Provider Manual Anthem Blue Cross and Blue Shield Healthcare Solutions Medicaid Managed Care
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Provider Manual Anthem Blue Cross and Blue Shield Healthcare Solutions Medicaid Managed Care ANV-PM-0005-20 Copyright April 2021 © Anthem, Inc. All rights reserved. This publication, or any part thereof, may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, storage in an information retrieval system or otherwise, without the prior written permission of the National Provider Communications Department, 5800 Northampton Blvd., Norfolk, VA 23502, telephone 757-473-2737. How to apply for participation If you are interested in participating in our network, please send a letter of intent along with a W-9 to [email protected] or call a Provider Relations representative at 702-228-1308. ANV-PM-0005-20 Table of Contents 1 INTRODUCTION ..................................................................................................................... 5 2 OVERVIEW .............................................................................................................................. 6 3 QUICK REFERENCE INFORMATION ................................................................................. 7 4 PRIMARY CARE PROVIDERS ............................................................................................ 11 4.1 Primary Care Providers/Primary Care Sites ....................................................................... 11 4.2 Provider Specialties.......................................................................................................... 12 4.3 PCP/PCS Onsite Availability............................................................................................ 12 4.4 Provider Disenrollment Process ........................................................................................ 12 4.5 Members Eligibility Listing .............................................................................................. 13 4.6 Member Enrollment ......................................................................................................... 13 4.7 Medicaid Enrollment of Pregnant Women......................................................................... 14 4.8 Medicaid Newborn Enrollment ......................................................................................... 14 4.9 Nevada Check Up Newborn Enrollment ........................................................................... 15 4.10 Member Identification Cards ............................................................................................ 15 4.11 Americans with Disabilities Act Requirements .................................................................. 16 4.12 Medically Necessary Services .......................................................................................... 16 5 ANTHEM HEALTH CARE BENEFITS ................................................................................ 17 5.1 Anthem Covered Services ................................................................................................ 17 5.2 Value-Added Benefits ...................................................................................................... 30 5.3 New Baby, New LifeSM Program ...................................................................................... 32 5.4 Early and Periodic Screening, Diagnosis and Treatment/Well-Child Visits/Healthy Kids.... 33 5.5 Immunizations ................................................................................................................. 35 5.6 Well-Child Visits Reminder Program ............................................................................... 35 5.7 Blood Lead Screening ...................................................................................................... 36 5.8 Pharmacy Services ........................................................................................................... 36 5.9 Specialty Drug Program ................................................................................................... 39 5.10 Behavioral Health Services............................................................................................... 39 5.11 Member Rights and Responsibilities ................................................................................. 41 5.12 Member Grievance........................................................................................................... 43 5.13 Authorization and Notice Timeliness Requirements .......................................................... 44 5.14 Notice of Action .............................................................................................................. 44 5.15 Medical Necessity Appeals............................................................................................... 45 5.16 Continuation of Benefits during Appeals or State Fair Hearings......................................... 47 5.17 Member State Fair Hearing Process .................................................................................. 47 5.18 First Line of Defense Against Fraud and Abuse ................................................................ 48 5.19 HIPAA ............................................................................................................................. 52 6 MEMBER MANAGEMENT SUPPORT ................................................................................ 52 6.1 Welcome Call .................................................................................................................. 52 6.2 Appointment Scheduling .................................................................................................. 53 6.3 24/7 NurseLine ................................................................................................................ 53 6.4 Interpreter Services .......................................................................................................... 53 6.5 Health Promotion ............................................................................................................. 53 6.6 Case Management ............................................................................................................ 54 6.7 Integrated Medical Management Model (IM3)................................................................... 55 ii 6.8 Disease Management/Population Health ........................................................................... 56 6.9 Consumer Advocacy Council ........................................................................................... 57 7 PROVIDER RESPONSIBILITIES ......................................................................................... 58 7.1 Medical Home ................................................................................................................. 58 7.2 Responsibilities of the PCP/PCS ....................................................................................... 58 7.3 PCP/PCS Access and Availability .................................................................................... 61 7.4 Member Missed Appointments ......................................................................................... 62 7.5 Noncompliant Anthem Members ...................................................................................... 62 7.6 PCP/PCS Transfers .......................................................................................................... 63 7.7 Covering Physicians......................................................................................................... 63 7.8 Specialist as a PCP/PCS ................................................................................................... 63 7.9 Reporting Changes in Address and/or Practice Status ........................................................ 64 7.10 Second Opinions .............................................................................................................. 64 7.11 Specialty Care Providers .................................................................................................. 64 7.12 Role and Responsibility of the Specialty Care Providers .................................................... 65 7.13 Specialty Care Providers Access and Availability.............................................................. 66 7.14 Cultural Competency ....................................................................................................... 67 7.15 Member Records.............................................................................................................. 69 7.16 Member Visit Data........................................................................................................... 71 7.17 Clinical Practice Guidelines.............................................................................................. 72 7.18 Advance Directives .......................................................................................................... 72 8 MEDICAL MANAGEMENT.................................................................................................. 74 8.1 Medical Review Criteria................................................................................................... 74 8.2 Utilization Management Decision Making ........................................................................ 75 8.3 Precertification/Notification Process ................................................................................. 76 8.4 Peer-to-Peer Discussion ..................................................................................................