Using Your Provider Manual

1
Using Your Provider Manual
2
Provider Manual

• General Services pages 7-59
• Provider Services
• Provider website
• Appointment Access
• Credentialing and re-credentialing
• Contracting
• Customer Care
• Enrollment
• Cultural Competency
• Care Management
• Family and Community Development (Outreach)
  Services
• Claims and Billing
• CMS 1500
• UB04

3
Provider Manual

• Enrollee Benefits and Authorizations pages 60-86
•  Benefits and Pharmacy List
• Care Management Services
• Utilization Management
• Authorization Guidelines
• Medical Necessity Criteria
• Appeals Process
• Fair Hearing Process
• OB/GYN
• Behavioral Health
• Care Management Services
• Utilization Management
• Authorization Guidelines
• Medical Necessity Criteria
• Appeals Process
• Fair Hearing Process
• OB/GYN
• Behavioral Health

4
Provider Manual

• Clinical Practice Standards pages 87-104
•  
• Primary Care and specialty services
• HealthCheck (formerly EPSDT)
• Supplemental Security Income (SSI) program
• Individuals with Disabilities Education Act
  (IDEA)
• Adult Care
• Vaccines
• Dental
• Clinical Practice Guidelines
• Advance Directives
• Mandatory Reporting
• Clinical conditions

5
Provider Manual

•  Regulatory Standards pages 138-142
•  Corporate Compliance
• Fraud, Waste and Abuse
• Audit and Oversight Activity
• Provider Responsibilities
• Appendix A Forms pages 143-157
• Behavioral Health Home Services Referral From
• Disclosure of Ownership
• Home Health Care Referral Form
• Mental Health Screening Tool
• OB Gobal Authorization and PsychoSocial Form
• Outpatient Treatment Report (Sample)
• Provider Interest Form
• Unusual Incident Report
• DC Medicaid Universal Referral Form
•  
• Appendix B Acronyms pages 158-159
•  

6
About Us

•  Health Services for Children with Special Needs
  (HSCSN) is a unique health plan that provides
  innovative care management services and benefits
  to pediatric and young adults (ages 0-26)
  receiving Medicaid and Supplemental Security
  Income (SSI) in Washington, DC.
• Each enrollee is assigned a care manager - a
  nurse, social worker or other qualified
  professional - throughout their entire
  enrollment. The HSCSN Care Manager provides
  coordination of care, ongoing support and
  collaboration with the primary care medical home
  and other specialty providers in order to
  successfully meet the physical, mental,
  behavioral and developmental service needs of
  each enrollee.
• HSCSN is a subsidiary of The HSC Foundation,
  along with The HSC Pediatric Center, and HSC Home
  Care.
•  

7
Department of Health Care Finance (DHCF)

• The mission of the Department of Health Care
  Finance is to improve health outcomes by
  providing access to comprehensive, cost-effective
  and quality healthcare services for residents of
  the District of Columbia.

8
DHCF Summary of Services

• DHCF, an agency created in FY 2009, that provides
  health care services to low-income children,
  adults, the elderly and persons with
  disabilities.
• Over 200,000 District of Columbia residents
  (nearly one third of all residents) receive
  health care services through DHCFs Medicaid
  Managed Care contracts and Alliance and
  Fee-for-service programs.

9
  Verifying Enrollee Eligibility

• Providers should verify an enrollees plan
  membership and eligibility prior to providing any
  service except a service in response to an
  Emergency Medical Condition. Providers are
  responsible for providing immediate services for
  an enrollees Emergency Medical condition in
  accordance with the providers license and scope
  of practice. Verification of an enrollees health
  plan membership is not required for requests for
  emergency medical assistance.
• If you need assistance with verifying an
  enrollees eligibility please contact the
  Customer Care Department at 202-467-2737 or
  866-WER-4Kiz or 1-866-937-4549.

10
Access Standards

• Enrollees with appointments who arrive by their
  scheduled appointment time shall not routinely be
  made to wait more than forty-five (45) minutes
  from their scheduled appointment time to see a
  PCP.
• PCPs shall offer new Enrollees an initial
  appointment within forty-five (45) days of their
  date of enrollment with the PCP or within thirty
  (30) days of request, whichever is sooner
• PCPs must accommodate the need for evening and
  weekend appointments
• Providers place of business must comply with the
  regulations outlined in the American Disabilities
  Act (ADA)
• Providers office must be culturally competent and
  not discriminate against any enrollee based on
  cultural or religious background
• Enrollees shall have access to services for the
  assessment and stabilization of psychiatric
  crises on a twenty-four (24) hour basis, seven
  (7) days a week, including weekends and holidays.
  
• Enrollees shall have access to twenty-four (24)
  hour access to Urgent Care and Emergency Care
  seven (7) days a week, including weekends and
  holidays. Urgent Care will be provided directly
  by enrollees PCP or HSCSN would provide other
  arrangements.

