specific to the specialty area of a Provider. Guidelines are prescribed for home

health, home infusion therapy, and home medical equipment.


38

Home Health

Home Health Division Quick Reference Document Contact Numbers:

Phone: 1-844-215-4264

Fax: 1-844-215-4265

Referral Process:

ALL referrals/orders must be faxed to Integrated at 1-844-215-4265.

Integrated digitizes the physician orders and routes them to the network provider.

Initial Authorizations:

Integrated will provide your initial administrative authorization via fax with the

physician orders.

Reauthorizations:

Please submit all reauthorization requests through the provider web portal. Please also

upload/attach the supporting documentation along with your request.


If you do not have scanning capabilities, you may fax your request form along with

supporting documentation to 1-844-215-4265 (form is attached).

DO NOT use both methods as this will cause duplication and delays.

Delay in Service:

Any delays in services that are provided outside of the times set in the service standards MUST

be communicated to Integrated. Fax notification to 1-844-215-4265. (The form is attached)



39

Service Standards for Home Health Services:

Expedited or STAT services: Should be stabilized prior to referral for Home Health

Routine: Scheduled per the following or as scheduled with patient

o RN Evaluation: 24 hours from receipt of complete referral, unless specific

medication

o PT Evaluation: joint replacement 48 hours from agency receipt of referral.

Routine PT - 72 hours from receipt of referral

o Nursing & Infusion Services: after first dose completion to be within 6 hours or

when next dose is due upon receipt of complete referral with clean order and

upon specific physician orders.

o MSW Evaluation: 1 week from receipt of referral.

All requests for further visits must be submitted with supporting documentation of

evaluation and visit notes within 48 hours of initial evaluation. Integrated’s eClaims

portal at https://apps.ihcscorp.com/medtrac/ is recommended for submission of re-

authorization and supporting documentation for all HH request.

Patient Discharge: Integrated requires the Network Provider to submit a discharge

summary to both the Primary Care Physician and Utilization Management Team.


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Notes:

Custodial Care: unless accompanied by a skilled appropriate service, home health aide is not

a covered benefit. Wound Care: please specify wound care needs (i.e., Supplies and wound

measurement)

MSW: only approved for patients with other skills in the home and do not provide skilled

nursing home placement.

All referrals must come directly from the referral source. Only referrals sent directly

from Integrated to your agency with authorized visits will be paid. The referral source

can request a specific agency and those requests will be strongly considered; however

our home health team makes the final determination of where best to refer a case and

the number and type of visits that meet criteria for reimbursement.

Billing and Claims:

Electronic EDI Claims:

o If you are using practice management software (Availity) to submit claims

electronically, your system needs to be set up with the payer ID IHCS1 All nursing

claims must have nursing and therapy notes attached.

All Medicare claims sent to Availity with service dates 7/1/2014 and after shall

be sent in 837i format


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Paper Claims: Must be submitted on the Professional 1500 HCFA Claim Form Version

02/12, any claims submitted on 1500 Version 08/05 will be rejected as of April 1, 2014.

(Please review CMS changes for further detail) Copies of the form cannot be used for

submission. Data must be typed not handwritten. Authorization number must include any

hyphens (entire auth #- 123456-1-1234) Box 23. NPI # of rendering location must be in Box

32a. Any claims not in this standard format will be denied / rejected.

o Exception: All Medicare paper claims with service dates 7/1/2014 and after shall

be sent using the UB04 form

Billing Codes:

o Only contracted procedure codes and authorized services will be paid. Provider

must only use procedure codes and HCPC codes that are detailed on the

contract, Letter of Agreement or Authorization received.

o Services performed on 7/1/2014 will use the new Medicare G-code set on the

authorization which contain revenue codes and modifiers. The claim must match

the exact billing code set found on the authorization; otherwise it will be denied.

o For example, if the authorization contained a revenue code and modifier, the

claim shall contain a revenue code and modifier

o If the authorization for a 7/1/2014 or later service date did not include a revenue

code, please contact your Integrated home health liaison to correct the

authorization.


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HIPPS Codes on Claims: All Medicare home health claims with 7/1/2014 service dates shall

contain a HIPPS code per CMS mandate.

o Only one HIPPS score shall be entered on a claim; otherwise the claim will be

denied

o The HIPPS code rate shall always be zero; otherwise the claim will be denied

o The HIPPS code shall have a revenue code of 0023; otherwise the claim will be

denied

o The HIPPS score service date shall be the first service date pertaining to the

HIPPS code

o It is the agency’s responsibility to research other CMS rules around HIPPS code

to ensure accurate claim filing. Inaccurate specification of HIPPS codes will result

in claim denials.

Timely Filing: All claims must be submitted 60 days from the date of service; this is

effective as of 1/1/2017. For resubmittal / corrected claims it is 60 days from the

Explanation of Payment

(EOP) disposition. Claims submission address (for paper claims): Integrated Home Care Services, Inc.

3700 Commerce Parkway

Miramar, FL 33025


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FAQ & Who Do I Call?

Home Health Services Contacts: Elizabeth Hoadley, LPN UM Case Manager 844-215-4264 ext. 7353 Grisel Ibanez, LPN UM Case Manager 844-215-4264 ext. 7354 Grace Iglesias Referral Coordinator 844-215-4264 ext. 7351

Wound Care Inquires: Elizabeth Hoadley, LPN UM Case Manager 844-215-4264 ext. 7353 Grisel Ibanez, LPN UM Case Manager 844-215-4264 ext. 7354

TPA: (Claims Inquires)

Petra Mendoza Claims Manager 844-215-4264 ext. 7365

Odalys Alfaro Claims Examiner 844-215-4264 ext. 7417

Network / Contracting Specialists: Name Region Phone Number E-mail Address Janet Palmer State of Florida 844-215-4264 ext. 7367 [email protected] Querby Metayer State of Florida 844-215-4264 ext. 7366 [email protected]


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POLICY AND PROCEDURE FOR

PATIENT INCIDENT REPORTING TO INTEGRATED

POLICY:

1. Network Provider will report to INTEGRATED’s Director of Utilization Management any

unusual occurrence or variance in providing patient care, products or services that result in

injury or potential harm to the patient.

2. The Network Provider is responsible for ensuring the incident report is promptly reported,

within 48 hours, to INTEGRATED after the incident occurs.

