MERIDIAN HEALTH PLAN
333 South Wabash Avenue
Suite 2900
Chicago, IL 60604
Phone: 312-705-2900
Fax: 312-980-0404
www.mhplan.com
CONTENTS
Contact Us
2
HEDIS Bonus Program
3
Member Engagement
3
Claims
6
Payments, Status & Billing
6
Claims Appeal Process
6
EDI Submission
6
Claim Billing Requirements
6
Meridian Members
No Co-Pays
7
Pharmacy Benefits
8
Meridian Service Area
9
Product Descriptions
10
Referral Guide
11-16
Fraud, Waste & Abuse
17-18
To Report Potential Fraud, Waste & Abuse
1
7
18
Annual Training Program
19
Quick Reference/Contact Information
20
CONTACT US
PHONE
Call 866-606-3700 or contact your Provider Network Development Representative directly.
You are assigned a local Provider Representative
to handle any questions or concerns
WEBSITES
www.mhplan.comwww.medicaremeridian.com
Use Meridian Health Plan’s website to access these features:
• Provider Manual & Orientation • Provider Directory
• Formulary • Bulletins/Updates
• Important Forms • Live Chat Services
PROVIDER PORTAL
www.mhplan.com/il/mcs
The Provider Portal gives contracted providers exclusive access to these features:
• Member Eligibility Verification • Authorizations
• Claims Status and Submission/Correction • Meridian Member Information & Reports
• Enrollment Lists • HEDIS Bonus Information • HEDIS Self-Reporting
• Member Utilization/Health History • Contact Meridian departments directly
A Meridian-supplied user name is required for access to the Provider Portal. To sign up, please visit
www.mhplan.com/il/mcs.
Questions? Please contact your Provider Network Development Representative.
MISSION
To continuously improve the quality of care in a low resource environment.
VISION
To be the premier service organization in healthcare.
To be the #1 health organization based on quality, innovative technology and service to our members.
2
HEDIS BONUS PROGRAM
Committed to ensuring quality care for our members, Meridian offers a HEDIS Bonus Program for all
contracted providers. The program includes generous incentives ranging between $20 and $200 per
service.
PROGRAM HIGHLIGHTS
• Paid over $18 million to participating providers (2012)
Bonus structure varies by line of business. For more details, please reference the Meridian Provider
Incentive Program Overview online at www.mhplan.com/il/providers.
If you have any questions about the HEDIS bonus program, or what bonuses you may qualify for, visit our
website at www.mhplan.com or call your Provider Network Development Representative.
MEMBER ENGAGEMENT
As part of the enrollment process, Meridian utilizes claims
data and various risk assessments to automatically enroll
members in outreach programs that meet their level of
need.
Providers can refer members to the Disease Management,
Care Coordination or Complex Case Management
programs as needed through the by:
• Clicking the “Notify Health Plan” button on our
Provider Portal
• Calling Meridian at 866-606-3700
• Faxing in the “Care Coordination/Complex Case
Management Referral Form” to Meridian. This form
can be found online at www.mhplan.com/il/providers,
in the “Documents and Forms” section
3
treach
am
Member Welcome Call
Claims Data
Risk Assessments
Stratification
Low
Medium
High
Health Outreach
Program
Care Coordination
Program
Complex Case
Management Program
Preventive Care Reminders
(phone and mail based)
Preventive Care Reminders
(phone, community and
mail based)
Preventive Care Reminders
(phone and mail based)
Condition-Specific Education
Complex Case Manager
Personal Care Coordinator
Transition Management
Person-Centered Plan of Care
Interdisciplinary Care Team
Condition-Specific Education
Intensive Case Management
Transition Management
Person-Centered Plan of Care
Interdisciplinary Care Team
Disease Management Program (included at all stratifications)
Preventive Care Reminders (phone and mail based) and Condition-Specific Education
PROGRAM DESCRIPTIONS
Health Outreach
Program
Disease Management
Program
Low Intervention
Level
Disease Management
Care Coordination
Complex Case
Periodic outreach,
as applicable, to remind members
Program
Program of important preventive
Management Program
services such as well visits and important screenings.
Low Intervention
Level + Self- Management
Needs
Care Coordination
Complex
Case
Available to allProgram
eligible members. Includes
education
for the following conditions:
Management Program
• Asthma
• Cardiovascular Disease
• Diabetes
• Emphysema/COPD
4
Care Coordination
Program
agement
am
Medium Intervention
Complex Case Level
Meridian’sManagement
Care Coordination
Program program uses interdisciplinary approaches to focus on
members (and their families) that have special health care, community support,
facility service, and behavioral health needs.
