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Provider Manual
Table of Contents
CHAPTER 1 – INTRODUCTION TO MERCY CARE ADVANTAGE HMO
- 1.0 Welcome
- 1.1 About SCHN
- 1.2 Disclaimer
- 1.3 MCA Overview
- 1.4 MCA Policies and Procedures
- 1.5 Eligibility
- 1.6 Annual Notice of Change
- 1.7 Model of Care
- 1.8 CMS Web Site Links
- 1.9 Key Medicare Coverages
CHAPTER 2 - MCA CONTACT INFORMATION
- 2.0 Health Plan Contacts Table
- 2.1 Health Plan Authorization Services Table
- 2.2 Community Resources Contact Information Table
CHAPTER 3 – PROVIDER RELATIONS
CHAPTER 4 – PROVIDER RESPONSIBILITIES
- 4.0 Provider Responsibilities Overview
- Providing Member Care
- 4.1 Medicare/AHCCCS Registration
- 4.2 Medicare Opt Out Providers
- 4.3 Appointment Availability Standards
- 4.3 – Appointment Availability Standards Table
- 4.4 Telephone Accessibility Standards
- 4.5 Covering Physicians
- 4.6 Verifying Member Eligibility
- 4.7 MercyOneSource
- 4.8 Member Temporary Move Out of Service Area
- 4.9 Coverage of Renal Dialysis – Out of Area
- 4.10 Health Risk Assessment
- 4.11 Preventive or Screening Services
- 4.12 Educating Members on their own Health Care
- 4.13 Emergency Services
- 4.14 Urgent Care Services
- 4.15 Specialist Providers
- 4.16 Women's Health Specialists
- 4.17 Direct-Access Immunizations
- 4.18 Second Opinions
- 4.19 Provider Assistance Program for Non-Compliant Members
- 4.1 Medicare/AHCCCS Registration
- Documenting Member Care
- 4.20 Member's Medical Record
- 4.21 Access to Facilities and Records
- 4.22 Confidentiality and Accuracy of Member Records
- 4.23 Advance Directives
- 4.24 Medical Record Audits
- 4.25 Documenting Member Appointments
- 4.26 Missed or Cancelled Appointments
- 4.27 Documenting Referrals
- 4.28 Respecting Member Rights
- 4.29 Provider Marketing
- 4.30 Health Insurance Portability and Accountability Act
of 1997 (HIPAA)
- 4.31 Cultural Competency
- 4.32 Health Literacy – Limited English Proficiency (LEP)
or Reading Skills
- 4.33 Individuals with Disabilities
- 4.34 PCP Assignments
- 4.35 Plan Changes
- 4.20 Member's Medical Record
- Provider Guidelines and Plan Details
- 4.36 Cost Sharing and Coordination of Benefits
- 4.37 Practice Guidelines
- 4.38 Office Administration Changes and Training
- 4.39 Contract Additions or Physician Terminations
- 4.40 Continuity of Care
- 4.41 Contract Changes or Updates
- 4.41 – Provider Record Updates Table
- 4.42 Credentialing/Re-Credentialing
- 4.43 Licensure and Accreditation
- 4.44 Receipt of Federal Funds, Compliance with Federal Laws
and Prohibition on Discrimination
- 4.45 Financial Liability for Payment for Services
- 4.36 Cost Sharing and Coordination of Benefits
CHAPTER 5 – COVERED AND NON COVERED SERVICES
CHAPTER 6 – BEHAVIORAL HEALTH
- 6.0 Behavioral Health Overview
- 6.1 RBHA Services and MCA Members
- 6.2 RBHA Covered Services
- 6.3 MCA Behavioral Health Emergency Services
- 6.4 PCP Responsibilities for MCA Care Behavioral Health Services
- 6.5 Coordination of Care
CHAPTER 7 – DENTAL AND VISION SERVICES
CHAPTER 8 - CASE MANAGEMENT AND DISEASE MANAGEMENT
- 8.0 Case Management and Disease Management Overview
- 8.1 Referrals
- 8.2 Case Management
- 8.3 HIV/AIDS
- 8.4 Disease Management
- 8.5 Asthma
- 8.6 Chronic Obstructive Pulmonary Disease (COPD)
- 8.7 Congestive Heart Failure (CHF)
- 8.8 Diabetes
- 8.9 Active Health
CHAPTER 9 – CONCURRENT REVIEW
- 9.0 Concurrent Review Overview
- 9.1 Milliman Care Guidelines®
- 9.2 Discharge Planning Coordination
- 9.3 Physician Medical Review
CHAPTER 10 – PHARMACY MANAGEMENT
- 10.0 Pharmacy Management Overview
- 10.1 Updating the Formulary
- 10.2 Notification of Formulary Updates
- 10.3 Pharmacy Transition of Care Process
- 10.4 LTC/ Nursing Facility
- 10.5 Part D Pharmacy Co-Payments
CHAPTER 11 – QUALITY MANAGEMENT
- 11.0 Quality Management Overview
- 11.1 Quality Management Department Responsibilities
- 11.2 Measurement Tools
- 11.3 Chronic Care Improvement Program
CHAPTER 12 – REFERRALS AND AUTHORIZATIONS
- 12.0 MCA Organization Determination Process
- 12.1 Prior Authorizations (Pre-Service Organization Determinations)
- 12.2 Referrals for Services
- 12.3 Prior Authorization Contacts
CHAPTER 13 - ENCOUNTERS, BILLING AND CLAIMS
- Encounters
- Billing and Claims
- 13.2 When to Bill a Member
- 13.3 When to File a Claim
- 13.4 Timely Filing of Claim Submissions
- 13.5 Cost Sharing and Coordination of Benefits
- 13.6 Injuries Due to an Accident
- 13.7 How to File a Claim
- 13.8a – Claim Form Table
- 13.8b Claims Address Table
- 13.8 Correct Coding Initiative
- 13.9 Correct Coding
- 13.10 Incorrect Coding
- 13.11 Modifiers
- 13.12 Checking Status of Claims
- 13.13 Payment of Claims
- 13.14 Claim Resubmission
- 13.15 Claim Disputes
- 13.16 Non-Contracted Provider Reconsiderations
- 13.17 Provider Payment Dispute Resolution Process for Non-Contracted
Providers
- 13.2 When to Bill a Member
- Instruction for Specific Claim Types
- Remittance Advice
CHAPTER 14 – MCA MEMBER GRIEVANCES AND APPEALS
- 14.0 Grievances
- 14.1 Filing and Resolving Grievances
- 14.2 Quality Improvement Organization - Quality of Care Grievances
- 14.3 Member Initiated Appeals (Reconsiderations)
- 14.4 Filing an Appeal on Behalf of a Member
- 14.5 How to Appoint a Representative
- 14.6 Standard Appeal Resolution
- 14.7 Expedited Reconsideration Resolution
- 14.8 Submitting an Appeal
CHAPTER 15 - MCA MEMBER COVERAGE DETERMINATIONS, EXCEPTIONS, APPEALS AND GRIEVANCES FOR PRESCRIPTION DRUGS
- 15.0 Medicare Prescription Drug Coverage Determinations
- 15.1 Formulary Exceptions
- 15.2 How To File a Part D Prescription Drug Redetermination (Appeal)
CHAPTER 16 – FRAUD, WASTE AND ABUSE
- 16.0 Fraud, Waste and Abuse Overview
- 16.1 Fraud, Waste and Abuse Defined
- 16.2 CMS Requirements
- 16.3 Seven Key Elements to a Compliance Plan
- 16.4 Relevant Laws that Apply to Fraud, Waste and Abuse
- 16.5 Administrative Sanctions
- 16.6 Civil Monetary Penalties (CMPS), Litigation and Settlements
- 16.7 Potential Civil and Criminal Penalties
- 16.8 Remediation
- 16.9 Exclusion Lists
- 16.10 Reporting Potential Fraud, Waste, and Abuse
Provider Manual
CHAPTER 1 - INTRODUCTION TO MERCY CARE ADVANTAGE HMO
1.0 Welcome
Welcome to Southwest Catholic Health Network (SCHN), dba Mercy Care Advantage (MCA)! Our ability to provide excellent service to our members is dependent on the quality of our provider network. By joining our network, you are helping us serve those Arizonans who need us most.
1.1 About SCHN
SCHN, hereafter Mercy Care when referring to all lines of business, is a not-for-profit partnership created in 1985 and sponsored by Catholic Healthcare West and Carondelet Health Network. Mercy Care is committed to promoting and facilitating quality health care services with special concern for the values upheld in Catholic social teaching, and preference for the poor and persons with special needs. Schaller Anderson, an Aetna Company, administers Mercy Care.
Mercy Care has an established, comprehensive model to accommodate service needs within the communities served. This manual contains specific information about MCA to which all Participating Healthcare Providers (PHPs) must adhere. Please refer to Provider Reference Tool on MCA’s web site for a listing of Forms, Provider Claim References and Provider Reference Guides. You can print the MCA Provider Manual from your desktop.
1.2 Disclaimer
Providers are contractually obligated to adhere to and comply with all terms of the plan and provider contract, including all requirements described in this manual, in addition to all federal and state regulations governing the plan and the provider. MCA may or may not specifically communicate such terms in forms other than the contract and this provider manual. While this manual contains basic information about the Arizona Health Care Cost Containment System (AHCCCS) and Centers for Medicare and Medicaid Services (CMS), providers are required to fully understand and apply AHCCCS and CMS requirements when administering covered services.
Please refer to www.ahcccs.state.az.us and http://www.cms.hhs.gov/ for further information on AHCCCS and CMS, respectively.
1.3 MCA Overview
MCA is a Medicare Advantage Special Needs Plan (SNP) covering dual eligible individuals with both Medicare and Medicaid (AHCCCS) medical assistance.
1.4 MCA Policies and Procedures
MCA has robust and comprehensive policies and procedures in place throughout its’ departments that assure all compliance and regulatory standards are met. Policies and procedures are reviewed on an annual basis and required updates made as needed.
1.5 Eligibility
MCA is offered in select counties in Arizona and provides coverage for Medicare Part A and Part B benefits and Medicare Part D prescription drugs. Individuals who meet the following plan eligibility requirements may enroll:
- If entitled to Medicare Part A and enrolled in Part B.
- If currently enrolled in AHCCCS medical assistance.
- Has not been diagnosed with end-stage renal disease (ESRD) (exceptions may apply).
- Permanently resides in Maricopa, Pima or Santa Cruz County.
The Social Security Administration determines Medicare entitlement and eligibility. The Code of Federal Regulations (Title 42, Part 422) outlines the requirements for individuals’ to enroll in Medicare Advantage Plans. AHCCCS determines eligibility for Medicaid medical assistance. If an individual loses eligibility for either AHCCCS or Medicare, MCA is required to end their coverage under MCA.
1.6 Annual Notice of Change
MCA plan benefits are subject to change annually. Members are provided with written notice regarding the annual changes by the date specified by CMS. The CMS Annual Election Period begins on November 15 each year for beneficiaries and ends on December 31. Providers can access the MCA website on or around November 15 for information on the individual plan and benefits that will be available for the following calendar year.
1.7 Model of Care
The Model of Care for the MCA Special Needs Plan (SNP) offers an integrated care management program with enhanced assessment and management for enrolled dual eligible beneficiaries. The processes, oversight committees, provider management, care management, and coordination efforts applied to address beneficiary needs result in a comprehensive and integrated model of care.
This program addresses the needs of beneficiaries who are often frail, elderly, and coping with disabilities, compromised activities of daily living, chronic co-morbid medical/behavioral illnesses, challenging social or economic conditions, and/or end-of-life care issues. Within the MCA program, there are three eligible populations: the dual eligible beneficiaries that qualify for Arizona's Long Term Care (ALTCS) program and dual eligible beneficiaries that qualify for the Acute and DDD programs (i.e. AHCCCS programs).
The program's combined provider and care management activities are intended to improve quality of life, health status, and appropriate treatment. Specific goals of the program include:
- Improving access to essential services such as medical, mental health and social services, and preventive health services;
- To assist beneficiaries in accessing appropriate and timely care (including medical and preventive health services, mental health services, and social services);
- Improving access to affordable care;
- Improve coordination of care through an identified point of contact;
- Improve seamless transitions of care across healthcare settings and providers;
- Assure appropriate utilization of services and assure cost-effective service delivery.
MCA efforts to assure cost-effective health service delivery include, but are not limited to the following:
- Review of network adequacy
- Clinical reviews and proactive discharge planning activities.
- Implementation of an integrated Case Management Program that includes comprehensive assessments, transition management, and provision of information directed towards prevention of complications and preventive care/services.
Many components of an integrated care management program impact beneficiary health. These include:
- Comprehensive beneficiary assessment, clinical review, proactive discharge planning, transition management, and education directed towards obtaining preventive care. These care management elements are intended to reduce avoidable hospitalization and nursing facility placements/stays.
- Identification of individualized care needs and authorization of required home care services/assistive equipment when appropriate. This is intended to promote improved mobility and functional status, and allow beneficiaries to reside in the least restrictive environment possible.
- Assessments and care plans that identify a beneficiary's greatest needs, which are used to direct education efforts that prevent medical complications and promote active involvement in personal health management.
- Case manager referrals and predictive modeling software that identify beneficiaries at increased risk for nursing home placement, functional decline, hospitalization, emergency department visits, and death. This information is used to intervene with the most vulnerable beneficiaries in a timely fashion.
Overall program goals will be evaluated by measuring the following:
- The proportion of beneficiaries that show the minimum number of primary care provider visits during a calendar year.
- Beneficiary satisfaction with health services using the Consumer Assessment of Healthcare Providers and Systems.
- Beneficiary self-rating of overall health.
For additional detail, please refer to Provider Reference Tool, Reference Guides, Mercy Care Advantage Special Needs Population Model of Care.
1.8 CMS Web Site Links
MCA administers the plan in accordance with the contractual obligations, requirements and guidelines established by the Centers for Medicare & Medicaid Services (CMS). There are several web site manuals on the CMS web site that may be referred to for additional information. Key CMS On-Line Manuals are listed below:
1.9 Key Medicare Coverages
- Part A – Hospital Insurance; pays for inpatient care, skilled nursing facility care, hospice and home health care.
- Part B – Medical Insurance; pays for doctor’s services, and outpatient care such as lab tests, medical equipment, supplies, some preventive care and some prescription drugs.
- Part C – Medicare Advantage Plans (MA): combines Part A and B health benefits through managed care organizations; most plans include Part D (MAPD plans).
- Part D – Medicare Prescription Drug Plan: helps pay for prescription drugs, certain vaccines and certain medical supplies (e.g. needles and syringes for insulin). Part D coverage is available as as standalone Prescription Drug Plan (PDP) or integrated with medical benefit coverage (MAPD).