3. The Director of Utilization Management will ensure that the health plan is informed within

48 hours of the incident.

4. Incident reports are confidential and privileged documents.

5. The Network Provider will ensure local authorities are notified, as appropriate following the

incident, e.g., Protective Services, Department of Elder Affairs, etc.

PURPOSE:

The purpose of the policy is to define the responsibilities and timelines of reporting patient

incident reports to INTEGRATED.

PROCEDURE:

1. Incidents will be reported to INTEGRATED’s Director of Utilization Management within 48

hours or sooner after the occurrence. The Director of Utilization Management, Compliance

Officer and other Corporate Officers are available 24 hours per day 7 days per week and

should be notified without delay.


45

2. When the incident involves a major injury or death of a patient the Network Provider shall

notify the Director of Utilization Management immediately. Failure to report this level of

incidents to the appropriate corporate staff is considered a violation of the Corporate

Compliance Program.

3. Disciplinary action up to and including termination of the contract may result from violations

of these standards.

4. If media attention is anticipated, the Director of Utilization Management will immediately

notify the Executive Vice President of Home Health Services and the Chief Executive Officer.

The health plan will be notified by a member of the Executive staff within 24 hours.

5. The Compliance Office will keep track of incident investigations and outcomes. Copies of

incident reports and all supportive documentation will be filed separately from the patient’s

medical record or financial records and will be protected against unauthorized disclosures to

any third party.

6. Problematic trends will be identified and action plans developed and implemented.

7. Incident trending data should be used in performance improvement activities as appropriate.

DOCUMENTATION: 1. Documentation and follow-up of the incident is entered into the incident reporting system.

2. The Incident Log is to be retained for a period of seven years.


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Quality Management Program Integrated’s IHC QM Program identifies opportunities for improvement of care and services to

our patients, health plan partners, and providers. This is accomplished through the assessment,

investigation, and evaluation and monitoring of health care services and implementing action

plans to address identified opportunities or gaps. This Quality Improvement Program covers all

lines of business (HH, DME, and Pharmacy).

Each year, the QM program is evaluated to determine if goals were met. We look at all

functions of the QM program, such as clinical and service activities. The evaluation includes

suggestions to improve the QM Program and develop goals for the next year.

Focus Areas

Key performance indicators specific to Quality Management may include but are not limited to:

Downstream Provider accessibility and availability

Downstream Provider Satisfaction

Provider credentialing

Under and over utilization

Clinical Review Criteria

Wound Care Program

Adverse outcomes/sentinel events

Medical record keeping practices

Member satisfaction/grievances

Timeliness of handling claims

Improvement of outcome for high-risk and complex population

If you would like more information about the QM program, please call Quality Management at

844-215-4264


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REQUEST FOR VISITS FORM: (Preferred Method through the web portal - https://apps.ihcscorp.com/medtrac/) Request for Visits

Patient’s Name HH#

Member# Health Plan:

PCP □ Specialist □ SOC Date: MD Notified of SOC □

Name of MD: Date Next MD Appt:

Diagnosis:

Objective Findings:

Teaching/Treatment Plan:

Goal:

REQUEST FOR VISITS:

Discipline Requested Number of Visits From (Date) To (Date)

HT□ SN□

PT□ OT□ ST□

MSW□

HHA□

Please include reasons for follow-up visits requested

WOUNDS:

Site Measurement Description

Signature & Title

Date Signed:

Name of Agency:



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Nursing Delay of Service Notification Form FAX: 1-844-215-4265 Date: ________________________________ Integrated HH# ________________________________________________________ Name of Agency: _______________________________________________________________________________________________ Patient’s Last Name: ____________________________First Name: _________________________________ MI: _________________________ Insurance Company: ______________________________________________Date Doctor Notified: ___________________________________ Original Visit Scheduled: ___________________________Actual Date of Visit: _____________________________________________________

□ Reason for Delay of Service:

□ Phone disconnected

□ Patient not answering phone

□ Patient not returning messages

□ No answer at door

□ Patient not discharged

□ Doctor’s appointment

□ Medication not delivered

□ Patient refused service

□ Other: __________________________________________________________________________

□ Discipline Delayed:

□ RN Evaluation – Start of Care

□ Skilled Nurse Visit

□ Physical Therapy Evaluation

□ Occupational Therapy

□ Speech Therapy

□ Social Worker visit

□ Home Health Aide visit Agency Signature: __________________________________________________Print Name: __________________________________________


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Wound Supply Order Form

Date: _____________ Insurance: ____________________Insurance ID#:__________________ Agency: ____________________________ HH#:_______________________________________ Agency Phone #______________________ Agency Fax:_________________________________ Florida County: Broward Dade Palm Beach Other State: Patient’s Name: Address: (include apt. #) City, State, Zip Code: Patient’s Tel. #: ( ) Ordered By: (your name) Wound #1 Wound #2 Wound #3 Location: Location: Location: Length: Length: Length: Width: Width: Width: Depth: Depth: Depth: Stage: Stage: Stage: Drainage: Drainage: Drainage: Wound care ordered: Frequency of dressing change:

Item U/M Amt. Req.

Amt. Ord. Item U/M

Amt. Req.

Amt. Ord.

ABD Pads 5"x9" (A6253) 20/Bx or Ea Silver Ag Mesh 4”x5” (A6403)

10/Bx or Ea

Cotton Tipped Applicators 6"-Str. 2/Pkg (A9270) ***For Packing Only*** Ea

Restore Ag (Aquacel Ag) 4”x4” (A6197)

10/Bx or Ea

Hydrogel 25 grams (1 oz.) (A6248) Ea Foam 4”x4” (A6210) 10/Bx or Ea

Kling 4” (A6447) 12/Bx or Ea Foam Adhesive (oval) 6”x5” (A6210) Ea

Kerlix Fluff 4-1/2” (A6449) Ea Foam Adhesive (square) 3.5”(A6210) Ea

Gauze, Sterile 4"x4" (A6402) 25/Bx or Ea Coban 3” (A6454) Ea

Gauze, Nonsterile 4”x4” (A6216) 200/Pkg Ace Bandage 3” (A6449) Ea

Packing Strips-Plain 1/4" 1/2" 1”(A6407) Ea ***Collagen Dressing *** (A6201) Ea

Packing Strips-Iodoform 1/4" 1/2" 1” (A6266) Ea ***Collagen Dressing AG *** (A6214) Ea

