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Advicare MCO Provider Manual - Advicare Health

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ADVICARE
A Managed Care Organization for the Entire Family
Provider Manual
2013-2014
Table of Contents
INTRODUCTION AND WELCOME TO ADVICARE .......................................................................... 1
ADVICARE VALUES ....................................................................................................................... 1
ADVICARE COMMITTMENT .......................................................................................................... 1
ADVICARE AT A GLANCE ............................................................................................................. 2
II. ID CARD AND ELIGIBILITY ................................................................................................................ 3
NEW MEMBER INFORMATION ............................................................................................................. 3
ELIGIBILITY VERIFICATION .................................................................................................................. 3
MEMBER IDENTIFICATION CARD ............................................................................................... 4
VISIT PROCEDURES ..................................................................................................................... 4
III.
PROVIDER RESPONSIBILITIES .................................................................................................... 4-5
PRIMARY CARE PROVIDER (PCP) ............................................................................................... 5
PANEL LIST .................................................................................................................................... 6
PCP ASSIGNMENT ........................................................................................................................ 6
PCP AVAILABILITY ......................................................................................................................... 6
PCP ACCESSIBILITY 6
MEMBER STATUS CHANGE ......................................................................................................... 7
24-HOUR ACCESS ......................................................................................................................... 7
APPOINTMENT ACCESS STANDARDS ........................................................................................ 7
OFFICE WAIT TIMES ...................................................................................................................... 7
LABORATORY SERVICES ............................................................................................................. 7
IN OFFICE LAB PROCEDURES..................................................................................................... 7
HOSPITAL ADMITTING PRIVILEGES ............................................................................................ 8
IV.
REFERRAL AND AUTHORIZATIONS .............................................................................................. 8
REFERRAL GUIDELINES ............................................................................................................... 8
AFTER HOURS AND EMERGENCY CARE ................................................................................... 8
AUTHORIZATION GUIDELINES ..................................................................................................... 8
UTILIZATION MANAGEMENT INPATIENT .................................................................................... 9
CONCURRENT REVIEW…………………………………………………………………………………..9
SECOND OPIONIONS…………………………………………………………………………………......9
DISCHARGE PLANNING………………………………………………………………………………….10
AUTHORIZATION GRID…..……………………………………………........................................ 11-13
UTILIZATION MANAGEMENT INPATIENT………………………………………………………….....13
REFERRALS INTO THE WOMEN, INFANT AND CHILDRENS (WIC) PROGRAM ..................... 14
OBSTETRICAL REGISTRATION ................................................................................................. 14
PROVIDER TERMINATION .......................................................................................................... 14
V.
MEDICAL RECORDS ...................................................................................................................... 15
REQUIRED INFORMATION ..................................................................................................... 15-16
MEDICAL RECORDS RELEASE .................................................................................................. 16
MEDICAL RECORDS TRANSFER FOR NEW MEMBERS .......................................................... 16
VI.
ADVICARE CASE AND DISEASE MANAGEMENT SERVICES .................................................. 17
CASE MANAGEMENT INTRODUCTION...................................................................................... 17
SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT (SBIRT)………........17
CASE MANAGEMENT PROGRAM............................................................................................... 18
COMPONENTS OF CASE MANAGEMENT ................................................................................. 18
DISEASE MANAGEMENT INTRODUCTION ................................................................................ 18
DISEASE MANAGEMENT STATES ............................................................................................. 18
DISEASE MANAGEMENT PROGRAM .................................................................................... 19-20
CASE AND DISEASE MANAGEMENT PROCESS ................................................................. 20-21
PREVENTIVE AND CLINICAL PRACTICE GUIDELINES ............................................................ 21
VII.
ROUTINE, URGENT AND EMERGENCY SERVICES ................................................................... 21
ROUTINE, URGENT AND EMERGENCY CARE SERVICES DEFINED ................................. 21-22
ELIGIBILITY AND ENROLLMENT ................................................................................................. 22
VIII.
Advicare Provider Manual 2013-2014
V.1
I.
IX.
X.
XI.
XII.
XIII.
XIV.
XV.
XVI.
ELIGIBILITY FOR THE ADVICARE PROGRAM ..................................................................... 22-23
VERIFYING ELIGIBILITY .............................................................................................................. 22
ENROLLMENT/MARKETING GUIDELINES FOR ADVICARE PROVIDERS .............................. 23
NON-COMPLIANT MEMBERS .................................................................................................. 23-24
NURSE RESPONSEВ® ................................................................................................................... 24
NON-EMERGENCY TRANSPORTATION SERVICES ................................................................. 24
EPSDT ............................................................................................................................................ 25
SOUTH CAROLINA EPSDT SERVICES AND STANDARDS .................................................. 25-26
IMMUNIZATIONS .......................................................................................................................... 27
BLOOD LEAD SCREENING ......................................................................................................... 27
BILLING AND CLAIMS ............................................................................................................. 27-30
GENERAL BILLING GUIDELINES ................................................................................................ 27
CLAIM FILING GUIDELINES ........................................................................................................ 28
BILLING A MEDICAID ADVICARE MEMBER .............................................................................. 29
MAILING ADDRESSES ................................................................................................................. 29
TIMELY FILING ............................................................................................................................. 29
ELECTRONIC FUNDS TRANSFER (EFT) ................................................................................... 29
QUALITY IMPROVEMENT .............................................................................................................. 30
QUALITY IMPROVEMENT PROGRAM ........................................................................................ 30
QUALITY IMPROVEMENT PROGRAM STRUCTURE ................................................................. 30
QUALITY IMPROVEMENT PROGRAM GOALS AND OBJECTIVES........................................... 31
QUALITY IMPROVEMENT PROGRAM SCOPE ..................................................................... 31-32
PRACTITIONER INVOLVEMENT ................................................................................................. 32
HEALTH CARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) ........................... 32
CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS) SURVEY........ 33
PROVIDER SATISFACTION SURVEY ......................................................................................... 33
AUTHORITY AND RESPONSIBILITY ........................................................................................... 34
Provider Initiated Grievance………………………………………………………………………………34
MEMBER SERVICES ...................................................................................................................... 35
MEMBER SERVICES .................................................................................................................... 35
MEMBER MATERIALS .................................................................................................................. 35
MEMBER RIGHTS & RESPONSIBILITIES .............................................................................. 36-37
CORE BENEFITS .......................................................................................................................... 38
CO-PAYMENTS............................................................................................................................. 38
SERVICES COVERED BY ADVICARE ................................................................................... 39-42
SERVICES COVERED BY MEDICAID FEE FOR SERVICE .................................................. 43-46
MEMBER GRIEVANCES .............................................................................................................. 46
APPEALS....................................................................................................................................... 47
EXPEDITED RESOLUTION OF APPEALS ................................................................................... 47
CONTINUATION OF BENEFITS .............................................................................................. 47-48
ASSISTANCE AND CONTACTING ADVICARE ........................................................................... 48
MEMBERS RIGHT TO STATE FAIR HEARING ........................................................................... 48
INTERPRETER/TRANSLATION SERVICES ................................................................................ 48
PROVIDER RELATIONS ASSISTANCE ........................................................................................ 49
PROVIDER RELATIONS AND CONTRACTING DEPARTMENTS .............................................. 49
PROVIDER RIGHTS ...................................................................................................................... 50
CREDENTIALING AND RECREDENTIALING ............................................................................... 51
ANNUAL REVIEWS ....................................................................................................................... 52
PROVIDER SANCTIONS .............................................................................................................. 52
PHARMACY .................................................................................................................................... 52
COVERED PHARMACY SERVICES ............................................................................................ 52
DEFINITIONS ........................................................................................................................... 53-54
FORMS AND OTHER KEY INFORMATION .............................................................................. 55-70
Advicare Provider Manual 2013-2014
V.1
I.
INTRODUCTION AND WELCOME TO ADVICARE
Advicare, Corp. (Advicare) is pleased to welcome you to its participating provider network. Advicare is a Managed
Care Organization (MCO) contracted with the South Carolina Department of Health and Human Services
(SCDHHS) to serve Medicaid members. At Advicare our sole mission is to improve the health care status of the
Medicaid population in the state of South Carolina. We believe this under-served population is entitled to the same
quality health care as the commercially-insured population, but requires a focused approach that is specifically
designed to meet their unique needs.
It is the policy of Advicare to conduct its business affairs in accordance with the standards and rules of ethical
business conduct and to abide by all applicable federal and state laws.
Advicare takes the privacy and confidentiality of our members’ health information seriously. We have processes,
policies and procedures to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
state privacy law requirements.
ADVICARE VALUES
Relationships
Members are the reason we are in the business of health care in a partnership with providers, government officials &
leaders and community based stakeholders/organizations. Providers, government officials & leaders and community
based stakeholders/organizations are our partners in the service to our members.
Respect
All associates must act in good faith and show consistent levels of respect and demonstrate a high level of integrity
that earns the trust of internal and external customers.
Responsibility
All associates must act in good faith and be responsible for the commitments made to members, providers,
government officials & leaders, community based stakeholders/organizations and fellow associates.
Results
We must produce positive results and get things done for our members, providers, government officials & leaders and
community and community based stakeholders/organizations.
ADVICARE COMMITTMENT
•
•
•
•
•
•
Serve and support the South Carolina Medicaid eligible population
Meet the health care needs of our members
Empower our members through education and member-focused services
Effectively integrate managed care administration and health care services
Support doctor/patient relationships by fostering strong provider relationships
Abide by all ethical standards and demonstrate integrity and quality in all business practices
1
ADVICARE AT A GLANCE
For your ease, we have included this reference guide to assist you in the day-to-day
operations of your office.
Contact
Physical Address
Advicare
Advicare, Inc.
531 S ou th Main Street, Suite RL-1
Greenville, SC 29601
Mailing Address
Advicare, Inc.
531 South Main Street, Suite RL-1
Greenville, SC 29601
Phone Numbers
(toll free)
(888) 781-4371 (Provider/Member Services)
Provider Relations
(toll free)
(888) 781-4371
24-hour Nurse Line
(toll free)
(888) 781-4371
Claims Inquiries
Claims Address
(toll free)
(888) 781-4371, Fax (646) 417-5836
Advicare
PO Box 5547
Hauppauge, NY 11788
EMDEON: PAYOR ID 45423
Website Address
Contracting
Medical Management
(Authorizations)
Transportation
(
www.Advicarehealth.com
(toll free)
(888) 781-4371
(toll free)
(888) 781-4371 or (855)
303-2427 Fax
Region 1: 866-910-7688
Region 2: 866-445-6860
Region 3: 866-445-9954
TTY: 866-288-3133
2
II.
ID Cards and Eligibility
New Member Information
Advicare members are sent a New Member Packet that includes helpful guidelines and instructions on how to
access their health benefits. This packet includes:
•
•
•
•
•
•
•
•
•
•
•
Welcome Letter
Member Handbook
Evidence of Coverage which details:
After hours care
Appropriate use of the Emergency Room
Benefits Summary
How to make appointments
Specialist Information
Primary Care Physician Information
Member Identification Card
Health Education Materials
Eligibility Verification
Each new member enrolled in Advicare will receive an individual member identification card. It is important to
remember that a member’s eligibility could change on a month-to-month basis. Consequently, you should verify
your patient’s eligibility each time they present for services. Participating primary care physicians (PCPs) can
verify eligibility through the monthly enrollment listing. Other providers may call for verification of eligibility.
For eligibility verification for Advicare members, call Member Services at (888) 781-4371 (toll free).
3
Member Identification Card
Patients should be asked to present their Member ID card at each visit. Remember that possession
of an ID card does not guarantee eligibility for benefits coverage or payment. The ID card includes
valuable information, as displayed below:
Medicaid Plan
Name: [member name]
Medicaid ID: [State Medicaid
#] Plan ID: [AVC plan ID#]
Eff Date: [eff date]
ecti : [member DOB]
ve
DO
Medical Group Name:
Primary Care Provider (PCP): [Provider Name]
PCP Contact #: [Provider Phone]
Member Reminder: Show this card along with
your SC Healthy Connections ID card at each medical visit
RxBIN:
004336
RxPCN:
ADV RxGrp:
RX4266
If you have an emergency, call 911, or go to your nearest Emergency Room.
For your convenience, Advicare members and providers may call the toll free
number: 1-888-781-4371 for the following services:
• Member Care (Eligibility & Benefits)
• Provider Inquiry
• Utilization Management
• 24 Hour Nurse Line TTY Line: 1-888-357-7188
Mail Claims to: Advicare Corp. Electronic Claims
Attn: Claims Department Emdeon Payer ID: 45423 PO Box 5547
Hauppauge, NY 11788
CVS Caremark: 1-855-383-9430
Pharmacy Help Desk: 1-800-364-6331 (For Members) (For Pharmacy)
SC Healthy Connections Choices at 1-877-552-4642
VISIT PROCEDURES
In order to work effectively with our members and to ensure prompt and accurate reimbursement for
services, we recommend the following visit procedures:
•
•
•
•
•
•
Identify the patient’s health insurance at the time of appointment scheduling.
Remind the patient to bring their Member ID card to their appointment.
Call Advicare Member Services to verify eligibility in advance if possible.
When the patient arrives, ask them to present their ID card
Verify eligibility, benefits and PCP assignment.
You may want to make a copy of the ID card for your files.
4
PCP offices should check their member enrollment listing. In a specialist’s office, make sure that
appropriate authorizations have been completed prior to rendering services.
III.
PROVIDER RESPONSIBILITIES
Participating physicians are responsible for fulfilling certain obligations and commitments as participants
in our provider network. Contracted providers agree to abide by all rules and guidelines stated in the
contract between Advicare and the South Carolina Department of Health and Human Services
(SCDHHS). Responsibilities include, but are not limited to, the following:
•
•
•
•
•
•
•
•
•
•
•
•
Provider shall provide Core Benefits to Members when such services are ordered by a
licensed physician or other Participating Provider and are within the scope of Provider’s
license.
Provider is a Participating Provider and a Medicaid Provider at all locations listed in the Participating
Provider Application and under all taxpayer identification numbers utilized by Provider.
Provider may not refuse to provide Medically Necessary or covered preventive services to
Members for non-medical reasons.
Provider shall not discriminate against Members for any reason and shall provide the same
standard of care and access to medical services as are offered to Provider’s other patients.
Provider agrees that Members shall not be subject to discrimination regardless of race, creed,
color, religions, physical/mental handicap, sexual orientation, marital status, national
origin/ancestry, health status as a Member, or type of coverage provided to Member (i.e.,
Medicaid, Medicare, commercial).
Provider shall verify the current status of a Member’s eligibility by contacting Advicare
during normal office hours; or utilizing the SCDHHS Web Tool or prior to providing
services.
Provider agrees to provide services related to Core Benefits in accordance with the applicable terms
and conditions of the Advicare Provider Manual, SCDHHS ADVICARE Policy and Procedure Guide
and CMS guidelines.
Provider agrees to comply with the SCDHHS Quality Assurance and Utilization Review
(QA/UR) Requirements contained in the SCDHHS ADVICARE Policy and Procedure Guide,
and any future amendments to such requirements. Provider further agrees to cooperate with
Advicare compliance with the SCDHHS QA/UR Requirements and CMS guidelines.
Provider shall prescribe drugs to Members that are contained in the Advicare Prescription Drug
Formulary.
Provider shall ensure that all of Provider’s Health Care Professionals, if any, have and shall maintain
in good standing, all licenses, permits, registrations and/or certifications required by law. Evidence of
maintaining such licenses permits, registrations and/or certifications shall be provided to Advicare
and/or CMS or SCDHHS upon request.
Provider shall ensure that persons with limited English skills receive free of charge the language
assistance necessary to afford them meaningful and equal access to the benefits and services
provided under the Provider Agreement with Advicare.