CHAPTER 2 - MCA CONTACT INFORMATION
2.0 Health Plan Contacts Table
| Health Plan | Telephone Number | Health Plan Web Address |
|---|---|---|
| MCA |
(602) 263-3000 (800) 624-3879 toll-free |
www.mercycareadvantage.com |
|
Express Service Codes Providers may use “Express Service” Monday through Friday from 8:00 a.m. to 5:00 p.m. To reach a specific service department:
MCA is available 24 hours a day, seven days a week to assist providers with prior authorization needs. |
||
| Service Area | Express Service Code | |
| Medical Prior Authorization | 622 | |
| Pharmacy Prior Authorization | 625 | |
| Claims | 626 | |
| Member Eligibility and Verification | 629 | |
| Provider Relations | 631 | |
| Provider Credentialing (MCA) | ||
| Providers wishing to contract with MCA may fax a letter of interest with a copy of their W-9 to (860) 975-3201, Attn: Network Development and Contracting. Contract requests will be reviewed and the requesting provider will be notified of contract status. To determine the status of a contract request, please call (602) 453-6148. | ||
| Department | Services |
|---|---|
| Medical or Dental Prior Authorization |
Prior Authorization Department
Medical and Dental Fax: You may also call our main number and use the express service code listed above. |
| MCA Claim Disputes |
Phone: (602) 263-3000 |
| Pharmacy Prior Authorization |
MCA |
| Medical Case Management |
Intake Referral |
| Behavioral Health, including Behavioral Health Crisis Line |
Mercy Care Behavioral Health Coordinator (BHC) The BHC serves as liaison between members, the Plan and RBHA. |
| Community Resource | Contact Information |
|---|---|
| Arizona’s Smokers Helpline (Ashline) |
Address: P.O. Box 210482 |
| Community Information and Referral |
Address: 2200 N. Central Avenue, Suite 601 |
CHAPTER 3 - PROVIDER RELATIONS
3.0 Provider Relations Overview
The Provider Relations department serves as a liaison between MCA and the provider community. They are responsible for training, maintaining and strengthening the provider network in accordance with regulations.
Provider Relations staff conducts onsite provider training, problem identification and resolution, site visits, accessibility audits and develops provider communication materials, including the Provider Manual. They support Network Development and Contracting with multiple functions, including the evaluation of the provider network and compliance, with regulatory network capacity standards.
A Provider Relations representative is assigned to each office. You may reach your representative directly by referring to the Find Your Provider Rep link on MCA's web site or by accessing Express Service Codes under Provider Tools to contact the Provider Relations department.
You may also access Provider Relations through MCA's web site to electronically verify member eligibility, request prior authorization, review claim status, find a provider, review the Preferred Drug List and find other important information.
Contact Provider Relations for:
- Recent updates
- Forms
- Member information
- Member eligibility
- To find a participating provider or specialist
- Prior authorization claim status
- To review or search the Preferred Drug List
- Term from practice
- Notifying the plan of changes to your practice
- Tax ID change
- Obtaining a web site Login ID
- Electronic Data Information, Electronic Fund Transfer, Electronic Remittance Advice
CHAPTER 4 - PROVIDER RESPONSIBILITIES
4.0 Provider Responsibilities Overview
These responsibilities are minimum requirements to comply with contract terms and all applicable laws. Providers are contractually obligated to adhere to and comply with all terms of the plan, provider contract and requirements in this manual. MCA may or may not specifically communicate such terms in forms other than the contract and this manual. This section outlines general provider responsibilities; however, additional responsibilities are included throughout the manual.
Providing Member Care
4.1 Medicare/AHCCCS Registration
Each provider must be registered with an active National Provider Identification (NPI) number as well as an active AHCCCS provider ID number in order to coordinate benefits and process claims.
4.2 Medicare Opt Out Providers
As specified by Medicare laws, rules and regulations, physicians may "opt out" of participating in the Medicare program and enter into private contracts with Medicare beneficiaries. If a physician chooses to opt out of Medicare due to private contracting, no payment can be made to that physician directly or on a capitated basis for Medicare-covered services. The physician cannot choose to opt out of Medicare for some Medicare beneficiaries but not others, or for some services but not others. MCA is not allowed to make payment for services rendered to MCA members to any physician or health care professional who has opted out of Medicare due to private contracting, unless the beneficiary was provided with urgent or emergent care.
Providers are listed on the Opt Out List, which is published by Noridian and available at: https://www.noridianmedicare.com/macj3b/enroll/optout/arizona optout.html
4.3 Appointment Availability Standards
Providers are required to schedule appointments for eligible members in accordance with the minimum appointment availability standards below. MCA will routinely monitor compliance and seek corrective action plans, such as panel or referral restrictions, from providers that do not meet accessibility standards.
4.3 – Appointment Availability Standards Table
| Community Resource | Provider Type | Emergency Services | Urgent Care | Preventative & Routine Care | High Risk | Wait Time in Office Standard |
|---|---|---|---|---|---|---|
| PCP | Same Day | Within 24 hours | Within 21 days | Less than 45 minutes | ||
| Specialty Referrals | Within 24 hours | Within 3 days of request | Within 45 days | Less than 45 minutes | ||
| Dental Care | Within 24 hours | Within 3 days of request | Within 45 days | Less than 45 minutes |
4.4 Telephone Accessibility Standards
Providers are responsible to be available during regular business hours and have appropriate after hours coverage. Providers must have coverage 24 hours per day, seven days per week, including on-call coverage. Call coverage does not include referrals to the emergency department.
Examples of after-hours coverage that will result in follow up from MCA:
- An answering machine that directs the caller to leave a message (unless the machine will then automatically page the provider to retrieve the message).
- An answering machine that directs the caller to go to the emergency department.
- An answering machine that has only a message regarding office hours, etc., without directing the caller appropriately, as outlined above.
- An answering machine that directs the caller to page a beeper number.
- No answering machine or service.
- If your answering machine directs callers to a cellular phone, it is not acceptable for charges to be directed to the caller (i.e., members should not receive a telephone bill for contacting their physician in an emergency).
- Telephones should be answered within five rings and hold time should not exceed five minutes. Callers should not get a busy signal.
4.5 Covering Physicians
Provider Relations must be notified if a covering provider is not contracted or affiliated with MCA. This notification must occur in advance of providing coverage and MCA must provide authorization. Reimbursement to covering physicians is based on the MCA Fee Schedule. Failure to notify MCA of covering physician affiliations may result in claim denials and the provider may be responsible for reimbursing the covering provider.
4.6 Verifying Member Eligibility
All providers, regardless of contract status, must verify a member's enrollment status prior to the delivery of non-emergent, covered services. A member's assigned provider must also be verified prior to rendering primary care services. MCA will not reimburse providers for services rendered to members that lost eligibility or were not assigned to the primary care provider's panel (unless, s/he is physician covering for a provider).
Member eligibility may be verified through one of the following ways:
- Web Site*: www.MercyCarePlan.com - Link available on homepage or you can login to the secure web site portal. *You must have a confidential password to access. To register, contact your Provider Relations representative. More information is available in this Provider Manual under section 4.7 Mercy1Source.
- MCA Telephone Verification: Use as a last resort. Call Member Services to verify eligibility at (602) 263-3000 and use Express Service Code 629. To protect member confidentiality, providers are asked for at least three pieces of identifying information such as member identification number, date of birth and address, before any eligibility information can be released. When calling MCA, use the prompt for the providers.
- Monthly Roster: Monthly rosters are found on the secure web site portal. Contact your Provider Relations representative for more information. Note that rosters are only updated once a month. More information is available in this Provider Manual under section 4.7 Mercy1Source regarding provider rosters.
4.7 Mercy1Source
MCP provides a web-based platform enabling health plans to communicate healthcare information directly with providers. Users can perform transactions, download information, and work interactively with member healthcare information. The following information can be attained from the Mercy1Source platform:
- Member Eligibility Search – Verify current eligibility on one or more members.
- Panel Roster – View the list of members currently assigned to the provider as the PCP.
- Provider List – Search for a specific health plan provider by name, specialty, or location.
- Claim Status Search – Search for provider claims by member, provider, claim number, or service dates. Only claims associated with the user's account provider ID will be displayed.
- Remittance Advice Search – Search for provider claim payment information by check number, provider, claim number, or check issue/service dates. Only remits associated with the user's account provider ID will be displayed.
- Authorization List – Search for provider authorizations by member, provider, authorization data, or submission/service dates. Only authorizations associated with the user's account provider ID will be displayed.
- Submit Authorizations – Submit an authorization request on-line. Three types of
authorization types are available:
- Medical Inpatient
- Outpatient
- DME - Rental
For additional information regarding Mercy1Source, please access the Mercy1Source Provider Web Navigation Guide under Provider Reference Tool.
4.8 Member Temporary Move Out of Service Area
CMS defines a temporary move as:
- An absence from the service area (where the member is enrolled in a Medicare Advantage plan) of six months or less, and
- Maintaining a permanent address/residence in the service area.
An MCA plan member is covered while temporarily out of the service area for emergent, urgent, post-stabilization and out-of-area dialysis services. If a member permanently moves out of the MCA plan service area or is absent for more than six months, the member will be disenrolled from MCA.
4.9 Coverage of Renal Dialysis – Out of Area
An MCA plan member may be temporarily out of the service area for up to six months. MCA pays for renal dialysis services obtained by an MCA plan member from a contracted or non-contracted Medicare-certified physician or health care professional while the member is temporarily out of MCA's service area.
4.10 Health Risk Assessment
An initial health risk assessment of each new MA plan member will be performed within 90 days of his/her enrollment in the MCA plan and annually thereafter. This health risk assessment is completed by telephone or in person. The information obtained through the survey will be used to set up their individualized care plan and shared with the member's PCP.
4.11 Preventive or Screening Services
Providers are responsible for providing appropriate preventive care for eligible members. Preventive health guidelines are located on the MCA web site in the Member Handbook. These preventive services include, but are not limited to:
- Welcome to Medicare exam, which is covered during the first 12 months of enrollment in Part B.
- Age-appropriate immunizations, disease risk assessment and age-appropriate physical examinations.
- Well woman visits (female members may go to a contracted obstetrician/gynecologist for a well woman exam once a year without a referral).
- Age and risk appropriate health screenings.
4.12 Educating Members on their own Health Care
MCA does not restrict or prohibit providers, acting within the lawful scope of their practice, from advising or advocating on behalf of a member who is a patient for:
- the member's health status, medical care or treatment options, including any alternative treatment that may be self-administered;
- any information the member needs in order to decide among all relevant treatment options;
- the risks, benefits, and consequences of treatment or non-treatment; and,
- The member's right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions.
4.13 Emergency Services
Prior authorization is not required for emergency services. In an emergency, members should go to the nearest emergency department.
If a member is having a behavioral health emergency, please call MCA's 24–hour Crisis
Line at
(800) 876-5835 for immediate assistance and intervention.
4.14 Urgent Care Services
While providers serve as the medical home to members and are required to adhere to the AHCCCS and MCA appointment availability standards, in some cases, it may be necessary to refer members to one of MCA's contracted urgent care centers (after hours in most cases). Please reference Find A Provider on MCA's web site and select Urgent Care Facility in the specialty drop down list to view a list of contracted urgent care centers.
MCA reviews urgent care and emergency room utilization for each provider panel. Unusual trends will be shared and may result in increased monitoring of appointment availability.
4.15 Specialist Providers
Specialist providers are responsible for providing services in accordance with the accepted community standards of care and practices. Specialists should only provide services to members upon receipt of a written referral form from the member's primary care provider or from another MCA participating specialist. Specialists are required to coordinate with the primary care provider when members need a referral to another specialist. The specialist is responsible for verifying member eligibility prior to providing services.
When a specialist refers the member to a different specialist or provider, then the original specialist must share these records, upon request, with the appropriate provider or specialist. The sharing of the documentation should occur with no cost to the member, other specialists or other providers.
Primary Care Providers (PCPs) should only refer members to MCA network specialists. If the member requires specialized care from a provider outside of the MCA network, a prior authorization is required.
4.16 Women's Health Specialists
MCA members have direct access to mammography screening services at a contracted radiology facility without a referral, as well as direct access to in-network women's health specialists for routine and preventive services.
4.17 Direct-Access Immunizations
MCA members may receive influenza and pneumococcal vaccines from any network provider without a referral, and there is no cost to the member if it is the only service provided at that visit. A PCP copayment will apply for all other immunizations that are medically necessary.
4.18 Second Opinions
A member may request a second opinion from a provider within the MCA contracted network. The provider should refer the member to another network provider within an applicable specialty for the second opinion.
4.19 Provider Assistance Program for Non-Compliant Members
The provider is responsible for providing appropriate services so that members understand their health care needs and are compliant with prescribed treatment plans. Providers should strive to manage members and ensure compliance with treatment plans and with scheduled appointments. If you need assistance helping non compliant members, MCA's Provider Assistance Program is available to you. The purpose of the program is to help coordinate and/or manage the medical care for members at risk. You may complete the Provider Assistance Program Form located on MCA's web site under Provider Reference Tool and submit it to Member Services for possible intervention.
If you elect to remove the member from your panel rather than continue to serve as the medical home, you must provide the member at least 30 days written notice prior to removal and ask the member to contact Member Services to change their provider. The member will NOT be removed from a provider's panel unless the provider's efforts and those of the Health Plan do not result in the member's compliance with medical instructions. If you need more information about the Provider Assistance Program, please contact your Provider Relations representative.
Documenting Member Care
4.20 Member's Medical Record
The provider serves as the member's "medical home" and is responsible for providing quality health care, coordinating all other medically necessary services and documenting such services in the member's medical record. The member's medical record must be legible, organized in a consistent manner and must remain confidential and accessible to authorized persons only.
All medical records, where applicable and required by regulatory agencies, must be made available electronically.
All providers must adhere to national medical record documentation standards. Below are the minimum medical record documentation and coordination requirements:
- Member identification information on each page of the medical record (i.e., name, AHCCCS identification number and CMS identification number)
- Documentation of identifying demographics including the member's name, address, telephone number, AHCCCS identification number and CMS identification number, gender, age, date of birth, marital status, next of kin, and, if applicable, guardian or authorized representative
- Initial history for the member that includes family medical history, social history and preventive laboratory screenings (the initial history for members under age 21 should also include prenatal care and birth history of the member's mother while pregnant with the member)
- Past medical history for all members that includes disabilities and any previous illnesses or injuries, smoking, alcohol/substance abuse, allergies and adverse reactions to medications, hospitalizations, surgeries and emergent/urgent care received
- Immunization records (recommended for adult members if available)
- Dental history if available, and current dental needs and/or services
- Current problem list
- Current medications
- Documentation, initialed by the member's PCP, to signify review of:
- Diagnostic information including:
- Laboratory tests and screenings
- Radiology reports
- Physical examination notes, and
- Other pertinent data.
- Reports from referrals, consultations and specialists
- Emergency/urgent care reports
- Hospital discharge summaries
- Behavioral health referrals and services provided, if applicable, including notification of behavioral health providers, if known, when a member's health status changes or new medications are prescribed, and
- Behavioral health history.
- Documentation as to whether or not an adult member has completed advance directives and location of the document
- Documentation related to requests for release of information and subsequent releases, and
- Documentation that reflects that diagnostic, treatment and disposition information related to a specific member was transmitted to the PCP and other providers, including behavioral health providers, as appropriate to promote continuity of care and quality management of the member's health care.
4.21 Access to Facilities and Records
Medicare laws, rules and regulations require that contracted providers retain and make available all records pertaining to any aspect of services furnished to MCA plan members or their contract with the MCA for inspection, evaluation and audit for the longer of:
- A period of 10 years from the end of the contract period of MCA contract;
- The date the Department of Health and Human Services, the Comptroller General or their designees complete an audit; or
- The period required under applicable laws, rules and regulations.