Transparent Film (Tegaderm) 2”x3”(A6257) Ea ***Oil Emulsion Dressing *** (A6223) Ea

Transparent Film (Tegaderm) 4"x5”(A6258) Ea ***Hydrogel Dressing *** (A6242) Ea

Telfa Pads 3"x4" (A6403) Ea Solutions

Hydrocolloid 4"x4” THIN (A6235) 5/Bx/Ea 0.9% Normal Saline 100mL (A4217) Ea

Vaseline Gauze 3"x9" (A6223) Ea Tapes

Xeroform Dressing 5"x9" (A6223) Ea Paper tape 2” (A4452) Ea

Calcium Alginate (Aquacel) 4"x4" (A6197) 10/Bx/Ea Mefix tape 2” (A4450) Ea

Calcium Alginate Rope 12" (A6199) Ea Micropore tape 2” (A4450) Ea

Adaptic 3x3 (A6224) Ea Other

Adaptic 3x8 (A6224) Ea FAX TO: 844-215-4265

Wound Supply Contact Phone Number: 844-215-4264


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Integrated DME Quick Reference Document for Florida Network Providers

Information:


Tax ID: 47-4693271

NPI: 1881061695

Payer ID:

Integrated

FTP Site:

Integrated eClaims Portal: https://www.visibiledi.com/ihcs/

Hours of Operations:

MONDAY - FRIDAY: 8:30 AM – 5:30 PM

SATURDAY 8:30 AM - 5:30pm

AFTER HOURS, WEEKENDS AND HOLIDAYS – ON CALL

Phone Numbers:

Phone: 1-844-215-4264

Fax: 1-844-215-4265

Referrals may be faxed to Integrated Health, Inc. at any time, 24 hours a day, and 7 days a week.

https://providers.univitahealth.com/

https://providers.univitahealth.com/


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Referral Process:

All referrals/orders must be faxed to Integrated at 1-844-215-4265. With the

exception of Nebulizer Closets and Pediatric Providers (Please see below)

All Nebulizer Consignment Closet Authorization request must be faxed to (844)215-4265

All Pediatric Suppliers must FAX all referrals/orders to the central intake designated

FAX Number: 844-215-4265

Integrated digitizes the physician orders and routes them to the network provider.

All referral/orders must be sent directly from Integrated to the DME provider with

authorization in order to avoid nonpayment of services.

All DME orders will be sent through the Medtrac system

to the network provider who will then review the order/referral, assign that order to

one of their drivers to perform the delivery, then close out the order in the Medtrac

Portal and upload/export all of the appropriate documents.

Initial Authorizations: Integrated will provide your initial administrative authorization via the Medtrac system along with the physician orders. The network provider will then review the order/referral, assign that order to one of their drivers to perform the delivery, then close out the order in Medtrac and upload/export all of the appropriate documents.


52

Eligibility: Integrated will verify eligibility of the member. *It is recommended that providers also verify

eligibility on a monthly basis.

DME Reauthorizations:

Reoccurring rental items: Provider will receive the initial authorization number for rental items,

this will be the same authorization number utilized throughout the rental period with the

following exceptions:

1. If patient becomes ineligible with the health plan

2. If patient becomes ineligible for the equipment

It is the responsibility of the Network Provider to verify eligibility monthly and contact

Integrated if the patient/member is no longer active or if the member has changed Health plans

in order for us to re-issue the authorization as needed.

Supplies (Sale Items): Provider is to request authorization for supplies before each delivery via

fax 844-215-4265.

*Services must NOT be provided until additional authorizations have been received.

PICK UP Items: Provider is to Fax in the signed pick up order to 1-844-215-4265 once pick up is

completed.

Notification of Delivery / Close Orders:

Providers are required to close order within 72 hours of the delivery date. Procedures

are as follows:

Via the Medtrac system ( Provider Portal)

Upload signed work orders/ delivery ticket and the required documents to

the FTP site in order to ensure processing of claims.

https://apps.all-medservices.com/medtrac/


53

Delay in Service:

Any delay in service (services or equipment that is provided outside of the times set in

Integrated’s service standards listed below) MUST be communicated to Integrated and ordering

physician. If a delay in service occurs, the process for notification is a follows:

DME: Fax notification to 1-844-215-4265 (The form follows at the end of this

document). ALSO call in to 1-844-215-4264 for any STAT delays.

Provider must call Integrated at 1-844-215-4264 to inform Integrated of the delay in

order for us to reprocess order as needed or inform Health Plan.

If a DME item is unavailable or not in stock provider must QA the item back to Integrated through

the Medtrac System (Provider Portal)

Integrated’s Service Standards:

STAT orders –MUST note as STAT to alert intake coordinator

Service standards for DME deliveries:

Discharges: delivery within 4 hours upon receipt of complete orders. Portable Oxygen

will be delivered to the hospital for transportation

Routine deliveries: Next day delivery or as scheduled with the patient

Ostomy / Urological Supplies: please specify supply items and quantity

Billing and Claims:

Claims: All claims must be submitted on approved red/CMS HCFA 1500 red and white claim

form version 02/12. If you are using practice management software (Availity) to submit

claims electronically, your system needs to be set up with the payer ID


54

Billing Codes: Only contracted procedure codes and authorized services will be paid.

Provider must only use procedure codes and HCPC codes that are detailed on the contract,

Letter of Agreement or Authorization received.

Paper Claims: Must be submitted on the Professional 1500 HCFA Claim Form Version

02/12, any claims submitted on 1500 Version 08/05 will be rejected as of April 1, 2014.

(Please review CMS changes for further detail) Copies of the form cannot be used for

submission. Data must be typed not handwritten. Authorization number must include any

hyphens (entire auth #- 123456-1-1234) Box 23. NPI # of rendering location must be in Box

32a. Any claims not in this standard format will be denied / rejected.

Timely Filing: All claims must be submitted 60 days from the date of service; this is

effective as of 11/1/2015. For resubmittal / corrected claims it is 60 days from the

Explanation of Payment

(EOP) disposition.

Claims submission address (for paper claims):

Integrated Home Care Services, Inc

3700 Commerce Parkway

Miramar FL, 33025


55

FAQ & Who Do I Call?

