SECTION
1: INTRODUCTION, CONTACT AND GENERAL PLAN INFORMATION
1.1 About Your BMC HealthNet Plan Provider Manual
1.1.1 Updates to the Provider Manual
1.2 We're Here when You Need Help
1.2.1 Dedicated Provider Relations Staff
1.2.2 Directory of Important Contacts for Plan Contracted Providers
1.2.3 Knowing What Number to Call
1.3 Services and Programs to Support You
1.3.1 Provider e-Services
1.3.2 Health Services Program
1.4 "Quick Reference" Charts and Code Lists
1.4.1 Billing Code Sets
1.4.2 Billing Guidelines Reference Charts
1.4.3 Medical/Surgical Prior Authorization Reference Charts
1.4.4 Member Information Reference Charts
1.4.5 Pharmacy Reference Charts
1.5 About the Plan
1.5.1 Network and Service Areas
1.5.2 Member Enrollment in BMC HealthNet Plan
SECTION
2: CLAIM SUBMISSION AND REIMBURSEMENT
2.1 Overview
2.2 Covered Benefits
2.3 Provider Reimbursement
2.3.1 Copayments
2.3.2 Contractual Terms
2.3.3 Reimbursement for Locum Tenens Physician Services
2.3.4 Prior Authorization Requests and Payment
2.3.5 Member Billing and Reimbursement for Non-Reimbursable Services
2.3.5.1 MassHealth members only
2.3.5.2 Commonwealth Care members only
2.3.6 Member Eligibility
2.3.7 Serious Reportable Events ("SREs"): Payment Policy, Reporting and Billing
2.3.8 NPI and Tax ID Requirements
2.4 Prior Authorization and Retrospective Review Prior to Claim Submission
2.5 How to Submit a Claim
2.5.1 Submitting a Paper Claim
2.5.2 Submitting an Electronic Claim
2.5.2.1 When You Must File a Paper Claim
2.5.2.2 Ways to Submit Claims Electronically
2.6 Claim Filing Time Limit
2.7 Other Party Liability Coverage and Credit Balance Adjustments
2.7.1 Provider's Role
2.7.2 Role of the Plan's Other Party Liability Department
2.7.2.1 Coordination of Benefits
2.7.2.2 Third Party Liability (TPL)
2.7.3 Credit Balance
2.7.3.1 Provider's Role
2.7.3.2 Role of the Plan's Credit Balance Department
2.8 Claims Payment
2.8.1 Clean Claims
2.8.2 Electronic Funds Transfer (EFT)
2.8.2.1 Convenient, Fast Service
2.8.2.2 How to Become an EFT Provider
2.9 Remittance Advice
2.10 Rejected or Denied Clam
2.10.1 Rejected Claims
2.10.2 Denied Claims
2.10.2.1 Provider Administrative Appeal of a Previously Denied Claim
2.11 Clinical Editing of Claims
2.11.1 Assistant Surgeon
2.11.2 Cosmetic Procedures
2.11.3 Extreme Age
2.11.4 Global Days
2.11.5 Gender (Procedural)
2.11.6 Gender (Diagnosis)
2.11.7 Investigational and/or Experimental Procedures
2.11.8 Multiple Surgeries
2.11.9 Inappropriate Modifier Combination
2.11.10 Place of Service
2.11.11 Unbundling
2.11.12 Same Day
2.11.13 Maximum Frequency per Day
2.11.14 Not a Primary Diagnosis Code
2.11.15 New Patient Evaluation Management (E/M) with Established E/M Services
2.11.16 Correct Billing for Bilateral Procedures
2.12 When and Where to Inquire about a Claim
2.12.1 Claims Resolution Unit (CRU)
2.12.2 Online Claims Status Inquiry and Remittance Advices
2.13 Payment Correction, Resubmission, Adjustment and Audit
2.13.1 To Submit a Corrected Claim
2.13.1.1 To Submit Corrected Paper Claims
2.13.1.2 To Submit Corrected Electronic Claims
2.13.2 Payment Retraction or Adjustment
2.14 Resubmitting a Claim
2.14.1 Payment Retraction or Adjustment
2.14.2 Claims Audit
2.14.2.1 Your Role
2.14.2.2 Role of our Audit Department
2.15 Plan-Specific Billing Guidelines by Service
2.15.1 Administratively Necessary Days (AND)
