The New Provider Orientation Handbook 1 Dear Contracted Provider, Elite Care Health Organization is sharing this provider orientation handbook to ensure that you, the Primary Care Physicians and/or Specialists, are trained on the Medi-Cal Managed Care program and policies and procedures. According to the State of California’s Department of Health Care Services, new contracted providers MUST be trained within 10 business days of active status. The information provided will allow you and your staff to gain a broad understanding of our shared mission, the importance of positive customer service experiences, member benefits, and member rights and responsibilities. Additionally, if you need clarification on any of the information provided, please contact ECHO MSO for further guidance. Welcome to Superior Choice Medical Group! 2 Medi-Cal Managed Care ................................................................................................... 4 Claims and Encounters ..................................................................................................... 5 Authorizations .....................................................................................................................6 Provider EZ-Net Portal Access .......................................................................................8 Seniors and Persons with Disabilities .............................................................................9 Health Assessments and Provider Toolkits..................................................................10 Child Health and Disability Prevention .......................................................................11 Behavioral Health .............................................................................................................16 Case Management ............................................................................................................17 Managed Long-Term Services and Supports ..............................................................18 Federal and State Statutes .......................................................................................................19 Access and Availability Standards .........................................................................................20 Member Rights and Responsibilities ...................................................................................... 21 Cultural and Linguistic Services ............................................................................................. 23 Customer Service ............................................................................................................. 24 3 Medi-Cal Managed Care Health Plan Delegated Model For more information on NQCA standards and Managed care plans delegate certain authorization and functions, please visit their website at claims processing to some of its contracted Participating http://www.ncqa.org/AboutNCQA.aspx. Provider Groups (PPG's) like Superior Choice Medi-Cal Managed Care provides high quality, Medical Group (SCMG) and Management Services accessible, and cost-effective health care through Organizations (MSOs) like ECHO. Delegation is when an entity gives another entity the authority to managed care delivery systems. Medi-Cal Managed carry out a function that it would otherwise perform, Care contracts for health care services through such as operating within the parameters agreed upon established networks of organized systems of care which between the emphasize primary and preventive care. Managed care plans, have been proven to be a cost-effective use of Managed care plan and Superior Choice Medical health care resources that improve health care access Group (SCMG). and assure quality of care. The National Committee on Quality Assurance (NCQA) holds managed care plans to the following requirements: • Delegation Agreement - A mutual agreement between Managed care plan and SCMG/ECHO outlining specific delegated functions that meet NCQA standards. • Oversight and Monitoring – Managed care plans must oversee the delegates to ensure that the delegateis properly performing all delegated functions. 4 Claims and Encounters Claim Forms and Submission Requirements 1. SCMG will not provide Claim Forms. Contracting Provider shall submit Claim Forms within ninety (30) days of date of service to IPA on CMS 1500 forms, or a mutually agreed upon reporting format, unless otherwise specified under the terms of this Agreement. 2. The CMS 1500 form is the required format for billing submission. The following information shall be included with respect to the Enrollee: 1. Full name and address; 2. Identification number (Insurance I.D. number); 3. Date of birth; 4. Sex; 5. Plan affiliation; 6. Diagnostic code and description (ICD-9); 7. Date of Service; 8. Place of Service; 9. Procedures, services or supplies furnished and related current CPT or HCPCS Coding and the charges for those services, procedures or supplies; 10. PHYSICIAN’s name (not name of physician group); 11. PHYSICIAN’s address and telephone number; 12. PHYSICIAN’s tax identification number, and 13. PHYSICIAN’s NPI and charges Claims forms shall be submitted to: Superior Choice Medical Group PO Box 910 La Verne, CA 91750 Attn: Claims Via EDI: Office Ally- SCPR1 5 Authorizations In order to determine who is responsible for • Routine Women’s health services – a woman can go authorization of services, please contact ECHO MSO or directly to any network provider for women’s health reference your contract with the SCMG for more care such as breast or pelvic exams information. ° This includes care provided by a Certified Professional authorizations and payment of claims for Nurse Midwife/OB-GYN and Certified Nurse those services are usually the responsibility of SCMG. Practitioners For all other services, SCMG/ECHO and the • Basic prenatal care – a woman can go directly to any managed care plan have a contractual document network provider for basic pre-natal care that defines which entity is responsible for a service (e.g., Division of Financial Responsibility and a • Family planning services, including: counseling, Delegation Agreement). For additional information on pregnancy tests and procedures for the termination of what services are paid for by the SCMG or managed pregnancy (abortion) care plan please call ECHO MSO • Treatment for Sexually Transmitted Diseases, includes: testing, counseling, treatment and prevention • Emergency medical transportation Services That Do Not Require Prior Authorization Services That May Require Prior Authorization Note: As the Prior Authorization process may • Emergency Services, whether in or out of covered vary between PPGs/MSOs, verify with SCMG county but within the continental USA (except for that these services are correct. care provided outside of the United States which is subject to retrospective review) • Non-emergency out of area care (outside covered • Emergency Care provided in Canada or Mexico county) is covered • Out of network care, services not provided by a • Urgent care, whether in or out of network contracted network doctor • Mental health care and substance use treatment • Inpatient admissions, post-stabilization/non- emergency/elective • Inpatient admission to skilled nursing facility or nursing home • Outpatient hospital services/surgery • Outpatient, non-hospital , such as surgeries or sleep studies • Outpatient diagnostic services, minimally invasive or invasive such as CT Scans, MRIs, colonoscopy, endoscopy, flexible sigmoidoscopy, and cardiac catheterization 6 Authorizations (continued) • Durable Medical Equipment, standard or customized; rented or purchased • Medical Supplies • Prosthetics and Orthotics • Home Health Care, including: nurse aide, therapies, and social worker • Hospice • Transportation (excluding emergency medical transportation) • Experimental or Investigation Services • Cancer Clinical Trials Hospital and Ancillary Provider Network You managed care plan maintains a network of contracted hospitals and ancillary providers. Please contact SCMG/ ECHO for the most recent list to be utilized for services provided to the managed care plan's Direct members. 7 Primary Care Physician EZ Net Portal Access Primary Care Physicians through the EZ Net Portal can: Submit requests for Authorization View status of submitted Referral Authorization Requests View members (please check eligibility with the Health Plan) For Portal Access: Please send an email to [email protected] with subject line: EZ Net Portal Access Please include: • Name of organization (as listed in the contract) • Organization address • Full name of person(s) that need access • Job title • Phone number • Email address Please note all Provider Portal registration requests will be processed within 1 - 3 business days. Please note Specialists do not have access to the EZ Net Portal. Please direct all referral authorization requests to the member's PCP. For Claim status questions please call 888)975-3246 Option 2 Please note Claims Department hours of operation are from 8am-2pm. For UM/ Referral questions please call 888)975-3246 Option 3 8 Seniors and Persons with Disabilities Under federal and state law, medical care providers must Examples of reasonable modifications health care provide individuals with disabilities: providers may need to make for individuals with • Full and equal access to their health care services disabilities are: and facilities • Spend additional time explaining individualized • Reasonable modifications to policies,