Pharmacy – IV Medications Jessie Gomez Pharmacy Intake Specialist 844-215-4264 ext. 7359 Jennifer De La Rosa Pharmacy Intake Specialist 844-215-4264 ext. 7360 Home Health Services – Skilled Nursing or Therapies

Maria Garron, BSN Director of Home Health 844-215-4264 ext. 7361

DME - Authorization Inquires

Yari San Jorge Director of Customer Service 844-215-4264 ext. 7328 Nicole Falconer Director of Referrals 844-215-4264 ext. 7367 TPA - Claims Inquires

Petra Mendoza Claims Manager 844-215-4264 ext. 7365

Odalys Alfaro Claims Examiner 844-215-4264 ext. 7417

Network / Contracting Specialists Janet Palmer Network / Contract 844-215-4264 [email protected] Querby Metayer Credentialing Specialist 844-215-4264 [email protected]


56

DME Delay of Service Report FAX: 1-844-215-4265

Date: __________ Authorization # ________________________ DME Provider (company name): ______________________________ Patient's Last Name: __________ First Name: _________ MI: ______ Insurance Company: __________ Date Dr. Notified, _______________ Original Visit Date: Actual Date of Visit: ______________________________

□ Reason for delay of service:

□ Patient refused service

□ No answer at door

□ Patient not discharged

□ MD appointment

□ Other: _______________________________________________

□ Type of equipment to be delivered:

□ Wheelchair

□ Walker

□ Bed

□ Commode

□ Cane/Crutches

□ Respiratory/Oxygen

□ OTHER ________________________ DME provider name (of company) _________________________________ Name of Delivery Personnel ________________________________________


57

GENERAL CLAIMS AND REIMBURSEMENT INFORMATION

MMA - Managed Medical Assistance program

Who MAY participate? The following individuals may choose to enroll in program:

Individuals who have other creditable health care coverage, excluding Medicare;

Individuals age 65 and over residing in a mental health treatment facility

meeting the Medicare conditions of participation for a hospital or nursing facility;

Individuals in an intermediate care facility for individuals with intellectual

disabilities (ICF‐IID); and Individuals with intellectual disabilities enrolled in the home and community

Based waiver pursuant to state law, and Medicaid recipients Where will recipients receive services?

Several types of health plans will offer services through the MMA program:

Standard Health Plan Health Maintenance Organizations (HMOs) Provider Service

Networks (PSNs)

Specialty Plans

Comprehensive Plans

Children’s Medical Services Network

What providers will be included in the MMA plans?

Plans must have a sufficient provider network to serve the needs of their plan enrollees, as determined by the State.

MMA plans may limit the providers in their networks based on credentials, quality indicators, and price, but they must include the following statewide essential providers:

Faculty plans of Florida Medical Schools;

Regional Perinatal Intensive Care Centers (RPICCs);

Specialty Children's Hospitals; and

Health care providers serving medically complex children, as determined by the State.


58

Claims Process

Claims are processed based on the Integrated authorization.

For all plans, providers are responsible for confirming eligibility and benefits with the member’s health plan for ongoing or add-on services. Failure to do so could lead to claim rejections and denials. It is imperative to check eligibility and benefits to ensure the member’s plan has not changed. To expedite payment of claims, the Provider should match the billable services against the authorization and your contracted Provider crosswalk. Claims for services, date of service or units that do not exactly match the authorization may be rejected or denied in part or in whole. Alternatively, if the Provider bills for a higher level of service, equipment or supply than the level authorized, payment may be made in accordance with the rate associated with the authorized service, equipment or supply, and Provider will accept that rate as payment in full.

Claims will be paid based on the lower of the Provider’s usual billed charge or the contracted/negotiated rate.

Authorization of services is not a guarantee of payment, and payment of services rendered is subject to the patient’s eligibility and coverage on the date of service, the medical necessity of the services rendered, coverage requirements, the applicable payer’s payment policies, including but not limited to, applicable the payer’s claim coding and bundling rules, Integrated’s claim coding and bundling rules and compliance with the Provider’s contract with Integrated. By submitting a claim for payment to Integrated, the Provider is certifying that it has met the above requirements, that the service has been rendered and that it has a record of all necessary documentation to support the foregoing. Claims that are not submitted within the timeframes set forth in the Provider Agreement and in accordance with the requirements of the Provider Agreement, this Provider Manual and the applicable health plan may be denied.


59

Checking Reimbursement Status

Providers should utilize the Integrated Provider portal to check the status of their claims.

Claim Form and Clean Claim Requirements

Claims must be submitted electronically or on standard paper claims forms (CMS 1500 or UB-

04). Home Health Providers must submit claims on an 837I or UB-04. Our required clean claim

data elements for both electronic and paper claims include the following:

Patient name, Subscriber ID number (including any prefix and/or suffix as

appropriate), address, relationship to subscriber, gender, and date of birth

Insurance name, group name and group number

Subscriber name, address, and gender

Place of service code

Primary diagnosis code(s) V codes will not be accepted as the

primary diagnosis code and Provider is expected to follow all ICD coding rules

Rendering Provider name, service location, and billing address

Rendering Provider National Provider Identifier (NPI) number, Federal Tax ID number,

Medicaid ID number (Medicaid network Providers only), and Taxonomy Code

Referring Provider/physician name and NPI number (837P)


60

Attending Provider/physician name and NPI number (837I)

Individual line level charge for each service

Number of invoiced units for each claim line

Integrated HCPCSS/ CPT code(s) and modifier combination

NDC codes, NDC description, NDC unit of measure, and NDC units (i.e. prescription drugs)

Date of service (FROM and TO required; FROM date, must be before the claim receipt date

and before or equal to the TO date)

Whether the patient’s condition is related to employment, auto accident or other accident

Other insurance information (if other insurance, include other insured’s name, date of

birth, other insurer’s name, group or policy number)

Coordination of benefits information for secondary claims (explanation of payment

from primary carrier)

Service authorization number

Revenue Code (institutional claims)

HIPSS code on all home health claims submitted for Medicare Advantage members

Description of miscellaneous code


61

Claims missing required information or containing incorrect required information may not be

processed. Paper claims without the correct required information may be returned, and the

Provider will be informed of the information that is missing or incorrect. Claims submitted

electronically without correct required information may be rejected by the clearinghouse with

corresponding reasons for the rejection. Such incomplete claims must be resubmitted by the

Provider to Integrated so that a complete or clean claim is received by Integrated within the

original timely filing timeframe as specified below subject to applicable law.