Provider shall comply with all applicable state and federal laws, regulations and guidelines
applicable the confidentiality of medical records (such as regulations implementing the
administrative simplification provisions of the Health Insurance Portability and Accountability Act of
1996, laws addressing advanced directives, and state and federal anti-discrimination laws (such as
the Civil Rights Act of 1964 and the Americans with Disabilities Act.)
Provider shall submit to Advicare all reports and clinical information required by Advicare contract
with SCDHHS, including Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) if
applicable.
PRIMARY CARE PROVIDER (PCP)
Primary Care Physicians (PCPs) in the Advicare network include Board Certified or Board Eligible
practitioners in the fields of Internal Medicine, General Practice, Family Practice and Pediatrics. Each
Advicare member chooses a PCP, who assumes responsibility for the management of our member’s health
5
care needs. An Obstetrician may assume care for members during pregnancy, but generally will refer back
to the PCP for health care issues unrelated to the pregnancy.
The PCP is the key to managing the member’s overall health and wellbeing. The PCP’s role includes:
•
•
•
•
Performing an initial health assessment for new members assigned to their panel to begin
establishing the physician patient relationship.
Direct provision or coordination of all healthcare services for the member to include 24-hour
coverage.
Contacting Advicare to obtain necessary prior authorization for designated services (e.g., out of
network referrals, specified diagnostic tests).
Complying with all established Advicare policies and procedures as documented in this provider
manual.
PANEL LIST
Each month, Primary Care Physicians will receive a list of all patients paneled to that provider. This listing
provides important information and should be reviewed by your office staff, as it may be used to verify
eligibility. Please refer to this list before providing services or referring members to specialists.
PCP ASSIGNMENT
•
•
•
•
•
New members are asked to select a Primary Care Physician at the time of enrollment. Members may
select any Advicare participating provider whose panel is open to accepting new members and who
matches the member’s age category.
If the member does not select a PCP, Advicare will select one on their behalf. We will consider all
available information related to any prior relationship the patient may have had with a PCP, special
clinical needs, age category, language requirements, as well as geographic proximity to the
provider.
Advicare will notify the member of their PCP assignment and will issue a Member Identification
Card with the PCP’s name and phone number.
The PCP will receive a Member List each month, reflecting all Advicare members paneled to
that provider.
Members may request a change to their PCP assignment at any time.
PCP AVAILABILITY
Availability is defined as the extent to which Advicare contracts with the appropriate type and
number of PCPs necessary to meet the needs of its members within defined geographical areas.
Advicare has implemented several processes to monitor its network for sufficient types and
distribution of PCPs.
PCP availability is analyzed annually by the Advicare’ Provider Relations (PR) Department. At
least annually, the PR department computes the percentage of PCPs with panels open for new
members versus those PCPs accepting only members who are already- existing patients in their
practice. The Member Services Department analyzes member surveys and member grievance
data to address SCDHHS and federal requirements regarding the cultural, ethnic, racial, and
linguistic needs of the membership. The Quality Improvement Department tracks and trends
member and provider grievances quarterly and monitors other data (such as appointment
availability audits, after hours use of the member hotline and member and provider satisfaction
surveys) that may indicate the need to increase network capacity.
PCP ACCESSIBILITY
Accessibility is the extent to which a patient can obtain available services at the time they are
needed. Such service refers to both telephone access and ease of scheduling an appointment, if
applicable. The Plan monitors access to services by performing access audits, tracking applicable
results of the Healthcare Effectiveness Data and Information Set/Consumer Assessment of Health
6
Plans Survey (HEDIS/CAHPS), and analyzing member grievances regarding access, and
reviewing telephone access.
MEMBER STATUS CHANGE
Advicare members may be dis-enrolled from Advicare by the South Carolina Department of Health and
Human Services (DHHS) if the member no longer meets DHHS’ eligibility requirements for Managed Care
enrollment. PCPs are responsible for notifying Advicare’s Member Services Department if they know of a
member’s change in eligibility status (e.g., admission to an extended care facility).
24-HOUR ACCESS
Each PCP is responsible to maintain sufficient facilities and personnel to provide covered
physician services and shall ensure that such services are available as needed twenty-four (24)
hours a day, 365 days a year. PCPs must provide members with an after-hours telephone number.
The after-hours number must connect the member to an answering service, a call center system, a
recording that directs the caller to another number to reach the PCP or PCP- authorized medical
practitioner, or a system that automatically transfers the call to another telephone line that is
answered by a person who will contact the PCP.
A hospital may be used for the 24-hour telephone coverage requirement if the 24-hour access is
not answered by the emergency department staff. The PCP must establish a communication and
reporting system with the hospital and the PCP must review the results of all hospital-authorized
services.
Advicare will monitor physicians’ offices through scheduled and unscheduled visits through our
Provider Relations staff.
APPOINTMENT ACCESS STANDARDS
The following schedule should be followed regarding appointment availability:
•
Routine well care visits should be scheduled within 4 to 6 weeks of
presentation
•
Urgent care visits should be performed within 48 hours of presentation or
notification at the delivery site
•
Emergency care visits should be performed immediately upon presentation or
notification at the delivery site
•
Wait Time shall not exceed forty-five (45) minutes for a scheduled appointment of a
routine nature.
Advicare will monitor appointment and after-hours availability on an ongoing basis through its
Quality Improvement Program.
LABORATORY SERVICES
Advicare has a network of contracted laboratory providers to provide outpatient laboratory services for our
members. Participating physicians should contact a network lab to arrange for specimen pick-up,
supplies, results and general information.
IN-OFFICE LAB PROCEDURES
Lab procedures performed in office must be performed according to your CLIA certification level. These in
office lab procedures performed in the office will be covered.
7
HOSPITAL ADMITTING PRIVILEGES
PCPs or specialist must establish and maintain hospital admitting privileges or enter into a
formal arrangement with another physician or group practice for the management of inpatient
hospital admissions of Advicare members. This requirement must be met prior to the PCP or
specialist providing medical services to members. An attestation must be signed by the PCP or
specialist attesting that a formal arrangement exists. By signing the attestation, the physician/group
agrees to accept responsibility for admitting and coordinating medical care for the member
throughout the member’s inpatient stay.
The following arrangement is acceptable:
•
•
•
IV.
A physician, a group practice, a hospital group, a physician call group (not necessarily a
ADVICARE provider) that is enrolled with the South Carolina Medicaid program,
and
has admitting privileges or formal arrangements at a hospital that is within 30
miles or
45 minutes’ drive time from the PCP’s or specialist office. If there is no hospital which
meets this geographic criterion, the closest hospital to the PCP or specialist practice is
acceptable.
Hospital admitting agreements with unassigned call doctors are unacceptable.
Exceptions may be granted in cases where it is determined the benefits of a PCP’s or
specialist participation outweighs the PCP’s or specialist inability to comply with the
admitting privileges requirement. Advicare is responsible for ensuring that all enrolled
Providers are eligible to participate in the Medicaid Program. If a Subcontractor is not
accepting new Medicaid Members, the Subcontractor cannot be listed on the
Spreadsheet. Additionally if a PCP or specialist does not have admitting privileges to at
least one of the contracted Hospital (s) listed on the Spreadsheet, the ADVICARE must
provide a detailed description of the mechanisms that will be used to provide services to
Medicaid ADVICARE Members. SCDHHS reserves the right to disapprove any Provider
Network submission based on the information provided.
REFERRALS AND AUTHORIZATIONS
Advicare Referral Authorization Process
Referral Guidelines
In order to reduce the administrative burden on providers, Advicare does not require notification or
completion of referral forms. PCPs may simply refer members to specialists, provided that such referrals are
in-network specialists. Any referrals to out-of-network providers will require prior authorization from
Advicare. When referring a member for specialty care, the PCP must document the referral in the member’s
medical record.
After Hours and Emergency Care
Members are not required to contact their PCP in emergent/urgent situations. The emergency
room staff will triage the member to determine whether or not an emergency exists. However, the PCP must
provide telephone coverage 24 hours per day/7 days a week
Authorization Guidelines
Advicare requires prior authorization for all inpatient admissions and certain outpatient services. To request
prior authorization, the admitting or referring physician, or the facility or provider rendering the service can
submit the request in one of the following ways:
•
•
Via telephone at toll free (888)-781-4371.
Via fax to toll free (888) 781-4316.
8
•
Soon you will also be able to submit via our website at www.Advicarehealth.com
Upon receipt of a prior authorization request, Advicare will verify member eligibility and benefits. We will
make case-by-case determinations based on the individual’s health care needs and medical history, in
conjunction with nationally-recognized standards of medical care. If medical necessity criteria are not met on
the initial review, the referring provider may discuss the case with an Advicare physician who is in the same
or similar specialty prior to the determination. If the request is denied, the appropriate denial letter (including
the member’s Fair Hearing appeal rights) will be mailed to the requesting provider, member’s PCP, and the
member.
To ensure timeliness of prior authorization requests, the requesting provider should include the following
information:
•
•
•
•
•
•
•
•
•
Member name and plan ID
Name, telephone and fax of the facility or provider who will be rendering the service
Proposed date(s) of service
Diagnosis with ICD9 code
Name of procedure(s) with CPT-4 code
Medical information to support the request
Signs and symptoms
Past and current treatment plans, including response to treatment plans
Medications, along with frequency and dosage
Inpatient Admission Review
Advicare reviews inpatient admissions within one business day of notification. We determine the member’s
status through:
•
•
Onsite review, when indicated
Communication with the hospital’s utilization review department
We then document the appropriateness of stay and refer specific diagnoses to our Health Services
department for care coordination or case management.
Inpatient Concurrent Review
To determine the authorization of coverage, we conduct a concurrent review of the hospital medical record:
•
•
At the hospital when indicated
Via telephone or fax
We conduct select continued stay reviews daily and review discharge plans. Our Utilization management
(UM) clinician will also try to meet with the member and/or family to:
•
•
Discuss any discharge planning needs
Verify they know the PCP’s name and address
We authorize the covered length of stay one day at a time. Our medical director can make exceptions for
severe illness and course of treatment or when it is pre-determined by state law. Examples include:
•
•
ICU, CCU
C-section or vaginal deliveries
We will communicate approved days and bed level coverage to the hospital for any continued stay.
9
Discharge Planning
Advicare’s utilization management (UM) clinician coordinates our members’ discharge planning needs with:
•
•
•
Hospital utilization review/discharge planning staff
The attending physician
The Advicare Services department
The attending physician, in concert with our UM clinician or Health Services Representative, coordinates the
member’s follow up care with the member’s PCP.
For ongoing care, we work with the provider to plan discharge to an appropriate setting such as:
•
•
•
•
Hospice
Convalescent care
Home health care program
Skilled nursing facility
10
Authorization Grid
Please visit www.Advicarehealth.com, or call toll free (888) 781-4371 for the most current version of prior
authorization guidelines.
Service
Allergy
Audiology
Bariatric Surgery
Cardiology
Cardiac Catheterization
Chemotherapy
Circumcision
Prior Authorization Guidelines
No prior authorization required.
Not covered for adults 21 years of age or older
Prior authorization is required.
No prior authorization is required.
No prior authorization is required for outpatient procedures
No prior authorization is required
No prior authorization is required
Clinical Trials
Dermatology
Prior authorization is required
No prior authorization is required for E&M or Testing
Some procedures may require prior authorization
Diagnostic Testing
Prior authorization is required for MRIs, MRAs, PET, EEG,
Nuclear Testing, MEG, CT Angiogram
Diabetic supplies
Diabetic shoes
Durable Medical Equipment
No prior authorization required
No prior authorization required
No prior authorization is required for DME below $500
Prior authorization is required for all DME that exceeds $500
DME rentals are capped at the purchase price
Early and Periodic
Screening, Diagnostic and
Treatment (EPSDT) Visit
No prior authorization is required
PCPs are required to use the EPSDT schedule and to document the
visits Note: vaccine serum is received under the Vaccines for
Children (VFC) program
Emergency Room
No prior authorization is required
Note: Advicare must be notified by the next business day if a member
is admitted to the hospital through the emergency room
ENT Services
(Otolaryngology)
No prior authorization is required for out-patient services
Endocrinology
Family Planning
No prior authorization is required
No prior authorization required
Members may self-refer for family planning services
Gastroenterology
General Surgery
No prior authorization is required for outpatient services
No prior authorization is required for outpatient or ambulatory
surgery center
Gynecology
Hearing Aids
Hearing Screening
No prior authorization is required for outpatient services
Covered by the State for <21
Not A Covered Benefit for >21 years of age
11
Service
Prior Authorization Guidelines
Covered by the State for <21 years of age per EPSDT
Guidelines
Hematology
Home Health Care
No prior authorization is required
Prior authorization is required
DME and Supplies are covered per authorization guidelines
Hospital Admissions
Prior authorization is required for all elective admissions
Advicare must be notified by the next business day of any
admissions
Medical Supplies
No prior authorization is required for disposable medical
Supplies
Nephrology
Neurology
Observation
No prior authorization required, including dialysis
No prior authorization is required
No prior authorization is required for observation services
Advicare must be notified by the next business day of any admissions
that resulted from observation services.
Obstetrical Care
No prior authorization is required
Please notify Advicare within one business day following the first
OB visit for referral to case management
Occupational Therapy
Prior authorization is required for adults over 21 years of age.
Covered by the State for children under 21 years of age.
Oncology
Ophthalmology
No prior authorization is required
No prior authorization is required for out-patient services
Services that are considered cosmetic are not covered benefits
Orthopedics
Out of Area/Out of Network
Care
No prior authorization is required
Prior authorization is required except for emergency care and
DHMH self-referred services
Outpatient/Ambulatory
Surgery (ASC)
No prior authorization is required
Pain Management
No Authorization required:
E&M
All other services will require a prior authorization
No prior authorization is required
Prior authorization is required
Perinatology
Plastic Reconstructive
Surgery
Podiatry
No prior authorization for Podiatry Services for:
Medically necessary services for members younger than 21
years old;
Diabetes care services specified in COMAR 10.09.67.24; and
Routine foot care for members, 21 years old or older with
vascular disease affecting the lower extremities
12
Service
Pulmonology
Physical Rehabilitation
(inpatient)
Prior Authorization Guidelines
No prior authorization is required
Prior authorization is required
Physical Therapy
(outpatient)
Prior authorization is required for adults over 21 years of age
Radiology
Rheumatology
Skilled Nursing Facility
Sleep Studies
Sterilization
See Diagnostic Testing
No prior authorization is required
Prior authorization is required
Prior authorization is required
No prior authorization is required for outpatient services or
services provided in an ambulatory surgery center
Provider must submit a completed consent form and Medicaid
Form (MA-30) for sterilizations
Reversal of sterilization is not a covered benefit
Substance Abuse Services
(Outpatient)
Member Self-Refer (no authorization required)
Substance Abuse Services
(Inpatient)
Prior authorization requirements are consistent with SCDHHS’s
Substance Abuse Initiative. For a complete description of the
SCDHHS Substance Abuse Initiative and prior authorization
requirements, please visit: https://www.scdhhs.gov/pressrelease/alcohol-and-other-drug-abuse-treatment-servicesauthorized-or-provided-state-agencies
Urology
No prior authorization is required
Second Opinions
If a member requests a second opinion, Advicare will provide the second opinion from a qualified health
care professional within our network at no additional cost to the member. If necessary we will arrange for
the member to obtain one outside of our network.
UTILIZATION MANAGEMENT INPATIENT
Concurrent Review
To determine the authorization of coverage, we conduct a concurrent review of the hospital
medical record:
•
•
At the hospital when indicated
Via telephone or fax
We conduct select continued stay reviews daily and review discharge plans. Our Utilization management
(UM) clinician will also try to meet with the member and/or family to:
•
•
Discuss any discharge planning needs
Verify they know the PCP’s name and address
We authorize the covered length of stay one day at a time. Our medical director can make exceptions for
severe illness and course of treatment or when it is pre-determined by state law. Examples include:
•
•
ICU, CCU
C-section or vaginal deliveries
13
We will communicate approved days and bed level coverage to the hospital for any continued stay.