Coordinated efforts links members with needed services and resources to achieve:
• Better access
• Skilled navigation through the complex health care and community
supports system
• Increased self-management and self-advocacy skills
A member’s personal Care Coordinator works with clinical and non-clinical
consultants to arrange the right care at the right time for all services, including
home and community based, nursing and other facility services.
The Care Coordinator collaborates with the member, their family and the
member’s care team to create a tailored person-centered plan of care. This plan
of care includes:
• A personal health record
• Problems, life goals and outcomes
• HCBS service plan summary authorization (if applicable)
The plan of care is developed by tailoring to the member’s specific preferences and
needs, delivering service with transparency, individualization, respect, linguistic and
cultural competence, quality care, quality of life and dignity.
THE CARE COORDINATOR IS THE MEMBER’S SINGLE POINT OF CONTACT.
INTE
G R AT E D C A R E T E A M
MEMBER
& FAMILY
CA
(cli
5
RE
C O O R D I N AT
nical
OR
& non- clinic
al)
agement
am
nation
m
Care Coordination
Program
Depending upon
member
population, specialized subprograms may include:
Complex
Case
• AdultsManagement
and Children
with Special Needs
Program
• Behavioral Health
• High ER Utilizers
• Home and community-based waiver programs, nursing and other facility care
• Integrated Care Program (all members)
• Maternity (all members)
• Medicare
• Meridian Advantage Dual • Eligible Special Needs (all members)
• Complete/MMAI (all members)
• Smoking Cessation
• Weight Management
Long Term Service & Support (LTSS) Program
A more specialized form of Care Coordination, the Meridian Long Term Services and
Supports (LTSS) Program is for members who are eligible for Home and Community
Based Service (HCBS) waiver programs or the Nursing Facility program.
Key strategies to improving the well-being of members in this program include:
• Avoiding hospital re-admissions
• Assisting members in returning to or remaining in the residence of their choice
(including home and community)
• Increasing quality of life
Complex Case
Management Program
High Intervention Level
Using the same consultant resources as Care Coordinators, case managers provide
more intensive counseling and management to high-risk members. These members
often have multiple, serious comorbidities.
Members have the option to accept or decline Complex Case Management for their
care; it is not a requirement.
Providers may refer members to Care Coordination by clicking the
“Notify Health Plan” button within our Provider Portal, or by calling Meridian
at 866-606-3700.
6
CLAIMS
PAYMENTS, STATUS & BILLING
Meridian is dedicated to processing your claims in under 10 days. You may status your claims several ways:
• Meridian’s secure Provider Portal at www.mhplan.com/il/mcs
• Call or fax our Claims department
Tel: 800-203-8206
Fax: 313-324-3642
• By Mail
FAST CLAIMS PROCESSING
Meridian Health Plan
Average claims processing time - 3 days
Claims Department
1001 Woodward Avenue
Suite 520
Detroit, MI 48226
CLAIMS APPEALS PROCESS
In cases where a claim has been denied, providers may submit an appeal in writing within 30 days of the
denial. Please include the following:
• Patient name and ID#
• Reason for appeal
• Any relevant clinical information to support your appeal
The Meridian Appeals Committee meets regularly to review these appeals. You will receive a written
response within 30 days.
EDI SUBMISSION
Meridian currently accepts EDI from all of our providers through the following vendors:
SSI Group: 800-880-3032
Relay Health: 800-527-8133
Availity: 800-282-4548
WebMD (Emdeon): 800-845-6592
PayerPath: 877-623-5706
Netwerkes: 866-521-8547
Payer ID#: 13189
Special instructions: PROFESSIONAL – PIN must be the NPI #. FACILITY – Use the NPI # for provider ID
(locator 51), attending physician ID (Locator 82) and the other physician ID (Locator 83).