4.22 Confidentiality and Accuracy of Member Records
Contracted providers must safeguard the privacy and confidentiality of and ensure the accuracy of any information that identifies an MCA plan member. Original medical records must be released only in accordance with federal or state laws, court orders, or subpoenas.
Specifically, MCA's contracted providers must:
- Maintain accurate medical records and other health information.
- Help ensure timely access by members to their medical records and other health information.
- Abide by all federal and state laws regarding confidentiality and disclosure of mental health records, medical records, other health information and member information.
4.23 Advance Directives
Providers are required to comply with federal and state law regarding advance directives for adult members. The advance directive must be prominently displayed in the adult member's medical record. Requirements include:
- Providing written information to adult members regarding each individual's rights under state law to make decisions regarding medical care and any provider written policies concerning advance directives (including any conscientious objections).
- Documenting in the member's medical record whether or not the adult member has been provided the information and whether an advance directive has been executed.
- Not discriminating against a member because of his or her decision to execute or not execute an advance directive and not making it a condition for the provision of care.
4.24 Medical Record Audits
MCA will conduct routine medical record audits to assess compliance with established standards. Medical records may be requested when MCA is responding to an inquiry on behalf of a member or provider, administrative responsibilities or quality of care issues. Providers must respond to these requests promptly. Medical records must be made available to AHCCCS or CMS for quality review upon request.
4.25 Documenting Member Appointments
When scheduling an appointment with a member over the telephone or in person (i.e. when a member appears at your office without an appointment), providers must verify eligibility and document the member's information in the member's medical record.
4.26 Missed or Cancelled Appointments
Providers must:
- Document and follow-up on missed or canceled appointments.
- Notify Member Services by completing a Provider Assistance Program Form located on MCA's web site under Provider Reference Tool for a member who continually misses appointments.
MCA encourages providers to use a recall system. MCA reserves the right to request documentation supporting follow up with members related to missed appointments.
4.27 Documenting Referrals
The provider is responsible for initiating, coordinating and documenting referrals to specialists, including dentists and behavioral health specialists within the MCA organization. The provider must follow the respective practices for emergency room care, second opinion and noncompliant members.
4.28 Respecting Member Rights
MCA is committed to treating members with respect and dignity at all times. Member rights and responsibilities are shared with staff, providers and members each year. Member rights are incorporated herein and may be reviewed in the Member Handbook located in the MCA web site.
4.29 Provider Marketing
MCA and their contracted providers must adhere to all applicable Medicare laws, rules and regulations relating to marketing. Per Medicare regulations, "marketing materials" include, but are not limited to, promoting MCA, informing Medicare beneficiaries that they may enroll or remain enrolled in MCA, explaining the benefits of enrollment in MCA or rules that apply to members, or explaining how Medicare services are covered under MCA.
Regulations prevent MCA from conducting sales activities in healthcare settings except in common areas. MCA is prohibited from conducting sales presentations and distributing and/or accepting enrollment applications in areas where patients primarily intend to receive health care services. MCA is permitted to schedule appointments with beneficiaries residing in long-term care facilities, only if the beneficiary requested it.
Physicians and other health care professionals may discuss, in response to an individual patient's inquiry, the various benefits of Medicare Advantage plans. Physicians are encouraged to display plan materials for all plans with which they participate. Physicians and health care professionals can also refer their patients to 1-800-MEDICARE, the State Health Insurance Assistance Program; the specific Medicare Advantage Organization's marketing representatives; or CMS' web site at www.medicare.gov for additional information. Physicians and health care professionals cannot accept MCA plan enrollment forms. MCA follows the federal anti-kickback statute and CMS marketing requirements associated with Medicare marketing activities conducted by providers and related to Medicare plans. Payments that MCA makes to providers for covered items and/or services will be fair market value, consistent with an arm's length transaction, for bona fide and necessary services, and otherwise will comply with relevant laws an requirements, including the federal anti-kickback statue.
For a complete description of laws, rules, regulations, guidelines and other requirements applicable to Medicare marketing activities conducted by providers, please refer to Chapter 3 of the Medicare Managed Care Manual, which can be found on the CMS website at http://www.cms.hhs.gov/manuals/downloads/mc86c03.pdf.
4.30 Health Insurance Portability and Accountability Act of 1997 (HIPAA)
The Health Insurance Portability and Accountability Act of 1997 (HIPAA) has many provisions affecting the health care industry, including transaction code sets, privacy and security provisions. HIPAA impacts what is referred to as covered entities; specifically, providers, health plans and health care clearinghouses that transmit health care information electronically. HIPAA has established national standards addressing the security and privacy of health information, as well as standards for electronic health care transactions and national identifiers. All PHPs are required to adhere to HIPAA regulations. For more information about these standards, please visit http://www.hhs.gov/ocr/hipaa/. In accordance with HIPAA guidelines, providers may not interview members about medical or financial issues within hearing range of other patients.
4.31 Cultural Competency
The Partnership for Clear Health Communication (PCHC) defines health literacy as the ability to read, understand and act on health information. Health literacy relates to listening, speaking, and conceptual knowledge. Health literacy plays an important role in positive patient outcomes. According to PCHC, people with low functional Health Literacy:
- Have poorer overall health status.
- Are less likely to adhere to treatment and incur a greater number of medication/treatment errors.
- Require more health related treatment and care, including 29-69% higher hospitalization rates.
- Increase higher health care costs - health care costs as high as $7,500 more per annum for a person with limited health literacy.
To increase health literacy, the National Patient Safety Foundation created the Ask Me 3™ program. MCA supports the Ask Me 3™ program, as it is an effective tool designed to improve health communication between patients and providers.
For an Ask Me 3 poster to be displayed in your office, visit: http://www.npsf.org/askme3/pdfs/AskMe_poster_APost-E.pdf.
In accordance with Title VI of the 1964 Civil Rights Act, national standards for culturally and linguistically appropriate health care services and State requirements, MCA is required to ensure that Limited English Proficient (LEP) members have meaningful access to health care services. Because of language differences and inability to speak or understand English, LEP persons are often excluded from programs they are eligible for, experience delays or denials of services or receive care and services based on inaccurate or incomplete information.
Members are to receive covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information or medical history, ability to pay or ability to speak English. PHPs are required to treat all members with dignity and respect, in accordance with federal law. Providers must deliver services in a culturally effective manner to all members, including:
- Those with limited English proficiency (LEP) or reading skills.
- Those with diverse cultural and ethnic backgrounds.
- The homeless.
- Individuals with physical and mental disabilities.
For more detailed information on cultural competence, please refer to the guide entitled Culturally Competent Patient Care: A Guide for Providers and Their Staff, by Georgia Hall, Ph.D. The guide was developed as a cooperative effort on behalf of AHCCCS health plans to assist providers, and is reprinted with the permission of the author.
4.32 Health Literacy – Limited English Proficiency (LEP) or Reading Skills
MCA complies with federal and state laws by offering interpreter and translation services, including sign language interpreters, to LEP members. This service affords members access to health care and benefits by providing a range of language assistance services at no cost to the member or provider. MCA strongly recommends the use of professional interpreters, rather than family or friends. Bilingual staff members are available in the Member Services department to assist LEP members and a TTY line is available for members who are hearing impaired. Further, MCA provides member materials in other formats to meet specific member needs. Providers must also deliver information in a manner that is understood by the member.
To access interpretation services to assist members who speak a language other than English or who use sign language, please call Language Line Services directly at (800) 523-1786. Language Line provides interpreter services in more than 170 languages. This service is available at no cost to you or the member. Additional information regarding Language Line Services can be accessed through the Provider Reference Tool, under Provider Reference Guides, titled Language Line Quick Reference Guide and Language Line Job Aid,
The PCP is responsible for providing appropriate services so that members understand their health care needs and the member is compliant.
4.33 Individuals with Disabilities
Title III of the Americans with Disabilities Act (ADA) mandates that public accommodations, such as a physician's office, be accessible to those with disabilities. Under the provisions of the ADA, no qualified individual with a disability may be excluded from participation in or be denied the benefits of services, programs or activities of a public entity, or be subjected to discrimination by any such entity. Provider offices must be accessible to persons with disabilities. Providers must also make efforts to provide appropriate accommodations such as large print materials and easily accessible doorways.
4.34 PCP Assignments
MCA may select their PCP or if no choice is made, automatically assigns members to a PCP upon enrollment. Members have the right to change their provider at any time. Member eligibility changes frequently, as a result, providers must verify eligibility prior to delivering services.
4.35 Plan Changes
MCA members may disenroll at the end of the month anytime during the calendar year. To maintain their eligibility for Medicare Part D, it is recommended that a member select another Part D plan, which will automatically disenroll them from MCA. Disenrolling from MCA will not affect their AHCCCS plan assignment.
Provider Guidelines and Plan Details
4.36 Cost Sharing and Coordination of Benefits
Providers must adhere to all contract and regulatory cost sharing guidelines. When a member has other health insurance, such as a commercial carrier, MCA will coordinate payment of benefits in accordance with the terms of the PHP's contract and federal and state requirements.
4.37 Practice Guidelines
MCA has Practice Guidelines and treatment protocols available to PHPs to help identify criteria for appropriate and effective use of health care services and consistency in the care provided to members and the general community. These guidelines are not intended to:
- Supplant the duty of a qualified health professional to provide treatment based on the individual needs of the patient;
- Constitute procedures for or the practice of medicine by the party distributing the guidelines; or,
- Guarantee coverage or payment for the type or level of care proposed or provided.
4.38 Office Administration Changes and Training
Providers are responsible to notify Provider Relations of changes in professional staff at their offices (physicians, physician assistants or nurse practitioners). Administrative changes in office staff may result in the need for additional training. Contact your Provider Services representative to schedule any needed staff training.
4.39 Contract Additions or Physician Terminations
In order to meet contractual obligations and state and federal regulations, providers must report any terminations or additions to their contract at least 90 days prior to the change in order for MCA to comply with CMS requirements. Providers are required to continue providing services to members throughout the termination period.
CMS requires that MCA make a good faith effort to provide written notice of a termination of a contracted physician at least 30 calendar days before the termination effective date to all members who are patients seen on a regular basis by the physician whose contract is terminating. However, please note that when a contract termination involves a PCP, all members who are patients of that PCP must be notified.
For information on where to send change information, refer to Provider Notice of Change Form under the Provider Reference Tool located on the MCA web site.
4.40 Continuity of Care
Providers terminating their contracts without cause are required to continue to treat MCA members until the treatment course has been completed or care is transitioned. Authorization may be necessary for these services. Members who lose eligibility and continue to have medical needs must be referred to a facility or provider that can provide the needed care at no or low cost. MCA is not responsible for payment of services rendered to members who are not eligible. Please refer to Reference Guide Low Cost/No Cost Health Care Referral List under the Provider Reference Tool if you identify a member in this circumstance. You may also contact MCA's Case Management Department for assistance.
4.41 Contract Changes or Updates
Providers must report any changes to demographic information to MCA at least 90 days prior to the change in order to be in compliance with contractual obligations and state and federal regulations. Providers are required to continue providing services to members throughout the termination period. For information on where to send change information, refer to the Table 8, Provider Record Updates (below). Please complete the Provider Notice of Change Form under the Provider Reference Tool located on the MCA web site.
4.41 – Provider Record Updates Table
| Type of Change | Notification Requirements | Send to | Notice Requirement |
|---|---|---|---|
| Individual or group name | Must mail updated W-9 and letter describing change and effective date | Provider Relations | 90 days |
| Tax ID number | Must mail updated W-9 and letter describing change and effective date | Provider Relations | 90 days |
| Address | Must fax (860) 975-3201 or mail | Provider Relations | 90 days |
| Staffing changes including physicians leaving the practice | Must fax (860) 975-3201 or mail letter describing change and effective date | Provider Relations | 90 days |
| Adding new office locations | Must fax (860) 975-3201 or mail letter describing change and effective date | Provider Relations | 90 days |
| Adding new physicians to current contract | Must fax (860) 975-3201 or mail letter describing change and effective date | Provider Relations | 90 days |
4.42 Credentialing/Re-Credentialing
Providers are re-credentialed every three years and must complete the required reappointment application. Updates on malpractice coverage, state medical licenses and DEA certificates are also required. Please note that providers may not treat MCA members until they are credentialed.
4.43 Licensure and Accreditation
Health delivery organizations such as hospitals, skilled nursing facilities, home health agencies and ambulatory surgical centers must submit updated licensure and accreditation documentation at least annually or as indicated.
4.44 Receipt of Federal Funds, Compliance with Federal Laws and Prohibition on Discrimination
Payments received by contracted providers from MCA for services rendered to plan members include federal funds; therefore, MCA's contracted providers are subject to all laws applicable to recipients of federal funds, including, without limitation:
- Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 CFR part 84;
- The Age Discrimination Act of 1975, as implemented by regulations at 45 CFR part 91;
- The Rehabilitation Act of 1973;
- The Americans With Disabilities Act;
- Federal laws and regulations designed to prevent or ameliorate fraud, waste and abuse, including, but not limited to, applicable provisions of federal criminal law;
- The False Claims Act (31 U.S.C. §§ 3729 et. seq.);
- The anti-kickback statute (section 1128B(b) of the Social Security Act); and
- HIPAA administrative simplification rules at 45 CFR parts 160, 162 and 164.
In addition, our contracted providers must comply with all applicable Medicare laws, rules and regulations, and, as provided in applicable laws, rules and regulations, contracted providers are prohibited from discriminating against any MCA plan member on the basis of health status.
4.45 Financial Liability for Payment for Services
In no event should MCA contracted providers bill an MCA plan member (or a person acting on behalf of an MCA plan member) for payment of fees that are the legal obligation of MCA. However, a contracted provider may collect deductibles, coinsurance or copayments from MCA plan members in accordance with the terms of the member's Evidence of Coverage.
Note: CMS issued a memo to MCA dated September 17, 2008, ("CMS Guidance") providing guidance regarding balance billing by providers of certain individuals enrolled in both Medicare Advantage plans and a State Medicaid plan ("Dual Eligible beneficiaries"). More specifically, this CMS Guidance states that providers are prohibited from balance billing Dual Eligible beneficiaries who are classified as Qualified Medicare Beneficiaries (QMB) for Medicare Parts A and B cost sharing amounts. The CMS Guidance explains that providers must accept Medicare and Medicaid payment(s), if any, as payment in full. A QMB has no legal liability to make payment to a provider or Medicare Advantage plan for Medicare Part A or B cost sharing, and a provider may not treat a QMB as "private pay patient" in order to bill a QMB patient directly. In addition, the CMS Guidance states that federal regulations require a provider treating an individual enrolled in a State Medicaid plan, including QMBs, to accept Medicare assignment. Providers participating in Medicare networks are required to comply with all of the requirements set forth in this CMS Guidance.
CHAPTER 5 - COVERED AND NON COVERED SERVICES
5.0 Coverage Criteria
All Medicare-covered services must be medically necessary, and except for emergency or urgently needed care, or otherwise authorized by MCA, must be provided by a participating PCP or other qualified participating providers. Benefit limits apply.
Participating providers are required to administer covered services to MCA members in accordance with the terms of their contract and member's benefit package.
5.1 Covered Services
MCA has specific covered and non-covered services. For a combined listing of covered services for all lines of business, please refer to Mercy Care's Benefit Matrix or Evidence of Coverage on MCA's web site.
5.2 Non Covered Services - MCA
- Services that are not covered under the Original Medicare Plan, except those listed as an additional benefit under MCA.