Advicare adheres to all notification and turn-around time requirements according to NCQA and COMAR
regulations.
Discharge Planning
Advicare Utilization Management clinician coordinates our members’ discharge planning needs with:
•
•
•
Hospital utilization review/discharge planning staff
The attending physician
The Advicare Services department
The attending physician, in concert with our Utilization Management clinician or Health Services
Representative, coordinates the member’s follow up care with the member’s PCP. For ongoing care, we work with
the provider to plan discharge to an appropriate setting such as:
•
•
•
•
•
Hospice
Convalescent care
Home health care program
Skilled nursing facility
Member’s home
REFERRALS INTO THE WOMEN, INFANTS, AND CHILDREN (WIC) PROGRAM
Advicare PCPs are required to refer potentially eligible members to the WIC program. The WIC program helps
women, infants and children protect their health and well-being through nutrition. The program is run by the South
Carolina Department of Health and Environmental Control (SCDHEC). Those who qualify receive vouchers to
redeem for food items such as fruits, vegetables, dairy products and cereal. For more information please call
SCDHEC at 1-800-868-0404.
OBSTETRICAL REGISTRATION FORM
Submit completed OB Registration Form (Attachment A) for expectant mothers within 5 days of first
prenatal visit via fax at toll free (888) 781-4316 or email at [email protected]
PROVIDER TERMINATION
Providers should refer to their Advicare contract for specific information about terminating
provider agreement.
14
V.
MEDICAL RECORDS
MEDICAL RECORDS
Advicare providers must keep accurate and complete medical records. Such records will enable
providers to render the highest quality healthcare service to members. They will also enable
Advicare to review the quality and appropriateness of the services rendered. To ensure the
member’s privacy, medical records should be kept in a secure location. Advicare requires
providers to maintain all records for members for at least ten years for adult patients and at least
thirteen years for minors. See Member Rights section of this manual for policies on member
access to medical records.
REQUIRED INFORMATION
Medical records means the complete, comprehensive member records including, but not limited
to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the
member’s participating primary care physician or provider, that document all medical services
received by the member, including inpatient, ambulatory, ancillary, and emergency care, prepared
in accordance with all applicable SCDHHS rules and regulations, and signed by the medical
professional rendering the services.
Providers must maintain complete medical records for members in accordance with the following
standards:
•
Member’s name, and/or medical record number on all chart pages;
•
Personal/biographical data is present (i.e. employer, home telephone number, spouse,
next of kin, etc.);
•
All entries must be legible;
•
All entries must be dated and signed, or dictated by the provider rendering the care;
•
Significant illnesses and/or medical conditions are documented on the problem list;
•
Medication, allergies, and adverse reactions are prominently documented in
uniform location in the medical record; if no known allergies, NKA or NKDA is
documented;
•
An up-to-date immunization record is established for pediatric members or an
appropriate history is documented in adult members’ charts;
•
Evidence that preventive screening and services are offered in accordance with
Advicare’ practice guidelines;
•
Appropriate subjective and objective information pertinent to the member’s
presenting grievances is documented in the history and physical;
•
Past medical history (for members seen three or more times) is easily identified and
includes any serious accidents, operations and/or illnesses, discharge summaries, and
ER encounters; for children and adolescents (18 years and younger) past medical
history relating to prenatal care, birth, any operations and/or childhood illnesses;
•
Working diagnosis is consistent with findings;
•
Documented treatment prescribed, therapy prescribed and drug(s)
administered or dispensed;
•
Documentation of prenatal risk assessment for pregnant women or
infant risk assessment for newborns;
•
Signed and dated required consent forms;
a
15
•
Unresolved problems from previous visits are addressed in subsequent visits;
•
Laboratory and other studies ordered as appropriate;
•
Abnormal lab and imaging study results have explicit notations in the record for
follow up plans; all entries should be initialed by the primary care provider (PCP) to
signify review;
•
Referrals to specialists and ancillary providers are documented including follow up
of outcomes and summaries of treatment rendered elsewhere;
•
Health teaching and/or counseling is documented;
•
For members ten (10) years and over, appropriate notations concerning use of
tobacco, alcohol and substance use (for members seen three or more times, a
substance abuse history should be queried);
•
Documentation of failure to keep an appointment;
•
Encounter forms or notes have a notation, when indicated, regarding follow-up care calls or
visits. The specific time of return should be noted as weeks, months or as needed;
•
Evidence that the member is not placed at inappropriate risk by a diagnostic
or therapeutic problem;
•
Confidentiality of member information and records protected;
•
Evidence that an advance directive has been offered to adults 18 years of age and older;
•
Pre-birth selection form.
•
Records must be secured and accessible only by authorized personnel.
•
Records must be made available to South Carolina Department of Health and Human Services or
their designee.
MEDICAL RECORDS RELEASE
All member medical records shall be confidential and shall not be released without the written
authorization of the covered person or a responsible covered person’s legal guardian. When the
release of medical records is appropriate, the extent of that release should be based upon
medical necessity or on a need to know basis.
Written authorization is required for the transmission of the medical record information of a current
Advicare member or former Advicare member to any physician not connected with Advicare.
MEDICAL RECORDS TRANSFER FOR NEW MEMBERS
All PCPs must transfer the member’s medical record to the receiving provider upon the change of
the member’s PCP and as authorized by the member within 30 days of the date of the request.
All PCPs are required to document in the member’s medical record attempts to obtain historical
medical records for all newly assigned Advicare members. If the member or member’s guardian is
unable to remember where they obtained medical care, or they are unable to provide addresses
of the previous providers then this should also be noted in the medical record.
16
VI.
ADVICARE CASE AND DISEASE MANAGEMENT
CASE MANAGEMENT INTRODUCTION
Case Management at Advicare is done in conjunction with the Disease Management program.
Individuals not meeting the identified disease entities (i.e. Cardiovascular Disease, Diabetes,
Asthma, HIV/AIDS and Cancer) are placed in the Case Management Program. Disease
Management is a comprehensive, integrated approach to care and reimbursement based on a
disease’s natural course (population based, disease focused). The Case Management Society of
America defines Case Management as a collaborative process which assesses plans,
implements, coordinates, monitors and evaluates options and services to meet an individual’s
health needs through communications and available resources to promote quality, cost effective
outcomes.”
Health care issues commonly placed in case management include but are not limited to:
•
•
•
•
•
•
•
•
High Risk OB
Children with Special Needs
Sickle Cell Anemia
Behavioral Health
Chronic Debilitating Illnesses
Transplants
Renal Failure
Spinal Cord Injuries
These diagnoses will be evaluated on an individual basis to identify the need for case
management. Not all diagnosed patients will require case management. An expanded program
description of each disease state follows at the end of this section.
SCREENING, BRIEF INTERVENTION AND REFERRAL TO TREATMENT
(SBIRT)
What is SBIRT?
SBIRT is an evidenced based, integrated and comprehensive approach to the Identification, Intervention and
Treatment of Substance (Drug and Alcohol) Usage, Domestic Violence, Depression, and Tobacco Usage.
The SBIRT program in South Carolina is specific to pregnant women to include 12 months postpartum.
What are the core clinical components of SBIRT?
Screening - Brief process of identifying substance use, behavioral health issues, domestic
violence and tobacco use
Brief Intervention - 5-10 minute session to raise awareness of risks and motivate the patient
toward acknowledging there is a problem
Referral - When risk is identified and treatment is needed
Treatment - Cognitive behavioral work for member to acknowledge risks and change behavior
Why is SBIRT important?
Research indicates SBIRT may:
1.
2.
3.
4.
Stem progression to independence
Improve medical conditions
Prevent medical conditions related to substance use, abuse and dependence
Decrease trauma related mortality: Alcohol alone is a factor in up to 70% of homicides,
40-50% of fatal motor vehicle accidents, 60% of fatal burns and 40% of fatal falls
.
17
How do I learn more about the SBIRT process?
Please click on SBIRT Tool Kit for the full provider tool kit, which includes (1) Screening Tools, (2) Referral
Forms, (3) Referral Resource Information and (4) Other information which can be accessed
at www.Advicarehealth.com under the Provider tab.
CASE MANAGEMENT PROGRAM
The goals of the Case Management Program are to:
•
•
•
•
Facilitate the delivery of individualized, coordinated care
Process ongoing or future service needs
Empower our members
Identify, assess, design, control and manage the care of our members to ensure optimum
outcomes
COMPONENTS OF CASE MANAGEMENT
The identification and monitoring of members needing case management includes:
•
•
•
•
•
•
Intake and Screening
Assessment and Reassessment
Care Plan Development
Care Coordination of services
Monitoring outcomes
Ongoing Documentation/Communication
DISEASE MANAGEMENT INTRODUCTION
Disease Management at Advicare is a program aimed at:
•
•
•
•
•
Understanding the course of identified diseases
Targeting members most likely to benefit from our interventions
Cost containment
Prevention
Member education.
The goal of disease management is to identify a member’s illness or condition to prevent the exacerbation of
that disease and the corresponding need for high cost resources. Warren Todd, in his book Disease
Management, A Systems Approach to Improving Patient Outcomes, defines disease management as a
comprehensive, integrated approach to care and reimbursement based on a disease’s natural course. In
contrast to case management with its emphasis on individualized patient management, the impetus for
disease management is a population-based, disease focused, preventative approach.
DISEASE MANAGEMENT STATES
At Advicare, we have identified the following four disease states as the most prevalent to address
in this population:
•
•
Asthma/COPD
Diabetes
18
•
•
Cardiovascular Disease
HIV/Oncology
Each disease state is managed by a licensed professional that is responsible for establishing,
updating and maintaining their disease management program and identifying their population
base. To assist our disease case managers in the managing of patients, we have developed
applicable assessment tools, are utilizing extensive patient education literature, the most current
clinical guidelines and are continually working to establish the necessary community and health
care relationships. An expanded program description of each disease state follows at the end of
this section.
DISEASE MANAGEMENT PROGRAM
Our program aims to identify individuals at risk or suffering from specific disease states and
stratify them by severity of illness or their health risk. Once identified, members are evaluated to
assess their specific needs and deficits. There are four (4) acuity levels that a member may be
placed in depending on the severity of illness:
•
•
•
•
Level I – Member is receiving preventative services, member is functioning
independently.
Level II – Member is receiving home health care services, continuous or special order
DME, or requiring consistent monitoring of needs.
Level III – Member is in an inpatient setting, high-cost, high utilization of resources, and/or
noncompliant.
Level IV – Catastrophic use of resources, multiple admission, multiple use of emergency
services, and/or noncompliant.
The assessment tools used are disease specific so Disease Managers can readily identify what a
member will need. Clinical guidelines from the Agency for Healthcare Research and Quality’s
National Guideline Clearinghouse and the Evidenced Based Medicine Resource Center will be
adopted to ensure that members are doing all the necessary things to keep them at an optimum
level of health. Clinical guidelines adopted by Advicare include but are not limited to:
•
•
•
•
•
Asthma
Cholesterol
Hypertension
Obesity
HIV
The Disease Management program strives to ensure that there is open team dialogue between
the Disease Manager, patient, Primary Care Physician, and Specialist (as needed). This
collaborative relationship helps the patient to take an active part in their care and allows the other
team members to assist the patient to participate in care plan development and compliance.
The members move through a continuum of care and can be discharged from disease
management. Members can be discharged for the following reasons:
•
•
•
•
•
•
•
Member is disenrolled
No response from the member after multiple phone and outreach attempts
Member expired
Criteria not met for placement in the program
Goals met and no further targets are needed
Member declines services
Member is non-compliant after exhausting all avenues.
19
We have developed outcome measures to evaluate our program and measure the effects of our
disease management. Outcome measures are under development for each disease state
managed. Some examples of outcome measures are:
Hospital Admission/ Readmissions
• Medication Compliance
• Emergency Room Visits
• Blood Pressure Screening
• Annual Eye Examination
• Annual Podiatry Examination
• Annual Physical Examination
• Annual Dental Examination
• Annual Lipid Profile
• Semi-annual CD4 count
• Semi-annual HBA1c
• Compliance with the Care Plan
• Verbalizes Understanding of Disease Condition
• Appropriate DME in the Home
• Verbalizes Understanding of DME usage
To track these outcomes and patient encounters, the Disease/Management Database is utilized.
CASE AND DISEASE MANAGEMENT PROCESS
Submit completed Disease/Case Management Request form (Attachment B) via fax toll free
at (855) 303-2427or email at [email protected] for any of your Advicare that you
would like to be enrolled into a case or disease management program.
Referrals to Case or Disease Management
Case Managers will act on the receipt of all appropriate external and internal referrals to the Case
Management Program. Referrals for case management can be made directly to the Medical
Management Department via telephone or the Case Management Referral Form.
Internal referrals may be received from:
•
•
•
•
•
•
•
Providers
Nurse Advice Line
Advicare Members
Outreach Department
Utilization Review Nurses
Quality Management Department
Customer Services
External referrals may be received from:
•
•
•
•
•
•
•
Primary Care Providers
Provider Specialists
Social Workers
Community Organizations
Hospital
Outpatient Clinics
Government Agencies
Admission to Case or Disease Management
20
Once the member has been accepted into the Case or Disease Management Program, the Case
Manager will:
•
Verify member eligibility
•
Determine if the member has been a part of case management previously, if not, create a new chart
•
Enter member data into Case Management database.
•
Determine current medical status through medical record review, PCP, therapist, or skilled nursing
assessment.
•
Contact member/member representative (parent, guardian, etc.).
•
Obtain verbal permission to be entered into case management and document consent/refusal in
chart.
•
Complete case management assessment.
•
Identify problem areas or needs.
•
Determine how the case management team can manage the case to improve outcomes in cost and
quality of care.
PREVENTIVE AND CLINICAL PRACTICE GUIDELINES
Advicare contractually requires network providers to deliver services in accordance with nationally recognized
clinical protocols and guidelines when available and established clinical guidelines when providing care to our
beneficiaries. The Medical Director facilitates the review and adoption of these guidelines for the Plan through
the Quality Improvement infrastructure. In addition, the Provider Manual will address provider practices; the
Provider Relations staff updates the Manual annually to reflect newly adopted or modified protocols and post
it on Advicare’s web site. Use of the protocols will also be included in Provider training sessions.
The Plan Administrative and Medical Management Teams will monitor utilization reports at the network
provider level to assure application of nationally recognized clinical practice guidelines. The Medical Director
and Medical Management team are responsible for the annual MOC training, which will include distribution of
network profiles for discussion with providers. The Director of Medical Management will also report these
results to the QIC, which will evaluate the results and assign corrective action plans to address opportunities
for improvement.
Clinical guidelines will also inform the Care Management program. Advicare’s Case Managers are Registered
Nurses specifically trained in the complex needs of the population and Licensed Clinical Social Workers with
experience in chronic care management. Clinical staff will have access to InterQual for supplemental
guidelines outside of the system. Advicare will also draw on the National Guideline Clearinghouse maintained
by the Agency for Healthcare Research and Quality as an additional resource for the Care Management unit.
Care Coordinators will also have access to condition-specific evidence-based guidelines in embedded in the
Advicare information system.
The Care Management staff at Advicare will apply the National Guideline Clearinghouseв„ў (NGC) evidencebased
clinical
practice
guidelines
criteria.
Online
access
to
guidelines
is
at
http://www.guideline.gov/index.aspx.The NGC guidelines will be used in efforts to execute on case and
disease management and will also be used in decisions to limit or reduce referrals.
The Medical Director may refer cases to peer reviewers or other physician specialist to assist in decisionmaking process.
All requests not meeting NGC criteria, or when criteria do not exist for that category of services, will be
referred to the Medical Director for review
Advicare will have the link to the National Guidelines Clearinghouse (NGC) website on its company website in
21
efforts for providers to access the guidelines or providers can go directly to the NGC site at
http://www.guideline.gov/index.aspx.