2.15.2 Billing Behavioral Health Services
2.15.3 Billing Requirements for Childbirthing Classes
2.15.4 Billing Chiropractic Services and Chiropractic Code Set
2.15.5 Billing for Medical Nutrition Therapy
2.15.6 Medication HCPCS Codes and Unit Billing Methods
2.15.7 Billing Newborn Care
2.15.8 Billing Observation Status
2.15.9 Billing Occupational Therapy and Physical Therapy Services in an Outpatient Clinic Setting
2.15.9.1 Definition of a Visit
2.15.9.2 Evaluations
2.15.10 Billing Optometry Services and Optometry Code Set
2.15.11 Billing Podiatry Services and Podiatry Code Set
2.15.12 Billing Primary Care Services
2.15.12.1 Reimbursement for services provided by mid-level clinicians
2.15.12.2 Billing Requirements for EPSDT Visits and Behavioral Health EPSDT Screenings
2.15.13 Billing School-Based Health Center Services
2.15.14 Inpatient Facility Billing
2.15.15 Modifiers
2.15.15.1 Ambulance Modifiers
2.15.15.2 Early Intervention Modifiers
2.15.15.3 Laboratory and Radiology Modifiers
2.15.15.4 Operative Note Required with Modifier
2.15.15.5 Primary Care Modifiers
2.15.15.6 Wound Care Modifiers
2.15.15.7 Tobacco Cessation
2.15.16. Billing Orally Administered Enterals
2.15.17 Billing Guidelines for Paravertabral Facet Joint and Transforaminal Procedures
2.15.18 H1N1 and Seasonal Flu Vaccine Administration
2.15.19 Corneal Tissue Transplant Material and Ocular Prosthetics
2.15.20 Billing Guidelines for Fluoride Varnish
2.16 Practice Site Differentials
2.17 Compliance with the Deficit Reduction Act and HIPAA Requirements
2.18 CMS-1500 Claim Forms
2.18.1 Claim Form Requirements for the CMS-1500 Form
2.18.2 Step-by-Step Block Instructions for the CMS-1500 Form
2.18.3 Place of Service Codes (Block 24B of the CMS-1500 Form)
2.18.4 Sample CMS-1500 Form
2.19 UB-04 Claim Form
2.19.1 Claim Form Requirements for the UB-04 Form
2.19.2 Step-by-Step Block Instructions for the UB-04 Form
2.20 Bill Type Codes for Block 4 of the UB-04 Form
2.20.1 Sample UB-04 Form
2.21 Sample BMC HealthNet Plan Remittance Advice
SECTION
3: PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT
3.1 Utilization Management Overview
3.1.1 Functions of the Prior Authorization Department
3.1.2 Acute Care Coordination
3.1.3 Long-Term Care Review
3.1.4 Retrospective
3.1.5 Emergency and Urgent Services
3.1.6 Nurse Advice Line 24/7
3.1.7 Utilization Management Decision Process
3.1.8 Utilization Management Requirements
3.1.9 MassHealth and Commonwealth Care Timelines for Utilization Review Decisions Policy
3.2 Plan Authorization Requirements
3.2.1 Out-of-Area Emergent (including post-stabilization) and Urgent Care
3.2.2 Maternity Program Guidelines and Requirements
3.2.2.1 Prenatal Home Care Visits
3.2.2.2 Third Trimester Pediatrician Visits
3.2.2.3 Out-of-Network Exceptions for Pregnant Members
3.3.2.4 Notification of Delivery
3.3.3.5 Postpartum Home Care Visits
3.2.2.6 Notification of Newborn Birth
3.2.2.7 Notification of Newborn Hospitalization Following Mother's Discharge
3.3 New Technology, Experimental Diagnostics and Experimental Treatment
3.4 Referrals
3.4.1 Prior Authorization Requirements for Medical/Surgical Referrals
3.4.2 Member Access to Care without PCP Referral
3.4.3 Second Opinions
SECTION
4: CARE MANAGEMENT PROGRAM
4.1 Overview
4.2 Care Management Services
4.2.1 Members Targeted for Telephonic Care Management and Complex Care Management