Integrated reserves the right to update, modify, and/or clarify HCPCS codes in accordance with

federal, state, or other regulatory bodies. It is the Provider’s responsibility to regularly check the

Integrated portal for updates to HCPCS codes, descriptions, and the Integrated billing crosswalk.

The current billing crosswalk can be found at: https://apps.ihcscorp.com/medtrac/.

Integrated will only accept original documents for payment consideration that are typed in

indelible ink without erasures, strikeovers, whiteout or stickers. Dot matrix printers should not

be used when typing information onto paper claims forms. Claims with handwritten

information will be rejected. Also, it is important that the name of the Provider organization

and service location on the claim match the Provider name on the related authorization form(s).


62

With regard to services delivered, the claim must include a description of the service

provided (i.e. “RN visit” or “CPAP rental”) as well as the relevant HCPCS, CPT or revenue

code and applicable modifier(s) found on the Integrated Service Authorization Form or the

billing crosswalk (located at www.Integratedportal.com). Claims without a description of the

service provided will be returned. The address to which claims should be sent is found in the

lower portion of the authorization form. Services should be billed at the contracted rates or

authorized rates as appropriate. The Provider Agreement rate is payment in full for covered

services and is all inclusive. Provider is not entitled to receive additional compensation

for covered services, including but not limited to, compensation for copies of records, sales

tax, reports, or other services contemplated by the Provider Agreement. No billing to the

patient or Health Plan of the difference between the negotiated or contracted rate and

the Provider’s list price is permitted. If Provider’s billing system is unable to support billing at

the contracted rate, the difference between the contract rate and Provider’s list price must

be adjusted off Provider’s accounts receivable. Doing so can help Provider avoid repeated

claims inquiries and in addition, when billing for custom equipment, the claim must reflect

the full rate, the discount as negotiated, and the net price. Provider must attach to the claim

the manufacturer’s specification sheet for the equipment. For custom equipment, you may

be instructed to complete 2 claims if required for specific Integrated Health Plan contracts.


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Claims submitted without all required information may be rejected or denied.

With respect to applicable sales tax, as indicated above, your network contract rate is

inclusive of any applicable sales tax. It is your obligation to 1) calculate and identify on your

claim that portion of your contract rate that is attributable to applicable sales tax; and 2)

remit the applicable sales tax amount to the appropriate regulatory authority.

For electronic claims processed through our Claims 2.0 platform, Integrated will utilize the

following electronic transaction messaging:

Integrated will transmit a 277CA - Accepted without Adjudication (AWA) for each

837 received and accepted by Integrated. Providers will not receive a full

acceptance (277CA – Acceptance) until Integrated receives the 277CA acceptance

from the Health Plan.

Integrated will transmit a 277CA - Acceptance after the Health Plan sends

Integrated a 277CA acceptance response.

Integrated will transmit a 277CA - Rejection, as applicable. The reasons for rejection

will be included in a single notification.


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Timely Filing

Clean claims must be filed at the address designated by Integrated within the time frame

described in the corresponding Provider Agreement or within the period of time required

by applicable law if longer. Claims received by Integrated after the filing deadline may be

denied, and Providers cannot bill the patient for such services. Note that Integrated may pay

some claims that were not submitted timely to Integrated if we believe there may still be time

to timely bill and receive payment from the Health Plan. However, please be aware that, if

the Payer does not pay the claim in full, Integrated may later deny the claim for failure to

timely file and recoup the prior payment.

Utilization Management Issues

Unless otherwise indicated by Integrated, Integrated does not perform appeals of utilization

management decisions, and the member appeal process is not delegated to Integrated.

Appeals of utilization management decisions by or on behalf of the member should be directed

to the appropriate payer.


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CLAIMS PAYMENT ISSUES

Corrected Claims

If you receive a denial from Integrated, and you agree with the denial, you can correct the

issue identified in the denial and resubmit the claim as a corrected claim. If submitted on

paper, the corrected claim must include clearly visible markings that indicate the claim has

been corrected.

Providers must send paper corrected claims to:

Providers that wish to submit paper corrected claims via Federal Express, UPS or

Certified Mail must send the corrected claims to:

Please note that corrected claims must be received by Integrated within the original timely

filing timeframe in order to be payable.

Claims Inquiries

Providers can submit claims inquiries through the Integrated Provider Portal


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Reconsideration

If you receive a payment from Integrated that is different from what you expected, you should

first try to understand the difference and reconcile the discrepancy. If you cannot reconcile

the discrepancy and wish to request a reconsideration, you must submit a request for

reconsideration in writing using our Claim Reconsideration Form which can be found on our

Provider portal at https://apps.ihcscorp.com/medtrac/. Prior to submitting a reconsideration

request, you should confirm:

1. If the claim was rejected or denied. Rejected claims can be resubmitted without

submitting a reconsideration request.

2. If the original claim has been altered in response to the denial. Only original claims

that do not require changes in response to the denial should be submitted as a claims

reconsideration request. Claims requiring correction to address the issue causing the

denial should be submitted as corrected claims.

Providers must send requests for reconsideration to:

Providers that wish to submit a request for reconsideration via Federal Express, UPS

or Certified Mail must direct the request for reconsideration to:

Your request for reconsideration must be received by Integrated at the designated address

within 45 days after the date of our explanation of payment, or within the period of time

permitted by applicable law if longer.


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After receipt of your completed request for reconsideration, we will research your concern

and respond to you as soon as possible. If the request for reconsideration is resolved in your

favor, the claim will be adjusted and an explanation of payment (EOP) issued. If it is not

resolved in your favor, you will be advised to submit an appeal in writing using our Appeal

Form which can be found on our Provider portal at https://apps.ihcscorp.com/medtrac/.

Please note that, if changes are required to the original claim, in lieu of submitting an appeal,

Providers should submit a corrected claim in accordance with our corrected claim process.

Providers must send completed Appeal Forms to:

Providers that wish to submit an appeal via Federal Express, UPS or Certified Mail

must direct the completed Appeal Form to:

Providers can submit the completed Appeal Form through our Provider Portal.