VII. ROUTINE, URGENT AND EMERGENCY SERVICES
ROUTINE, URGENT AND EMERGENCY CARE SERVICES DEFINED
Members are encouraged to contact their PCP prior to seeking care, although it is not required in
an emergency.
The following are definitions for routine, urgent, and emergency services.
Routine - Services to treat a condition that would have no adverse effects if not treated within
twenty-four (24) hours or could be treated in a less acute setting (e.g., physician’s office) or by the
patient. Examples include treatment of a cold, flu, or mild sprain.
Urgent - Services furnished to treat a medical condition that requires attention within forty eight
hours. If the condition is left untreated for 48 hours or more, it could develop into an emergency
condition.
Emergency* Medical Condition - An emergency medical condition is defined as a medical
condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such
that a prudent layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in placing the health of
the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child)
in serious jeopardy or serious impairment to bodily functions, or serious dysfunction of any bodily
organ or part.
Emergency Services area covers inpatient and outpatient services that are as follows:
(1) furnished by a provider that is qualified to furnish these services under this title; and
(2) needed to evaluate or stabilize an emergency medical condition.
An emergency medical condition shall not be defined or limited based on a list of diagnoses or
symptoms.
*Emergency Care is not subject to prior authorization or pre-certification. Urgent care provided in
an urgent care facility does not require authorization. Emergency Services must be provided by a
qualified Provider regardless of network participation. The PCP plays a major role in educating
members about appropriate and inappropriate use of hospital emergency rooms. The PCP is
responsible to follow up on members who receive emergency care from other providers.
VIII. ELIGIBILITY AND ENROLLMENT
ELIGIBILITY FOR THE ADVICARE PROGRAM
The State of South Carolina has the sole responsibility for determining eligibility for Medicaid for
all coverage groups except for Supplemental Security Income (SSI). The Social Security
Administration (SSA) determines eligibility for SSI.
VERIFYING ELIGIBILITY
22
Providers are responsible for verifying eligibility every time a member schedules an appointment,
and when they arrive for services. PCPs should also verify that a member is their assigned
member.
Call toll free 1-888-781-4371 to reach Member Services for eligibility
verification
Or check online at:
https://portal.scmedicaid.com
(Must have provider login and
password from SCDHHS)
ENROLLMENT/MARKETING GUIDELINES FOR ADVICARE PROVIDERS
Advicare’ contract with SCDHHS defines how the ADVICARE and its providers market and
advertise the program. Accordingly, providers may not include any reference to their affiliation
with SCDHHS or Advicare, in their marketing or advertising without prior approval from Advicare
and SCDHHS. SCDHHS requires providers to submit to Advicare samples of any marketing
materials they intend to distribute, and to obtain state approval prior to distribution or display.
Advicare Provider Relations staff will submit these materials to SCDHHS within five (5) business
days of receipt, and will send providers written notice of approval or of any changes required by
SCDHHS within five (5) business days of receiving notice from SCDHHS
Advicare Provider Relations staff will give an overview of the marketing plan to all network
physicians and their staff and present them with the SCDHHS ADVICARE Policy and Procedure
Guidelines on General Marketing and Enrollment. This will define what a provider may or may not
do in regards to marketing to our members.
Provider communication tools will include brochures, directories, booklets, handbooks,
newsletters, letters and videos. Some specific examples of the tools Advicare might use include:
•
•
•
•
•
•
IX.
Provider orientation meetings/town hall meetings
Provider newsletters
Provider manual
Provider directory
Informational letters, flyers and other mailings
Interactive Web portal
NON-COMPLIANT MEMBERS
NON-COMPLIANT MEMBERS
There may be instances when a PCP feels that a member should be removed from his or her
panel. A PCP may request a member be transferred to another practice for any of the following
reasons:
•
•
•
Repeated disregard of medical advice
Repeated disregard of member responsibilities
Personality conflicts between physician and/or staff with member
Examples of reasons that a PCP may request to remove a member from their panel could
23
include, but not be limited to:
A member is disruptive, unruly, threatening, or uncooperative to the extent that the member
seriously impairs the provider’s ability to provide services to the member or to other members and
the member’s behavior is not caused by a physical or behavioral condition.
All requests to remove a member from a panel must be made in writing, contain detailed
documentation and must be directed to:
Advicare
Attention: Director, Customer Services
531 South Main Street, Suite RL-1
Greenville, SC 29601
Upon receipt of such request, Member Services may:
•
•
•
•
Interview the provider or their staff that are requesting the disenrollment, as well as
any additional relevant providers
Interview the member
Review any relevant medical records
Involve other Advicare departments as appropriate to resolve the issue
A PCP should never request a member be disenrolled for any of the following reasons:
•
•
Adverse change in the members health status or utilization of services which are medically
necessary for the treatment of a member’s condition
On the basis of the member’s race, color, national origin, sex, age, disability, political or religion.
NURSE RESPONSEВ®
Our members have many questions about their health, their primary care provider and access to emergency
care. Our health plan offers a nurse line service to encourage members to talk with their physician and to
promote education and preventive care.
Nurse Response is our 24-hour nurse line for members. The registered nurses provide basic
health education, nurse triage and answer questions about urgent or emergency access, all day
long. The staff often answers questions about pregnancy and newborn care. In addition, members
with chronic problems, like asthma or diabetes, are referred to case management for education
and encouragement to improve their health.
Members may use Nurse Response to request information about providers and services available
in your community after the health plan is closed. Providers can use it to verify eligibility any time
of the day. The Nurse Response staff is conversant in both English and Spanish and can offer the
Language Line for additional translation services. The nurses document their calls in a webbased data system
We provide this service to support your practice and offer our member’s access to an RN every
day. If you have any additional questions, please call Care Management or Nurse Response toll
free at 1-888-781-4371.
NON-EMERGENCY TRANSPORTATION SERVICES
Advicare members may need transportation to or from a Medicaid covered service to receive
medically necessary care. Non-emergency transportation is only available to eligible recipients
who cannot obtain transportation on their own through other available means, such as family,
friends or community resources.
24
South Carolina Medicaid Transportation program provides non-emergency transportation for members. If a
member needs to schedule a ride for non-emergency reason, the member is to call Logisticare. They will
schedule the ride for the member. The member or provider can also call the Member/Provider Services
Department toll free at 1-888-781-4371 if they are having difficulty scheduling their ride for a medical
appointment. Member Services can assist the member in contacting the transportation broker to arrange
transportation.
LOGISTICARE REGIONS and CONTACT NUMBER
Region 1: 866-910-7688
Abbeville
Cherokee
Greenville
Laurens
Oconee
Saluda
Anderson
Edgefield
Greenwood
McCormick
Pickens
Spartanburg
Region 2: 866-445-6860
Aiken
Bamberg
Calhoun
Clarendon
Kershaw
Lee
Newberry
Richland
Union
Allendale
Barnwell
Chester
Fairfield
Lancaster
Lexington
Orangeburg
Sumter
York
Region 3: 866-445-9954
Beaufort
Charleston
Colleton
Dillon
Florence
Hampton
Jasper
Marlboro
Berkeley
Chesterfield
Darlington
Dorchester
Georgetown
Horry
Marion
Williamsburg
TTY: 866-288-3133
X.
EPSDT
SOUTH CAROLINA EPSDT SERVICES AND STANDARDS
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, is a program of
comprehensive preventive health services available to Advicare recipients through the month of
their 21st birthday. The program is designed to maintain health by providing early intervention to
discover and treat health problems. EPSDT is a preventive program that
combines diagnostic screening and medically necessary follow-up care for dental, vision and
hearing examinations for eligible members.
EPSDT services include:
•
•
Outreach and informing
Screening in accordance with the SCDHHS periodicity schedule
25
•
•
Tracking compliance with EPSDT requirements
Diagnostic and treatment services
Standards for providing EPSDT services are described and are included in the state ADVICARE
Policies and Procedures Manual.
PCPs are required to perform EPSDT medical check-ups in their entirety and at the
required intervals. All components of exams must be documented and included in the medical
record of each EPSDT eligible member. Initial well-child exams are to be completed within ninety
days of the initial effective date of membership and within twenty-four (24) hours of birth for all
newborns.
The components of these visits are as follows:
•
•
•
•
•
•
•
•
•
•
Comprehensive health and developmental history -- (including assessment of both
physical and mental health development);
Comprehensive unclothed physical exam;
Appropriate immunizations -- (according to the schedule established by the Advisory
Committee on Immunization Practices (ACIP) for pediatric vaccines);
Laboratory tests -- including blood level assessments appropriate for age and risk factors;
Lead Toxicity Screening- according to established guidelines
Anticipatory Guidance/Health Education -- Health education is a required component of
screening services and includes anticipatory guidance. At the outset, the physical and/or
dental screening provides the initial context for providing health education.
Health
education and counseling to both parents (or guardians) and children is required and is
designed to assist in understanding what to expect in terms of the child's development
and to provide information about the benefits of healthy lifestyles and practices as well as
accident and disease prevention;
Vision Screening – Vision should be assessed at each screening. In infants,
the
history and subjective findings of the ability to regard and reach for objects, the ability to
demonstrate an appropriate social smile, and to have
age
appropriate interaction
with the examiner is sufficient. At ages four and above, objective measurement using the
age- appropriate Snellen chart, Good lite Test, or Titmus Test should be done and
recorded. If needed, a referral should be made to an ophthalmologist or optometrist;
Dental Screening – A general assessment of the dental condition (teeth and/or gums)
is obtained on all children, including fluoride treatments. As indicated and beginning at
age 2 years old a referral should be made to a dentist;
Hearing Screening – A hearing test is required appropriate to the child’s age and
educational level. For the child under age four, hearing is determined by whatever
method is normally used by a provider, including, but not limited to, a hearing kit. For the
child over age four, an audiometer, if available is recommended. If needed, an
appropriate referral should be made to a specialist. It is recommended that high-risk
neonates be evaluated with objective measures, such as brain stem evoked response
testing, prior to discharge from the hospital nursery;
Other Necessary Healthcare – States must provide other necessary healthcare,
diagnosis services, treatment, and other measures described in section 1905(a) of the
Social Security Act to correct or ameliorate defects, and physical and mental illnesses
and conditions discovered by the screening services.
Periodic Screening - EPDST beneficiaries are eligible to receive 20 screenings in 21 years of
life. Screening ranges are determined according to age of the child and, in some circumstances,
when last screened. The following is a general guide for the ranges in which screenings should
occur (refer also refer to the American Academy of Pediatrics website at
http://www2.aap.org/immunization/IZSchedule.html).
•
•
•
•
Neonatal exam (identified from hospital claim and not billable as an EPSDT screening)
Birth to 1 month
1 month through 2 months
3 months through 4 months
26
•
•
•
•
•
•
•
5 months through 7 months
8 months through 11 months
12 months through 14 months
15 months through 17 months
18 months through 20 months
21 months through 24 months (when the child passes age 2, another screening is not due
until age 3)
3 years through month of 21st birthday (screenings are recommended annually)
Note: The codes for reporting screening services for new and established patients are as follows:
•
•
99381 - New Patient under one year
99382 - New Patient (ages 1-4 years)
•
•
•
•
•
•
•
•
•
•
99383 - New Patient (ages 5-11 years)
99384 - New Patient (ages 12-17 years)
99385 - New Patient (ages 18-39 years)
99391 - Established patient under one year
99392 - Established patient (ages 1-4 years)
99393 - Established patient (ages 5-11 years)
99394 - Established patient (ages 12-17 years)
99395 - Established patient (ages 18-39 years)
99431 - Newborn care (history and examination)
99432 - Normal newborn care
Screenings for children 17 years and under should be billed with Diagnosis code V20.2 and for
children 18-21 V70.0
Preventive health is a major principal on which managed care organizations are based, measured
and held accountable. Advicare supports its PCPs to encourage their Advicare patients to
participate in the State of South Carolina preventive care program, EPSDT. Advicare will send
reminders of the need for a well-child examination to all EPSDT eligible members. For newborns,
parents/guardians will receive a letter explaining the EPSDT schedule through 2 years old. For
the child’s second birthday, an EPSDT reminder postcard will be sent advising of the two
suggested exams before the child turns three. For ages 3 through 20, reminders will be sent
annually based on the month of the birth. Providers must demonstrate compliance with the
EPSDT periodicity schedule and screening requirements (including blood lead screening) for at
least 80% of their eligible members, in accordance with the methodology prescribed by the
Centers for Medicare and Medicaid Services.
IMMUNIZATIONS
Children must be immunized during medical checkups according to the EPSDT Routine
Immunization Schedule by age and immunizing agent.
Advicare encourages all members under the age of 18 to be immunized by their PCP unless
medically contraindicated or against parental religious beliefs. Providers shall report all
immunizations to the State Immunization Information System (SIIS) administered by the South
Carolina Department of Health and Environmental Control (DHEC), effective with the
implementation of SIIS.
Since immunizations are a required component of EPSDT screening services, an assessment of
the child’s immunization status should be made at each screening and immunizations
administered as appropriate. If the child is due for an immunization, it must be administered at the
time of the screening. However, if illness precludes immunization, the reason for delay should be
27
documented in the child’s record. An appointment should be given to return for administration of
immunization at a later date.
Immunization of children should be provided according to the guidelines recommended by the
Department of Health and Environmental Control (DHEC), the Centers for Disease Control
(CDC), the Advisory Committee on Immunization Practices (ACIP), the American Academy of
Family Physicians (AAFP), the American Academy of Pediatrics, and South Carolina State Law.
PCPs should participate with the Vaccine for Children Program (VFC). If a provider does not
routinely administer immunizations as part of his/her practice, they should refer the child to the
county health department but must maintain a current record of the child’s immunization status.
BLOOD LEAD SCREENING
Advicare EPSDT guidelines include Blood Lead Level Screenings for children from the ages of
nine months through 72 months. A Lead Screening Questionnaire should be completed at the
time of each routine office visit for children in this age group.
All Medicaid children are considered at increased risk for having elevated blood lead levels
(BLLs). A blood lead test must be used when screening Medicaid-eligible children. An elevated
BLL is considered anything >10 ug/dl. A blood lead test result equal to or greater than 10 ug/dl
obtained by capillary specimen (finger stick) must be confirmed using a venous blood sample.
According to CMS policy, all Medicaid children require a screening blood lead test at 12 and 24
months of age. Children between the ages of 36 and 72 months of age must receive a screening
blood lead test if they have not been previously screened for lead poisoning.
XI.
BILLING AND CLAIMS
GENERAL BILLING GUIDELINES
For additional information concerning core services and limitations, please refer to the Advicare
Policy and Procedures manual, or provider manuals for the applicable area (Physicians,
Hospitals, etc.)
Provider agrees to accept as payment in full for Medically Necessary Core Benefits to Members
the applicable reimbursement schedules(s) set forth in their agreement with Advicare, or
Provider’s actual billed charges, which is less.
Unless otherwise specified by in writing by the parties, Advicare shall submit payment to the
name and address of Provider specified on the signature page of this Agreement.
Provider shall bill Advicare at the address noted on the Member’s ID card for Core Benefits to
Advicare within three hundred sixty-five (365) days of performing the Core Benefits.
Claim Filing Guidelines
Advicare is required by State and Federal regulations to capture and report specific data regarding
services rendered to its members. All services rendered, including capitated encounters and Fee-ForService claims, must be submitted on the CMS 1500 (HCFA 1500) or UB-04 claim form, or via electronic
submission in a HIPAA compliant 837 or NCPDP format. Advicare follows South Carolina Medicaid
billing requirements. Advicare prefers that claims are filed electronically and this will ensure that claims
are paid as quickly as possible.
28
Claims for billable services provided to Advicare members must be submitted by the provider that
rendered the services.
Claims filed with Advicare are subject to the following procedures:
•
Verification that all required fields are completed on the claim
•
Verification that all diagnosis codes, modifiers and procedure codes are valid for the date
of service
•
Verification of member's eligibility for services under Advicare during the time period in which
services were provided
•
Verification that the provider has been given approval for services that require
prior authorization by Advicare
•
Advicare is the "payer of last resort" on all claims submitted for members of its health plan.