4.2.2 Care Management Process
4.2.3 Community Service Resource Support
4.3 Maternity Care Management Program
4.4 Contacting the Care Management Staff
SECTION
5: BEHAVIORAL HEALTH MANAGEMENT
5.1 Overview
5.1.1 Behavioral Health Department Activities
5.1.2 Scope of Coverage for Behavioral Health Services
5.1.3 Plan Requirements by Categories of Care
5.2 Communication and Coordination of Member Treatment
5.3 Beacon Contact and Other Information
5.3.1 Claims
5.3.2 Contracting and Credentialing
5.3.3 Other Contact Information
5.4 List of Emergency Services Programs (ESPs)
SECTION
6: BEHAVIORAL HEALTH CLINICAL GUIDELINES
SECTION 6: (RESERVED FOR FUTURE USE)
SECTION
7: PHARMACY SERVICES
7.1 Pharmacy Contacts for Providers
7.2 Overview
7.3 Pharmacy and Therapeutics Committee
7.4 Drug Utilization Evaluation Program
7.5 Controlled Substance Management Program
7.6 Pharmacy Networks Affiliated with the Plan
7.6.1 Pharmacy Benefit Manager (PBM)
7.6.2 Specialty Pharmacy Networks
7.6.3 Mail Order Pharmacy
7.7 Pharmacy Benefits
7.7.1 The Plan Formulary
7.7.2 Over-the-Counter Products
7.8 Pharmacy Management Programs
7.8.1 Quantity Limitation Program
7.8.2 Step Therapy Program
7.8.3 Mandatory Generic Drug Program
7.8.4 Pharmacy Prior Authorization Program
7.8.5 New-to-Market Drugs
7.8.6 Medication Exception Process
7.9 Pharmacy Copayments
7.9.1 Member Copayment Amounts
7.9.2 Annual Copayment Caps
7.9.3 Pharmacy Copayment Compliance
7.9.4 Plan Action with Non-Compliant Pharmacies for MassHealth Members
SECTION
8: PROVIDER RESPONSIBILITIES
8.1 Overview
8.2 Verifying Member Status
8.2.1 MassHealth: Two Member Identification Cards Issued
8.2.2 Commonwealth Care: One Member Identification Card Issued
8.2.3 Verifying MassHealth or Commonwealth Care Eligibility
8.2.4 Summary of Plan Eligibility Verification Process
8.2.5 Newborn Eligibility Guidelines
8.2.6 Step-by-Step Instructions for Verifying Member Eligibility
8.2.6.1 Verifying Member Eligibility (Except Newborns)
8.2.6.2 Verifying Newborn Member Eligibility
8.3 Access to Care Guidelines for Medical/Surgical Services
8.3.1 Access to Care Guidelines for Emergency Services
8.3.2 Access to Care Guidelines for Outpatient Primary Care Services
8.3.3 Access to Care Guidelines for Outpatient Specialty Services and Newborn Care
8.3.4 Access to Care Guidelines for Urgent Dental Services
8.3.5 Access to Care Guidelines for Members affiliated with the Massachusetts Department of Mental Health (DMH) Children in Care or Custody of Department of Children and Families (DCF) (formerly DSS) and Youth Affiliated with the Massachusetts Department of Youth Services (DYS)
8.3.6 Access to Care Guidelines for Other Healthcare Services
8.4 Office/Service Waiting Time Standard
8.5 Requirements for All Contracted Provider
8.5.1 Cultural and Linguistic Responsibilities of All Contracted Providers
8.5.2 General Provider Contract Requirements for All Providers
8.5.2.1 Care Coordination Requirements for All Contracted Providers
8.5.2.2 Credentialing, Coverage and Administrative Requirements for All Contracted Providers
8.5.2.3 New Provider Requests Participation in the Network
8.5.2.4 If a New Provider Joins a Plan-Contracted Entity
8.5.2.5 If a Contracted Provider Requests Participation of Additional Provider Site
8.5.2.6 Provider Requirements for Locum Tenens Physician Services