Your appeal must be received by Integrated within 30 days from the date of our written

notice (EOP, letter, etc.) advising that your request for reconsideration was not resolved in

your favor or within the period of time permitted by law if longer.


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Appeals

Our Appeals Unit will endeavor to complete the review of your appeal within 30 calendar

days of the date the Appeals Unit receives all information necessary to review your appeal.

We will communicate the results of our review of your Appeal in writing which may include,

when payment is issued, a check along with an explanation of payment.

Integrated Network Providers may not bill a patient or that patient’s insurance company (if

the insurance company is an Integrated client) during the reconsideration or appeals process or for a

balance remaining after a decision has been made on an Integrated Network Provider appeal.


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Dispute Resolution

If the Provider is not satisfied with the resolution of the appeal, the Provider may request in

writing that the parties attempt in good faith to resolve the dispute promptly by negotiation

between representatives of the parties who have authority to settle the dispute within 60

days of the date of the appeal decision letter. If the matter is not resolved within 60 days of

the Provider’s written request for such negotiation, the Provider may submit the matter

for resolution in accordance with the dispute resolution process outlined in the Provider’s

contract with Integrated. The right to submit the matter for dispute resolution will be waived

if the matter is not submitted for dispute resolution within 120 days of the date of the

appeal decision letter or within the time period required by applicable law if applicable

law requires a time period longer than such 120 day period. If the Provider Agreement does

not provide for a specific dispute resolution mechanism, the following dispute resolution

process shall apply to the extent permitted by applicable law:

Your appeal must be received by Integrated within 30 days from the date of Integrated’s

termination notice or the period of time required by law if longer. Your appeal will be

handled in accordance with any appeal processes required by applicable law, and we will

endeavor to complete our review of your appeal within 30 calendar days of the date we

receive your appeal. We will communicate the results of our review of your appeal in writing.

If you are dissatisfied with the results of your appeal, you may request that the termination

be reviewed in accordance with the Dispute Resolution and Binding Arbitration provisions

set forth above.


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CUSTOMER ACKNOWLEDGEMENT AND RESOLUTION MANAGEMENT

Complaint, audit and resolution management allows for the prompt resolution of inquiries,

complaints and concerns expressed from an external source, whether that is a member,

Provider or other complainant. As a Provider, you are expected to submit patient records or

to provide additional information and documentation, as requested and at no charge, so

that a complaint or audit may be investigated and resolved. It is important that documents

are submitted to Integrated within the requested timeframe. If a request for records is

received directly from a Health Plan, please notify your Integrated Provider Operations

contact.

Provider specific complaint data is tracked, trended, analyzed and used during the re-

credentialing process and to promote on-going process improvement. If an adverse trend is

identified, Integrated may initiate appropriate corrective action. This action may be in the

form of, but is not limited to, verbal counseling, written warning, a formal corrective action

plan or, in the most severe instances, termination from the network. Providers are required

to comply with corrective action plans required by Integrated to address quality of care,

quality of service or other issues related to the Provider’s failure to comply with the

Provider’s obligations under the Provider Contract, this Provider Manual, or applicable law.

All downstream providers must be aware that Integrated Home Care Services, Inc. is

responsible for monthly ODAG (Organizational Determination) reports to be sent to our

participating plan partners. In order to extract this data, all orders must contain sufficient data

for the following service points:


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Notice Requirements for Standard Organization Determinations

When an enrollee has made a request for a service, the Medicare health plan must notify the enrollee of its determination as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after the date the organization receives the request for a standard organization determination.

Notice Requirements for Expedited Organization Determinations

A Medicare health plan that approves a request for expedited determination must make the determination and notify the enrollee and the physician involved, as appropriate, of its determination as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after receiving the request. Although the Medicare health plan may notify the enrollee orally or in writing, the enrollee must be notified within the 72 hour time frame. Mailing the determination within 72 hours in and of itself, is insufficient. The enrollee must receive the notice in the mail within 72 hours. If the Medicare health plan first orally notifies an enrollee of an adverse expedited determination, the Medicare health plan must mail written confirmation to the enrollee within three calendar days of the oral notification.

Notice Requirements upon Denial of a request for an Expedited Organization Determination

If a Medicare health plan denies a request for an expedited organization determination, it must automatically transfer the request to the standard time frame and make a determination within 14 calendar days (the 14-day period starts when the request for an expedited determination is received by the Medicare health plan), give the enrollee prompt oral notice of the denial including the enrollee’s rights, and subsequently deliver to the enrollee, within 3 calendar days, a written letter of the enrollee’s rights.


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Notice Requirements to Extend the processing timeframe of an Organization Determination

The Medicare health plan may extend the time frame up to 14 calendar days. This extension is allowed to occur if the enrollee requests the extension or if the organization justifies a need for additional information and documents how the delay is in the interest of the enrollee (for example, the receipt of additional medical evidence from non-contract providers may change a Medicare health plan’s decision to deny). When the Medicare health plan grants itself an extension to the deadline, it must notify the enrollee, in writing, of the reasons for the delay, and inform the enrollee of the right to file a grievance if he or she disagrees with the Medicare health plan’s decision to grant an extension. The Medicare health plan must notify the enrollee, in writing, of its determination as expeditiously as the enrollee’s health condition requires, but no later than the expiration of any extension that occurs, in accordance with this chapter

Notice of Denial of Payment If the Medicare health plan decides to deny services or payments, in whole or in part, or discontinues/reduces a previously authorized ongoing course of treatment, then it must give the enrollee a written notice of its determination

Notice Requirements for Non-Contracted Providers If the Medicare health plan denies a request for payment from a non-contract provider, the Medicare health plan must notify the non-contract provider of the specific reason for the denial and provide a description of the appeals process.

Notice of Medicare Non-Coverage (NOMNC) Consistent with 42 CFR 422.624(b)(1), providers must distribute the NOMNC at least two days prior to the enrollee’s CORF or HHA services ending and two days prior to termination of SNF services (last covered day).

Detailed Explanation of Non-Coverage (DENC) The DENC is a standardized written notice that provides specific, and detailed information to Medicare enrollees concerning why their SNF, HHA, or CORF services are ending (see Appendix 9). The DENC meets the notice requirements set forth in 42 CFR 422.626(e)(1). The Medicare health plan (or the provider by delegation) must issue the DENC to the enrollee (with a copy provided to the QIO) whenever an enrollee appeals a termination decision about their SNF, HHA or CORF services.