Providers must verify whether the member has Medicare coverage or any other third party
resources and, if so, submit an EOB from the primary and/or secondary payer as appropriate
•
Prior authorization is required for all out of network office visits
When data elements are missing, incomplete, invalid or coded incorrectly, Advicare cannot
process the claim.
NOTE: Rejected claims are defined as claims with invalid or missing data elements, such as the
National Provider Identification Number (NPI), that are returned to the submitter or EDI source
without registration in the claim processing system. Since these claims are not recorded in the claim
system, the provider must resubmit corrected claims within 180 calendar days from the date of
service. This guideline applies to claims submitted on paper or electronically. Rejected claims are
different than denied claims, which are registered in the claim processing system but, do not meet
requirements for payment under Advicare guidelines.
BILLING A MEDICAID ADVICARE MEMBER
Provider may only bill a Medicaid Advicare Member under the following conditions:
1.
When Provider renders services that are non-covered services and are not Additional
Services, as long as the Provider:
•
Provides to the Medicaid Advicare Member a written statement of the services
prior to rendering said services, which must include:
The cost of each service(s)
-
•
2.
An acknowledgement of Medicaid Advicare Member’s payment
responsibility, and
Obtains Medicaid Advicare Member’s signature on the
statement.
When the service provided has a co-payment, as allowed by the Advicare, Provider may
charge the Medicaid Advicare Member only the amount of the allowed co-payment, which
cannot exceed the co-payment amount allowed by SCDHHS.
29
Mailing Addresses
Submit claims, or claim appeals, oral or written for all medical services to Advicare:
Advicare Attention: Claims Dept., P O Box 5547, Hauppauge, NY 11788
Requests for appeals or adjustments may be submitted by telephone by calling toll free (888) 7814371 or sent via fax toll free (888) 781-4316.
NOTE: Please be sure to use the Advicare Adjustment and Appeal Form (Exhibit H1) for all
requested appeals. This form can be found on the website under the “Provider Communication and
Forms” link at www.Advicarehealth .com.
Administrative appeals must be submitted in writing to:
Advicare Attention: Appeals 531 South Main Street, Suite RL-1 Greenville, SC 29601
Medical appeals must be submitted in writing to:
Advicare Attention: Appeals 531 South Main Street, Suite RL-1 Greenville, SC 29601
NOTE: Be sure to include the member's Advicare Identification Number on all claims, this number is
also the member’s Medicaid identification number.
TIMELY FILING GUIDELINES
Original claims must be submitted to Advicare within 365 calendar days from the date of service. Resubmission of previously denied claims with corrections and requests for adjustments must be
submitted within 180 calendar days from the date of remittance.
ELECTRONIC FUNDS TRANSFER (EFT)
Advicare and Emdeon Business Services have partnered to offer you direct deposit for your claims
payment. Health care professionals/providers interested in receiving electronic payments through
Emdeon may get additional information through the Emdeon website, www.Emdeon.com/epayment or
by contacting Advicare Provider Relations Department toll free at (888) 781- 4371 .
XII.
QUALITY IMPROVEMENT
QUALITY IMPROVEMENT PROGRAM
Advicare has designed a provider centric system and quality-based program for the support of the
provider network and the monitoring and evaluation of proper quality and utilization of services.
This program is the Quality Improvement Plan (QIP) and is also designed to comply with
applicable quality standards, including those of the Centers for Medicare and Medicaid Services’
(CMS) Quality Improvement System for Managed Care (QISMC), and the need and requirements
of Federal and State authorities that conduct oversight.
The purpose of the QIP is to develop a systematic process to monitor and evaluate provider
service utilization and progress on the Managed Care Organization program. In addition, the QIP
will identify quality indicators, monitor, and measure, evaluate, and then provide a quantitative
basis for continuous improvement of outcomes and the care process through which these
30
outcomes are achieved.
The QIP seeks to define the quality of services by assessing the following components deemed
integral to the quality of all healthcare services:
•
•
•
•
•
•
•
•
•
•
Appropriateness and Necessity of Services
Access to and Availability of Care
Timeliness of Service
Case and Disease Management
Utilization Management / Use of Services
Health Education for Members
Preventative Services
Health Care System Stability
Prudent Management of Healthcare Resources
Member and Provider Satisfaction
QUALITY IMPROVEMENT PROGRAM STRUCTURE
To ensure continuity of operations within Advicare and ensure the execution of the QIP, the
following guidelines apply:
•
The Executive Manager’s appointment by the Board of Directors will be reflected in the Board of
Director’s proceeding and minutes
•
The Board of Directors will be apprised of the absences of the Executive Manager in writing and the
temporary appointment of a designee as the acting Executive Manager for Advicare.
•
The Medical Director shall be licensed in South Carolina. Through participation as chairman of the
Quality Management and its subcommittees, the Medical Director will demonstrate active
participation in the development of related policies and procedures.
•
In the absence of the Medical Director, a duly licensed physician, authorized to practice in South
Carolina will be designated in writing to fulfill the role and obligations of the Medical Director with the
approval of the President and the Board of Directors.
•
The Quality Management Committee and all subordinate committees will perform under the
supervision of the Medical Director.
QUALITY IMPROVEMENT PROGRAM GOALS AND OBJECTIVES
•
To provide and maintain the highest standard and quality of healthcare.
•
To assure compliance with all local, federal, and contractual regulations.
•
To continuously identify new areas for improvement of the delivery of healthcare and services for our
members.
•
To assess the impact of Case and Disease Management and health education on the quality of
for our members as well as sound resource management practices for Advicare.
•
To ensure that the quality of care and healthcare services provided meets professionally recognized
standards of practice.
•
To promote the advancement of quality management and delivery of services through continued
analysis, education, and resource management.
life
31
•
To provide a systematic approach for monitoring the appropriateness of the delivery of care so
to ensure that the healthcare provided results in optimal outcomes for the members of Advicare.
•
To assess the medical necessity of all care as well as ensuring optimal utilization practices.
•
To evaluate and ensure significant community, consumer, and provider
satisfaction.
•
To communicate the results of our quality activities with the employees and providers of Advicare
Health.
•
To assess the impact of wellness programs and preventative care on the prevention of disease
resource management.
•
To identify member specific needs, taking into consideration unique demographics, assessed special
and cultural needs, and preference.
•
To evaluate and improve accessibility and timeliness of all care and services provided to
Advicare members.
confidence
as
and
and
QUALITY IMPROVEMENT PROGRAM SCOPE
The Quality Improvement Program is integrated into clinical and non-clinical services involved with
care for Advicare patients. The QIP will assess the impact of Case and Disease Management and
health education on the quality of life for our members as well as sound resource management
practices for Advicare patients, health care providers and affiliated providers. The program is
designed to monitor, evaluate, and continually improve all care and services delivered by Advicare
providers. These services include:
•
•
•
•
•
•
•
•
•
Primary Care Services
Specialist Physicians
Advanced Practice Nurses
Pharmacy Services
Home Health Services
EPSDT
Pregnancy Related services (all family planning, prenatal, perinatal and postpartum care)
Case Management Services
Diabetes Care Services
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Dental Services for Children
Inpatient Hospital Services
Outpatient Hospital Services
Diagnostic Testing
Laboratory Testing
Nursing Facility Services
Outpatient Rehabilitation Services
Inpatient Rehabilitation Services
Dialysis
Blood and Blood Products
Mental Health Services
Substance Abuse Services
Emergency Services
Services for speech, language, and hearing for children less than 21 years old
Health Education Programs
Transportation Services (non-emergency and emergency)
32
•
•
•
•
•
•
•
•
Podiatry Services
Vision Services
Day Treatment Services
Personal Care Services
Durable Medical Equipment (DME)
Disposable Medical Supplies (DMS)
Long Term Care Services
Transplants
PRACTITIONER INVOLVEMENT
Advicare recognizes the integral role practitioner involvement plays in the success of its quality
improvement program. Practitioner involvement in various levels of the process is highly
encouraged through provider representation. Advicare encourages PCP, Behavioral Health,
Pediatrics, OB/GYN representation on key quality committees and select ad-hoc committees.
HEALTH CARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS)
HEDIS is a set of standardized performance measures developed by the National Committee for
Quality Assurance (NCQA) which allows comparison across health plans. HEDIS gives
purchasers and consumers the ability to distinguish between health plans based on comparative
quality instead of simply cost differences. HEDIS reporting is a required part of the SCDHHS
contract. SCDHHS holds Advicare accountable for the timeliness and quality of healthcare
services (acute, preventive, mental health, etc.) delivered to its diverse membership.
HEDIS consists of 20+ Effectiveness of Care type measures as well as Access to Care and Use
of Services measures for which the health plan contractually reports rates to the State of South
Carolina based on claims and/or medical record review data.
As both the State and Federal governments move toward a healthcare industry that is driven by
quality, HEDIS rates are becoming more and more important, not only to the health plan, but to
the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to
evaluate the effectiveness of a Health Insurance Company’s ability to demonstrate an
improvement in Preventive Health outreach to its members. Physician specific scores are being
used as evidence of preventive care from primary care office practices. The rates then serve as a
basis for physician incentive programs such as �pay for performance’ and �quality bonus funds’.
These programs pay providers an increased premium based on scoring of such quality indicators
used in HEDIS.
How are HEDIS rates calculated?
HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative
data consists of claim or encounter data submitted to the health plan. Measures typically
calculated using administrative data include: annual mammogram, annual Chlamydia screening,
annual Pap test, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma,
cholesterol management, antidepressant medication management, access to PCP services, and
utilization of acute and mental health services.
Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data
requires review of a random sample of member medical records to abstract data for services
rendered but that were not reported to the health plan through claims/encounter data. Accurate
and timely claim/encounter data reduces the necessity of medical record review. Measures
typically requiring medical record review include: comprehensive diabetes care, control of highblood pressure, immunizations, prenatal care, and well-child care.
What can be done to improve my HEDIS scores?
Understand the specifications established for each HEDIS measure.
Submit claim/encounter data for each and every service rendered. All providers must bill (or
33
report by encounter submission) for services delivered, regardless of contract status.
Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not
billed or not billed accurately they are not included in the calculation. Accurate and timely
submission of claim/encounter data will positively reduce the number of medical record reviews
required for HEDIS rate calculation. Chart documentation must reflect the services provided.
If you have any questions, comments, or concerns related to the annual HEDIS project or the
medical record reviews, please contact Advicare’ Quality Improvement Department toll free at
(888)-781-4371.
CONSUMER ASSESSMENT
(CAHPS) SURVEY
OF
HEALTHCARE PROVIDERS AND SYSTEMS
This is a member satisfaction survey that is included as a part of HEDIS and NCQA accreditation.
It is a standardized survey administered annually to members by an NCQA certified survey
vendor. The adult CAHPS survey provides information on the experiences of Medicaid members
with the Advicare services and gives a general indication of how well the Advicare meets
members’ expectations. Global rating questions reflecting overall satisfaction include rating of
personal doctor and rating of specialist seen most often. Composite scores summarize responses
in key areas such as getting care quickly, getting needed care, how well doctors communicate,
and shared decision making. The child CAHPS survey looks at the same global and composite
areas
but provides information on parents’ experience with Advicare services. Member responses to the
CAHPS survey are used in various aspects of the quality program including monitoring of
practitioner access and availability.
PROVIDER SATISFACTION SURVEY
Advicare conducts an annual provider satisfaction survey which includes questions to evaluate
provider satisfaction with our services such as claims, communications, utilization management,
and provider services. The survey is conducted by an external vendor. Participants are randomly
selected by the vendor, meeting specific requirements outlined by Advicare, and the participants
are kept anonymous. We encourage you to respond timely to the survey as the results of the
survey are analyzed and used as a basis for forming provider related quality improvement
initiatives.
AUTHORITY AND RESPONSIBILITY
The Advicare Compliance Officer has overall responsibility and authority for carrying out the
provisions of the compliance program.
Advicare is committed to identifying, investigating, sanctioning and prosecuting suspected fraud
and abuse.
The Advicare provider network must cooperate fully in making personnel and/or subcontractor
personnel available in person for interviews, consultation, grand jury proceedings, pre-trial
conferences, hearings, trials and in any other process, including investigations. These are the
primary agencies to which incidents or practices of abuse and/or fraud are to be reported:
ADVICARE
Attention: Compliance Officer
531 South Main Street, Suite RL1
Greenville, SC 29601
Toll free 1-888-781-4371
SCDHHS
34
Department of Fraud
P.O. Box 8206
Columbia, SC 29202-8206
Toll free 1-888-364-3224
Provider Initiated Grievance
Providers may file a grievance if the Provider has a concern regarding issues such as:
•
•
•
•
General dissatisfaction
Difficulty getting through on the telephone
Complaints about a member
Claims resolution
A provider may file a grievance both orally or in writing by contacting Advicare at the number listed
below or by sending a written grievance to Advicare at the address listed below:
ADVICARE
Attention: Manager, Appeals and Grievances
531 South Main Street, Suite RL1
Greenville, SC 29601
Toll free 1-888-781-4371
XIII. MEMBER SERVICES
MEMBER SERVICES
Advicare is committed to providing its members with information about the health benefits that are
available to them through the Advicare program. Advicare encourages members to take
responsibility for their healthcare by providing basic information to assist with making decisions
about their healthcare choices. Other functions of the member services department:
•
•
•
Provide additional information about Advicare providers,
Facilitate referrals to providers; and
Assist in the resolution of service and/or medical delivery concerns or problems.
Advicare has developed targeted programs to address the needs of its members. Members
receive specific disease management bulletins and treatment updates, appointment reminder
cards, and informational mailings.
As a provider for Advicare, please remember that it is your obligation to identify any member who
35
requires translation or interpretation language services. Advicare will pay for these services
whenever you need them to effectively communicate with an Advicare member. Advicare
members are not to be held liable for these services. To arrange for any of the above services,
please call the Advicare Member Services Department:
Toll Free 1-888-781-4371
MEMBER MATERIALS
Members will receive various pieces of information from Advicare through mailings and through
face-to-face contact. The Member Handbook is printed in English and Spanish and can be
requested in other languages identified by the state. These materials include:
•
•
•
•
•
•
Quarterly Newsletters
Targeted Case and Disease Management Brochures
Provider Directory
Nurse Response Information
Emergency Room Information
Member Handbook which includes Member rights and responsibilities
Providers interested in receiving any of these materials may contact:
Member Services Department
Toll Free 888-781-4371
Fax Toll Free 888-781-4316
TDD/TTY Toll Free 888-357-7188
www.Advicarehealth.com
MEMBER RIGHTS & RESPONSIBILITIES
Members are informed of their rights and responsibilities through the Member Handbook.
Advicare providers are also expected to respect and honor member’s rights.
Below are the member rights that are given to Advicare member’s upon enrollment:
1. To be treated with respect and with due consideration for his or her dignity and privacy.
2. To participate in decisions regarding his or her healthcare, including the right to refuse treatment, as
well as, the right to receive information on available treatment options.
3. To be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience or retaliation, as specified in the federal regulations on the use of restraints and
seclusion.
4. To be able to request and receive a copy of his or her Medical Records, and request that they be
amended or corrected.
5. To receive healthcare services that are accessible, are comparable in amount, duration and scope to
those provided under Medicaid FFS and are sufficient in amount, duration and scope to reasonably
be expected to achieve the purpose for which the services are furnished.
36
6. To receive services that are appropriate and are not denied or reduced solely because of diagnosis,
type of illness, or medical condition.
7. To receive all information including but not limited to Enrollment notices, informational materials,
instructional materials, available treatment options, and alternatives in a manner and format that may
be easily understood.
8. To receive assistance from both SCDHHS and Advicare in understanding the requirements and
benefits of the plan.
9. To receive oral interpretation services free of charge for all non-English languages, not just those
identified as prevalent.
