Beacon Health Options Provider Handbook www.beaconhealthoptions.com/providers/beacon/ Beacon Health Options | Provider Handbook | Version 4.1.21 TABLE OF CONTENTS 1. Introduction.......................................................................................................................................... 9 1.01 Overview ........................................................................................................................ 9 1.02 About Beacon ............................................................................................................... 10 1.03 Contact Information ...................................................................................................... 11 2. E-Commerce Initiative........................................................................................................................ 12 3. Electronic Resources ......................................................................................................................... 13 3.01 CAQH ........................................................................................................................... 13 3.02 ProviderConnect ........................................................................................................... 13 3.03 Electronic Claim Submission and Clearinghouses ........................................................ 14 3.04 Payspan ....................................................................................................................... 14 3.05 Beaconhealthoptions.com ............................................................................................. 14 3.06 Achieve Solutions ......................................................................................................... 14 3.07 eServices ...................................................................................................................... 15 3.08 Communications ........................................................................................................... 15 4. Participating Providers ....................................................................................................................... 16 4.01 Beacon Provider Identification Numbers ....................................................................... 16 4.02 Provider Satisfaction Survey ......................................................................................... 17 4.03 Changes to Beacon Provider Records .......................................................................... 17 4.04 Policies and Procedures ............................................................................................... 17 5. Credentialing and Re-Credentialing ................................................................................................... 18 5.01 Credentialing ................................................................................................................ 18 5.02 Re-Credentialing ........................................................................................................... 19 5.03 Standards ..................................................................................................................... 20 5.04 Site Visits ...................................................................................................................... 21 5.05 Updates ........................................................................................................................ 21 5.06 Delegation .................................................................................................................... 22 6. Sanctions .......................................................................................................................................... 22 7. Appeals of National Credentialing Committee/Provider Appeals Committee Decisions ....................... 24 7.01 Professional Review Activities/Fair Hearing Process .................................................... 25 8. Office Procedures .............................................................................................................................. 26 8.01 Member Rights and Responsibilities ............................................................................. 26 8.02 Confidentiality, Privacy, and Security of Identifiable Health Information ........................ 27 8.03 Appointment and Availability Standards ........................................................................ 27 8.04 Out-of-Office Coverage ................................................................................................. 28 8.05 Termination and Leave of Absence .............................................................................. 29 8.06 Catastrophic Event ....................................................................................................... 29 8.07 Requests for Additional Information .............................................................................. 29 9. Services to Members ......................................................................................................................... 29 9.01 Emergency Services ..................................................................................................... 31 9.02 Referrals ....................................................................................................................... 31 9.03 EAP Transition to Health Plan Benefits ......................................................................... 31 Beacon Health Options | Provider Handbook | i 9.04 Coordination with Primary Care/Treating Providers ...................................................... 31 9.05 Continuation following Provider Agreement Expiration or Termination .......................... 32 9.06 Certain Regulatory Requirements ................................................................................. 33 9.07 Fraud, Waste, and Abuse ............................................................................................. 33 10. Participating Provider Complaints, Grievances, and Appeals ............................................................ 34 10.01 Complaints Regarding the Provider Agreement .......................................................... 34 10.02 General Complaints and Grievances .......................................................................... 34 11. Claims Procedures and E-Commerce Initiative................................................................................. 35 11.01 E-Commerce Initiative................................................................................................. 35 11.02 Member Expenses ...................................................................................................... 35 11.03 Preauthorization, Certification, or Notification ............................................................. 36 11.04 No Balance Billing ....................................................................................................... 36 11.05 Claim Submission Guidelines ..................................................................................... 36 11.06 Required Claim Elements ........................................................................................... 38 11.07 Requests for Additional Information ............................................................................ 39 11.08 Claims Processing ...................................................................................................... 39 11.09 Provider Summary Vouchers ...................................................................................... 40 11.10 Coordination of Benefits.............................................................................................. 40 11.11 Overpayment Recovery .............................................................................................. 40 11.12 Requests for Review ................................................................................................... 41 11.13 Claims Disputes .......................................................................................................... 41 11.14 Claims Billing Audits ................................................................................................... 42 11.15 Appeal ........................................................................................................................ 43 11.16 Reporting Fraud, Waste, and Abuse ........................................................................... 44 12. Utilization Management ................................................................................................................... 44 12.01 New and Emerging Technologies ............................................................................... 46 12.02 Treatment Planning .................................................................................................... 46 12.03 Clinical Review Process .............................................................................................. 46 12.04 Retrospective Review ................................................................................................. 47 12.05 Definition of Medical Necessity ................................................................................... 48 12.06 Medical Necessity Criteria .......................................................................................... 49 12.07 Clinical Practice Guidelines .......................................................................................