CLAIM BILLING REQUIREMENTS
• Facility - UB04
• Professional - CMS 1500 or *IL HFS 2360
• **Laboratory - CMS 1500 or *IL HFS 2360
* Meridian accepts claims billed on both a CMS 1500 and IL HFS 2360, but prefers the submission of the CMS 1500
** All laboratory charges should be submitted to Meridian on a CMS 1500 or IL HFS 2360
7
MERIDIAN MEMBERS
MEDICAID (TANF/SPD):
Meridian Health Plan is a Medicaid managed care organization (MCO)
with subsidiary operations in Michigan, Illinois and Iowa. In July 2013,
Meridian began providing managed care to the Seniors and Persons
with Disabilities (SPD) population, expanding our service area in Illinois.
MEDICARE (D-SNP):
Meridian Advantage Plan (HMO-SNP) is a Medicare Advantage
Prescription Drug Dual Special Needs Plan (MAPD-SNP) for people who
have both Medicare and Medicaid. This plan provides members with Part A,
Part B and Part D prescription drug benefits and includes additional
benefits not covered by Original Medicare.
MERIDIAN COMPLETE:
Meridian Complete (Medicare-Medicaid Plan) integrates managed care
for individuals living in the greater Chicago area who are eligible for both
Medicare and Medicaid under one plan.
MERIDIAN PRIME:
Meridian Prime is a Medicare Prescription Drug Plan (MAPD) that provides
Part A, Part B and Part D prescription drug benefits and include additional
benefits that are not covered by Original Medicare.
Effective Date:
Member Name:
Member ID:
PCP:
Member Services: 866-606-3700
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
Phone:
TTY Number: 711
RxBIN: 610241
RxPCN: MHPILMCD
Meridian Advantage Plan of Illinois (HMO SNP)
Effective Date:
ID:
Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 001
Primary Care: $0
Specialist: $0
ER: $0
Member Name:
RxBin: 610241
RxPCN: MHPILCOMP
Member ID:
H6080-001
Meridian
Prime (HMO)
Effective Date:
ID:
Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 002
Primary Care: $5
Specialist: $40
ER: $65
EASILY VERIFY MEMBER ELIGIBILITY
Member Eligibility may be checked by using Meridian’s Eligibility Verification Line. Just call 855-291-5228
and follow the directions as prompted. The system will verify if the member is eligible on the date of
service indicated. You may also verify eligibility via the Meridian Provider Portal, the MEDI System or by
calling the Meridian Member Services department at 866-606-3700.
The Illinois MEDI card will indicate that the patient is enrolled with Meridian. This may be viewed and
verified at each encounter. In addition, the MEDI website offers eligibility verification for Meridian
members.
Use Meridian’s eligibility verification line to easily confirm member
eligibility on an indicated date of service
PCPs will receive monthly enrollment via fax by the first of every month from Meridian Health Plan.
NO CO-PAYS
Instead of lowering your reimbursement and burdening your office with the responsibility of collecting
co-pays, Meridian has made the decision not to implement co-pays for our Medicaid members in
cooperation with our provider partners.
8
MERIDIAN MEMBERS
HELP YOUR PATIENTS ENROLL WITH MERIDIAN!
Meridian makes it easy for providers to help their patients enroll with us!
• Benefit Enrollment Specialists - Meridian has licensed representatives to help educate members with
their health care options and assist with enrollment into Meridian Health Plan.
• Letters – Meridian will supply providers with a State approved letter that may be mailed out to
Medicaid recipients.
• Cell Phones – Meridian can offer providers prepaid cell phones that may be given to members so they
may contact the ICEB while in the office.
• Laptops – Meridian may provide laptops to provider offices that would like to offer members the
ability switch while waiting to see the doctor.
If you are interested in learning more about these resources, please contact your Provider Network
Development Representative for additional details.
PHARMACY BENEFITS
Meridian uses MeridianRx to manage our pharmacy benefit. MeridianRx provides Meridian with a
pharmacy network, pharmacy claims management services, a drug formulary, and pharmacy claims
adjudication. Member eligibility is determined prior to authorizing any drug benefit.