10. To be notified that oral interpretation is available and how to access those services.
11. As a potential member, to receive information about the basic features of managed care; which
populations may or may not enroll in the program and Advicare’s responsibilities for Coordination of
Care in a timely manner in order to make an informed choice.
12. To receive information on Advicare’s services, to include, but not limited to:
a) Benefits covered
b) Procedures for obtaining benefits, including any authorization requirements
c) Any cost sharing requirements
d) Service Area
e) Names, locations, telephone numbers of and non-English language spoken by current
contracted Providers, including at a minimum, primary care physicians, specialists, and
hospitals.
f) Any restrictions on member’s freedom of choice among network Providers.
g) Providers not accepting new patients.
h) Benefits not offered by Advicare but available to members and how to obtain those benefits,
including how transportation is provided.
13. To receive a complete description of Disenrollment rights at least annually.
14. To receive notice of any significant changes in the Benefits Package at least thirty (30) days before
the intended effective date of the change.
15. To receive information on the Grievance, Appeal and Fair Hearing procedures.
16. To receive detailed information on emergency and after-hours coverage, to include, but not limited to:
a) What constitutes an Emergency Medical Condition, emergency services, and PostStabilization Services?
b) That Emergency Services do not require Prior Authorization.
c) The process and procedures for obtaining Emergency Services.
d) The locations of any emergency settings and other locations at which Providers and hospitals
furnish Emergency Services and Post-Stabilization Services covered under the contract.
e) Member’s right to use any hospital or other setting for emergency care.
f) Post-Stabilization care Services rules as detailed in 42 CFR В§422.113(c).
17. To receive Advicare’s policy on referrals for specialty care and other benefits not provided by the
member’s PCP.
18. To have his or her privacy protected in accordance with the privacy requirements in 45 CFR parts
160 and 164 subparts A and E, to the extent that they are applicable.
19. To exercise these rights without adversely affecting the way Advicare, its Providers, or SCDHHS treat
the members.
Advicare members are expected to do the following:
♦
Be familiar with Advicare’s procedures to the best of your ability
♦
Call or contact Advicare to obtain information and/ or have questions clarified.
♦
Choose a personal doctor from the Advicare Network of Primary Care Physicians (PCP).
♦
Get your primary medical care through the Advicare list of participating primary doctors
37
♦
Carry your SC Healthy Connections (Medicaid) card along with your Advicare ID card with
you when obtaining health care services.
♦
Give Advicare and your personal doctor the information they need to care for you and provide
participating network providers with accurate and complete medical information.
♦
Inform Advicare of any changes such as:
пѓј
Change of address or telephone number.
пѓј
Change of name
пѓј
Death of a family Member.
пѓј
New additions to their family, such as a baby.
пѓј
Availability of other insurance coverage.
пѓј
A move to somewhere outside of the South Carolina.
♦
Inform Advicare how we can work better for you.
♦
Inform Advicare of the loss or theft of your Advicare or SC Healthy Connections ID cards.
♦
Keep your doctor’s appointments or call to cancel at least 24 hours in advance; make every
effort to keep any agreed upon appointments.
♦
Whenever you visit the doctor’s office, tell the doctor you are a Member of Advicare. Ask
questions and talk with your doctor about your health, and listen to what the doctor tells you
♦
Follow the prescribed treatment plan recommended by the provider or letting the provider
know the reasons the treatment cannot be followed, as soon as possible.
♦
Access Preventive Care services
♦
Know what an emergency is, how to keep emergencies from happening, and what to do if
one does happen.
♦
Know the difference between a true emergency and a condition needing urgent care.
♦
Treat Advicare employees and providers with respect.
CORE BENEFITS
Co-Payments
Some adult members will need to pay a small amount (co-payment) for the following services.
Amount
Type of Service
$1.15 per date of service
Chiropractor
$3.30 per date of service
Ambulatory Surgical Center
Federally Qualified Health Center (FQHC)
Home Health
Optometrist
Physician Office Visit- (Physician/Nurse Practitioner)
Rural Health Clinic (RHC)
$3.40 per date of service
*Durable Medical Equipment and Supplies
Dental
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Pharmacy (per prescription/refill)
(Copay will apply to ages 19 and above only)
$3.40 per claim
Outpatient Hospital (Non-emergency)
$25.00 per admission
Inpatient Hospital
There will be no co-payment for children less than 19 years of age, pregnant women, and individuals
receiving emergency services or federally recognized Native Americans.
* Includes: doctors, nurse practitioners, licensed midwifes and optometrists.
A Medicaid beneficiary may not be denied services if they are unable to pay the co-payment at the time the
service is rendered, however this does not relieve the beneficiary of the responsibility for the co-payment. It is
the provider’s responsibility to collect the co-payment from the beneficiary to receive full reimbursement for a
service.
Pursuant to federal regulations, the following beneficiaries are excluded from copayment requirements:
children under the age of 19, pregnant women, institutionalized individuals (such as persons in a nursing
facility or ICF-MR), and members of a Federally Recognized Indian Tribe (for services rendered by the
Catawbas Service Unit in Rock Hill, SC and when referred to a specialist or other medical provider by the
Catawbas Service Unit).
Additionally, the following services are not subject to a copayment: Medical equipment and supplies provided
by DHEC; Orthodontic services provided by DHEC; Family Planning services, End Stage Renal Disease
(ESRD) services, Infusion Center services, Emergency services in the hospital emergency room, Hospice
benefits and Waiver services.
Please call member Services at toll free 888-781-4371 if you questions concerning co-payments.
Services Covered by Advicare:
Some of the covered services may require a Prior Authorization, if you have any questions, please contact
Provider Services toll free (888) 781- 4371.
Covered Service
Ambulance Transportation
Ancillary Medical Services
Description
These trips may be routine or non-routine transports and
will provider stretcher trips, air ambulance, and Medivac
transportation
These services include, but are not limited to:
* Pathology
* Radiology
* Emergency Medicine
* Anesthesia
Actions
Call 911 if there is an
emergency
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Audiological Services
Services include diagnostic testing, screening, preventive
and/or corrective services for hearing disorders or for
determining if you have a hearing disorder under the
direction of an Audiologist. Get a referral from your PCP
or other Licensed Health Care Professional of the
Healing Arts (LPHA).
This benefit only covers
members under the age of
21.
Chiropractic Care
Chiropractic services are available to all members. Make
an appointment with a participating an Advicare
partipating chiropractor.
Services are limited to 6
visits each year.
Communicable Disease
Services include services to help control and prevent
diseases such as tuberculosis (TB), syphilis, other
sexually transmitted diseases (STDs) and HIV/AIDS.
Services include exams, assessments, diagnostic
procedures, health education/counseling, treatment, and
contact tracing. Seek care from any public health agency
or make an appointment with your PCP
Disease Management
Disease management is comprised of all activities for
members with special healthcare needs to coordinate
and monitor their treatment for specific identified
chronic/complex conditions and diseases, as well as
educate members to maximize appropriate selfmanagement.
Covered Service
Description
Durable Medical Equipment
Durable Medical Equipment (DME) is equipment that
provides therapeutic benefits and enables a member
to perform certain task he or she would otherwise be
unable to undertake due to certain medical conditions
and/or illness. Services include medical products,
surgical supplies and equipment when ordered by a
physician as medically necessary in the treatment of
a specific medical condition.
Early & Periodic Screening,
diagnosis, and Treatment (EPSDT)
/Well-child) Visit
Visits for your regular medical checkups from birth to
age 21 at your assigned Primary Care Physician
(PCP) that you chose from the Advicare Provider
Directory. These visits may include immunizations
(shots).
Actions
Make an appointment with your
PCP.
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Family Planning
This service is a health care service available to help
prevent unplanned pregnancies. This service
provides any examinations, assessments, diagnostic
procedures, health education and counseling
services related to alternative birth control and
prevention prescribed by physician, pharmacies,
hospitals, and clinics. As a member, you have the
freedom to receive Family Planning Services from
any appropriate Medicaid Providers without
restrictions, this includes your PCP.
Hearing Aids and Hearing Aid
Accessories
The Hearing Aids and accessories will be considered
a DME
This benefit only covers
members under the age of 21.
Home Health Services
Healthcare services that are delivered to your home.
Home health services include intermittent skilled
nursing, home health aides, physical, occupational,
and speech therapy. Get a referral from your PCP.
You must visit an in-network provider.
These services are not cover when given in nursing
homes and institutions.
Adult members age 21 years
and older are limited to 50 visits
per year.
Independent Lab and x-rays
Services
Services ordered by a doctor and provided by
independent laboratories and x-ray facilities.
Inpatient Services
Services that are rendered via medical and/or
behavioral services provided under the direction of a
doctor if you are admitted to a hospital when the stay
is expected to last more than 24 hours. Includes
room and board, miscellaneous hospital services,
medical supplies and equipment.
All Inpatient Services will
require prior approval
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Covered Service
Description
Outpatient Pediatric Aids
Clinics Services (OPAC)
OPAC operates exclusively for the purpose of
providing specialty care, consultation and counseling
services for HIV infected and exposed Medicaid
children and their families.
Outpatient Services
Services include preventive diagnostic, therapeutic,
rehabilitative, surgical and emergency services
received for the treatment of a disease or injury at an
outpatient/ambulatory care facility for a period of time
under 24 hours
Physician Services
Physician services include the full range of
preventive care services, Primary care medical
services, and physician specialty services.
Prescriptions
Prescriptions and Over-the-counter drugs are
limited to 4 medicines per month (There is a
maximum 31-day supply for each medicine). An
additional 3 medicines (per month) can be covered.
To get additional medicines a prescription override
will have to be approving by Advicare.
Generic medicine and supplies will be provided when
available.
For adults ages 21 and older, there is no limits
applied to certain drugs, insulin syringes and
associated supplies.
Please refer to the PDL for a list of Advicare's
approved medications. Some medicines on the list
will require Prior Approval.
Preventive and Rehabilitative
Services for Primary Care
Enhancement (PSPCE/RSPCE)
These services are available to Medicaid member
that has medical risk factors. PSPCE/RSPCE
includes activities related to medical/dental plan of
care to promote changes in behavior, improve health
status, develop healthier practices by building client
and/or care giver self-sufficiency, and promote
appropriate use of primary medical care.
Psychiatric Services
These services include assessments, treatment plan
development, and modification, and therapy services.
Actions
Comprehensive
neurodevelopment and/or
psychological development
assessment and testing
services are covered for
children under the age of 21.
Take your prescription(s) to
an Advicare participating
pharmacy. Present your
Advicare and Medicaid ID
cards.
Call Member Services for
complete information about
covered medicines, the
appeal process, or a
complete list of participating
pharmacies.
These services are limited to
a maximum of 1 assessment
per member every 6 months.
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Covered Service
Description
Rehabilitative Therapies for
Children- Non-Hospital Based
Under these services, Advicare provides a wide
range of therapeutic services available to individuals
under the age 21 who have sensory impairments,
mental retardation, physical disabilities, and/or
developmental disabilities or delays.
This benefit covered Private Providers that are
rendering Rehabilitative Therapy Services to include:
(1) Speech-language Pathology
(2) Audiology
(3) Physical and Occupational Therapies
(4) Nursing Services for children under 21 years of
age.
Transplant and Transplant Related Services
This service will require approval before being
performed. Depending on the service and transplant,
coverage may be provided by Advicare or by
Medicaid.
Advicare Transplant benefits covers:
* All services for corneal transplants
* Services before and after a kidney transplant and
other transplants.
Vision Care
Children under 21 years can get 1 comprehensive
eye exam each year and one pair of eyeglasses with
no co-pay. Call Member Services for a list of
Advicare providers.
Substance Abuse Services
Covers services administered through Department of
Alcohol and Other Drug Abuse Services (DAODAS)
Actions
Advicare providers do not
require prior authorization.
Providers NOT in the Advicare
network require prior
authorization
Please contact Provider Services toll free (888) 781-4371 for a complete list of services provided by either
Advicare or Medicaid. Services not covered by Advicare or Medicaid are non-covered services.
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Services Covered by Medicaid Fee-for-Service:
The services detailed below are those services which will continue to be provided and reimbursed by the
current Medicaid program and are consistent with the outline and definition of covered services in the Title
XIX SC State Medicaid Plan. Payment for these services will remain fee-for-service. MCOs are expected to
be responsible for the Continuity of Care for all Medicaid MCO Members by ensuring appropriate referrals
and linkages are made for the Medicaid MCO Member to the Medicaid fee-for-service Provider.
Covered Service by
Medicaid FFS
Description
Actions
Mental Health Authorized or
Provided by State Agencies
Mental health services
authorized or provided by a
state agency are reimbursed by
Medicaid fee-for-service. Such
services require a unique
authorization number issued by
the state agency to ensure the
claim is appropriately
adjudicated by SCDHHS.
Advicare will coordinate the
referral of Members for services
that are outside of the required
Core Benefits.
Medicaid Providers. These services are
consistent with the outline and definition of
Covered Services in the Title XIX SC State
Medicaid Plan. These services include, but
are not limited to, Targeted Case
Management services, intensive family
treatment services, therapeutic day services
for children, out-of-home therapeutic
placement services for children, inpatient
psychiatric hospital and residential
treatment facility services.
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Covered Service by
Medicaid FFS
Description
Actions
Medical (Non-Ambulance)
Transportation
Medical non-ambulance
transportation is defined as
transportation of the Beneficiary
to or from a Medicaid Covered
Service to receive medically
necessary care. This
transportation is only available
to Eligible Beneficiaries who
cannot obtain transportation on
their own through other available
means, such as family, friends
or community resources.
Advicare staff will communicate
directly with the brokers to
ensure services are arranged,
scheduled, and fulfilled as
required for a Medicaid MCO
Member’s access to Medicaidcovered services. These
services are paid fee-for-service.
Advicare shall assist the Member in
obtaining medical transportation services
through the SCDHHS Enrollment broker
system as part of its Care Coordination
responsibilities, as detailed below. BrokerBased Transportation (Routine NonEmergency Medicaid Transportation)
These are transports of Medicaid MCO
Members to Covered Services as follows:
• Urgent transportation for Medicaid MCO
Member trips and urgent transportation for
follow-up medical care when directed by a
medical professional
• Unplanned or unscheduled requests for
immediate transportation to a medical
service when directed by a medical
professional (i.e., pharmacy, hospital
discharge)
Routine non-Emergency transportation to
medical appointments for Eligible Medicaid
MCO Members (Any planned and/or
scheduled transportation needs for
Medicaid Beneficiaries must be
prearranged via direct contact with the
regional brokers)
• Non-Emergency transports requiring BLS
that are planned/scheduled transports to a
scheduled medical appointment (i.e.,
transport from nursing home to physician’s
office, nursing home to dialysis center or
hospital to residence)
• Non-Emergency wheelchair transports
that require use of a lift vehicle and do not
require the assistance of medical personnel
on board at the time of transport to medical
appointments for Eligible Beneficiaries
(These transports do not require the use of
an ambulance vehicle.)
Vision Care Services
Advicare Members age 21 and
older may only receive vision
services when those services
are identified as being Medically
Necessary and not routine care.
45
Covered Service by
Medicaid FFS
Description
Actions
Dental Services
Routine and emergency dental
services are available to Medicaid
MCO Members under the age of 21.
The dental program for Medicaid
MCO Members under age 21 is
administered by the SCDHHS
dental broker, DentaQuest.
Dental services are a non-covered
benefit for Advicare Members age 21
and over. Dental services for Medicaid
MCO Members age 21 and over
covered by SCDHHS on a fee-forservice basis are limited to dental
procedures performed for the following
medical reasons; Organ Transplants,
Oncology: Radiation of the head and/or
neck for cancer treatment,
Chemotherapy for cancer treatment,
Total Joint Replacement and Heart
Valve Replacement
Targeted Case
Management (TCM)
Services
Targeted Case Management (TCM)
consists of services which will assist
an individual eligible under the State
plan in gaining access to needed
medical, social, educational, and
other services.