11
Access Standards

• Health Check/ initial EPSDT screens shall be
  offered to new Enrollees within sixty (60) days
  of the Enrollees enrollment date with HSCSN or
  at an earlier time if an earlier exam is needed
  to comply with the periodicity schedule
• Health Check / initial screen shall be completed
  within three (3) months (90 days) of the
  Enrollees enrollment date, unless provider
  determines that the new Enrollee is up-to-date
  with the EPSDT periodicity schedule.
• All Health Check / EPSDT screens, laboratory
  tests, and immunizations shall take place within
  twenty (20) days of their scheduled due dates for
  children under the age of two (2) and within
  thirty (30) days of their due dates for children
  over the age of two (2). Periodic EPSDT screening
  examinations shall take place within thirty (30)
  days of a request.
• IDEA multidisciplinary assessments for infants
  and toddlers at risk of disability shall be
  completed within thirty (30) days of request, and
  any needed treatment shall begin within fifteen
  (15) days of the completed assessment
• Enrollees have the right to second opinions if
  he/she refuses or disagrees with a recommended
  Plan of Treatment (POT).

12
Cultural Competency

• Understanding Cultural Competency
•  
• Healthcare providers are expected to obtain
  cultural background information on a patient, to
  help them better understand the patients needs
  and apply the knowledge in the course of their
  care to that patient. HSCSN providers are
  required and expected to intimately acquaint
  themselves with the cultural essence of a child
  with special needs so as to assist in the
  management and care of the child.
•  Assessing Cultural Competence
•  
• There are some unique indicators that have been
  determined for Special Needs Children. These key
  indicators are very important in assessing
  cultural competency for special need children and
  include
•  Physical disability
•  Mental disability
•  Family background
•  Language
•  Diet and nutrition
•  Race and ethnicity
•  Cultural Beliefs

13
Cultural Competency

• Domain areas in assessment of Cultural Competence
  by a Healthcare provider, as defined in HRSA
  (Health Resources and Services Administration)
  findings are as follows  
• Organizational Values An organization's
  perspective and attitudes with respect to the
  worth and importance of cultural competence and
  its commitment to provide culturally competent
  care.
•  
• Governance The goal-setting, policy-making, and
  other oversight vehicles an organization uses to
  help ensure the delivery of culturally competent
  care.
•  
• Planning and Monitoring/Evaluation The
  mechanisms and processes used for a) long- and
  short-term policy, programmatic, and operational
  cultural competence planning that is informed by
  external and internal consumers and b) the
  systems and activities needed to proactively
  track and assess an organization's level of
  cultural competence.
•  
• Communication The exchange of information
  between the organization/providers and the
  clients/population, and internally among staff,
  in ways that promote cultural competence.
•  
• Staff Development An organization's efforts to
  ensure staff and other service providers have the
  requisite attitudes, knowledge and skills for
  delivering culturally competent services.
•  
• Organizational Infrastructure The organizational
  resources required to deliver or facilitate
  delivery of culturally competent services.
•  
• Services/Interventions An organization's
  delivery or facilitation of clinical,
  public-health, and health related services in a
  culturally competent manner.
•  Excerpt from Indicators of Cultural Competence
  in Health Care Delivery Organizations An
  Organizational Cultural Competence Assessment
  Profile. http//www.hrsa.gov/culturalcompetence/in
  dicators/

14
Care Coordination

• Care Coordination is a series of activities
  provided by HSCSN Care Managers to assist
  enrollees in gaining access to necessary services
  (medical, behavioral and others), coordinate
  preventative and specialty services and
  facilitate communication and coordination in the
  medical home. Care coordination is
  individualized, empowering, comprehensive, and
  outcome-focused.
• What are the Care Managers role and
  responsibilities?
• Develop a relationship with and support the
  enrollee and/or caregiver
• Develop relationships with physicians and
  providers servicing enrollees
• Communicate with enrollee, caregiver, treating
  physician(s) and providers
• Assist the family with identifying their medical
  needs
• Facilitate access and coordinating services for
  the enrollee (identify provider, schedule
  appointments, coordinate transportation)
• Develop and monitor the care coordination plan
• Educate enrollees and families on HSCSN benefits,
  resources and processes
• Identify and coordinate enrollee/caregiver
  education needs (classes, literature, referrals)
  
• Support the relationship between the enrollee and
  their providers
• Connect the enrollee/caregiver with resources
• Make referrals to educational advocates and
  attend educational meetings (with permission of
  enrollee/caregiver)
• Assist the provider with obtaining home
  evaluations and/or social work assessments
• Assist the provider and family to address
  overutilization and underutilization of services
  and noncompliance
•  

15
Care Coordination

• Working with the Care Manager what is the role
  of the Provider?
• Comply with EDSDT and adult preventive care
  requirements and guidelines
• Collaborate in development of the Care
  Coordination Plan (review, edit, sign, and
  return)
• Follow the HSCSN Referral Guidelines for services
  requiring preauthorization
• Ensure that referrals for home care, durable
  medical equipment and medical supplies are
  complete and that services are monitored as
  indicated
• Communicate with the HSCSN Care Manager about
  concerns (risks, noncompliance, overutilization,
  underutilization, health education needs, etc.)
  and progress