ePrescribring - allows for accurate, error-free electronic submissions
of prescriptions to pharmacies
MeridianRx Specialty Pharmacists and clinical staff assist providers in prescribing appropriate medications
based on efficiency and cost control. Consumers receive friendly, clinically-accurate support:
• Encouraging the taking and/or administration of medications as prescribed
• Managing any medication side effects
• Monitoring symptoms and responses to therapy
• Counseling on health conditions
• Coordinating new and refill prescriptions
• Working with insurers to verify benefits
Comprehensive drug formulary and licensed pharmacists are
available through MeridianRx for consultation
9
MERIDIAN SERVICE AREA
Stephenson
Jo Daviess
Lake
McHenry
Winnebago Boone
*ONLY CHICAGO
Carroll
Ogle
Cook
DeKalb
Whiteside
Kane
DuPage Chicago
Lee
Service
Area
Kendall
Bureau
Rock Island
Mercer
Putnam
McLean
Ford
Meridian Prime
Mason
Schuyler
Logan
Cass
Brown
Morgan
Pike
Iroquois
Meridian Advantage Plan
Tazewell
Fulton
McDonough
Meridian Complete
Livingston
Woodford
Peoria
Henderson
Vermilion
De Witt
Menard
Champaign
Douglas
Sangamon
Coles
Greene
Clark
Shelby
Macoupin
Cumberland
Montgomery
Jersey
Advantage-Plus Meridian
Edgar
Moultrie
Christian
Calhoun
Serves ALL
counties
Piatt
Macon
Scott
Meridian Health Plan ICP
Kankakee
Marshall
Knox
Warren
Adams
Meridian Health Plan
Grundy
Stark
Hancock
Will
La Salle
Henry
Plan Product
Fayette
Jasper
Crawford
Bond
Madison
Clay
Clinton
St. Clair
Monroe
Randolph
Marion
Jackson
Union
Alexander
Pulaski
Lawrence
Wabash
Wayne
Washington
Perry
Richland
Edward
Franklin
Hamilton
Williamson
Saline
Johnson
Pope
White
Gallatin
Hardin
Massac
10
PRODUCT DESCRIPTIONS
MERIDIAN HEALTH PLAN OFFERS SEVERAL PRODUCTS IN THE STATE OF ILLINOIS, INCLUDING:
Meridian Health Plan
Provides health care services to TANF (Temporary Assistance for Needy Families) population, which
includes Medicaid beneficiairies enrolled in the AllKids, Family Care, Moms and Babies programs.
Meridian Health Plan Integrated Care Program (ICP)
Provides health care services to the Seniors and Persons with Disabilities (SPD) population.
Meridian Complete (Medicare-Medicaid Plan)
Integrates managed care for individuals who are eligible for both Medicare and Medicaid under one
plan.
Meridian Advantage Plan (HMO-SNP)
A Medicare Advantage Prescription Drug Dual Special Needs Plan (MAPD-SNP) for people who have
both Medicare and Medicaid. This plan provides members with Part A, Part B and Part D prescription
drug benefits and includes additional benefits not covered by Original Medicare.
Meridian Prime (HMO)
A Medicare Prescription Drug Plan (MAPD) in Michigan, Illinois and Iowa. MAPDs are a type of
Medicare health plan that provides Part A, Part B and Part D prescription drug benefits and include
additional benefits that are not covered by Original Medicare.
Advantage-Plus Meridian (PDP)
A Medicare Prescription Drug Plan (PDP) which adds only Part D prescription drug coverage to
Original Medicare and some Medicare Cost Plans, Medicare Private Fee-for-Service Plans and
Medicare Medical Savings Account Plans. These Plans do not include any Part A or Part B coverage.
11
MERIDIAN HEALTH PLAN - Illinois Referral Guide
PHONE: 866-606-3700 | FAX: 312-980-0444
Services that DO NOT require a referral include:
• Long Acting Reversible Contraception (LARCs)
• Office visits to Meridian-contracted (in-network) providers
• Referrals to Meridian-contracted (in-network) Specialists
• Behavioral health outpatient services (first 20 visits)
• Chiropractic services (for members under 21 years of age)
• All outpatient/ambulatory services not listed in Appendix A
FHP/ACA
PRIOR AUTHORIZATION OVERVIEW
Meridian
Meridian
Meridian
ICP
Complete
SNP
Meridian
Prime
Meridian
Prime (HMO)
Effective Date:
Member Name:
Member ID:
PCP:
Member Services: 866-606-3700
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
SERVICE:
Acute Inpatient