Home- and CommunityBased Waiver Services
Home- and community-based
waiver services target persons with
long-term care needs and provide
Beneficiaries access to services that
enable them to remain at home
rather than in an institutional setting.
Pregnancy Prevention
Services – Targeted
Populations
The Medicaid program provides
reimbursement for pregnancy
prevention services for targeted
populations through state and
community Providers. The Medicaid
Program will reimburse fee-forservice directly to enrolled Medicaid
Providers for these services.
46
MAPPS Family Planning
Services
Medicaid Adolescent Pregnancy
Prevention Services (MAPPS)
provide Medicaid funded Family
Planning Services to at-risk youths.
Covered Service by
Medicaid FFS
Description
Actions
Developmental Evaluation
Services (DECs)
Developmental Evaluation Services
(DECs) are defined as Medically
Necessary comprehensive
neurodevelopment and
psychological developmental,
evaluation and treatment Services
for Beneficiaries between the ages
of 0 to 21 years.
DECs are provided by one of the three
tertiary level facilities located within the
Departments of Pediatrics at the
Greenville Hospital System, Greenville,
SC; The University of South Carolina
School of Medicine, Columbia, SC; or
the Medical University of South Carolina
a Charleston, SC. Pediatric day
treatment, when rendered by DECs, is
considered as one of the DEC treatment
services.
Please contact Provider Services at 888-781-4371 for a complete list of services provided by either
Advicare or Medicaid. Services not covered by Advicare or Medicaid are non-covered services.
MEMBER GRIEVANCES
A grievance is an expression of dissatisfaction about any matter other than an “action” with any aspect of
Advicare or a provider's operation.
Examples:
• Quality of care issues
• Rudeness of a provider or employee
• Failure to respect the member’s rights
Who has the authority to file?
•
•
A member or member’s authorized representative
A provider, acting on behalf of the member (must obtain written authorization from the member)
Grievances may be filed either orally or in writing with Advicare. Advicare will notify the member or
authorized representative that the grievance has been received in writing within 5 business days of
receipt of the grievance. Members or their authorized representative may file a grievance by
contacting Member Services toll free-888-781-4371 or by submitting written notification to:
Advicare Appeals/Grievances Coordinator
531 South Main Street, Suite RL-1
Greenville, SC 29601
47
Advicare will resolve all grievances within 90 calendar days from the receipt of the grievance.
A member, provider, authorized representative, or Advicare can request an extension for up to 14 calendar
days. Advicare will have to submit the extension request to SCDHHS. If approved, Advicare will send a letter
to the requestor advising the extension.
Once the grievance has been resolved, Advicare will send a resolution letter to the requestor advising of
Advicare’s actions taken within 5 days of the determination.
APPEALS
An appeal is the request for review of an “action”. An “action” is:
•
the denial or limited authorization of a requested service, including the type or level of
service
•
the reduction, suspension, or termination of a previously authorized service
•
the denial, in whole or part of payment for a service
•
the failure to provide services in a timely manner, as defined by the State
•
the failure of an ADVICARE or PIHP to act within the timeframes stated in the Code of
regulations
•
for a resident of a rural area with only one ADVICARE, the denial of a Medicaid enrollee’s
request to exercise his or her right, to obtain services outside the network.
An appeal review may be requested orally or in writing in which both are handled in the same
manner and is resolved within 30 calendar days
Who may file an Appeal?
• Advicare members
• Authorized representative of an Advicare member
• Provider acting on behalf of member
Requests for an Appeal must be made within ninety (90) calendar days from the date of the
Notice of Proposed Action.
A member, provider, authorized representative, or Advicare can request an extension for up to 14 calendar
days. Advicare will submit extension request to SCDHHS for approval. If approved, Advicare will send a letter
to the requestor advising the extension.
Advicare will send a written decision within thirty (30) calendar days from the date of receipt of an appeal.
EXPEDITED RESOLUTION OF APPEALS
If a decision on an appeal is required immediately due to the member’s health needs which
cannot wait with the standard resolution time, an expedited appeal may be requested. Advicare’
decision on the expedited resolution will be provided within 3 business days of receipt of the
request for the review.
***NOTE** Under certain circumstances, members have the right to request, within 10 days of the date of the
Notice of Action, that benefits be continued while an appeal is pending.
CONTINUATION OF BENEFITS
Advicare members may continue receiving services or items until a decision is made about
his/her appeal or fair hearing process if the member was receiving ongoing services that were
suspended, reduced or terminated.
Advicare must continue the member’s benefits if:
• The member or the provider files the appeal timely
48
•
•
•
•
The appeal involves the termination, suspension, or reduction of a previously authorized course
treatment
The services were ordered by an authorized provider
The original period covered by the original authorization has not expired; or
The member requests an extension of benefits
of
If the member request to continue his/her benefits while the appeal is pending, Advicare will continue or
reinstate the member’s benefits until one of the following occurs:
• The member withdraw the appeal
• Ten (10) calendar days pass after Advicare mails the notice providing the resolution of the Appeal
against the member
• A State Fair hearing officer issues a hearing decision adverse to the member
• The time period or service limits of a previous authorized services has been met.
Member’s responsibility for services furnished while the appeal is pending
• If the final resolution of the appeal is adverse to the member and Advicare’s decision is upheld,
Advicare may recover the cost of the services furnished to the member while the Appeal was pending
ASSISTANCE AND CONTACTING ADVICARE
Advicare Appeals and Grievance Coordinator is available to assist members who need help
in filing a grievance or request for appeal or in completing any element in the grievance or
appeal process. Members may seek assistance or initiate a grievance or request for appeal by
calling toll free-888-781-4371 (or TDD/TTY toll free-888-357-7188).
MEMBERS RIGHT TO STATE FAIR HEARING
If the member has exhausted Advicare’s level appeal process, Advicare must notify the member
by certified mail, return receipt of his or her right to request a State Fair hearing.
.
A member or member's authorized representative may request in writing a State Fair Hearing
within thirty (30) calendar days from the date of the certified mail return receipt. The parties to the
State Fair Hearing shall include Advicare, as well as the member, Member's Authorized
Representative, or representative of a deceased member's estate. A provider can, with written
consent from the member, request a State Fair Hearing on behalf of a member. The request for
the State Fair Hearing should be mailed to:
South Carolina Department of Health and Human Services Division of Appeals and Hearings
P.O. Box 8206
Columbia, SC
29202-8206
1-803-898-2600
INTERPRETER/TRANSLATION SERVICES
Advicare is committed to ensuring that staff and subcontractors are educated about, remain
aware of, and are sensitive to the linguistic needs and cultural differences of its members. In order
to meet this need, Advicare is committed to the following:
•
•
Providing Language Line services that will be available twenty-four (24) hours a day,
seven(7) Days a week in 140 languages to assist providers and members in
communicating with each other when there are no other translators available for the
language
TDD/TTY access for hearing impaired members through toll free 888-357-7188.
49
•
Advicare medical advice line, Nurse Response, provides 24 hour access, seven days a
week for interpretation of Spanish or the coordination of non- English/Spanish needs via
the Language Line
•
Providing or making available Member Services and Health Education materials in
alternative formats as needed to meet the needs of the members, such as language
translation; all alternative methods must be requested by the member or designee
•
Providers must call Member Services toll free 888-781-4371 if interpreter services are
needed. Please have the member’s ID number; date/time service is requested and any
other documentation that would assist in scheduling interpreter services.
XIV. PROVIDER RELATIONS ASSISTANCE
PROVIDER RELATIONS & CONTRACTING DEPARTMENTS
The Provider Relations Department at Advicare is designed around the concept of making your
experience with Advicare a positive one by being your advocate within Advicare. Provider
Relations is responsible for providing the services listed below which include but are not limited
to:
•
•
•
•
•
Contracting
Maintenance of existing Advicare Provider Manual
Eligibility distribution
Development of alternative reimbursement strategies
PMPM and shared savings updates/status
•
•
•
•
Network performance profiling
Individual physician performance profiling
Physician and office staff orientation
Ongoing provider education, updates, and training
The goal of this department is to furnish you and your staff with the necessary tools to provide the
highest quality of healthcare to Advicare enrolled membership. To contact the provider relations
specialist for your area contact:
Director of Provider Relations and/or designee will receive notification from
Credentialing/Contracting Department of new Providers. Upon notification, The PR Department
shall provide education for the provider.
Provider Relations Department
Toll Free 888-781-4371
Provider Relations staff is available to you and your staff to answer questions, listen to your
concerns, assist with members, and respond to your Advicare inquiries
New Provider Orientation
Orientations for new offices must be scheduled within ten (10) days of the provider’s effective date.
Orientations shall be completed within thirty (30) days of the effective date of the contract. In the event a new
provider orientation cannot be completed within the thirty (30) day timeframe, it shall be documented in the
contracting file and new provider orientation must be completed no later than sixty (60) days after the
effective date of the contract.
Ongoing Education and Training
Primary Care Physicians (PCPSs) shall be trained on a quarterly basis or as requested by the PCP.
Facilities, Hospitals and Specialists shall be trained on a yearly basis or as requested by the entity.
Provider and their office staff will be educated on the following: Network contractual obligations as prescribed
50
in the Provider Service Agreement. Regulatory requirements and utilization management protocol as detailed
in the Orientation presentation
Provider Rights
•
Each Advicare care professional/provider shall be assured of the following rights:
•
A healthcare professional, acting within the lawful scope of practice, shall not be prohibited from
advising or advocating on behalf of a member who is his/her patient, for the following:
o
o
o
o
The member’s health status, medical care or treatment options, including any
alternative treatment that may be self-administered.
Any information the member needs in order to decide among all relevant treatment
options.
The risks, benefits and consequences of treatment or non-treatment.
The member’s right to participate in decisions regarding his/her healthcare, including
the right to refuse treatment and to express preferences about future treatment
decisions.
•
To receive information on the grievance, appeal and fair hearing procedures.
•
To have access to Advicare’s policies and procedures covering the authorization of services.
•
To be notified of any decision by Advicare to deny a service authorization request or to authorize a
service in an amount, duration or scope that is less than requested.
•
To challenge, on behalf of the Advicare members, the denial of coverage of, or payment for,
medical assistance.
•
Advicare’s health care professional/provider selection policies and procedures must not
discriminate against particular health care professionals/providers that serve high-risk populations
or specialize in conditions that require costly treatment
•
To be free from discrimination for the participation, reimbursement, or indemnification of any
Provider who is acting within the scope of his or her license or certification under applicable State
law, solely on the basis of that license or certification.
Right to review information
• The organization must have written policies and procedures for notifying practitioners of their right to
review information it has obtained to evaluate their credentialing application, attestation or CV.
Evaluation of the credentialing application includes information obtained from any outside source
(e.g., malpractice insurance carriers, state licensing boards), with the exception of references,
recommendations or other peer-review protected information.
Right to correct erroneous information
• The organization must have written policies and procedures for notifying practitioners when
credentialing information obtained from other sources varies substantially from that provided by the
practitioner.
• The organization is not required to reveal the source of information if the information is not obtained
to meet organization credentialing verification requirements or if law prohibits disclosure.
• Policies and procedures must state the practitioner's right to correct erroneous information submitted
by another source, and include the following:
o The time frame for changes.
o The format for submitting corrections.
o The person to whom corrections must be submitted.
o Documentation of receipt of the corrections.
o How practitioners are notified of their right to correct erroneous information.
51
Right to be informed of application status
• The organization must have written policies and procedures for notifying practitioners of their right to
be informed of the status of their application upon request, and must describe the process for
responding to such requests, including information that the organization may share with practitioners.
Credentialing and Recredentialing Program Description
Overview of Program
The Credentialing and Recredentialing Program of Advicare shall be comprehensive to ensure that its
practitioners and providers meet the standards of professional licensure and certification. The process
enables Advicare to recruit and retain a quality network of practitioners and providers to serve its members.
It consistently and periodically assesses and evaluates a practitioner’s or provider’s ability to deliver quality
care between credentialing or re-assessment cycles, and it emphasizes and supports a practitioner’s and
provider’s ability to successfully manage the health care of network members in a cost-effective manner.
The Credentialing Program enables Advicare to ensure that all practitioners and providers are continuously
in compliance with Advicare policies and procedures, the SC Department of Health and Human Services
(SCDHHS) policies and procedures, the Utilization Review Accreditation Commission (URAC) standards,
the National Committee for Quality Assurance (NCQA) standards and any other applicable regulatory or
accreditation entity.
Advicare’s Board of Directors (the “Board”) has ultimate authority, accountability and responsibility for the
credentialing evaluation process (the “Credentialing Program”). The Board has delegated full oversight of
the Credentialing Program to the Credentialing Committee. The Credentialing Committee accepts the
responsibility of administering the Credentialing Program, having oversight of operational activities, which
include, but are not limited to making the final approval or denial decision on all practitioners and
providers, as applicable.
Credentialing Committee Structure & Activities
The Medical Director is responsible for the oversight and operation of the Credentialing Program, and
serves as Chairperson or may appoint a Chairperson, with equal qualifications. The Credentialing
Committee is a peer-review body that includes representation from a range of participating practitioners
including primary care (i.e., family practice, internal medicine, pediatrics, general medicine, obstetrics and
gynecology) and specialty practice. Allied health representatives include mental health, rehabilitation, etc.,
and may be appointed to serve as non-voting members, on an ad hoc basis. Members may be appointed
or requested to attend the meeting representing Advicare’s internal staff.
•
Receive and review the credentials of all practitioners being credentialed or recredentialed
who do not meet the organization's established criteria, and to offer advice, which the
organization considers. This includes evaluating practitioner files that have been identified
as problematic (e.g., malpractice cases, licensure issues, quality concerns, missing
documentation, etc.).
•
Review practitioner credentials and give thoughtful consideration to the credentialing
elements before making recommendations about a practitioner's ability to deliver care.
•
Establish, implement, monitor, and revise policies and procedures for Advicare
credentialing and recredentialing.
•
Report to the QIC and CQIC and other proper authorities, as required.
•
Annual Review of the credentialing program description, and other related objectives.
•
Credentialing activities can be performed by Advicare staff or a third party credentialing
52
organization at the discretion of Advicare with SCDHHS approval.
ANNUAL REVIEWS
Advicare conducts an annual review of the credentialing process to assess compliance with policies and
procedures in accordance with Advicare standards, DHHS standards, and the standards set forth by
URAC, NCQA and other applicable regulatory bodies. Additionally, Advicare conducts annual reviews on
delegated vendors to assure that they are in compliance with Advicare, regulatory and accreditation
standards and other applicable regulatory bodies.
PROVIDER SANCTIONS
Advicare has developed policies and procedures for credentialing activities including sanctioning
practitioners or providers on issues of quality of care and service. Sanctions may include mandated
continuing education, corrective action planning, probationary periods, and re-evaluation of the contract
and/or the termination of the practitioner or provider from the network. The policies include an appeal
process for practitioners and providers, which are communicated to them through a variety of media.
Advicare also maintains procedures to guide reporting of serious quality concerns to the appropriate
authorities.
XV. PHARMACY
COVERED PHARMACY SERVICES
Prescription drug benefits are managed and administered through CVS Caremark.
Monthly Prescription Limit Override Criteria for Adult Beneficiaries
Pharmacists may utilize an override code to exceed the monthly prescription limit for adult Medicaid
beneficiaries if the prescription limit override criteria are met. Pharmacists should submit the prescription limit
override code, a “5” in the Prior Authorization Type Code (PATC) field, if all of the following criteria
are met. Adult Medicaid beneficiaries are entitled to four prescriptions per month and up to three overrides
for prescriptions that meet the following criteria. Pharmacists should submit the prescription limit override
code on the claim if:
•
•
•
The monthly prescription limit has been met, and
The adult patient has one of the following conditions, and
The prescription is for an essential drug used in the adult patient’s treatment plan for one of these
conditions:
o
o
o
o
o
o
o
o
o
o
o
o
Acute sickle cell disease
Behavioral health disorder
Cancer
Cardiac disease (including hyperlipidemia)
Diabetes
End stage lung disease
End stage renal disease (ESRD)
HIV/AIDS
Hypertension
Life-threatening illness (not otherwise specified)
Organ transplant
Terminal stage of an illness
“If a pharmacist is uncertain as to the appropriateness of a prescription limit override for a particular
medication, the pharmacist should contact the prescriber to obtain additional clinical information so that an
53
informed Medicaid coverage decision may be made”.