- Services that are not reasonable or necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by MCA as a covered service.
- Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial. In 2008 CMS will continue to pay through Original Medicare for clinical trial items and services covered under the September 2000 National Coverage Determination that is provided to MCA plan members. Experimental procedures and items are those items and procedures determined by MCA and the Original Medicare Plan to not be generally accepted by the medical community.
- Surgical treatment of morbid obesity unless medically necessary and covered under the Original Medicare plan.
- Private room in a hospital, unless medically necessary.
- Private duty nurses.
- Charges for personal convenience items, such as a telephone or television in a room in a hospital or skilled nursing facility.
- Nursing care on a full-time basis in the member's home.
- Custodial care unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. "Custodial care" includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered. If enrolled in the Mercy Care Plan (MCP) Arizona Long Term Care System (ALTCS), this may be a covered service through its arrangement with ALTCS.
- Homemaker services. If enrolled in MCP this may be a covered service through its arrangement with ALTCS.
- Charges imposed by immediate relatives or members of the household.
- Meals delivered to the home. If enrolled in the ALTCS, this may be a covered service through its arrangement with Meals On Wheels.
- Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary.
- Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as the unaffected breast, to produce a symmetrical appearance.
- Orthopedic shoes unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease.
- Supportive devices for the feet, with one exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease.
- Radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
- Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
- Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices.
- Acupuncture.
- Naturopath services.
- Services provided to veterans in Veterans Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under MCA, we will reimburse veterans for the difference. Members are still responsible for our Plan cost-sharing amount.
CHAPTER 6 - BEHAVIORAL HEALTH
6.0 Behavioral Health Overview
MCA covers behavioral health services under certain conditions and includes:
- Partial hospital program and intensive outpatient programs.
- Medication monitoring (first eight visits are covered without Prior Authorization for contracted providers).
- Counseling by an Independent Licensed Social Worker, Psychologist, Psychiatrist or Nurse Practitioner (first ten visits are covered without Prior Authorization for contracted providers).
- Inpatient psychiatric services with a limitation on freestanding psychiatric hospitals. There is a 190 day limit for free standing psychiatric hospitals. If the member goes to a behavioral health unit contained in the hospital this limit does not apply.
- Substance Abuse Treatment - MCA members who are also enrolled in ALTCS will receive behavioral health services through contracted MCA providers. Other related services may be provided by MCA. If a member is enrolled in MCA and MCP Acute, they have to enroll with the RBHA in order to receive other behavioral health services. If an MCA member is enrolled in another AHCCCS LTC plan, the member will need to contact the other health plan for additional services and the provider will need to coordinate benefits with the secondary payer.
6.1 RBHA Services and MCA Members
Coinsurance amounts for MCA outpatient mental health and substance abuse services are paid by MCA for ALTCS members and by the RBHA for all RBHA enrolled members. For MCA members that are enrolled in the AHCCCS Acute or DDD programs, it is important that the behavioral health provider encourages members to enroll with the RBHA so that the co-pays for behavioral health services are potentially covered by the RBHA.
6.2 RBHA Covered Services
The following are RBHA covered services and coinsurance should be billed to the RBHA, if RBHA enrolled, otherwise, billed to MCA:
- Behavior management (behavioral health personal care, family support/home care training, self-help/peer support)
- Behavioral health case management serevices (limited)
- Behavioral health nursing services
- Case management related to behavioral health
- Emergency behavioral health care
- Emergency and non-emergency transportation
- Evaluation and assessment
- Individual, group and family therapy and counseling
- Inpatient hospitalization for behavioral health and psychiatric disorders
- Non hospital inpatient psychiatric facilities services
- Laboratory and radiology services for psychotropic medication regulation and diagnosis
- Opioid Agonist treatment
- Partial care (supervised day program, therapeutic day program and medical day program)
- Psychosocial rehabilitation (living skills training; health promotion; supportive employment services)
- Psychotropic medication
- Psychotropic medication adjustment and monitoring
- Respite care (with limitations)
- Rural substance abuse transitional agency services
- Screening
- Behavioral health therapeutic foster care
6.3 MCA Behavioral Health Emergency Services
If a member is in a behavioral health crisis, call the MCA Behavioral Health Hotline at: (800) 876-5835. Unlike Acute MCP members, there is no three-day limit of responsibility for coverage of emergency inpatient behavioral health services for MCA members. Medicare covers medically necessary services. MCA members are eligible for behavioral health services through contracted behavioral health providers.
6.4 PCP Responsibilities for MCA Care Behavioral Health Services
Members should be screened by their PCP for behavioral health needs during routine or preventive visits. If a provider feels that a member needs behavioral health services, referrals for these services should be coordinated through the member's case manager for long term care members and the behavioral health coordinator for acute plan members.
6.5 Coordination of Care
The PCP will be informed of the member's behavioral health provider so that communication may be established. It is very important that PCPs develop a strong communication link with the behavioral health provider. PCPs are expected to exchange any relevant information such as medical history, current medications, current behavioral health diagnosis and treatment within 10 business days of receiving the request.
Where there has been a change in a member's health status identified by a medical provider, there should be coordination of care with the behavioral health provider within a timely manner. The update should include but is not limited to; diagnosis of chronic conditions, support for the petitioning process, and all medication prescribed.
The PCP should also document and initial signifying review receipt of information received from a behavioral health provider who is treating the member.
The behavioral health providers should supply the PCP with information regarding services that they are providing so that they may be included in the member's permanent medical record.
CHAPTER 7 - DENTAL AND VISION SERVICES
7.0 Dental Services Overview
Medicare covers limited non-routine dental care – surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a doctor.
Additional preventative dental services which cover limited oral exams and cleaning, fluoride treatments and dental x-ray may be covered. Please consult the Evidence of Coverage for details.
MCA has a limited allowance for restorative dental services, which may include:
- Removal of decay
- Fillings
- Filling replacements
- Single crowns
Please consult the Evidence of Coverage (EOC) for details.
7.1 Vision Services Overview
Medicare covers the following services:
- Exams to diagnose and treat diseases and conditions of the eye.
- Annual glaucoma screening for eligible members at risk for glaucoma.
- One (1) pair of Medicare covered eye glasses or contact lenses after each cataract surgery.
The following additional vision services are covered:
- One (1) routine eye exam every year.
- Limited allowance for eye wear every year.
CHAPTER 8 - CASE MANAGEMENT AND DISEASE MANAGEMENT
8.0 Case Management and Disease Management Overview
MCA has a comprehensive case management program. The Medical Case Management team considers the medical, social and cultural needs of members by targeting, assessing, monitoring and implementing services for members identified as "at risk." Case Management services are available for all eligible members, however, members who are identified as "at risk," such as transplant, hemophilia and HIV members, or those who are high-service utilizers are assigned a case manager.
A wide spectrum of services are available for members, providers and families who need assistance in finding and using appropriate health care and community resources. The MCA case management staff:
- Considers the medical, social and cultural needs of members in targeting, assessing, monitoring and implementing services for members.
- Provides assistance to members and families in navigating through the complex medical and behavioral health systems.
Please refer to the Practice Guidelines available on MCA's web site for treatment protocol related to:
- Diabetes
- Asthma
- Congestive Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Community Acquired Pneumonia (CAP)
- Major Depressive Disorder in Adults
- HIV
- Attention Deficit/Hyperactivity Disorder (ADHD)
8.1 Referrals
The MCA central intake coordinator accepts referrals from any source. Please call the central intake coordinator at (602) 453-8391 to make a referral. For the most part, the central intake coordinator can respond to questions and resolve the issue during the initial call. However, a case management referral is initiated for members that require more than a single intervention. Case managers will contact the member either by telephone or by letter. The case management staff communicates with members, family and the PCP on an ongoing basis while the member's case is open.
8.2 Case Management
Case management services are provided to medically complex members. The members are assigned to an RN, LPN or social work case manager who works closely with the PCP and member to coordinate care and services. The case manager also collaborates with community resources, home health services and PCPs to coordinate medical care and assure appropriate access to medical and social services.
Members who meet any of the following criteria and do not fall under other identified categories of case management also will be considered for case management services:
- High utilizers of services
- Frequent inpatient readmissions
- Substance abusers
- Poor compliance with prescribed medical treatment
- Experiencing social problems that are impacting medical care
- Overuse of emergency department
- Complex care needs
A health assessment will be conducted of each member accepted into case management. A care plan will be developed and the member's compliance with the plan will be monitored. The case manager interacts routinely with the PCP, the member and the member's care giver/family.
8.3 HIV/AIDS
Early identification and intervention of members with HIV allows the case manager to assist in developing basic services and information to support the member during the disease process. The case manager links the member to community resources that offer various services, including housing, food, counseling, dental services and support groups. The member's cultural needs are continually considered throughout the care coordination process.
The MCA case manager works closely with the PCP, the MCA corporate director of pharmacy, and a MCA medical director to assist in the coordination of the multiple services necessary to manage the member's care. PCPs wishing to provide care to members with HIV/AIDS must provide documentation of training and experience and be approved by the MCA credentialing process. These PCPs must agree to comply with specific treatment protocols and AHCCCS requirements. PCPs may elect to refer the member to an AHCCCS approved HIV specialist for the member's HIV treatment.
8.4 Disease Management
The Disease Management team administers disease management programs intended to enhance the health outcomes of members. Disease management targets members who have illnesses that have been slow to respond to coordinated management strategies in the areas of diabetes, respiratory (COPD, asthma), and cardiac (CHF). The primary goal of disease management is to positively affect the outcome of care for these members through education and support and to prevent exacerbation of the disease, which may lead to unnecessary hospitalization.
The objectives of disease management programs are to:
- Identify members who would benefit from the specific disease management program
- Educate members on their disease, symptoms and effective tools for self-management
- Monitor members to encourage/educate about self care, identify complications, assist in coordinating treatments and medications, and encourage continuity and comprehensive care
- Provide evidence-based, nationally recognized expert resources for both the member and the provider;
- Monitor effectiveness of interventions.
The following conditions are specifically included in MCA's Disease Management programs and have associated Practice Guidelines that are reviewed annually.
8.5 Asthma
The Asthma Disease Management program offers coordination of care for identified members with primary care physicians, specialists, community agencies, the members' caregivers and/or family. Member education and intervention is targeted to empower and enable compliance with the physician's treatment plan.
Providers play an important role in helping members manage this chronic disease by promoting program goals and strategies, including:
- Preventing chronic symptoms
- Maintaining "normal" pulmonary function
- Maintaining normal activity levels
- Maintaining appropriate medication ratios
- Preventing recurrent exacerbation and minimizing the need for emergency treatment or hospitalizations
- Providing optimal pharmacotherapy without adverse effects
- Providing education to help members and their families better understand the disease and its prevention/treatment
8.6 Chronic Obstructive Pulmonary Disease (COPD)
The COPD Disease Management program is designed to decrease the morbidity and mortality of members with COPD. The goal of the program is to collaborate with providers to improve the quality of care provided to members with COPD, decrease complication rates and utilization costs, and improve the members' health. The objectives of the COPD Disease Management program are to:
- Identify and stratify members
- Provide outreach and disease management interventions
- Provide education through program information and community resources
- Provide provider education through the COPD guidelines, newsletters and provider profiling
8.7 Congestive Heart Failure (CHF)
The CHF Disease Management program is designed to develop a partnership between MCA, the primary care provider and the member to improve self-management of the disease. The program involves identification of members with CHF and subsequent targeted education and interventions. The CHF Disease Management Program educates members with CHF on their disease, providing information on cardiac symptoms, blood pressure management, weight management, nutritional requirements and benefits of smoking cessation.
8.8 Diabetes
The Diabetes Disease Management program is designed to develop a partnership between MCA, the primary care physician and the member to improve self-management of the disease. The program involves identification of members with diabetes and subsequent targeted education and interventions. In addition, the program offers providers assistance in increasing member compliance with diabetes care and self-management regimens. Providers play an important role in helping members manage this chronic condition. MCA appreciates providers' efforts in promoting the following program goals and strategies:
- Referrals for formal diabetes education through available community programs
- Referrals for annual diabetic retinal eye exams by eye care professionals as defined in MCA's Diabetes Management Practice Guidelines
- Laboratory exams that include:
- Glycohemoglobins at least twice annually
- Micro albumin
- Fasting lipid profile annually
- Management of co-morbid conditions like blood pressure, CHF, and blood cholesterol.
8.9 Active Health
MCA has contracted with Active Health Management to administer a patient health-tracking program that was implemented in October of 2008 with providers. Effective March of 2010, members will be receiving letters concerning their "Care Considerations" as well.
Active Health will expand MCA's opportunities to identify members at risk for poor health outcomes and to communicate directly with the providers who are responsible for their care, in a time-critical mode. It also enables the member to work closely with their physician to choose treatments and tests that are right for them, Active Health utilizes data received through claim, lab and pharmacy submissions to identify potential opportunities to meet evidence based guidelines, such as through the addition of new therapies, avoidance of contraindications or prevention of drug interactions. When an opportunity is identified for our member, a formal patient-specific communication will be sent to the provider to assist in offering health care to the patient based upon the physician's independent medical judgment. A "Care Consideration" letter will be sent to the member as well, encouraging them to discuss the "Care Consideration" with their physician.
It is important to note that this program is not a utilization review mechanism and does not constitute consultation. MCA's goal is to offer timely, accurate and patient-specific information to facilitate patient care and improve outcomes.
Examples of "Care Consideration" are:
- If the member is a diabetic and there are no records that the patient has had their eyes checked or an HgA1c lab has been done.
- If the patient has a heart condition and there are no records to show that the member is on any type of drug to lower cholesterol.
CHAPTER 9 - CONCURRENT REVIEW
9.0 Concurrent Review Overview
MCA conducts concurrent utilization review on each member admitted to an inpatient facility, including skilled nursing facilities and freestanding specialty hospitals. Concurrent review activities include both admission certification and continued stay review. The review of the member's medical record assesses medical necessity for the admission, and appropriateness of the level of care, using the Milliman Care Guidelines®. Admission certification is conducted within one business day of receiving notification.
Continued stay reviews are conducted before the expiration of the assigned length of stay. Providers will be notified of approval or denial of length of stay. MCA nurses conduct these reviews. The nurses work with the medical directors in reviewing medical record documentation for hospitalized members. MCA medical directors make rounds on site as necessary.
9.1 Milliman Care Guidelines@reg;
MCA uses the Milliman Care Guidelines@reg; to ensure consistency in hospital–based utilization practices. The guidelines span the continuum of patient care and describe best practices for treating common conditions. The Milliman Care Guidelines® are updated regularly as each new version is published. A copy of individual guidelines pertaining to a specific case is available for review upon request.
9.2 Discharge Planning Coordination
Effective and timely discharge planning and coordination of care are key factors in the appropriate utilization of services and prevention of readmissions. The hospital staff and the attending physician are responsible for developing a discharge plan for the member and for involving the member and family in implementing the plan.
The MCA concurrent review nurse (CRN) works with the hospital discharge team and attending physicians to ensure that cost-effective and quality services are provided at the appropriate level of care. This may include, but is not limited to:
- Assuring early discharge planning.
- Facilitating or attending discharge planning meetings for members with complex and/or multiple discharge needs.
- Providing hospital staff and attending physician with names of contracted MCA providers (i.e., home health agencies, DME/medical supply companies, other outpatient providers).