Notice of Action Letters (NOA) The Managed Care Plan shall notify the provider and give the enrollee written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration or scope that is less than requested.


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COMPLAINTS AND GRIEVANCES

The Company is committed to resolving all patient and provider Complaints, quality of care

concerns and including allegations of fraud, waste or abuse, hereafter referred to collectively for

this policy as “Complaints”. The Company has established a standard process to ensure that all

Complaints are received, documented and reconciled in accordance with law and regulations,

accreditation standards, contractual obligations and respect for patients. All patients are

provided with a written description of the process to express a Complaint to the Company. The

Company monitors and analyzes Complaints to identify opportunities to improve the product and

services provided. The Company will report Complaints received to the designated payer as

required by each contract and report 99% of such notices within 7 business days for standard

Complaints and 24 hours for urgent Complaints.

Reference:

ATTACHMENT II: MMA CORE CONTRACT PROVISIONS

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Attachment_II-

Core_Contract_Provisions_2015-11-01.pdf

ATTACHMENT II EXHIBIT II-A (MMA) PROGRAM

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Exhibit_II-A-

Managed_Medical_Assistance_MMA_Program_2015-11-01.pdf

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Attachment_II-Core_Contract_Provisions_2015-11-01.pdf

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Attachment_II-Core_Contract_Provisions_2015-11-01.pdf

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Exhibit_II-A-Managed_Medical_Assistance_MMA_Program_2015-11-01.pdf

https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/2015-11-01/Exhibit_II-A-Managed_Medical_Assistance_MMA_Program_2015-11-01.pdf


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Definitions:

Complaint: Any expression of dissatisfaction with products and/or services to the Company, a

health plan, provider, facility or Quality Improvement Organization (QIO) by an enrollee made

orally or in writing. This can include concerns about the operations of the Company, providers or

health plans such as: waiting times, the demeanor of health care personnel, the adequacy of

facilities, the respect paid to enrollees, the claims regarding the right of the enrollee to receive

services or receive payment for services previously rendered. It also includes a plan’s refusal to

provide services to which the enrollee believes he or she is entitled. A complaint could be either

a grievance or an appeal, or a single complaint could include elements of both. Every complaint

must be handled under the appropriate grievance and/or appeal process described in this Policy.

[FL Medicaid Medical Assistance Program (FL MMA): A complaint not resolved by close of

business on the day following receipt of the complaint must be classified as a grievance.]

Grievance: Any complaint or dispute, other than an organization determination, expressing

dissatisfaction with the manner in which a health plan or delegated entity provides health care

services, regardless of whether any remedial action can be taken. An enrollee or their

representative may make the complaint or dispute, either orally or in writing, to the Company, a

health plan, provider, or facility. An expedited grievance may also include a complaint that a

health plan refused to expedite an organization determination or reconsideration, or invoked an

extension to an organization determination or reconsideration time frame. [FL MMA: Health

Plans must provide members written acknowledgment of receipt of a grievance within five (5)

business days of the filing of the grievance.]

Inquiry: Any oral or written request to the Company, a health plan, provider, or facility, without

an expression of dissatisfaction, e.g., a request for information or action by an enrollee. Inquiries

are routine questions about benefits (i.e., inquiries are not complaints) and do not automatically

invoke the grievance or organization determination process.


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PROCEDURE – MEMBER COMPLAINTS:

1. Members/Patients may express their Complaints verbally, or in writing, to any member

of the staff. Complaints may be received in person, by phone, fax, mail or e-mail. Contact

information for Complaint reporting:

a. Complaints are categorized as one of the following:

i. Tier I Complaint - expression of general dissatisfaction with a

Company service, item, employee or otherwise, no further action

required to resolve the member’s/patient’s concerns.

ii. Tier II Complaint - urgent or high, service that is outstanding,

order has not been closed and patient has active needs that have

not been addressed, quality of care concerns of a patient on

service, allegations of fraud, waste or abuse or privacy violations.

2. Department Managers, Supervisors, and Account Managers are encouraged to report

Complaints to the Customer Care Pod to ensure a complete and timely reconciliation of the

event.

3. Employees who receive Complaints or other expressions of dissatisfaction with a product

or service provided by the Company will promptly report the event to his/her supervisor. The

supervisor will report the Complaint to the Customer Care Pod. The Customer Care Pod will

document the Complaint in the Complaints and Grievances SharePoint Site. The employee and

his/her supervisor who receive the initial call will also verbally respond to the patient in real time

(i.e., while the patient or caller is on the telephone, or by a return telephone call) and make every

reasonable effort to reconcile the concern and address any outstanding service items. The

employee will document such efforts in the patient’s electronic


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medical record under Patient Notes, if applicable, and record the resolution and appropriate Tier

in the Grievances and Appeals SharePoint Site.

4. Complaints may also be received directly from a health plan customer. Each health plan

customer will be directed to deliver all provider and member/patient Complaints to a Company

lead account manager. The lead account engagement employee will immediately report the

Complaint to the Customer Care Pod. The Customer Care Pod will document the Complaint in

the Complaints and Grievances SharePoint Site. A Customer Care Pod employee and his/her

supervisor will verbally respond to the patient in real time (i.e., by a return telephone call) and

make every reasonable effort to reconcile the concern and address any outstanding service

items. The Customer Care Pod employee will document such efforts in the patient’s electronic

medical record under Patient Notes, if applicable, and record the resolution and appropriate Tier

in the Grievances and Appeals SharePoint Site.

5. Complaints documented in the Complaints and Grievances Share Point Site will send an

email notification to the Customer Care Pod (for Member Complaints), the Chief Compliance

Officer, Clinical Division, the designated Compliance representative, and the lead account

manager for Complaints initiated by the health plan.

A. The lead account manager will provide written or secure email notice to the health plan

customer that a Complaint has been received. For Tier I Complaints, the notice will

confirm the nature of the Complaint and the resolution. For Tier II Complaints, the

notice should confirm the nature of the Complaint and that a written response will be

provided. (FL MMA: All notices of receipt of a complaint will be provided to the health

plan no later than close of business on the day following receipt of the complaint. A

complaint not resolved by close of business the day following receipt of the complaint

shall be labeled as a “grievance”.)