DEFINITIONS
Care Coordination – The manner or practice of planning, directing and coordinating health care needs and
services of Medicaid ADVICARE Program Members.
Coordination of Benefits – The method of determining primary responsibility for payment of Core Benefits
under the terms of the applicable Evidence of Coverage and laws and regulations, when more than one
payer may have liability for payment for services rendered to a Medicaid ADVICARE Member.
Core Benefits – Schedule of health care benefits provided to Medicaid ADVICARE Members enrolled in
plan as specified under the terms of this Agreement.
Designated Provider means those subcontracted arrangements, capitated or otherwise, whereby certain
specialty service or ancillary vendors and/or providers have assumed financial risk for the provision of
certain Core Benefits rendered to Medicaid ADVICARE Members.
Designated Services means that certain category or set of Core Benefits within a certain medical specialty
that are made available by a Designated Provider.
Evidence of Coverage – The term which describes services and supplies provided to Medicaid ADVICARE
Members, which includes specific information on benefits, coverage limitations and services not covered.
Healthcare Professional – A physician or any of the following: a podiatrist, optometrist,
chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist
assistant, speech-language pathologist, audiologist, registered or practical nurse (including nurse
practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse midwife),
licensed certified social worker, registered respiratory therapist, certified respiratory therapy technician, or
any other provider of healthcare services or products; with appropriate licensure or certification with the
state of South Carolina.
Imminent Harm – Circumstances involving (i) imminent harm to a Medicaid ADVICARE Member's health;
(ii) fraud or misfeasance; or (iii) action by a state medical or other licensing board or other government
agency that effectively impairs the ability of Provider to provide Core Benefits.
Medicaid – The medical assistance program authorized by Title XIX of the Social Security Act.
Other Payer – An entity or individual, other than PPC, that is financially responsible for payment for health
care services provided to a Medicaid ADVICARE Member. Other Payer is applicable only when third party
liability is appropriate.
Participating Provider – A Healthcare Medicaid Provider which has entered into an agreement with PPC to
provide Core Benefits to Medicaid ADVICARE Members.
Post-stabilization services – Core Benefits, related to an emergency medical condition that are provided
after a Medicaid ADVICARE Member is stabilized in order to maintain the stabilized condition, or improve or
resolve the Medicaid ADVICARE Member’s condition.
Prior Authorization – The act of authorizing specific approved services by the Provider before they are
rendered.
Advicare Provider Manual –The operational manual that serves as a source of information for Core
Benefits, utilization review requirements and other policies, procedures and other information that will assist
in ensuring contractual and regulatory compliance with the program.
Provider Network–Advicare’s network of Participating Providers.
54
Quality – As related to external quality review, the degree to which an ADVICARE increases the likelihood
of desired health outcomes of its members through structural and operational characteristics and the
provision of health services consistent with current professional knowledge.
Quality Assessment – The measurement and evaluation of success of care and services offered to
individuals, groups or populations.
SCDHHS – The South Carolina Department of Health and Human Services.
SCDHHS ADVICARE Policy and Procedure Guide -The South Carolina Department of Health and
Human Services guide that documents the medical and program policies and requirements
implemented by the SCDHHS for ADVICAREs wishing to conduct business in South Carolina.
Utilization Review – The functions, including Case Management, performed by PPC or any entity acting on
behalf of PPC that has been duly authorized and/or licensed, as applicable, to review and determine
whether Core Benefits provided, or to be provided, were or are Medically Necessary.
55
XVI. FORMS AND OTHER KEY INFORMATION
Attachment A – Obstetrical Registration Form
Attachment B – Disease/Case Management Request Form
Attachment C – WIC Referral Form
Attachment D – Medical Record Release
Attachment E – Grievance Form
Attachment F – Member Primary Care Provider
Attachment G – Logisticare Information
(Non-Emergent Transportation)
Attachment H – Pharmacy Prior Authorization Form
Attachment I – Immunization Schedule for Ages 0 – 18
Attachment J – Change Control Record
56
Attachment A – Obstetrical Registration Form
Obstetrical Registration Form
(please fax or email)
Instructions
1. Complete
the demographics section.
:
2. Complete the clinical/social section. Check the trimester a condition or risk identified by the provider office
(an unchecked box indicates that the risk was not identified).
531 South Main Street, Suite RL-1
3. Fax or Email to Care Management Dept at (888)
781-4316 or [email protected]
Greenville, South Carolina 29601
Phone: (888)781-4371
Fax: (888) 781-4316
Member/Enrollee Name (First, Middle, Last)
Date of Birth
Provider Name (First, Last)
Member/Enrollee ID#
NPI or Provider Number
Alternate Phone
Home Phone
Phone #
Fax #
Language Spoke
Date of 1st Prenatal Visit
Gravida
Gestational age
Para
TAB
Live Births
wks
EDC
Hospital/Birthing Center for Delivery
Past OB Complications
Gestational Diabetes
Incompetent cervix
DIUGR
Preeclampsia/Eclampsia
Premature ROM
Preterm delivery <32 wks
Preterm delivery 32-36 wks
Preterm labor <32 wks
Previous C-Section
Prior fetal loss (1 st )(2 nd)(3 rd)
Infant or child death
Current Risk Factors
2 nd/3 rd trimester bleeding
Trimester
1st 2nd 3rd
Current Risk Factors
Anemia Hb <10
Abnormal placenta
Asthma
Gestational diabetes
Cardiac ______________________________
Missed Prenatal Care
Chronic hypertension
Perinatal depression
Oral problems: _________________
or N
Dental visit past 6 mos? Y
Excessive
Weight gain Poor
Disability
______________________________
Premature ROM
Clotting disorder _____________________
Preterm dilation of cervix (>1.5cm)
Previous delivery within 1 year
Underweight BMI<19
Renal disease
__________________________________
STI _______________________________
Preeclampsia/Eclampsia
Sickle cell disease
Tobacco Use
HIV
Hepatitis
_________________________________
Thyroid disease
____________________________
Mental health disorder
or Preterm Labor <32 weeks)
Cessation Services Offered
Domestic violence
Street / Rx drug abuse
History of chronic depression
Depression screening
Eating disorder
_______________________________
Housing problems
Diabetes
Seizure disorder
Obese BMI>30,
Overweight BMI>25,
Current Medication
_______________________________________
______________
Other medical issues:
_______________________________________
_______________
List Referrals Made by Provider
Teen pregnancy
WIC Y
Head of Household Aware
Others:
Transportation problems
Other risks:
N
Trimester
1st 2nd 3rd
Disease/Case Management Referral
Form
Medical record or most recent visit summary and SBIRT may
be attached. Please fax completed form to 1-855-303-2427
or email to [email protected]
Date: _________________Referred By: ___________________________________________________
Phone/Fax:__________________________________________
Member Name: _________________________________ DOB: ______________________________________
Member ID: ____________________________________ Phone: ____________________________________
Address: ___________________________________________________________________________________
Reason for Referral
High Risk Obstetrics EDD: ________________
Pregnancy-induced hypertension
Diabetes
History of complication:__________________________
Confirmed psychosocial issues: _________________________
Other: _____________________________
Substance abuse, including tobacco use: __________________________________________________________
Screening Brief Intervention Referral Treatment (SBIRT) Please complete and submit with this referral.
Catastrophic/Complex Events
More than 3 ER visits per month
More than 3 inpatients in 6 months
Bariatric Surgery
Readmission within 30 days for the same or similar diagnosis
Transplant (type): ____________________________________________________________________________
Non-controlled lab data (attach labs):____________________________________________________________
Major trauma (MVA, TBI, GSW, etc.):_____________________________________________________________
Four or more chronic conditions (specify):________________________________________________________
Polypharmacy-30 or more prescriptions per quarter
Suicide/Homicide risk within the last 6 months
Psychosocial Risks-Check all that applies:
Access to care
Undomiciled
Transportation
Cost of Care
Self-care deficit
Fall risk
Disease Management
Asthma/COPD
Pregnancy
Diabetes
Hypertension
ESRD
Behavioral Health (specify diagnosis):________________________
Orthopedic
Substance Abuse (type): __________________________________
Special needs
HIV/AIDS
Vascular (specify diagnosis):_____________________
Cardiovascular (specify diagnosis): ______________
Oncology (stage, type): ________________________
Other: ____________________________________
531 South Main Street, Suite RL-1 Greenville, South Carolina 29601
Phone 1(888) 781-4371 Fax 1(888)781-4316
Attachment C – WIC Referral Form
WIC REFERRAL FORM
PL103-448, В§204(e) requires States using managed care arrangements to serve their Medicaid
beneficiaries to coordinate their WIC and Medicaid Programs. This coordination should include
the referral of potentially eligible women, infants, and children and the provision of medical
information to the WIC Program. To help facilitate the information exchange process, please
complete this form and send it to the address listed below. Thank you for your cooperation.
Name of Person being referred:
Address:
Phone:
The following classifications describe the populations served by the WIC program. Please check the
category that most appropriately describes the person being referred:
Pregnant woman
Woman who is breast feeding her infant(s) up to one year postpartum
Woman who is non-breast feeding up to six months postpartum
Infant (age 0-1)
Child under age 5
States may consider using this space to either include specific medical information or to indicate that
such information can be provided if requested by the WIC Program.
Provider's Name:
Provider's Phone:
I, the undersigned, give permission for my provider to give the WIC Program any required medical
information.
_
(Signature of the patient being referred or, in the case of children and infants, signature and printed
name of the parent/guardian)
Send completed form to:
WIC Program Contact
Address
Phone Number
Please go to http://www.scdhec.gov/health/mch/wic/map.htm for the WIC Program Contact
name, address and phone number for the Regional WIC site in your area.
531 South Main Street, Suite RL-1 Greenville, South Carolina 29601
Phone 1(888) 781-4371 Fax 1(888)781-4316
Attachment D – Medical Record Release
MEDICAL RECORD RELEASE
I, the undersigned, give permission for my provider, acting on my behalf, to refer
my name for WIC services and to release necessary medical record information
to the WIC agency.
Signature
(Signature of patient being referred or, in case of children and infants, the
signature and printed name of the parent/guardian)
Date
531 South Main Street, Suite RL-1 Greenville, South Carolina 29601
Phone 1(888) 781-4371 Fax 1(888)781-4316
Attachment E – Grievance Form
ADVICARE GRIEVANCE FORM
*Note: For reporting grievances regarding ADVICARE Providers
ONLY
Mail the completed, signed form to: Advicare
531 South Main Street, Suite 307
Greenville, SC 29601
Name of Person Completing this Form:
(may be ADVICARE member, designated friend/family member, medical provider, hospital, community
member, etc.)
Relationship to Member:
ADVICARE Member Name:
Medicaid ID:
Date Form Completed:
DOB:
County of Residence:
Address:
Telephone Number:
Name of Doctor:
Practice:
Please describe your grievance in detail including dates/names. Please attach any
additional documentation.
531 South Main Street, Suite RL-1 Greenville, South Carolina 29601
Phone 1(888) 781-4371 Fax 1(888)781-4316
Continued (See Consent Statement and Signature)
531 South Main Street, Suite RL-1 Greenville, South Carolina 29601
Phone 1(888) 781-4371 Fax 1(888)781-4316
ADVICARE GRIEVANCE FORM
(Page 2)
Advicare staff reviews all grievances that come to our office. We take each grievance
seriously and have a process in place for addressing each one. It is not necessary for us
to use your name when investigating a grievance. However, it is more effective to have
your name when describing the concern to the provider. Therefore, we have included a
place to sign your name on this form that will let us use your name when investigating
your grievance. Please do not sign both statements.
If you agree to allow us to use your name in investigating this grievance,
please sign the following:
I give the SC ADVICARE Managed Care staff permission to use my name when
sharing my grievance with the Primary Care Provider (PCP) named in my grievance.
The PCP has my permission to respond to the SCADVICARE staff concerning my
grievance and release medical records regarding the patient when necessary.
Signature of Complainant
Date
Signature of Patient/Parent/Legal Guardian
Date of Birth
OR
If you would like your name to remain confidential and you do not want us to
use your name in the investigation of this grievance, please sign below:
Signature of Complainant
Date
Signature of Patient/Parent/Legal Guardian
Date of Birth
If you have any questions regarding the use of this form or the ADVICARE Grievance Process,
please contact the Advicare office at Toll-free (888) 781-4371. Thank you for giving us this
opportunity to serve you better.
Please Do Not Write Below This Line
ADVICARE PCP Name:
ADVICARE PCP#:
ADVICARE Practice Name:
Location:
Comments:_
531 South Main Street, Suite RL-1 Greenville, South Carolina 29601
Phone 1(888) 781-4371 Fax 1(888)781-4316
Attachment F – Member Primary Care Provider Transfer
Member Primary Care Provider Transfer
(please fax or email)
Instructions
1. For Provider Use Only
2. Please complete form and provide documentation to support your request to transfer PCP.
3. Fax or Email to the Palmetto Physician Connections Member Services Department at:
531 South Main Street, Suite RL-1
(888) 781-4316 or [email protected]
Greenville, South Carolina 29601
Phone: (888)781-4371
Fax: (888) 781-4316
The member is enrolled with the following practice: ______________________________________________________________
The member(s) listed are to be transferred to Primary Care Provider: ________________________________________________
List reason for transfer: ________________________________________________________________________________________
PRINT NAME OF EACH FAMILY
MEMBER TO BE TRANSFERRED
DOB
MEDICAID NUMBER
IS MEMBER AWARE
OF TRANSFER?
Family Address: _______________________________________________________________ City: __________________________
State:___________ Zip: ________________ Phone number: (______) _______________________________
Member Signature: _____________________________________________________________(MEMBER MUST SIGN IF PRESENT)
Provider Name: ________________________________________________ Medicaid Provider number: _____________________
Phone: (____) _______________________ Title: ________________________________________
Name: _______________________________Signature:____________________________________
Date: _______________
Attachment G – Logisticare (Non-Emergent Transportation)
LOGISTICARE
Transportation Beneficiary Information
Transportation is available for doctor appointments, dialysis, x-rays, lab work, drug store or
other medical appointments. To ask for a ride call at least 3 days before your appointment.
Call Monday – Friday 8:00am to 5:00pm. To cancel a ride call at least 24 hours in advance.
To reach Region 1, call (866) 910-7688, Region 2, call (866) 445-6860, Region 3, call (866) 4459954.
Region 1
Region 2
Region 3
•Abbeville
•Aiken
•York
•Laurens
•Lancaster
•Beaufort
•Anderson
•Allendale
•Florence
•McCormick
•Lee
•Berkeley
•Cherokee
•Bamberg
•Georgetown
•Oconee
•Lexington
•Charleston
•Edgefield
•Barnwell
•Hampton
•Pickens
•Newberry
•Chesterfield
•Greenville
•Calhoun
•Horry
•Saluda
•Orangeburg
•Colleton
•Greenwood
•Chester
•Jasper
•Spartanburg
•Richland
•Darlington
•Clarendon
•Marion
•Sumter
•Dillon
•Fairfield
•Marlboro
•Union
•Dorchester
•Kershaw
•Williamsburg
Attachment H – Pharmacy Prior Authorization Form
Attachment I – Immunization Schedule for Ages 0 - 18
Attachment J – Change Control Record
Advicare Provider Manual
Manual Updated
CHANGE CONTROL RECORD
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