- Informing hospital staff and attending physician of covered benefits as indicated.
9.3 Physician Medical Review
MCA medical directors conduct medical review for each case with the potential for denial of authorization. The CRN (Inpatient) or the prior authorization nurse (Outpatient) reviews the documentation for evidence of medical necessity according to established criteria. When the criteria are not met, the case is referred to a MCA medical director. The medical director reviews the documentation, discusses the case with the nurse and may call the attending or referring physician for more information. The requesting physician may be asked to submit additional information. Based on the discussion with the physician or additional documentation submitted, the medical director will decide to approve, deny, modify, reduce, suspend or terminate an existing or pending service.
Utilization management decisions are based only upon appropriateness of care and service. MCA does not reward practitioners, or other individuals involved in utilization review, for issuing denials of coverage or service. The decision to deny a service request will only be made by a physician.
For inpatient denials, the attending physician and hospital staff are verbally notified when MCA is stopping payment. The hospital will receive written notification with the effective date of termination of payment or reduction in level of care. The attending or referring physician may dispute the finding of the medical director informally by phone or formally in writing. If the finding of the medical director is disputed, a dispute may be filed according to the established MCA's dispute process.
CHAPTER 10 - PHARMACY MANAGEMENT
10.0 Pharmacy Management Overview
Prescription drugs may be prescribed by any authorized prescriber, such as a PCP, specialist, attending physician, dentist, etc. Prescriptions should be written to allow generic substitution whenever possible and signatures on prescriptions must be legible in order for the prescription to be dispensed. The formulary identifies all of the Part D prescription drugs covered by MCA. The formulary has been approved by CMS and the drugs have been selected by the Pharmacy and Therapeutics Committee (P&T Committee) to ensure that they are clinically appropriate to meet the therapeutic needs of our members in a cost effective manner.
- MCA's formulary may also be downloaded to mobile devices (e.g. Blackberry, Palm, Windows Mobile and iPhone) by going to www.epocrates.com.
- All formulary utilization management restrictions are approved by CMS and the P&T Committee.
10.1 Updating the Formulary
MCA's formulary is continuously reviewed by the P&T Committee and prescription drugs are added or removed based on objective, clinical and scientific data and market changes. All updates to the formulary must be approved by CMS and adhere to CMS guidance on changes. Considerations include efficacy, side effect profile, and cost and benefit comparisons to alternative agents, if available.
Key considerations:
- Therapeutic advantages outweigh cost considerations in all decisions to change drugs listed in the formulary. Market share shifts, price increases, generic availability and varied dosage regimens may affect the actual cost of therapy.
- MCA formulary must adhere to CMS requirements.
- Products are not added to the list if there are less expensive, similar products on the formulary.
- When a drug is added to the formulary, other drugs in the same category may be removed.
- Participating physicians may request additions or deletions for consideration by
the P&T Committee. Requests should include:
- Basic product information, indications for use, and its therapeutic advantage over drugs currently on the formulary.
- Which drug(s), if any, would be replaced by the recommended drug in the formulary.
- Any published supporting literature from peer reviewed medical journals.
MCA may invite the requesting physician to the P&T Committee to support the addition to the formulary and answer related questions. However, MCA does not permit pharmaceutical representatives to participate or attend P&T Committee meetings. All formulary requested additions should be sent to:
Schaller Anderson, an Aetna Company
Corporate Director of Pharmacy
4645 E. Cotton Center Blvd.
Building 1, Suite 200
Phoenix, AZ 85040
10.2 Notification of Formulary Updates
MCA must follow CMS policy regarding formulary changes. MCA may add drugs to the formulary or delete utilization management requirements at any time during the year. After March 1st each year, MCA may only make maintenance changes to the formulary, such as replacing a brand name drug with a new generic, or modifications to quantity limits based on new drug safety information. CMS limits non-maintenance formulary changes and must be approved by CMS. If approved, members currently taking the affected drugs are exempt from the change until the remainder of the calendar year. MCA will provide notice to affected members at least 60 days notice prior to removing a covered Part D drug from the formulary, or provide the member with a 60-day supply of the drug. If the FDA deems a drug unsafe or it is removed from the market by its manufacturer, MCA will provide a retrospective notice as soon as possible. A list of formulary changes is maintained on the MCA website. MCA may notify providers of changes to the formulary via direct letter or through the MCA web site.
Federal Part D regulations require MCA to have a formulary that contains at least two Part D prescription drugs in each approved category, and all drugs in the six special classes listed below:
- Antidepressants
- Antipsychotic
- Anticonvulsants
- Antiretroviral
- Antineoplastics
- Immunosuppressant
Both generic and brand name drugs are covered by MCA, but some drugs are statutorily excluded from coverage under Medicare Part D, or are excluded for certain indications. Excluded drugs include, but are not limited to:
- Drugs for anorexia, weight loss or weight gain;
- Fertility drugs;
- Erectile Dysfunction drugs;
- Drugs for cosmetic purposes or hair growth;
- Drugs for symptomatic relief of cough and cold (exceptions may apply);
- Prescription vitamins and mineral products (except pre-natal vitamins and fluoride preparations);
- Electrolytes/Replenishers
- Non-prescription drugs;
- Barbiturates;
- Benzodiazepines
- Drugs covered under Medicare Part A or Part B (exceptions may apply)
10.3 Pharmacy Transition of Care Process
New members (within their first 90 days) taking prescription drugs that are not on the MCA formulary, or formulary drugs that are subject to certain restrictions, such as prior authorization or step therapy, will receive a temporary transitional fill of up to a 30-day supply of a non-formulary drug, or a formulary drug requiring prior authorization at a retail pharmacy. Members and their prescribing physician will receive a letter instructing them to consult with their prescribing physician to decide if they should switch to an equivalent drug that is on the MCA formulary or to request a formulary exception in order to get coverage for the drug.
MCA will not pay for additional fills for the drug(s), unless the prescriber submits a request for a coverage determination or formulary exception and MCA approves. If a formulary exception is approved, the approval will be valid through the remainder of the calendar year, unless prescribed for a lesser period.
10.4 LTC/ Nursing Facility
If a new member is a resident of a long term care facility, MCA will cover multiple fills of a temporary transitional fill of up to a 31-day supply within their first 90 days. MCA will also cover an additional 31-day emergency supply (unless the prescription is for fewer days) for a member past the first 90 days while MCA processes a requested coverage determination.
If the member has unplanned level of care changes, (e.g., discharged from a hospital to a home, or ending a stay at a long term care facility and returning home), MCA will provide an emergency 31-day supply of a currently prescribed drug to transition the member to their new level of care setting. The member and the member's physician will receive a letter notifying them that they will need to transition to a prescription drug on our formulary or request a coverage determination.
Please note that the MCA transition policy applies only to Part D drugs filled at a network pharmacy.
10.5 Part D Pharmacy Co-Payments
Co-payments for covered Part D prescription drugs are mandatory per federal regulations. MCA members are required to pay a small co-pay for each prescription drug they receive. The maximum co-pay a member has to pay for drugs is based on federal Low Income Subsidy (LIS) thresholds. Certain members may have a $0 co-pay.
CHAPTER 11 - QUALITY MANAGEMENT
.11.0 Quality Management Overview
MCA works in partnership with providers to continuously improve the care given to our members. The MCA Quality Management (QM) Department is comprised of the following areas:
- The Quality of Care Review Unit monitors the quality of care provided by the PHP network, as well as the review and resolution of issues related to the quality of health care services provided to members.
- The Prevention and Wellness Unit is responsible for quality improvement activities and clinical studies using data collected from providers and encounters.
- The Credentialing Unit is responsible for provider credentialing/recredentialing activities.
- The Special Needs Unit is responsible for coordination and liaison with the Acute Care behavioral health services provided by the Regional Behavioral Health Authorities (RBHA) statewide. In addition, the unit works to coordinate Acute Care health services for MCA DD LTC members.
11.1 Quality Management Department Responsibilities
The QM Department is responsible for development of practice guidelines and policies related to quality management. Whenever possible, MCA adopts practice guidelines from national organizations known for their expertise in the area of concern. Practice Guidelines are available at the MCA web site. Providers may also request copies from the QM Department or their Provider Relations representative.
11.2 Measurement Tools
MCA must measure performance using measurement tools specified by CMS and report its performance to CMS. MCA is required to make available to CMS information from these measures to provide members with a means to assess the value they receive for their health care dollar and to hold health plans responsible for their performance. As a contracting medical provider, you may be required to assist in medical record data collection.
11.3 Chronic Care Improvement Program
MCA is required to have a Chronic Care Improvement Program (CCIP). This program must identify members with multiple or sufficiently severe chronic conditions who meet criteria for participation in the program, and must have a mechanism for monitoring member participation in the program. As a contracting medical provider, you may be required to assist in medical record data collection or verification to confirm eligibility or participation in the CCIP.
CHAPTER 12 - REFERRALS AND AUTHORIZATIONS
12.0 MCA Organization Determination Process
Medicare beneficiaries enrolled in MCA are entitled to request an Organization Determination (OD), which is a decision/determination concerning the rights of the member with regard to services covered by Medicare and/or MCA, and any decision/determination concerning the following items:
- Reimbursement for coverage of emergency, urgently needed services or post-stabilization care.
- Payment for any other health services furnished by a provider or supplier other than the organization that the member believes are Medicare covered or, if not covered by Original Medicare, should have been furnished, arranged for or reimbursed by the organization.
- The provider' or organization's refusal to provide coverage of an item or service the member has not received but believes should be covered.
- Discontinuation of coverage of a service, if the member disagrees with the determination that the coverage is no longer medically necessary.
Members or their providers can request an expedited or standard pre-service OD decision (e.g. prior authorization). MCA will review and process the request in accordance with the CMS requirements and timeframes. MCA will notify the member of its decision as quickly as the member's health condition requires, but no later than 14 calendar days. MCA must automatically provide an expedited OD if the physician believes a standard review may seriously jeopardize the life, or health of the enrollee, or the member's ability to regain maximum function. An expedited review is completed within 72 hours. If the member requests reimbursement for a service already received, it will be reviewed as a request for a payment OD. If the member's request is denied, the member may exercise his/her appeal rights.
12.1 Prior Authorizations (Pre-Service Organization Determinations)
- Laboratory Services: Prior authorization is NOT required for approved in office lab procedures that are CLIA certified. MCA is contracted with Sonora Quest to provide laboratory services. All lab services must be performed by Sonora Quest unless approved by MCA under the prior authorization process.
- Prior Authorization: Prior authorization must be obtained from MCA when referring members outside of the PHP network and/or prior to the member receiving a service that requires PA. .
- Radiology Services: Prior authorization IS required for certain radiology services. The prior authorization summary on the MCA web site contains additional information on services that require prior authorization.
- Infusion or Enteral Therapy Services: Prior authorization IS required for any medically necessary services rendered by an infusion or enteral provider.
- Durable Medical Equipment (DME); DME equipment and related services may require prior authorization.
For more detail regarding prior authorization requirements, please consult the Prior Authorization Grid available at the MCA web site or the Evidence of Coverage.
12.2 Referrals for Services
- Laboratory Services: PHP's will be held accountable for non-authorized referrals to non-participating labs and the member must be held harmless.
- Referrals: Providers must only refer members to MCA participating PHPs.
- Radiology Services Referrals: PHPs must refer members to MCA network radiology providers. Certain radiology services require prior authorization before member is referred.
- Infusion or Enteral Therapy Referrals: PHPs must refer members to MCA participating infusion or enteral provider.
- Durable Medical Equipment (DME) Referrals: PHPs must refer members to a participating DME provider.
12.3 Prior Authorization Contacts
Inpatient Hospital and Hospice Services
Fax: (602) 659-1963
(866) 300-3926
(Toll Free)
Pharmacy Prior Authorization
Mercy Care Advantage
Fax: (800) 854-7614 (Toll Free)
CHAPTER 13 - ENCOUNTERS, BILLING AND CLAIMS
Encounters
13.0 Billing Encounters and Claims Overview
The MCA Claims Department is responsible for claims adjudication, resubmissions, claims inquiry/research and provider encounter submissions to CMS.
MCA is required to process claims in accordance with Medicare claim payment rules and regulations.
Physicians and health care professionals must use valid International Classification of Disease, 9th Edition, Clinical Modification (ICD-9 CM) codes and code to the highest level of specificity. Complete and accurate use of CMS' Healthcare Common Procedure Coding System (HCPCS) and the American Medical Association's (AMA) Current Procedural Terminology (CPT), 4th Edition, procedure codes are also required. Hospitals and physicians using the Diagnostic Statistical Manual of Mental Disorders, 4th Edition, (DSM IV) for coding must convert the information to the official ICD-9 CM codes. Failure to use the proper codes will result in diagnoses being rejected in the Risk-Adjustment Processing System.
- The ICD-9 CM codes must be to the highest level of specificity: assign three-digit codes only if there are no four-digit codes within that code category, assign four-digit codes only if there is no fifth-digit sub-classification for that subcategory and assign the fifth-digit sub-classification code for those sub-categories where it exists.
- Report all secondary diagnoses that impact clinical evaluation, management and/or treatment.
- Report all relevant V-codes and E-codes pertinent to the care provided. An unspecified code should not be used if the medical record provides adequate documentation for assignment of a more specific code.
Review of the medical record entry associated with the claim should obviously indicate all diagnoses that were addressed were reported.
Again, failure to use current coding guidelines may result in a delay in payment and/or rejection of a claim.
13.1 CMS Risk Adjustment Data Validation
Risk Adjustment Data Validation (RADV) is an audit process to ensure the integrity and accuracy of risk-adjusted payment. CMS may require MCA to request medical records to support randomly selected claims to verify the accuracy of diagnosis codes submitted. Medicare Advantage plans like MCA, are annually selected for data validation audits by CMS.
It is important for physicians and their office staff to be aware of risk adjustment data validation activities because MCA may request medical record documentation. Accurate risk-adjusted payment depends on the accurate diagnostic coding derived from the member's medical record.
The Balanced Budget Act of 1997 (BBA) specifically required implementation of a risk-adjustment method no later than January 1, 2000. In 2000-2001, encounter data collection was expanded to include outpatient hospital and physician data. Risk adjustment is used to fairly and accurately adjust payments made to MCA by CMS based on the health status and demographic characteristics of an enrollee. CMS requires MCA to submit diagnosis data regarding physician, inpatient and outpatient hospital encounters on a quarterly basis, at minimum.
CMS uses the Hierarchical Condition Category payment model referred to as CMS-HCC model. This model uses the ICD-9 CM as the official diagnosis code set in determining the risk-adjustment factors for each member. The risk factors based on HCCs are additive and are based on predicted expenditures for each disease category. For risk-adjustment purposes, CMS classifies the ICD-9 CM codes by disease groups known as HCCs.
Physicians and health care professionals are required to submit accurate, complete and truthful risk adjustment data to MCA. Failure to submit complete and accurate risk adjustment data to CMS may affect payments made to MCA and payments made by MCA to the physician or health care professional organizations delegated for claims processing.
Certain combinations of coexisting diagnoses for an enrollee can increase their medical costs. The CMS-HCC model for coexisting conditions that should be coded for hospital and physician services are as follows:
- Code all documented conditions that coexist at time of encounter/visit and that require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
- Physicians and hospital outpatient departments should not code diagnoses documented as "probable," "suspected," "questionable," "rule out" or "working" diagnosis. Rather, physicians and hospital outpatient departments should code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results or other reason for the visit.