Admissions (Including
Acute Rehab and LTAC)
Inpatient Mental Health
and Substance Abuse
Skilled Nursing Facility
Partial Hospitalization
Intensive Outpatient
Program
Residential Services
Electro Convulsive
Treatment
Elective Inpatient
Admissions
Behavioral Health
Outpatient Services
>20 visits
Ambulance
Transportation
Non-emergent
Elective Cesarean
Sections
Dialysis
Prenatal Care
Deliveries
Dental Anesthesia in
Facility >6 years of age
Phone:
TTY Number: 711
RxBIN: 610241
RxPCN: MHPILMCD
Effective Date:
Member Name:
Member ID:
PCP:
Member Services: 866-606-3700
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
Meridian Advantage Plan of Illinois (HMO SNP)
Phone:
TTY Number: 711
RxBIN: 610241
RxPCN: MHPILMCD
RxBin: 610241
RxPCN: MHPILCOMP
Member Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 001
Effective Date:
ID:
Name:
Member ID:
Primary Care: $5
Specialist: $40
ER: $65
Primary Care: $0
Specialist: $0
ER: $0
H6080-001
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 002
Effective Date:
ID:
Name:
PA REQUIRED?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Yes
Yes
Yes
Yes
Yes
12
MERIDIAN HEALTH PLAN - Illinois Referral Guide
PHONE: 866-606-3700 | FAX: 312-980-0444
FHP/ACA
PRIOR AUTHORIZATION OVERVIEW
Meridian
Meridian
Meridian
ICP
Complete
SNP
Meridian
Prime
Meridian
Prime (HMO)
Effective Date:
Member Name:
Effective Date:
Member Name:
Member ID:
PCP:
Phone:
Member ID:
PCP:
Phone:
Member Services: 866-606-3700
TTY Number: 711
Member Services: 866-606-3700
TTY Number: 711
Member ID:
RxBIN: 610241
RxPCN: MHPILMCD
H6080-001
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
SERVICE:
DME
Assistive and
Augmentive
Communication
Enteral and Parenteral
Services
Genetic Testing
Experimental and
Investigational
Procedures
Sterilization Procedures
Abortion
Hearing Aids
Home Health Care
Hospice Care
Home Infusion
Orthotics and Prosthetics
Services by an Out of
Network Provider/Facility
with the exception of:
• Emergency
Department services
• Women’s Health
• Family Planning &
Obstetrical Services
• Child & Adolescent
Health Center Services
• Local Health
Department (LHD)
services
• Other services based
on state requirements
Outpatient Surgeries/
Procedures (Refer to
Appendix A for select
procedures)
13
Meridian Advantage Plan of Illinois (HMO SNP)
RxBIN: 610241
RxPCN: MHPILMCD
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
RxBin: 610241
RxPCN: MHPILCOMP
Member Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 001
Effective Date:
ID:
Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 002
Effective Date:
ID:
Name:
Primary Care: $5
Specialist: $40
ER: $65
Primary Care: $0
Specialist: $0
ER: $0
Yes, >$1,000
Yes, >$1,000
PA REQUIRED?
Yes, >$1,000
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes, >$1,000
Yes, >$1,000
FHP/ACA
PRIOR AUTHORIZATION OVERVIEW
Meridian
Meridian
Meridian
ICP
Complete
SNP
Meridian
Prime
Meridian
Prime (HMO)
Effective Date:
Member Name:
Effective Date:
Member Name:
Member ID:
PCP:
Phone:
Member ID:
PCP:
Phone:
Member Services: 866-606-3700
TTY Number: 711
Member Services: 866-606-3700
TTY Number: 711
Member ID:
RxBIN: 610241
RxPCN: MHPILMCD
H6080-001
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
SERVICE:
Physical Therapy
(excluding initial
evaluation)
Speech Therapy
(excluding initial
evaluation)
Occupational Therapy
(excluding initial
evaluation)
Pulmonary and Cardiac
Rehabilitation
Pain Management
Specialty Pharmacy
(including chemotherapy
and biologicals)
MeridianRx is the PBM
for all lines of business.
Phone: 855-580-1688
Fax: 855-580-1695
Radiation Therapy
Transplants (including
evaluation)
Weight Management
(prior to bariatric
surgery)
Nutritional Counseling
Wound Vac
Long Term Supports
and Services, if waiver
eligible (Refer to
Appendix B)
Meridian Advantage Plan of Illinois (HMO SNP)
RxBIN: 610241
RxPCN: MHPILMCD
Prescriptions: 855-580-1688
Behavioral Health: 866-796-1167
(Available 24 hours a day, 7 days a week.)
