2021 | Provider Manual Sponsored by Johns Hopkins HealthCare LLC and The Maryland Community Health Systems Introduction to the Provider Manual THE MARYLAND HEALTHCHOICE PROGRAM MEDICAID and HEALTHCHOICE HealthChoice is the name of Maryland Medicaid’s managed care program. There are approximately 1.2 million Marylanders enrolled in Medicaid and the Maryland Children’s Health Program. With few exceptions Medicaid beneficiaries under age 65 must enroll in HealthChoice. Individuals that do not select a Managed Care Organization (MCO) will be auto-assigned to an MCO with available capacity that accepts new enrollees in the county where the beneficiary lives. Individuals may apply for Medicaid, renew their eligibility and select their MCO online at www.marylandhealthconnection.gov or by calling 855-642-8572 (TYY: 855-642-8572. Members are encouraged to select an MCO that their PCP participates with. If they do not have a PCP they can choose one at the time of enrollment. MCO members who are initially auto-assigned can change MCOs within 90 days of enrollment. Members have the right to change MCOs once every 12 months. The HealthChoice program’s goal is to provide patient-focused, accessible, cost-effective, high quality health care. The state assesses the quality of services provided by MCOs through various processes and data reports. To learn more about the state’s quality initiatives and oversight of the HealthChoice program go to: https:// mmcp.health.maryland.gov/healthchoice/Pages/Home.aspx Providers who wish to serve individuals enrolled in Medicaid MCOs are now required to register with Medicaid. Priority Partners also encourages providers to actively participate in the Medicaid fee-for service (FFS) program. Beneficiaries will have periods of Medicaid eligibility when they are not active in an MCO. These periods occur after initial eligibility determinations and temporarily lapses in Medicaid coverage. While MCO providers are not required to accept FFS Medicaid, it is important for continuity of care. For more information go to: https://eprep.health.maryland.gov/sso/login.do?.All providers must verify Medicaid and MCO eligibility through the Eligibility Verification System (EVS) before rendering services. We do not prohibit or otherwise restrict, a provider acting within the lawful scope of practice,from advising or advocating on behalf of an enrollee who is his or her patient. 2 www.jhhc.com | Provider Manual 2021 This manual is divided into 9 sections: SECTION I – Introduction and General Information. This section provides general descriptive information on the HealthChoice program including, but not limited to, program eligibility, MCO reimbursement policies, continuity of care and member rights and responsibilities. SECTION II – Outreach and Support Services, Appointment Scheduling, Early Periodic Diagnostic and Treatment (EPSDT) Requirements and Special Populations. This section details Priority Partners outreach and support services, non-emergency transportation services, state support services and other information. SECTION III – Member Benefits and Services. This section provides a listing of the benefits that are and are not the responsibility of all MCOs that participate in HealthChoice. This section briefly outlines some of the optional benefits that Priority Partners may provide. This section also identifies benefit limitations and services that are not the responsibility of Priority Partners and gives information on the Rare and Expensive Case Management (REM) program. SECTION IV – Preauthorization and Member Complaint, Grievance and Appeal Procedures. This section describes services requiring preauthorization, services not requiring preauthorization, preauthorization procedures, medical necessity criteria and other procedures and criteria. SECTION V – Pharmacy Management. This section provides information on pharmacy benefit management, specialty pharmacy, prescriptions and the Priority Partners formulary, the Maryland Prescription Drug Monitoring Program, Corrective Managed Care Program and the Maryland Opioid Policy. SECTION VI – Claims Submission, Provider Appeals, Quality Initiatives and Pay-for-Performance. This section covers the claims submission process, billing inquiries, the appeal process, quality initiatives and other claims and appeal information. SECTION VII – Provider Services and Responsibilities. This section gives an overview of provider responsibilities, along with information on credentialing and re-credentialing, PCP responsibilities, contract terminations, specialty providers and other topics. SECTION VIII – Quality Assurance Monitoring Plan and Reporting Fraud, Waste and Abuse. This section provides information on Priority Partners’ assurance monitoring plan, as well as fraud, waste and abuse policies and procedures. SECTION IX – Additional Priority Partners Information. Provider Manual 2021 | www.jhhc.com 3 TABLE OF CONTENTS SECTION I. Introduction and General Information .........................10 Medicaid and the HealthChoice Program ............................................11 HealthChoice Eligibility .........................................................11 Overview of Priority Partners .....................................................12 Member Rights and Responsibilities ...............................................12 A. As a HealthChoice member, you have the right to ...............................12 B. As a HealthChoice member, you have the responsibility to ........................13 C. Nondiscrimination Statement ..............................................13 D. Notice of Privacy Practices.................................................15 Procedure for Selecting a PCP.....................................................15 Default Assignment of a PCP .....................................................15 HIPAA and Member Privacy Rights ................................................15 Member Privacy Practices ........................................................16 Safeguarding Your Protected Health Information ..................................16 How PPMCO May Use and Disclose Your Protected Information.....................16 Uses and Disclosures Relating to Treatment, Payment or Health Care Operations .........17 Other Uses and Disclosures of Health Information Required or Allowed by Law ..........17 For More Information ......................................................18 To Report a Problem about our Privacy Practices ..................................18 Anti-Gag Provisions ............................................................19 Assignment and Reassignment of Members...........................................19 Credentialing and Re-Credentialing ................................................20 Types of Providers Requiring Credentialing ......................................20 Types of Individual Professional Providers Requiring Credentialing ....................21 Types of Other Allied Health ProfessionalsRequiring Credentialing ....................21 Rights to Appeal the Denial of Re-Credentialing ..................................22 Provider Reimbursement.........................................................22 Self-Referral & Emergency Services.................................................23 Self-Referred Services for Children with Special Health Care Needs ....................23 Continuity of Care .............................................................24 Preauthorization for Health Care Services........................................24 Right to Use Non-Participating Providers........................................24 SECTION II. Outreach and Support Services, Appointment Scheduling, EPSDT and Special Populations . .26 Priority Partners Outreach and Support Services .......................................27 Member Services ..........................................................27 Special Needs/Enhanced Care Management (Care or Case) ..........................27 Health Education ..........................................................28 State Non-Emergency Medical Transportation (NEMT) Assistance ........................28 4 www.jhhc.com | Provider Manual 2021 Priority Partners Transportation Assistance ...........................................29 State Support Services ..........................................................29 Scheduling Appointments........................................................31 Early Periodic Screening Diagnosis and Treatment (EPSDT) .............................32 EPSDT Requirements ......................................................32 EPSDT Outreach and Referral to LHD .........................................33 State Designated Special Needs Populations ..........................................33 Outreach and Referral to LHD ...............................................34 Services for Pregnant and Postpartum Women ....................................34 Maryland Prenatal Risk Assessment.................................................36 Childbirth Related Provisions.................................................36 Children with Special Health Care Needs........................................37 Children in State-Supervised Care .............................................38 Individuals with HIV/AIDS..................................................38 Individuals with Physical or Developmental Disabilities.............................39 Homeless Individuals .......................................................39 Rare and Expensive Case Management Program ......................................