Annually, CMS conducts a medical record review to validate the accuracy of the risk-adjustment data submitted by MCA. Medical records created and maintained by providers must correspond to and support the hospital inpatient, outpatient and physician diagnoses submitted by the provider to MCA. In addition, Medicare Advantage regulations require that providers submit samples of medical records for validation of risk-adjustment data and the diagnoses reported to CMS, as required by CMS. Therefore, providers must give access to and maintain medical records in accordance with Medicare laws, rules and regulations. CMS may adjust payments to MCA based on the outcome of the medical record review.
For more information related to risk adjustment, visit the Centers for Medicare and Medicaid Services web site at http://csscoperations.com/.
Additional information can be attained in the Provider Reference Tool under Reference Guides titled Mercy Care Advantage Risk Adjustment.
Billing and Claims
13.2 When to Bill a Member
All PHPs must adhere to federal financial protection laws and are prohibited from balance billing any MCA member beyond the member's cost sharing.
A member may be billed ONLY when the member knowingly agrees to receive non-covered services under both MCA and MCP.
- Provider MUST notify the member in advance that the charges will not be covered under MCA or MCP.
- Provider MUST have the member sign a statement agreeing to pay for the services and place the document in the member's medical record.
13.3 When to File a Claim
All claims and encounters must be reported to MCA, including prepaid services.
13.4 Timely Filing of Claim Submissions
In accordance with contractual obligations, claims for services provided to a MCA member must be received in a timely manner. MCA's timely filing limitations are as follows:
- New Claim Submissions – Claims must be filed on a valid claim form within 180 days (6 months) from the date services were performed, unless there is a contractual exception. For hospital inpatient claims, date of service means the date of discharge of the patient.
- Other Claim Submissions – Claims must be filed on a valid claim form within 180 days (6 months) from the date services were performed, unless there is a contractual exception. For hospital inpatient claims, date of service means the date of discharge of the patient.
- Claim Resubmission - Claim resubmissions must be filed within 365 days (1 year) from the date of provision of the covered service. If a provider disagrees with resubmission outcome or recoupment of a claim, the provider must submit the claim for resubmission within 60 days of the decision to pay, deny or recoup the claim. Please submit any additional documentation that may effectuate a different outcome or decision.
Failure to submit claims and encounter data within the prescribed time period may result in payment delay and/or denial.
Non-contracted providers rendering prior authorized services follow the same timely filing guidelines as Original Medicare guidelines.
13.5 Cost Sharing and Coordination of Benefits
MCA must first identify payers that are primary to Medicare, the amounts payable to those payers, and must then coordinate benefits for its Medicare members with these payers. These payers may include but are not limited to:
- Group health plans that cover working aged individuals and their spouses
- Large group health plans that cover individuals entitled to Medicare based on their employment status
- Group health plans that cover individuals entitled to Medicare based on a diagnosis of end-stage renal disease
- Workers' compensation plans
- Property and casualty insurance plans
- Liability and no-fault insurance plans, including self-insured plans.
If a member receives covered benefits that are covered under another insurance policy or plan, MCA may bill or authorize a provider to bill any of the following:
- The insurance carrier, the employer or any other entity that is liable for payment for the services.
- The Medicare enrollee, to the extent that the carrier has paid him or her, employer or other entity for covered medical expenses.
Medicare Secondary Payer (MSP) rules established under the Medicare Advantage program supersede any state laws, regulations, contract requirements or other standards that would otherwise apply to Medicare Advantage Plans, only to the extent that those state laws are inconsistent with MSP standards.
MCA has the right to authorize providers to collect and retain funds subject to coordinate benefits procedures. For example, if MCA receives a claim for payment of covered services, but it is the responsibility of another insurer, MCA is permitted to return the claim to the provider with instructions to bill the third party.
Coordination of benefits will be handled as follows between:
- Mercy Care Advantage (Primary) and Mercy Care Plan (Secondary): For members enrolled in both Mercy Care plans, MCA is primary payer and MCP is secondary.
- Mercy Care Advantage and Another AHCCCS Plan: If an MCA member has an AHCCCS plan, the provider is responsible for coordinating benefits and claims submissions.
- MCA, MCP and Another Health Plan: If a member has insurance other than MCA and MCP (e.g. group health coverage), the provider is responsible for determining if the other insurance is primary over MCA.
For MCA members enrolled in both MCP and MCA, any cost sharing responsibilities will be coordinated between the two payers. For the most part, providers only need to submit one claim to MCP and MCA and benefits will be automatically coordinated. There may be exceptions to this, which are covered in this chapter under the section titled Instruction for Specific Claim Types.
13.6 Injuries Due to an Accident
Medicare law only permits subrogation in cases where there is a reasonable expectation of third party payment. In cases where legally required insurance (i.e. auto-liability) is not actually in force, MCA is required to assume responsibility for primary payment.
13.7 How to File a Claim
- Select the appropriate claim form (refer to table below).
13.7a – Claim Form Table
| Service | Claim Form |
|---|---|
| Medical and professional services | CMS 1500 Form |
| Hospital inpatient, outpatient, skilled nursing and emergency room services | CMS UB-04 Form |
| General dental services | ADA 2002 Claim Form |
| Dental services that are considered medical services (oral surgery, anesthesiology) | CMS 1500 Form |
Instructions on how to fill out the claim forms can be found at the following AHCCCS web site addresses:
- Complete the claim form.
- Claims must be legible and suitable for imaging and/or microfilming for permanent record retention. Complete ALL required fields and include additional documentation when necessary.
- The claim form may be returned unprocessed (unaccepted) if illegible or poor quality copies are submitted or required documentation is missing. This could result in the claim being denied for untimely filing.
- Submit original copies of claims electronically or through the mail (do NOT fax).
To include supporting documentation, such as members' medical records, clearly label
and send to the Claims Department at the correct address.
-
Electronic Clearing House
Providers who are contracted with MCA can use electronic billing software. Electronic billing ensures faster processing and payment of claims, eliminates the cost of sending paper claims, allows tracking of each claim sent and minimizes clerical data entry errors. Additionally, a Level Two report is provided to your vendor, which is the only accepted proof of timely filing for electronic claims.
- The EDI vendors that MCA uses are as follows:
- Emdeon
- SPSI
- SSI
- Contact your software vendor directly for further questions about your electronic billing.
- Contact your Provider Relations representative for more information about electronic billing. Additional information can be attained by accessing the Provider Reference Tool under Provider Claim References titled Electronic Submission of Claims – Electronic Fund Transfer – Electronic Remittance Advice.
- The EDI vendors that MCA uses are as follows:
All electronic submission shall be submitted in compliance with applicable law including HIPAA regulations and MCA policies and procedures.
-
- Through the Mail
13.7b Claims Address Table
| Claims | Mail To | Electronic Submission* |
|---|---|---|
| Medical |
Mercy Care Advantage Claims Department Attention: Resubmissions P. O. Box 52089 Phoenix, AZ 85072-2089 |
Through Electronic Clearing House |
| Dental |
Mercy Care Advantage Dental Claims Department Attention: Resubmissions P. O. Box 61235 Phoenix, AZ 85082-1235 |
Not available at this time |
| Refunds |
Mercy Care Advantage Attention: Finance Department P.O. Box 52089 Phoenix, AZ 85072-2089 |
Not Applicable |
*See individual sections for further information: 13.15 Claim Resubmission and 13.16 Claim Disputes.
13.8 Correct Coding Initiative
MCA follows the same standards as Medicare's Correct Coding Initiative (CCI) policy and performs CCI edits and audits on claims for the same provider, same recipient, and same date of service. For more information on this initiative, please feel free to visit: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.
MCA utilizes ClaimCheck as our comprehensive code auditing solution that will assist payors with proper reimbursement. Correct Coding Initiative guidelines will be followed in accordance with CMS. Additional information will be released shortly regarding provider access to our unbundling software through Clear Claim Connection.
Clear Claim Connection is a web-based stand-alone code auditing reference tool designed to mirror MCA's comprehensive code auditing solution through ClaimCheck. It enables MCA to share with our providers the claim auditing rules and clinical rationale inherent in ClaimCheck.
Providers will have access to Clear Claim Connection through MCA's web site through a secure login. Clear Claim Connection coding combinations can be used to review claim outcomes after a claim has been processed. Coding combinations may also be reviewed prior to submission of a claim so that the provider can view claim auditing rules and clinical rationale prior to submission of claims.
Further detail on how to use Clear Claim Connection can be accessed at MCA's web site under Provider Reference Tool, Clear Claim Connection Provider Web Navigation Guide.
13.9 Correct Coding
Correct coding means billing for a group of procedures with the appropriate comprehensive code. All services that are integral to a procedure are considered bundled into that procedure as components of the comprehensive code when those services:
- Represent the standard of care for the overall procedure, or
- Are necessary to accomplish the comprehensive procedure, or
- Do not represent a separately identifiable procedure unrelated to the comprehensive procedure.
13.10 Incorrect Coding
Examples of incorrect coding include:
- "Unbundling" - Fragmenting one service into components and coding each as if it were a separate service.
- Billing separate codes for related services when one code includes all related services.
- Breaking out bilateral procedures when one code is appropriate.
- Downcoding a service in order to use an additional code when one higher level, more comprehensive code is appropriate.
13.11 Modifiers
Appropriate modifiers must be billed in order to reflect services provided and for claims to pay appropriately. MCA can request copies of operative reports or office notes to verify services provided. Common modifier issue clarification is below:
Modifier 59 – Distinct Procedural Services - must be attached to a component code to indicate that the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Medical records must reflect appropriate use of the modifier. Modifier 59 cannot be billed with evaluation and management codes (99201-99499) or radiation therapy codes (77261 -77499).
Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service - must be attached to a component code to indicate that the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Medical records must reflect appropriate use of the modifier. Modifier 25 is used with Evaluation and Management codes and cannot be billed with surgical codes.
Modifier 50 – Bilateral Procedure - If no code exists that identifies a bilateral service as bilateral, you may bill the component code with modifier 50. MCA follows the same billing process as CMS and AHCCCS when billing for bilateral procedures. Services should be billed on one line reporting one unit with a 50 modifier.
Please refer to your Current Procedural Terminology (CPT) manual for further detail on all modifier usage.
13.12 Checking Status of Claims
Providers may check the status of a claim by accessing MCA's secure web site or by calling the Claims Inquiry department.
Online Status through MCA's Secure Web Site
MCA encourages providers to take advantage of using online status, as it is quick, convenient and can be used to determine status for multiple claims. To register, go to http://www.MercyCarePlan.com and select "Login" at the top of the page or contact your Provider Relations representative to establish a Login. More information is available in this Provider Manual under section 4.7 Mercy1Source.
Calling the Claims Inquiry Department
The Claims Inquiry Department is also available to:
- Answer questions about claims.
- Assist in resolving problems or issues with a claim.
- Provide an explanation of the claim adjudication process.
- Help track the disposition of a particular claim.
- Correct errors in claims processing:
- Excludes corrections to prior authorization numbers (providers must call the Prior Authorization Department directly).
- Excludes rebilling a claim (the entire claim must be resubmitted with corrections, see section 13.15 Claim Resubmission.
Please be prepared to give the service representative the following information:
- Provider name and AHCCCS or NPI number with applicable suffix if appropriate.
- Member name and AHCCCS member identification number.
- Date of service.
- Claim number from the remittance advice on which you have received payment or denial of the claim.
13.13 Payment of Claims
MCA processes claims and notifies the provider of outcome using a Remittance Advice. Providers may choose to receive checks through the mail or electronically. MCA encourages providers to take advantage of receiving Electronic Remittance Advices (ERA), as you will receive much sooner than receiving through the mail, enabling you to post payments sooner. Please contact your Provider Relations representative for further information on how to receive ERA. Remittance Advice samples are available under Provider Reference Tool. Links to those remits are available under the section 13.27 Provider Remittance Advice in this Provider Manual.
Through Electronic Funds Transfer (EFT), providers have the ability to direct funds to a designated bank account. MCA encourages you to take advantage of EFT. Since EFT allows funds to be deposited directly into your bank account, you will receive payment much sooner than waiting for the mailed check. You may enroll in EFT by submitting a Mercy Care Plan EFT Enrollment Form found under the Provider Reference Tool. Submit this form along with a voided check to process the request. Please allow at least 30 days for EFT implementation. Your Provider Relations representative will assist you with this.
Additional information can be attained by accessing the Provider Reference Tool under Provider Claim References titled Electronic Submission of Claims – Electronic Fund Transfer – Electronic Remittance Advice.
13.14 Claim Resubmission
Providers have twelve (12) months from the date of service to resubmit a revised version of a processed claim. The review and reprocessing of a claim does not constitute a reconsideration or claim dispute.
Providers may resubmit a claim that:
- Was originally denied because of missing documentation, incorrect coding, etc.
- Was incorrectly paid or denied because of processing errors
Include the following information when filing a resubmission:
- Use the Resubmission Form located under the Provider Reference Tool.
- An updated copy of the claim. All lines must be rebilled. A copy of the original claim (reprint or copy is acceptable).
- A copy of the remittance advice on which the claim was denied or incorrectly paid.
- Any additional documentation required.
- A brief note describing requested correction.
- Clearly label as "Resubmission" at the top of the claim in black ink and mail to appropriate claims address as indicated in 13.8b Claim Address Table.
Resubmissions may not be submitted electronically. Failure to mail and accurately label the resubmission to the correct address will cause the claim to deny as a duplicate.
13.15 Claim Disputes
Conditions for payment are outlined in PHP's contractual agreement and fee schedule with MCA. Claim payments are adjudicated in accordance with the provider agreement. CMS prohibits Medicare Advantage plans from applying the mandated Medicare member appeal process to participating providers. PHPs are encouraged to contact the Claims Department with questions on how their claim paid. MCA will work with the provider to resolve the issue if an error is discovered. In some situations, MCA may require the provider to resubmit the claim for reprocessing. Please note that MCA contracted providers do not have appeal rights and cannot balance bill the member.
13.16 Non-Contracted Provider Reconsiderations
A provider that does not have a contractual arrangement with MCA, on his or her own behalf, is permitted to file a standard appeal (reconsideration) for a denied claim payment only if a waiver of liability form is completed and submitted with the appeal. The waiver of liability form is a binding agreement which the provider has agreed to hold the member financially harmless, regardless of the outcome of the appeal. This form can be found on the MCA website at www.MercyCareAdvantage.com. The provider must submit the appeal with the required documentation and be received by MCA within 60 calendar days of the Remittance Advice for the claim denial.
If MCA receives the appeal without the completed waiver of liability form, the request will be held for up to 60 days after the request is received. If MCA does not receive the form by the conclusion of the appeal time frame, MCA will forward the case to the independent review entity with a request for dismissal.
MCA will notify the provider of a decision in writing not later than 60 days after receipt of the appeal and waiver of liability form.
To appeal a claim denial, write a letter and mark the top of the request "appeal" and include the following:
- Statement indicating basis for appeal
- A signed Waiver of Liability
- Copy of the original claim
- Copy of the remit notice showing the claim denial
- Any additional information, clinical records or documentation
Send information to:
Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
Fax: (602) 351-2300
13.17 Provider Payment Dispute Resolution Process for Non-Contracted Providers
Providers that do not have a contractual relationship with MCA have access to a Medicare Advantage Payment Dispute Process. If the non-contracted provider believes that the payment amount received for a service provided to a MCA plan member is less than the amount they would be entitled to receive under Original Medicare, or provider disagrees with a decision made by MCA to pay for a different service than the service for which was billed, the provider has the right to dispute the payment amount.