RxBin: 610241
RxPCN: MHPILCOMP
Member Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 001
Effective Date:
ID:
Name:
RxBIN: 610241
RxPCN: MHPILSNP
CMS#: H5779
PBP: 002
Effective Date:
ID:
Name:
Primary Care: $5
Specialist: $40
ER: $65
Primary Care: $0
Specialist: $0
ER: $0
PA REQUIRED?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes; visit
Yes; visit
Yes; visit
Yes; visit
Yes; visit
www.meridianrx.com to www.meridianrx.com to www.meridianrx.com to www.meridianrx.com to www.meridianrx.com to
review PA requirements review PA requirements review PA requirements review PA requirements review PA requirements
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Notify Plan
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/A
Yes
Yes
N/A
N/A
Diabetic Testing Supplies: J&B Medical Supplies is the preferred provider and can be contacted at 800-737-0045
Behavioral Health Services: Please call 866-796-1167 or fax to 312-980-0443
14
MERIDIAN HEALTH PLAN - Illinois Referral Guide
PHONE: 866-606-3700 | FAX: 312-980-0444
APPENDIX A: SELECT OUTPATIENT SURGERY/PROCEDURE CODES
Procedure
Code
Abdominoplasty (and removal of excess skin and fat from other areas),
Panniculectomy, Suction Lipectomy, Lipoabdominoplasty & Ventral Hernia
Hair Plugs
15819, 15824, 15825, 15826,15828, 15829, 15830, 15832, 15833, 15834, 15835,
15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 17999
15778, 15775
59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857,59866,S0190,
S2260,S2265,S2266,S2267, S0191, S0199- Medication to induce abortions
22520, 22521, 22522, 22523, 22524, 22525, 22526, 22527, 22532, 22533, 22534,
22548,22551, 22552, 22554, 22556, 22558 22585, 22590, 22595, 22600, 22610,
22612, 22614, 22630, 22632, 22633, 22634 22800, 22802, 22804, 22808, 22810,
22812, 22818, 22819, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846,
22847, 22848, 22849, 22850, 22851, 22856, 22857, 22861, 22862, 22864, 22865,
22899, 62287, 62351, 62365, 62367, 62368, 62369, 62370, 63001, 63003, 63005,
63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043,
63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064,
63066, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102,
63103, 63170, 63172, 63173, 63075, 63076, 63077, 63078, 63180, 63182, 63185,
63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251,
63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276,
63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295,
63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 63600, 63610,
63615, 63620, 63621, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688,
63710
22220, 22222, 22224, 22226, 20930, 20931
43644, 43645, 43647, 43648, 43770, 43771, 43772, 43773, 43774, 43842, 43843,
43845, 43846, 48847, 43775, 43848, 43886, 43887, 43888, 43999
S2083
11950,11951, 11952, 11954, 15820, 15821, 15822, 15823, 67900, 67901, 67902,
67903, 67904, 67906, 67908, 67909, 67911, 67999
11920, 11921, 11922, 11970, 11971, 19316, 19318, 19324, 19325, 19328, 19330,
19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369,
19370, 19371, 19380, 19396, 19499, L8020, L8039, L8600, S2066, S2067, S2068
19316, 19318, 19300, 19304
69714, 69715, 69717, 69718, 69799, 69930, 92640, S2235, L8614,L8615, L8616,
L8617, L8618, L8619, L8621, L8622, L8623, L8624, L8627, L8628, L8629, 61875
(Neuro-stimulator), 69930 (L8614 Is included with this procedure code and needs
to be reported when submitting claims)
15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 17340,
17360, 17999 (Unlisted skin procedure)
58600, 58605, 58611, 58615
33208, 33202, 33203, 33206, 33207, 33213, 33214, 33215, 33216, 33218, 33220,
33221, 33222, 33223, 33224, 33225, 33226, 33227, 33228, 33229, 33231, 33234,
33235, 33236, 33237, 33238, 33240, 33241, 33217, 33249, 33230, 33263, 33264,
33282
Abortion/pregnancy termination
Back/neck surgery
Osteotomy of Spine including discectomy
Bariatric surgery/gastric bypass
Lap Band Gastric Adjustment
Blepharoplasty (and repair of blepharoptosis)
Breast reconstruction (including, but not limited to: mammaplasty
augmentation, breast implants)
Breast reduction
Cochlear implantation/device
Dermabrasion