8.5.2.7 Hours of Operation
8.5.2.8 Consent of Treatment
8.6 Responsibilities of Contracted PCPs
8.6.1 PCP Requirements
8.6.2 Requesting a Change in a Member's PCP Assignment
8.7 Responsibilities of Contracted Specialists and Ancillary Providers
8.8 Responsibilities of Contracted Hospitals
8.8.1 Hospital Responsibilities Related to Medical/Surgical Services
8.8.1.1 Plan Prior Authorization for Medical/Surgical Hospital Services
8.8.1.2 Plan Notification for Emergency Medical/Surgical Admissions
8.8.1.3 Plan Notification for Observation Status
8.8.1.4 Plan Notification of Newborn Delivery
8.8.1.5 MassHealth and Commonwealth Care Notification of Newborn Delivery
8.8.1.6 Plan Notification of Newborn Hospitalization Following Mother's Discharge
8.8.1.7 Plan Continued Stay review for Medical/Surgical Services
8.8.1.8 Ever Events
8.9 EPSDT Services
8.9.1 Eligible Providers
8.9.2 Reimbursement Terms - Non-Capitated Providers
8.9.3 Reimbursement Terms - Capitated Providers
8.9.4 Training Available On the Web
8.9.5 Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Medical Protocol and Periodicity Schedule
8.10 Legal Notice
SECTION
9: QUALITY MANAGEMENT
9.1 Quality Improvement Program (QIP) Mission
9.2 Quality Improvement Program Objectives
9.3 Quality Structure and Quality Improvement Committees
9.3.1 Quality and Clinical Management Committee (Q&CMC)
9.3.2 Quality and Improvement Committee (QIC)
9.3.3 Credentialing Committee
9.3.4 Quality Improvement (QI) Work Groups (Work Groups)
9.3.5 Quality Improvement Project Teams (Project Teams)
9.3.6 Delegation Steering Committee
9.3.7 Other Related Committees
9.4 Scope of the Quality Improvement Program
9.5 Ongoing Monitoring and Evaluation
9.5.1 Integration of Network Components
9.5.2 Plan Quality Improvement (QI) Goals
9.5.3 Healthcare Effectiveness Data and Information Set Guidelines (HEDIS)
9.5.3.1 Domains of HEDIS
9.5.3.2 Consumer Assessment of Healthcare Providers and Systems (CAHPS)
9.5.3.3 HEDIS Methods
9.5.3.4 Provider Profiling
9.6 Plan Investigation of Non-Behavioral Health Adverse Incidents and Serious Reportable Events
9.7 Medical Record Charting Standards
9.7.1 Medical Record Charting Standards - All Providers
9.7.2 Medical Record Charting Standards - Preventive Care
9.7.3 Medical Record Charting Standards - Pediatrics
9.7.4 Medical Record Charting Standards - Behavioral Health Services
9.8 Medical Record Audits
9.8.1 Medical Record Audits for PCPs and OB/GYNS
9.8.2 Medical Record Audits for Specialists
9.9 Provider Communication
9.10 Clinical Practice Guidelines
SECTION
10: APPEALS, INQUIRIES, AND GRIEVANCES
10.1 Overview
10.2 MassHealth Appeals: Related Definitions
10.2.1 Administrative Appeal
10.2.2 Administrative Appeals Committee
10.2.3 Authorized Representative
10.2.4 Appeals and Grievances Specialist
10.2.5 Adverse Action
10.2.6 Board of Hearings (BOH)
10.2.7 Board of Hearings (BOH) Appeal
10.2.8 Continuing Services
10.2.9 Date of Action
10.2.10 Expedited Internal Appeal
10.2.11 Final Internal Appeal
10.2.12 First-Level Standard Internal Appeal
10.2.13 Grievance
10.2.14 Inquiry
10.2.15 Provider
10.3 Commonwealth Care Appeals: Related Definitions
10.3.1 Administrative Appeal
10.3.2 Administrative Appeals Committee
10.3.3 Authorized Representative
10.3.4 Appeals and Grievances Specialist
10.3.5 Appeal
10.3.6 Final Adverse Determination
10.3.7 Grievance