To file a payment dispute, please send your written dispute to:
Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
(602) 351-2300 (fax)
Please provide MCA with all appropriate documentation to support your payment dispute (e.g., remittance advice and letter addressing your concerns). You must submit your payment dispute to MCA no later than 60 days from the date you initially received the disputed payment from MCA.
MCA will review your payment dispute and respond to you within 30 days from the time the provider payment dispute is first received by MCA. If we determine that you are owed additional payment amounts after reviewing your payment dispute, we will pay you this additional amount, including any interest owed under federal law, if applicable. We will inform you in writing if the payment dispute is not decided in your favor.
Effective January 1, 2010, CMS established new rules that allow you to file an additional request for review with an independent review organization contracted with CMS if MCA informs you that your payment dispute is not decided in your favor. The current independent review organization contracted with CMS is First Coast Service Options, Inc. ("First Coast").
To file this additional request for review of a payment dispute with the independent review organization, you should contact the organization directly at:
First Coast Service Options, Inc.
Payment Dispute Resolution Contractor
P.O. Box 44017
Jacksonville, FL 32231-4017
First Coast may also be reached by email at PDRC@fcso.com and by phone at (904) 791-6430. Please note that you must first fully complete the MCA internal payment dispute resolution process before you can request a review by the independent review organization contracted with CMS.
Additional information regarding First Coast Service Options is available at the following web site: http://www.fcso.com/148866.pdf.
Instruction for Specific Claims Types
13.18 MCA General Claims Payment Information
MCA claims are always paid in accordance with the terms outlined in the PHP's contract. Prior authorized services from Non Participating Health Providers will be paid in accordance with Original Medicare claim processing rules.
13.19 Skilled Nursing Facilities (SNF)
Providers submitting claims for SNFs should use CMS UB-04 Form.
Refer to the Skilled Nursing Facility Guidelines located under the Provider Reference Tool for additional information.
Providers must bill in accordance with standard Medicare RUGS billing requirement rules for MCA, following consolidated billing. For additional information regarding CMS Consolidated Billing, please refer to the following CMS web site address: http://www.cms.gov/SNFPPS/05_ConsolidatedBilling.asp
The coordinating claim on the Medicaid side will require separate billing in accordance with the provider contract. This is one of the few situations where billing requirements differ on the MCA side versus the MCP side.
13.20 Home Health Claims
Providers submitting claims for Home Health should use CMS 1500 Form.
Providers must bill in accordance with their contract terms. Non Participating Health Providers must bill according to CMS HHPPS requirement rules for MCA. For additional information regarding CMS Home Health Prospective Payment System (HHPPS), please refer to the following CMS web site address: http://www.cms.gov/HomeHealthPPS/ .
13.21 Dental Claims
- Claims for dental services should be submitted on the standard American Dental Association form ADA 2002 Claim Form.
- Services provided by an anesthesiologist or medically related oral surgery procedure should be submitted on CMS 1500 Form.
13.22 Durable Medical Equipment (DME) Rental Claims
Providers submitting claims for DME Rental should use CMS 1500 Form.
DME rental claims are only paid up to the purchase price of the durable medical equipment.
There is a billing discrepancy rule difference between Days versus Units for DME rentals between MCA and MCP. Units billed for MCA equal 1 per month. Units billed for MCP equal the amount of days billed. Since appropriate billing for CMS is 1 Unit per month, in order to determine the amount of days needed to determine appropriate benefits payable under MCP, the claim requires the date span (from and to date) of the rental. MCP will calculate the amount of days needed for the claim based on the date span.
13.23 Same Day Readmission
Providers submitting claims for inpatient facilities should use CMS UB-04 Form.
There may be occasions where a member may be discharged from an inpatient facility and then readmitted later that same day. MCA defines same day readmission as a readmission with 24 hours.
Example:
Discharge Date: 10/2/10 at 11:00 a.m.
Readmission Date: 10/3/10 at 9:00 a.m.
Since the readmission was within 24 hours, this would be considered a same day readmission per above definition.
13.24 Hospice Claims
The only claims payable during a hospice election period by MCA would be additional benefits covered under MCA that would not normally be covered under Original Medicare covered services. All other claims need to be resubmitted to Original Medicare for processing, regardless of whether they are related to hospice services or not. Please refer to the Provider Claims Reference titled Hospice Election Coverage While Covered Under Mercy Care Advantage in the Provider Reference Tool for additional information.
13.25 HCPCS Codes
There may be differences in what codes can be billed for Medicare versus Medicaid. MCA follows Medicare billing requirement rules, which could result in separate billing for claims under MCP. While most claims can be processed under both MCA and MCP, there may be instances where separate billing may be required.
Remittance Advice
13.26 Provider Remittance Advice
MCA generates checks weekly. Claims processed during a payment cycle will appear on a remittance advice ("remit") as paid, denied or reversed. Adjustments to incorrectly paid claims may reduce the check amount or cause a check not to be issued. Please review each remit carefully and compare to prior remits to ensure proper tracking and posting of adjustments. We recommend that you keep all remittance advices and use the information to post payments and reversals and make corrections for any claims requiring resubmission. Call your Provider Relations representative if you are interested in receiving electronic remittance advices.
The Provider Remittance Advice (remit) is the notification to the provider of the claims processed during the payment cycle. A separate remit is provided for each line of business in which the provider participates.
Information provided on the remit includes:
- The Summary Box found at the top right of the first page of the remit summarizes the amounts processed for this payment cycle.
- The Remit Date represents the end of the payment cycle.
- The Beginning Balance represents any funds still owed to MCP for previous overpayments not yet recouped or funds advanced.
- The Processed Amount is the total of the amount processed for each claim represented on the remit.
- The Discount Penalty is the amount deducted from, or added to, the processed amount due to late or early payment depending on the terms of the provider contract.
- The Net Amount is the sum of the Processed Amount and the Discount/Penalty.
- The Refund Amount represents funds that the provider has returned to MCP due to overpayment. These are listed to identify claims that have been reversed. The reversed amounts are included in the Processed Amount above. Claims that have refunds applied are noted with a Claim Status of REVERSED in the claim detail header with a non-zero Refund Amount listed.
- The Amount Paid is the total of the Net Amount, plus the Refund Amount, minus the Amount Recouped.
- The Ending Balance represents any funds still owed to MCP after this payment cycle. This will result in a negative Amount Paid.
- The Check # and Check Amount are listed if there is a check associated with the remit. If payment is made electronically then the EFT Reference # and EFT Amount are listed along with the last four digits of the bank account the funds were transferred. There are separate checks and remits for each line of business in which the provider participates.
- The Benefit Plan refers to the line of business applicable for this remit. TIN refers to the tax identification number.
- The Claim Header area of the remit lists information pertinent to the entire claim.
This includes:
- Member/Patient Name
- ID
- Birth Date
- Account Number,
- Authorization ID, if Obtained
- Provider Name,
- Claim Status,
- Claim Number
- Refund Amount, if Applicable
- The Claim Totals are totals of the amounts listed for each line item of that claim.
- The Code/Description area lists the processing messages for the claim.
- The Remit Totals are the total amounts of all claims processed during this payment cycle.
- The Message at the end of the remit contains claims inquiry and resubmission information as well as grievance rights information.
The following Remittance Advice samples are available under Provider Reference Tool or by clicking on the form listed below:
- Mercy Care Advantage Remit Format for Check
- Mercy Care Advantage Remit Format for EFT
More information is available in this Provider Manual under section 4.7 Mercy1Source regarding Remittance Advice Search.
An electronic version of the Remittance Advice can be attained. In order to qualify for an Electronic Remittance Advice (ERA), you must currently submit claims through EDI and receive payment for claim by EFT. You must also have the ability to receive ERA through an 835 file. We encourage our providers to take advantage of EDI, EFT, and ERA, as it shortens the turnaround time for you to receive payment and reconcile your outstanding accounts. Please contact your Provider Relations representative to assist you with this process. Additional information can be attained by accessing the Provider Reference Tool under Provider Claim References titled Electronic Submission of Claims – Electronic Fund Transfer – Electronic Remittance Advice.
CHAPTER 14 – MCA MEMBER GRIEVANCES AND APPEALS
14.0 Grievances
Grievances are defined as any member complaint or dispute, other than one involving an adverse organization determination, expressing dissatisfaction with the manner in which MCA or a delegated entity provides health care services, regardless of whether any remedial action can be taken. Members or their representative may make the complaint or dispute, either orally or in writing, to MCA, a provider, or a facility. An expedited grievance may also include a complaint that MCA refused to expedite an OD or reconsideration, or invoked an extension to an OD or reconsideration time frame.
In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet the accepted standards for delivery of health care.
Examples of grievance issues include, but are not limited to quality of care provided, accessibility, availability or quality of services, interpersonal relationships, cultural barriers or insensitivity or failure to respect a member's rights.
14.1 Filing and Resolving Grievances
MCA will review and attempt to resolve any member grievance under the Medicare grievance process. Members are encouraged to submit verbally or by writing MCA Member Services:
Mercy Care Advantage
Member Services Department
4350 E. Cotton Boulevard, Building D
Phoenix, AZ 85040
Phone: (602) 263-3000
Toll Free: (800) 624-3879
Fax: (602) 351-2313
Members should submit a grievance no later than 60 days after the event or incident that precipitates the grievance. Grievances received after 60 days will be reviewed, tracked and trended. MCA will investigate the complaint and respond to the grievance in accordance with CMS requirements. MCA will notify the member of its decision as expeditiously as the member's health condition requires, but no later than 30 days after the date MCA receives the grievance.
14.2 Quality Improvement Organization - Quality of Care Grievances
A member may file a grievance regarding concerns of the quality of care received with MCA, or with the CMS contracted Quality Improvement Organization (QIO). In Arizona, the QIO is Health Services Advisory Group (HSAG), which is located at:
1600 East Northern Avenue, Suite 100
Phoenix, AZ 85020
Phone: (602) 264-6382
Toll-Free: (800) 359-9909
Fax: (602) 241-0757
14.3 Member Initiated Appeals (Reconsiderations)
MCA members have the right to appeal an adverse organization determination by MCA if they disagree with the decision to deny a requested benefit or service, or one that involves a denied claim or reimbursement request. Reconsiderations must be submitted in writing within 60 calendar days of the date of the denial notice sent to the member. MCA may extend this timeframe if the member provides evidence of "good cause".
14.4 Filing an Appeal on Behalf of a Member
Regardless of whether the member files a standard appeal, or asks for an expedited review, the member can solicit the help of a friend, lawyer, advocate, relative, physician, or someone else. The member can appoint a trusted individual to represent them as an appointed representative. The appeal must include the member's Appointment of Representative (AOR) form, or legal representative documents. Members are encouraged to contact the Medicare Rights Center toll free at 1-888-HMO-9050 for assistance in filing an appeal.
14.5 How to Appoint a Representative
The member may appoint an individual to act as his/her representative to file an appeal by completing the following steps:
- Complete the 07/05 edition of the CMS Appointment of Representative (AOR) 1696 form, available under Provider Reference Tool, under Forms.
- Provide the member's name, Medicare number and the CMS -1696 form that appoints an individual as the member's representative (Note: a member may appoint a physician, relative, friend, attorney or advocate).
- The member must sign and date the form.
- The appointed representative must also sign and date this form.
- The appointed representative must include this signed form with the appeal.
- A contracting physician may serve as a member's representative upon appointment.
- A non-contracted health care provider that has furnished a service to a member may file a standard appeal of a denied claim if he/she completes the Medicare Waiver of Liability form that attests the provider will not hold the member financially liable regardless of the outcome of the appeal. The Medicare Waiver of Liability form may be found under Provider Reference Tool, under the Forms section.
14.6 Standard Appeal Resolution
- MCA's Appeals team will review its initial decision. A medical director, who was not involved in the original determination, will review the reconsideration based on known evidence of Medicare coverage and medical necessity.
- MCA will issue a decision as expeditiously as the member's health requires, but no later than 30 days from receipt of the request.
- The timeframe may be extended by up to 14 days if the member requests the extension or if MCA needs additional information and the extension may benefit the member. MCA will make a decision as expeditiously as the member's health requires, but no later than the end of any extension period.
- If MCA decides in the member's favor, MCA will provide or authorize the requested service as expeditiously as the member's health requires, but no later than 30 days from the date the request was received.
- When MCA upholds its original decision to deny, MCA will automatically forward the case file to the CMS contracted Independent Review Entity (IRE), MAXIMUS Federal Services. The IRE will review the case to determine if MCA made the decision based on Medicare regulations and guidelines. MAXIMUS Federal Services will notify the member or representative of the final decision.
- If the member disagrees with the IRE decision, and the amount in dispute reaches a certain threshold, an appeal may be submitted to an Administrative Law Judge.
14.7 Expedited Reconsideration Resolution
- Members have the right to request an expedited decision affecting medical treatment if the member or their physician believes that applying the standard decision timeframe could seriously jeopardize the member's life, health or ability to regain maximum function. To request an expedited review, the member, the member's appointed or legal representative, or physician may submit a written reconsideration request to MCA.
- If the member has submitted a standard appeal, their physician may change the appeal to an expedited review by calling the MCA Appeals unit.
- If MCA decides, based on medical criteria, that the situation is time-sensitive,
or if any physician requests an expedited review, MCA will issue a decision as expeditiously
as the Member's health requires, but no later 72 hours after receiving the request.
- This timeframe may be extended up to 14 days if the member requests the extension or if the plan needs additional information and the extension benefits the member. MCA will make a decision as expeditiously as the member's health requires, but no later than the end of the 14 day extension period.
- If the request does not meet the definition of time sensitive, it will be handled within the standard review process. The member will be informed in writing that the request for expedited review has been denied and that the standard timeframe will be applied. If the member disagrees with MCA's decision to deny the request for the expedited timeframe, the member may file an expedited grievance with MCA.
- A request for payment of a Part D prescription drug already provided to the member is not eligible to be reviewed as an expedited redetermination.
14.8 Submitting an Appeal
Submit an appeal to:
Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
Fax: (602) 351-2300
CHAPTER 15 - MCA MEMBER COVERAGE DETERMINATIONS, EXCEPTIONS, APPEALS AND GRIEVANCES FOR PRESCRIPTION DRUGS
15.0 Medicare Prescription Drug Coverage Determinations
MCA also covers members under Medicare Part D prescription drug coverage. While typically prescribing providers submit requests to MCA to make a coverage determination, members have the right to request a coverage determination concerning a prescription drug they believe they are entitled to receive under their plan, including:
- Basic prescription drug coverage.
- The amount, if any, that the member is required to pay for a drug.
MCA will process coverage determinations under the standard timeframe of 72 hours, unless the prescriber has indicated that the member would be harmed if we apply the standard timeframe. In these cases, MCA will process the review under the expedited timeframe of 24 hours, or as fast as the member's health condition requires. If MCA fails to process the request within the required timeframe, CMS requires MCA to submit the request to the Independent Review Entity, MAXIMUS Federal Services. Should this occur, MCA will notify both the member and the prescribing provider that MAXIMUS will conduct the review.