Division of Fallopian Tube
Dual Chamber pacemaker insertion
15
APPENDIX A: SELECT OUTPATIENT SURGERY/PROCEDURE CODES
Procedure
Code
Ectopic pregnancy
Gastric neurostimulator
59135, 59136, 59150, 59151
64590, 64595, 43647, 43648, 43881, 43882 43999, 95980, 95981, 95982
51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58275,
58290, 58291, 58292, 58293, 58294, 58267, 58270, 58280, 58285, 58541, 58542,
58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573,
58578, 58952, 58953, 58951, 58954, 58956, 59135, 59525
58565
63650, 63655, 63661, 63662, 63663, 63664, 63668, 63685, 64581
58670, 58671, 58679
19300
59866
21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143,
21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193,
21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230,
21235, S8262, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949,
D7950, D7995
54360, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417
30400, 30410, 30420, 30430, 30435, 30450, 30620, 30520
15786, 15787, 31830
36468, 36469, 36470, 36471, 36475, 36476, 36478, 36479, 37700, 37718, 37722,
37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202
55250, 55450
43280, 43279
43281
43499
27125, 27130, 27132, 27134, 27137, 27138
99183
95951
58340, 74740, 58345, 55350, 58350
64553, 64555, 64566, 64561, 64565, 64569, 64570, 64575, 64580 64581, 64585,
61870, 64875, 61880, 61885, 61888, 61886, 64568
49652, 49653, 49560, 49561, 49565, 49566, 49568
96910, 96912, 96913, 96920, 96921, 96922, 96999
33282, 33284
Hysterectomy
Hysteroscopy, sterilization
Implantation of neurostimulator (SPINE ONLY)
Laparoscopy, tubal cautery/block
Mastectomy for gynecomastia
Multifetal pregnancy reduction
Orthognathic surgery
Penile Implant/Prosthesis
Septoplasty/ Rhinoplasty
Scar excision/revision
Varicose vein treatment/surgery
Vasectomy, removal/ligation of sperm duct(s)
Laparoscopy fundoplasty
Laparoscopy para-esophageal hernia repair
Esophagus surgery procedure
Hip arthroplasty
Hyperbaric Oxygen Therapy
Video EEG
Fertility tests
Implant Neuroelectrodes
Ventral Hernia Repairs
Photo chemotherapy for Psoriasis
Cardiac Implant Recorder/ Loop Recorder
16
MERIDIAN HEALTH PLAN - Illinois Referral Guide
PHONE: 866-606-3700 | FAX: 312-980-0444
APPENDIX B: LONG TERM SUPPORTS AND SERVICES:
FHP/ACA,
ICP &
MMAI POPULATIONS
Waiver
Services*
Persons with
Brain Injury
Persons with
Disabilities
Persons who are
Elderly
Persons with
HIV/AIDS
X
24 hour response/security staff
Adult day care
Supportive
Living Facilities
X
X
X
X
Ancillary (transportation to group/ community
activities, shopping, arranging outside services)
X
Behavioral services
X
Day habilitation
X
Environmental accessibility adaptations
X
X
X
X
Health promotion and exercise
Home delivered meals
X
X
Homemaker
X
X
X
X
X
Housekeeping
X
Intermittent nursing
X
Laundry
X
Maintenance
X
Medication oversight and assistance with
self-administration
X
Personal care (personal assistant)
X
X
X
Personal emergency response system
X
X
Physical, occupational and speech therapy
X
X
X
Prevocational services
X
Respite
X
X
X
Skilled nursing and home health aide
X
X
X
X
X
X
Social/recreational programming
Specialized medical equipment and supplies
X
Supported employment services
X
X
Transportation for employment
*All services require prior authorization. Existing care plan service will not require authorization for first 180 days.
17
X
X
X
FRAUD, WASTE & ABUSE
Healthcare fraud, waste and abuse affect every one of us. It is estimated to account for between 3% and
10% of the annual expenditures for health care in the U.S. Healthcare fraud is both a state and federal
offense. Based on the HIPAA regulations of 1996, a dishonest provider or member may be subject to fines
or imprisonment of not more than 10 years, or both (18USC, Ch. 63, Sec 1347).
THE FOLLOWING ARE THE OFFICIAL DEFNITIONS OF FRAUD, WASTE AND ABUSE:
42 CFR §455.2 Definitions.
Fraud means an intentional deception or misrepresentation made by a person with the knowledge that
the deception could result in some unauthorized benefit to him or some other person. It includes any act
that constitutes fraud under applicable Federal or State law.