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B. For Tier II Complaints, the Customer Care Pod will investigate and provide a response to

the designated Compliance representative verbally, or in writing and will document the

investigation results in the patient’s/member’s electronic medical record. The designated

Compliance representative will ensure that a written response to Tier II Complaints is

prepared and provided to the lead account manager for the health plan customer. The

lead account manager will provide the written response to the health plan. After a

response has been provided the designated Compliance representative will close the

Complaint in the Complaints and Grievances SharePoint Site.

C. The Company will respond to Complaints within the time frame required by the

applicable health Plan customer. Absent a specific health plan requirement, the

Company will respond to 99% of urgent and open service Complaints within 24 hours

and 99% of standard Complaints within 7 business days.

D. Any Complaint that appears to be the result of process failure, gross negligence,

fraud/waste/abuse, quality of care, or potential litigation, must be forwarded to the

Chief Compliance Officer for reconciliation and formal response as soon as reasonably

possible, but no later than 24 hours after receiving the Complaint.

6. In the event that a Complaint involves a patient/member who has not received care and

patient safety or quality of care concerns is evident, the lead account manager for the

health plan or the Customer Care Pod Representative will provide a timeline and pertinent

information to the Line of Business (LOB) leader so they can take necessary steps to

expedite care to the patient. Each LOB will provide an escalation list to the account

managers and the Customer Care Pod Representatives.


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7 When deviations in process, failure to follow policy/protocol or policy/protocol is

ineffective, the Customer Care Pod will notify the business leader to initiate process

review and/or employee counseling. At the same time, the Department of

Compliance, Quality & Regulatory Affairs will be notified. Appropriate referrals to the

Quality Improvement Chairperson(s) will be facilitated by the Quality Manager and

monitoring of corrective actions will be reported through the QM Program.

8 The Compliance Officer, Clinical Division, or his/her designee, monitors all reported

concerns and Complaints received. All Tier M II and formal written responses must be

reviewed by Compliance prior to submission.

9 Members/Patients have the right to notify any external patient quality control

organization with concerns or dissatisfaction they experienced with any service or

product provided by the Company. This includes organizations such as Accreditation

Commission for Health Care (ACHA) at 855-937-2242 or by writing to ACHC 139

Weston Oaks Ct. Cary, NC 27513 and/or the Food & Drug Administration. The State

toll-free hotline number is also provided within the Patient Handbook.

10 The Compliance Department monitors and measures all Complaints received. The

data is aggregated no less than quarterly to identify potential adverse trends and

opportunities for improvement. The Compliance Department reports the Complaint

metrics to the applicable Clinical Operations Quality Management Committees and

Clinical Division Leadership.

11 The Clinical Operations Quality Management Committee reviews the Complaint data

to ensure that the Company is meeting its operational performance metrics. In the


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event that any Complaint category reaches or exceeds 1% of the total volume of

services provided by any LOB in a given reporting period, immediate interventions may

be imposed by the President and General Manager with the Compliance Officer, and

Clinical Division.

12 When operational performance does not meet Company expectations, an internal

corrective action plan may be initiated by the LOB. The Compliance Department will

support each corrective action plan and may independently issue corrective action

plans for significant operational performance challenges.

13 All new employees are oriented to this policy during their new hire process, not to

exceed 90 days from the date of hire, and annually.

PROCEDURE – PROVIDER COMPLAINTS

1. Provider Complaints are received, documented and processed through the

Provider Relations department. It is the role of the Provider Relations

Representative to follow Provider Relations Complaint process in

responding to all provider Complaints, and to record all provider

Complaints in the Complaints and Grievances SharePoint site. The

Compliance Department may assist in such investigations. When the

Complaint has been identified as a quality concern, the Complaint will be

investigated by the Compliance Department.


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Definition:

Provider / Claims Complaint - is defined as a provider or provider representative call, expressing

concerns for claims not paid or general provider issues surrounding matter for services

PROCEDURE

a) The Provider Relations Representative documents all provider claim complaints in the

system for tracking purposes.

b) The name of the provider, along with the date the complaint was received, and with a

description of the complaint(s)

c) The provider will need to submit the claims in question along with any available EOBs

electronically to the Provider Relations Representative.

d) The Provider is mailed written notification of acknowledgment along with the appeal

e) Once the claims and the EOBs are received, The Provider Relations Representative will

audit the claims to determine cause for denial.

f) If an error occurred due to an internal process, the Provider Relations Representative

will contact the claims examiner and advise of error and make immediate adjustment in

the Plexis system. The provider will be contacted and advised of the error and a

payment will be released on the first available check cycle.

g) If the denial was caused due to a provider related error, the provider is then contacted

and re-training will be conducted.


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h) Once completed provider will be required to resubmit corrected claims for reprocessing,

prior to the timely filing deadline.

i) The Provider Relations Representative is required to mail out to the provider a written

notification of resolution and to include the appeals rights.

j) Once completed provider will be required to resubmit corrected claims for reprocessing,

prior to the timely filing deadline.

k) The Provider Relations Representative will continue to monitor the provider for 60 days

to ensure accuracy and understanding to the claims process

l) After the 60 days the provider will receive a letter stating that during the 60 days all

claims were received and processed with no issues.

m) A quarterly report of all retrained providers, is generated and forwarded up to the Chief

Operating Officer for a signature.

Provider Complaint System

IHCS maintains a provider complaint system that permits a provider to dispute

IHCS’s policies and Procedures, or any aspect of the administrative functions,

including proposed actions and claims

IHCS has a copy of the provider complaint system policies and procedures in its

handbook

The IHCS Complaint system policy and procedures, includes distribution of the

provider complaint system policies, to include claims issues, to out of-network

providers upon request.


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IHCS will distribute a summary of these policies and procedures, the summary

will include information about how the providers may access the full policies and

procedures on the IHCS website. The summary will include details on how the

downstream providers may obtain a hard copy from IHCS at no charge.

IHCS allows providers 45 calendar days to file a written complaint for issues not

pertaining to claims

The Provider Relations Manager is responsible to investigate each complaint

using applicable statutory, regulatory, contractual provisions.

For more information on the Provider Complaint System please contact the IHCS Provider

Relations Department 1-844-215-4264 EXT # 1534


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