A member or the member's representative may submit a request to MCA to make a coverage determination for a formulary exception. MCA has provided a form on the MCA's web site titled MCA Pharmacy Coverage Determination Request Form. The request for a coverage determination must be filed directly with MCA. If a member or member representative submits a request directly to MCA, CMS requires MCA to obtain the prescribing provider's supporting statement before this request can be reviewed. MCA provides the MCA Pharmacy Coverage Determination Request Form for your convenience at www.MercyCareAdvantage.com.
MCA requires the prescribing physician to submit in writing via fax directly to MCA's Pharmacy Prior Authorization department:
MCA Pharmacy Fax: (800) 871-6898
A coverage determination is any decision made by MCA regarding a request for Part D drug benefit or payment. There are two (2) types of coverage determinations:
- Formulary UM Requirements – A request for approval for a formulary UM requirement such as prior authorization, step therapy and quantity limitations.
- Formulary Exceptions - Request for Part D prescription drug not listed on the formulary or a request for an exception to the formulary UM requirements.
15.1 Formulary Exceptions
As a Medicare Part D Prescription Drug Plan, MCA must approve a formulary exception to the MCA Formulary if it is determined the requested drug treatment is medically necessary. MCA is required to follow specific review guidelines to determine if a request meets CMS-defined criteria for formulary exception.
Based on the information given by prescribing provider, MCA must review for evidence of medical necessity, which is required to support an approval. The prescriber should provide any medical records that support their position. If MCA is unable to determine medical necessity, MCA will deny the request.
The prescribing physician must provide a written supporting statement that the requested prescription drug is medically required and all other applicable formulary drugs and dosage limits would NOT be as effective because:
- All covered drugs on the formulary have been tried and failed, or caused or would have caused adverse effects;
- The number of doses available under a dose restriction has either been ineffective or based on sound clinical evidence and medical/scientific evidence is likely to be ineffective, or would adversely affect patient compliance due to known physical or mental characteristics of the member;
- The formulary alternatives on the formulary or required under step therapy requirements has either been ineffective or based on sound clinical evidence and medical/scientific evidence is likely to be ineffective, or would adversely affect patient compliance due to known physical or mental characteristics of the member; or would likely cause harm.
Medical documentation to support the prescriber's request is recommended. If MCA does not receive the prescriber's supporting statement, MCA is unable to review and the request will be denied.
Once the physician's supporting statement is received and MCA has made a coverage determination for a formulary exception, MCA will notify the member or the member's appointed representative and the prescribing physician involved as expeditiously as the member's health condition requires, but no later than 72 hours for standard requests, and no later than 24 hours for expedited requests.
For a complete description of MCA's coverage determination and exceptions process, and how to contact MCA if you are assisting a member with this process, please refer to the Grievances and Coverage Determination section available under the Members section of the MCA web site at www.MercyCareAdvantage.com.
15.2 How To File a Part D Prescription Drug Redetermination (Appeal)
- A member or a member's representative or prescribing physician or other prescriber may request a redetermination (appeal) if a request for a Part D prescription drug coverage determination is denied.
- A standard redetermination request must be filed orally or in writing to the MCA Appeals Department within 60 calendar days from the date of the notice of the coverage determination. If the representative is appointed, the request must include the member's written Appointment of Representative form to file an appeal on his/her behalf.
- Submit an appeal to:
Mercy Care Advantage
Appeals Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
Fax: (602) 351-2300 - MCA will issue a decision within 7 calendar days for a standard redetermination. If waiting for the standard timeframe would seriously affect the member's health, MCA will complete an expedited redetermination within 72 hours. The redetermination time frame is calculated from the date and time the redetermination request is received by MCA, and if a request involves a formulary exception that was denied for lack of a prescriber's supporting statement, the timeframe begins when the statement is received. Medical documentation to support to the request is typically required.
- If MCA upholds their original decision to deny, the member or their appointed or legal representative may submit an appeal in writing to MAXIMUS Federal Services, the CMS contracted independent review entity (IRE). Prescribers must be appointed by the member in order to submit an appeal to the IRE. If the representative is appointed, the appeal must include the appointment of representative form. Legal representative documentation is required for legal representatives to file on the member's behalf. The written appeal must be sent to the IRE within 60 calendar days after the date of the appeal denial notice from MCA.
- IRE reconsideration requests can be mailed or faxed to:
MAXIMUS Federal Services, Inc.
Medicare Part D QIC
Cross Keys Office Park
Fairport, NY 14450
Fax: (866) 825-9507
CHAPTER 16 – FRAUD, WASTE AND ABUSE
16.0 Fraud, Waste and Abuse Overview
MCA supports efforts to detect, prevent and report fraud, waste and abuse within the Medicare system. These efforts are consistent with our mission to provide care to the poor and those with special needs while exercising sound fiscal responsibility. Management of limited resources is a key part of this responsibility.
Fraudulent activity hurts everyone. We hope you will join us in our efforts to ensure that tax dollars spent for health care are spent responsibly and used to provide necessary care for as many members as possible.
CMS requires that Medicare Advantage have a compliance plan that guards against potential fraud, waste and abuse under 42 C.F.R. §422.503 (b)(4)(vi) and 42 C.F.R §423.504(b)(4)(vi).
CMS combats fraud by:
- Close coordination with contractors, provider and law enforcement agencies.
- Developing Medicare Program compliance requirements that protect stakeholders.
- Early detection through medical review and data analysis.
- Effective education of physicians, providers, suppliers and beneficiaries.
A provider's best practice for preventing Fraud, Waste and Abuse is to:
- Develop a compliance program.
- Monitor claims for accuracy - ensure coding reflects services provided.
- Monitor medical records – ensure documentation supports services rendered.
- Perform regular internal audits.
- Establish effective lines of communication with colleagues and staff members.
- Ask about potential compliance issues in exit interviews.
- Take action if you identify a problem.
- Remember that you are ultimately responsible for claims bearing your name, regardless of whether you submitted the claim.
16.1 Fraud, Waste and Abuse Defined
Fraud: An intentional act of deception, misrepresentation, or concealment in order to gain something of value.
Waste: Over-utilization of services (not caused by criminally negligent actions) and the misuse of resources.
Abuse: Excessive or improper use of services or actions that is inconsistent with acceptable business or medical practice. Abuse refers to incidents that, although not fraudulent, may directly or indirectly cause financial loss.
Examples of Fraud, Waste and Abuse include:
- Charging in excess for services or supplies.
- Providing medically unnecessary services.
- Billing for items or services that should not be paid for by Medicare.
- Billing for services that were never rendered.
- Billing for services at a higher rate than is actually justified.
- Misrepresenting services resulting in unnecessary cost to the Medicare program, improper payments to providers, or overpayments.
- Physical or sexual abuse of members.
Fraud, Waste and Abuse can incur risk to providers:
- Participating in illegal remuneration schemes, such as selling prescriptions.
- Switching a patient prescription based on illegal inducements rather than based on clinical needs.
- Writing prescriptions for drugs that are not medically necessary, often in mass quantities, and often for individuals that are not patients of a provider.
- Theft of a prescriber's Drug Enforcement Agency (DEA) number, prescription pad, or e-prescribing log-in information.
- Falsifying information in order to justify coverage.
- Failing to provide medically necessary services.
- Offering beneficiaries a cash payment as an inducement to enroll in Part D.
- Selecting or denying beneficiaries based on their illness profile or other discriminating factors.
- Making inappropriate formulary decisions in which costs take priority over criteria such as clinical efficacy and appropriateness.
- Altering claim forms, electronic claim records, medical documentation, etc.
- Limiting access to needed services – for example, by not referring a patient to an appropriate provider.
- Soliciting, offering, or receiving a kickback, bribe, or rebate (for example, paying for a referral of patients in exchange for the ordering of diagnostic tests and other services or medical equipment).
- Billing for services not rendered or supplies not provided would include billing for appointments the patient failed to keep. Another example is a "gang visit" in which a physician visits a nursing home billing for 20 nursing home visits without furnishing any specific service to individual patients.
- Double billing such as billing both Medicare and the beneficiary, or billing Medicare and another insurer.
- Misrepresenting the date services were rendered or the identity of the individual who received the services.
- Misrepresenting who rendered the service, or billing for a covered service rather than the non-covered service that was rendered.
Fraud, Waste and Abuse can incur risk to individuals as well:
- Unnecessary procedures may cause injury or death.
- Falsely billed procedures create an erroneous record of the patient's medical history.
- Diluted or substituted drugs may render treatment ineffective or expose the patient to harmful side effects or drug interactions.
- Prescription narcotics on the black market contribute to drug abuse and addition.
In addition, member fraud is also reportable and examples include:
- Falsifying identity, eligibility, or medical condition in order to illegally receive the drug benefit.
- Attempting to use the enrollee identity card to obtain prescriptions when the enrollee is no longer covered under the drug benefit.
- Looping (i.e., arranging for a continuation of services under another beneficiaries ID).
- Forging and altering prescriptions.
Doctor shopping is when a beneficiary consults a number of doctors for the purpose of obtaining multiple prescriptions for narcotic painkillers or other drugs. Doctor shopping might be indicative of an underlying scheme, such as stockpiling or resale on the black market
16.2 CMS Requirements
Federal law requires MCA to have a Compliance Plan. MCA must:
- Create a Compliance Plan that incorporates measures to detect, prevent, and correct fraud, waste, and abuse.
- Create a Compliance Plan that must consist of training, education, and effective lines of communication.
- Apply such training, education and communication requirements to all entities which provide benefits or services under MCA.
- Produce proof from related entities to show compliance with these requirements.
16.3 Seven Key Elements to a Compliance Plan
An effective Compliance Plan includes seven core elements:
- Written Standards of Conduct: Development and distribution of written Standards of Conduct and Policies and Procedures that promote MCA's commitment to compliance and that address specific areas of potential fraud, waste, and abuse.
- Designation of a Compliance Officer: Designation of an individual and a committee charged with the responsibility and authority of operating and monitoring the compliance program.
- Effective Compliance Training: Development and implementation of regular, effective education, and training.
- Internal Monitoring and Auditing: Use of risk evaluation techniques and audits to monitor compliance and assist in the reduction of identified problem area.
- Disciplinary Mechanisms: Policies to consistently enforce standards and addresses dealing with individuals or entities that are excluded from participating in CMS programs.
- Effective Lines of Communication: Between the compliance officer and the organization's
employee's, managers, and directors and members of the compliance committee, as
well as related entities.
- Includes a system to receive, record, and respond to compliance questions, or reports of potential or actual non-compliance, will maintaining confidentiality.
- Related entities must report compliance concerns and suspected or actual misconduct involving MCA.
- Procedures for responding to Detected Offenses and Corrective Action: Policies to respond to and initiate corrective action to prevent similar offenses including a timely, responsible inquiry.
16.4 Relevant Laws that Apply to Fraud, Waste and Abuse
There are several relevant laws that apply to Fraud, Waste and Abuse:
The False Claims Act (FCA)
The False Claims Ace (FCA) was enacted in 1863 to fight procurement fraud in the Civil War. The FCA has historically prohibited knowingly presenting or causing to be present to the federal government a false or fraudulent claim for payment or approval.
The FCA was recently amended through the American Recovery and Reinvestment Act of 2009 (ARRA) to expand the scope of liability and give the government enhanced investigative powers. FCA liability now extends to subcontractors working on government funded projects as well as those who submit claims for reimbursement to government agents and state agencies. This may indicate FCA liability for claims submitted to MCA.
Anti-Kickback Statute
The Anti-Kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items of services reimbursable by a Federal health care program.
Remuneration includes anything of value, directly or indirectly, overtly or covertly, in cash or in kind.
Beneficiary Inducement Statute
The Beneficiary Inducement Statute prohibits certain inducements to Medicare beneficiaries, i.e., waives the coinsurance and deductible amounts after determining in good faith that the individual is in financial need; or fails to collect coinsurance or deductible amounts after making reasonable collection efforts.
Self-Referral Prohibition Statute (Stark Law)
Prohibits physicians from referring Medicare patients to an entity with which the physician or physician's immediate family member has a financial relationship – unless an exception applies.
Red Flag Rule (Identity Theft Protection)
Requires "creditors" to implement programs to identify, detect, and respond to patterns, practices, or specific activities that could indicate identity theft.
Health Insurance Portability and Accountability Act (HIPAA):
- Transaction standards
- Minimum security requirements
- Minimum privacy protections for protected health information
- National Provider Identifier numbers (NPIs)
OIG and GSA Exclusion Program
Prohibits identified entities and or individuals excluded by the OIG or GSA from conducting business or receiving payment from any Federal health care program.
16.5 Administrative Sanctions
Administrative sanctions can be imposed, as follows:
- Denial or revocation of Medicare provider number application.
- Suspension of provider payments.
- Addition to the OIG List of Excluded Individuals/Entities (LEIE).
- License suspension or revocation.
16.6 Civil Monetary Penalties (CMPS), Litigation and Settlements
The Social Security Act authorizes the imposition of CMPs when Medicare determines that an individual or entity has violated Medicare rules and regulations. Typically penalties involve assessments of significant damages such as CMPs up to $25,000 for each Medicare Advantage enrollee adversely affected.
The United States Attorney's Office may file a civil suit or decide that the interest of the Medicare Program is best served by settling a case out of court. The civil suit or settlement may include a Corporate Integrity Agreement (CIA, which requires the individual or entity to accomplish specific goals (e.g., educational plan, corrective action plan, reorganization) and be subject to period audits by the federal government.
16.7 Potential Civil and Criminal Penalties
- False Claims Act – For each false claim the penalty could range from $5,500.00 - $11,000.00. If the government proves it suffered a loss, the provider is liable for three times the loss.
- Anti-Kickback Statute – Up to five years in prison and fines of up to $25,000.00 for violations of the Anti-Kickback Statute. If a patient suffers bodily injury as a result of the scheme, the prison sentence may be 20+ years.
16.8 Remediation
Remediation may include any or all of the following:
- Education
- Administrative sanctions
- Civil litigation and settlements
- Criminal prosecution
- Automatic disbarment
- Prison time
16.9 Exclusion Lists
MCA is required to check the OIG and General Services Administration (GSA) exclusion lists for all new employees and at least once a year thereafter to validate the employees and other entities that assist in the administration or delivery of service to Medicare beneficiaries are not included on such lists.
The OIG list of Excluded Individuals/Entities (LEIE) can be found at the following web site: http//exclusions.oig.hhs.gov/search.html.
The General Services Administration (GSA) database of excluded individuals/entities can be found at the following web site: http://epls.arnet.gov/.
16.10 Reporting Potential Fraud, Waste, and Abuse
Anyone who suspects member or provider fraud, waste, and abuse may report it as follows:
| By Phone: | 1-800-HHS-TIPS (1-800-447-8477) |
| By Fax: |
1-800-223-2164
(no more than 10 pages please) |
| By E-Mail: | HHSTips@oig.hhs.gov |
| By Mail: |
Office of the Inspector General HHS TIPS Hotline P.O. Box 23489 Washington, DC 20026 |
4350 E. Cotton Center Blvd.,
Bldg D, Phoenix,
Arizona 85040
Member Services
Available 24 hours per day, 7 days a week
602-263-3000,
Toll-free 1-800-624-3879
(TTY/TDD)
Toll-free: 1-866-602-1982
If you or a family member has a medical emergency, dial 911.