Waste involves the taxpayers not receiving reasonable value for money in connection with any
government funded activities due to an inappropriate act or omission by players with control over or
access to government resources (e.g. executive, judicial or legislative branch employees, grantees or
other recipients).
Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates
primarily to mismanagement, inappropriate actions and inadequate oversight from the Inspector General.
Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices,
and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not
medically necessary or that fail to meet professionally recognized standards for health care. It also
includes recipient practices that result in unnecessary cost to the Medicaid program.
HERE ARE SOME EXAMPLES OF FRAUD, WASTE AND ABUSE:
Fraud
• Providers billing for services not provided
• Providers billing for the same service more than once (i.e., double billing)
• Providers performing inappropriate or unnecessary services
• The misuse of a Medicaid card to receive medical or pharmacy services
• Altering a prescription written by a doctor
Waste & Abuse
• Going to the Emergency Room for non-emergent medical services
• Threatening or abusive behavior in a doctor’s office, hospital or pharmacy
18
FRAUD, WASTE & ABUSE
Meridian encourages members, providers and employees to report all cases of fraud, waste and abuse. If
you know of any Medicaid members or providers, including doctors, hospitals and pharmacies, who have
committed actions of fraud, waste or abuse, you can report them using the process described below. You
may report them anonymously if you choose.
TO REPORT POTENTIAL FRAUD, WASTE AND ABUSE:
Contact Meridian’s Provider Services department at 866-606-3700. Ask to speak with the Director of
Provider Services. You can explain details of the possible fraud, waste or abuse; Meridian will investigate
and file a report with the IDHFS Program Investigations Section, if necessary.
Meridian members, providers or employees can also report potential instances of fraud, waste and abuse
directly to the State of Illinois:
Healthcare and Family Services Office of Inspector General
217-785-7030 (phone)
217-524-6037 (fax)
You can report anonymously if you choose.
In addition, members, providers and employees can report online to the Illinois State Police Medicaid
Fraud Control Unit at http://www.isp.state.il.us/crime/medicaidfraud.cfm.
THE FALSE CLAIMS ACT
The False Claims Act is aimed at establishing a law enforcement partnership between federal law
enforcement officials and private citizens who learn of fraud against the Government. Under the False
Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for
payment of government funds are liable for up to three times the government’s damages plus civil
monetary penalties. The False Claims Act explicitly excludes tax fraud.
The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit
on behalf of the Government against the person or business that committed the fraud. The lawsuit is
known as a “qui tam” case, but it is more commonly referred to as a “whistleblower” case. If the lawsuit is
successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and
25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats,
harassment, abuse, intimidation or coercion by his or her employer.
For more information on the False Claims Act, please contact the Meridian Corporate Compliance Officer
at 866-606-3700.
19
ANNUAL TRAINING PROGRAM
Meridian follows the CMS guidelines to deliver the appropriate educational pieces to its provider network.
Together, we can achieve outstanding quality and increased value in the care provided to our members.
MODEL OF CARE (MOC)
Our MOC training module outlines the role of contracted providers in delivering care to our Special Needs
Plan (SNP) members.
FRAUD, WASTE & ABUSE
Our FWA training module assists provider in participating in fraud, waste and abuse prevention and
detection. CMS requires the completion of FWA training by all Meridian network providers on an annual
basis.
CULTURAL COMPETENCY
Our cultural competency training provides important information to support providers in caring for our
members.
20
QUICK REFERENCE/CONTACT INFORMATION
DEPARTMENT
PHONE
FAX
Member Services
Medicaid: 866-606-3700
Medicare: 855-827-1769
312-980-0445
Provider Services
866-606-3700
312-980-0418
MeridianRx (PBM)
Medicaid: 855-580-1688
Medicare: 877-440-0175
855-580-1695
Quality Improvement
866-606-3700
312-980-0444
Utilization Management
866-606-3700
312-980-0444
Meridian Health Plan Main Line
312-705-2900
312-980-0404
Behavioral Health
866-796-1167
312-980-0443
Claims
800-203-8206
313-324-3642
Authorizations
312-980-0444
Non-Emergent Transportation
(Medicaid Only)
866-796-1165
Illinois Client Enrollment Broker (ICEB)
877-912-8880
Eligibility Verification Line
855-291-5228
Illinois Relay Services
711
WEBSITES
www.mhplan.com
www.medicaremeridian.com
21
PROVIDER PORTAL
www.mhplan.com/il/mcs
NOTES
22
Provider Orientation
September 2014