10.3.8 Inquiry
10.3.9 Office of Patient Protection (OPP)
10.3.10 Provider
10.4 Clinical Right of a Provider to Discuss an Adverse Action/Determination
10.5 Provider Administrative Appeal
10.5.1 Level One and Level Two Administrative Appeals
10.5.2 Information Required for Administrative Appeals
10.5.2.1 Required Documentation
10.5.2.2 Required Data Elements for Administrative Appeals
10.5.2.3 Recommended Documentation for Administrative Appeals
10.5.3 Filing an Administrative Appeal
10.5.4 Documentation Checklist Sorted by Type of Administrative Appeal
10.5.4.1 Reimbursement Appeal
10.5.4.2 Claim Denied for Lack of Plan Authorization
10.5.4.3 Claim Denied for Submission Over the Filing Limit
10.5.4.4 Claim Denied Because Member Ineligible on the Date of Service
10.5.4.5 Claim Denied for Coding and Clinical Editing
10.5.5 Administrative Appeals Committee
10.5.6 Timeframes for Administrative Appeal Determination
10.6 MassHealth Member Inquiries, Grievances, and Appeals
10.6.1 How a Member Submits an Inquiry, Grievance, or Appeal
10.6.2 Monitoring Member Appeals
10.6.3 Standard Internal Appeal
10.6.4 Expedited Internal Appeal
10.6.5 Board of Hearings (BOH) Appeal
10.6.6 Member or Authorized Representative Pharmacy Copayment Appeal Process
10.7 Commonwealth Care Member Inquiries, Grievances and Appeals
10.7.1 Internal Inquiry Process
10.7.2 Internal Grievance Process
10.7.3 Member or Authorized Representative Commonwealth Care Pharmacy Copayment Grievance Process
10.7.4 Internal Appeals Process
10.7.5 Expedited Internal Appeals Process
10.7.6 Reconsideration of a Final Adverse Determination
10.7.7 Independent External Review Process
10.8 Provider Reviews Related to Inquiries, Grievances, and Appeals
10.8.1 Monitoring Provider Performance
10.8.2 Provider Quality Issues
SECTION
11: CREDENTIALING
11.1 Overview
11.2 BMC HealthNet Plan and HealthCare Administrative Solutions, Inc. (HCAS)
11.3 Credentialing and Recredentialing Process
11.3.1 Types of Providers Credentialed
11.3.2 Information Required for Credentialing
11.3.3 Your Right to Review and Correct Erroneous Information
11.3.4 Your Right to Review Information
11.3.5 Your Right to be Informed
11.3.6 Credentialing File Review, Determinations, Notice and Reporting
11.3.7 Hospital Affiliation
11.4 Credentialing/Recredentialing Criteria
11.5 Recredentialing
11.6 Ongoing Monitoring and Off-Cycle Credentialing Reviews and Actions
11.7 Credentialing Appeals Process for Practitioners
11.7.1 Right of Appeal
11.7.2 Notice
11.7.3 Practitioner Request for Appeal
11.7.4 Credentialing Committee Reconsideration
11.7.5 Appeals Panel Hearing and Notice
11.8 Re-Application following Denial or Termination
11.9 Role of the Credentialed Practitioner
11.9.1 Role of the Credentialed Primary Care Practitioner (PCP)
11.9.2 Role of the Credentialed Specialist
11.10 Organizational Providers
SECTION
12: MEMBERSHIP OVERVIEW
12.1 Member Enrollment in BMC HealthNet Plan
12.2 MassHealth Membership Overview
12.2.1 MassHealth Benefit Categories and Eligibility Criteria for BMC HealthNet Plan Membership
12.2.1.1 MassHealth Basic Plan
12.2.1.2 MassHealth Family Assistance Plan
12.2.1.3 MassHealth Standard Plan
12.2.1.4 MassHealth Essential Plan
12.3 Commonwealth Care Membership Overview
12.3.1 Commonwealth Care Eligibility Criteria
12.3.2 Commonwealth Care Eligibility Categories
