2021 Provider Manual PROV16-NE-00025 1 Table of Contents WELCOME ................................................................................................................................ 4 About Us ................................................................................................................................ 4 About This Manual .................................................................................................................. 4 Key Contacts .......................................................................................................................... 4 Populations Served ................................................................................................................ 5 VERIFYING ELIGIBILITY .......................................................................................................... 7 Member Identification Card ..................................................................................................... 7 Online Resources ................................................................................................................... 8 Secure Website ...................................................................................................................... 8 Lock-in .................................................................................................................................... 9 GUIDELINES FOR PROVIDERS ..............................................................................................10 Medical Home Model .............................................................................................................10 Primary Care Providers (PCP) ...............................................................................................10 Member Panel Capacity ........................................................................................................11 Reimbursement to FQHC’s and RHC’s ..................................................................................13 Referrals ................................................................................................................................14 Specialist Responsibilities .....................................................................................................15 Mainstreaming .......................................................................................................................16 Appointment Accessibility and Access Standards ..................................................................16 Minimum PCP Hours .............................................................................................................18 Covering Providers ................................................................................................................18 Telephone Arrangements ......................................................................................................19 24-Hour Access .....................................................................................................................19 Hospital Responsibilities ........................................................................................................20 Advance Directives ................................................................................................................20 Voluntarily Leaving the Network ............................................................................................21 CULTURAL COMPETENCY ....................................................................................................22 BENEFIT EXPLANATIONS AND LIMITATIONS ......................................................................24 Covered Services ..................................................................................................................24 Special Services to Assist Members ......................................................................................27 Value Added Services ...........................................................................................................28 NETWORK DEVELOPMENT AND MAINTENANCE ................................................................32 Non-Discrimination ................................................................................................................33 Tertiary Care .........................................................................................................................33 MEDICAL MANAGEMENT .......................................................................................................34 Integrated Care .....................................................................................................................34 Complex Care Management Program ...................................................................................35 Early and Periodic Screening, Diagnostic & Treatment ..........................................................41 Emergency Care Services .....................................................................................................42 Medical Necessity ..................................................................................................................43 Utilization Management .........................................................................................................43 Clinical Practice Guidelines ...................................................................................................55 PHARMACY .............................................................................................................................57 Preferred Drug List (PDL) ......................................................................................................57 Compounds ...........................................................................................................................57 Pharmacy and Therapeutics Committee (P&T) ......................................................................58 Unapproved Use of Preferred Medication ..............................................................................58 2 Prior Authorization Process ...................................................................................................58 Newly Approved Products .....................................................................................................59 Step Therapy .........................................................................................................................59 Prospective DUR Response Requirements ...........................................................................60 Injectable Drugs.....................................................................................................................60 Biopharmaceuticals and Injectables.......................................................................................60 Dispensing Limits, Quantity Limits and Age Limits .................................................................61 Mandatory Generic Substitution .............................................................................................61 Over-The-Counter Medications ..............................................................................................61 Working With the Pharmacy Benefit Manager (PBM) ............................................................61 Pharmacy Portal and Provider Links ......................................................................................63 PROVIDER RELATIONS AND SERVICES ..............................................................................64 Provider Relations .................................................................................................................64 Provider Services ..................................................................................................................64 CREDENTIALING AND RE-CREDENTIALING ........................................................................65 Overview ...............................................................................................................................65 Which Providers Must be Credentialed? ................................................................................65 Information Provided at Credentialing ....................................................................................66 Credentialing Committee .......................................................................................................67 Re-Credentialing....................................................................................................................67 Right to Review and Correct Information ...............................................................................68 Right to Be Informed of Application Status.............................................................................68 Right to Appeal Adverse Credentialing Determinations..........................................................68 Disclosure of Ownership and Control Interest Statement .......................................................69 RIGHTS AND RESPONSIBILITIES ..........................................................................................70 Member Rights ......................................................................................................................70 Member Responsibilities ........................................................................................................71 Provider Rights ......................................................................................................................72