12.4 Overview of BMC HealthNet Plan Benefits
12.4.1 Member Self-Referral Services
12.4.2 Special Programs and Items for Members
12.5 Member Identification Cards
12.6 Member Eligibility
12.7 PCP Selection and Assignment
12.7.1 Request for PCP Change
12.8 Continuity of Care for New and Existing Plan Members
12.9 Confidentiality and Provider Access to Member Information
12.10 Member Rights and Responsibilities
12.10.1 Member Rights
12.10.2 Member Responsibilities
12.11 Member Outreach and Communication
12.11.1 Member Marketing
12.11.2 Member Services Department
12.11.3 Behavioral Health Hotline
12.11.4 Nurse Advice Line
12.11.5 New Member Materials
12.11.6 Member Orientation
12.11.7 Ongoing Member Communication
SECTION
13: MEMBER BENEFITS AND NON-COVERED SERVICES
13.1 MassHealth Member Benefits and Non-Covered Services
13.1.1 MassHealth Covered Services Lists
13.1.1.1 MassHealth Standard Covered Services List
13.1.1.2 MassHealth Basic Covered Services List
13.1.1.3 MassHealth Family Assistance Covered Services List
13.1.1.4 MassHealth Essential Covered Services List
13.1.2 MassHealth Non-MCO Covered Services
13.1.3 MassHealth Non-Reimbursable Services
13.2 Commonwealth Care Covered Services and Excluded Services - Effective July 1, 2010
13.2.1 Commonwealth Care Covered Services and Copayments Lists
13.2.1.1 Commonwealth Care Plan Type I Covered Services and Copayments List
13.2.1.2 Commonwealth Care Plan Type II Covered Services and Copayments List
13.2.1.3 Commonwealth Care Plan Type III Covered Services and Copayments List
13.2.2 Commonwealth Care Excluded (Non-Reimbursable) Services
13.2.3 Commonwealth Care Excluded Pharmacy Products and Services
SECTION
14: ADDITONAL WAYS WE HELP PROVIDERS
14.1 Overview
14.2 Care Coordination
14.2.1 Clinical Initiatives
14.3 Provider Network Administration
14.3.1 Plan Redirection to Network Providers
14.3.2 Finding a Provider
14.3.3 Our Website
14.3.3.1 Website Features
14.3.3.2 Access to Our Website
14.4 Claims Payment Turnaround
14.5 Dedicated Provider Lines
14.5.1 Provider Line for General Administration and Prior Authorization
14.5.2 Care Management Department Line
14.6 Provider Education and Communication
14.7 Positive Provider/Member Relationship
14.7.1 PCP Selection and Assignment
14.7.2 PCP Requests for Change in Member's PCP Assignment
14.8 Value-Added Services for Plan Members
SECTION
15: PROVIDER FORMS
15.1 Administrative Appeal Form
15.2 Behavioral Health Forms
15.2.1 Combined MCO Behavioral Health Provider/Primary Care Provider Communication Form
15.2.2 Consent Form for the Release of Medical Information
15.2.3 Intensive Clinical Management Release of Medical and Pharmacy Information Form
15.3 Claim Forms
15.3.1 Claims Resolution Unit Request Form
15.3.2 Electronic Funds transfer Authorization Form (EFT-1)
15.3.3 Credit Balance Refund Data Sheet
15.3.4 Coordination of Benefits Indicator Form
15.4 Medical/Surgical/DME Prior Authorization Form
15.4.1 Medical/Surgical/DME Prior Authorization Form
15.5 Miscellaneous Forms
15.5.1 Member PCP Transfer Request Form
15.5.2 Primary Care Provider Selection Form
15.5.3 Provider Data Form
15.5.4 Website Provider Login ID Request Form
15.5.5 Abbreviated Credentialing Form
15.5.6 Change Form
SECTION
16: NETWORK NOTIFICATIONS
SECTION
17: PROVIDER NEWSLETTERS
SECTION
18: GLOSSARY
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