16
General Claims

• HSCSN will process all claims through an
  automated system. Our goal is to pay providers
  for covered services within 30 days of receipt of
  each completed clean claim form. Your tax
  identification number is your provider ID. Please
  include it and the NPI on every claim to help
  expedite payment.
• Professional providers and Home Health Agencies
  are required to submit for payment of covered
  services on the Centers for Medicare and Medicaid
  Services (CMS)-1500 Health Insurance Claim Form
  and Home Health Agencies. Hospitals are required
  to submit for payment of covered services on the
  CMS UB04. These forms are available from CMS at
  http//www.cms.hhs.gov/CMSForms.
• Providers have the option of submitting claims
  electronically through EMDEON or via mail.
  HSCSNs payor ID is 37290. Claims should be
  mailed to
• HSCSN
• PO Box 29055
• Washington, DC 20017

17
General Claims

• Timely Processing of Claims
•  In accordance with D.C. Code 31-3132, HSCSN
  shall accept Network and non-Network Provider
  initial Claims for Covered Services no later than
  one hundred and eighty (180) days from the date
  of service.
•  
• Health Care Acquired Conditions
•  The Patient Protection and Affordable Care Act
  of 2010 include provisions prohibiting Federal
  Financial Participation (FFP) to States for
  payments for health care acquired conditions
  (HCACs) and other provider preventable conditions
  or Never Events. 
•  
• HSCSN shall no longer reimburse providers for
  procedures relating to the following health care
  acquired conditions when any of the following
  conditions are not present upon admission in any
  inpatient setting, but subsequently acquired in
  that setting.
• Appeals
•  Claim payments or denials can be appealed in
  writing within 90 days of the denial or payment.

18
General Claims

• Electronic Billing
• Providers now have the opportunity to submit
  claims electronically and check your claims
  through a system called claims status link. HSCSN
  encourages you to sign up by visiting the HSCSN
  website and follow the link www.Emdeon.com/PAYERL
  ISTS/payerlists.php
• HSCSN PAYOR ID 37290

19
General Claims

• Coordination of Benefits
• Health Services for Children with Special Needs,
  Inc. (HSCSN), is always the payer of last resort
  when the enrollee has another insurance coverage.
  As a provider, you must
• always submit your claims to the other insurance
  company first. Once you receive
• an explanation of payment from them, you should
  file the claim with HSCSN. You
• must attach a copy of the explanation of payment
  from the other carrier or a copy
• of the letter of denial. HSCSN will coordinate
  the payment with the other carriers
• payment. HSCSN will pay up to the amount that is
  contracted. The provider will not
• receive payment for more than the charge or
  contracted amount when combining
• the payments of both payers.
• HSCSNs Provider Manual, Pages 24-59, has further
  information on Claims.

20
Authorizations

• These services DO NOT require authorization
• Specialty office visits (except behavioral
  health)
• Primary care visits
• Well woman care (including Depoprovera shots)
• Vision services (including eye glasses)
• Labs and Radiology (including X-Rays, sonograms,
  MRIs, CT and PET Scans) 

21
Authorizations

• Required Authorizations for Medical/Surgical
• Early Intervention Services
• Rehabilitative therapies (physical, speech,
  occupational)
• OB Global services and services associated with
  pregnancy
• Home health (nursing, personal care aide and
  rehab therapies) and hospice care
• Durable Medical Equipment and Assistive
  Technology
• Supplies and Nutritional supplements
• Anesthesia for dental procedures
• Elective medical admissions (including feeding
  programs)
• Facility admissions - Sub-acute, Rehab,
  Transitional and Long Term Care
• Elective surgery (including plastic surgery),
  outpatient and inpatient
• Home Modification

22
Authorizations

•  Required Authorizations for Behavioral
• Psychiatric and Neuropsychiatric evaluations
• Psychological testing and evaluations
• Psychotherapy, Counseling and Applied Behavioral
  Analysis (ABA)
• Psychotropic medication management visits
• Intensive Outpatient Programs and Day
  Rehabilitative services
• Partial hospitalization programs
• Sub-acute admission
• Substance Abuse treatment (inpatient and
  outpatient)
• Residential Treatment Facility
• Intermediate Care Facility for Mental Retardation
  (ICF-MR)
•  

23
Authorizations

• Home Health Services- Medical
• Home health services (Skilled Nursing) must be
  ordered by a physician. The ordering provider
  must submit a completed HSCSN Home Care Referral
  Form prior to service initiation. The form will
  improve and expedite referrals, reviews and
  authorizations. The completed HSCSN Home Care
  referral form can be faxed to 202-721-7190. The
  care requested must be appropriate to the home
  setting and to the enrollees needs. The request
  will be reviewed every 60 days within the Home
  Health Unit for medical necessity. The
  requesting provider must review and sign the plan
  of care from the home care agency every 60 days
  to ensure that services are appropriate and
  continue to be medically necessary.
•  
• For Personal Care Aides HSCSN requires an
  in-home assessment of the enrollees personal
  care needs by an RN prior to the initial
  authorization of services and a minimum of every
  6 months for ongoing services.
• Please call HSCSN at 202-467-2737 and request to
  speak with the Home Health Review Nurse if you
  need assistance.

24
Authorizations

• Home Health Services- Behavioral
• The goal of our behavioral health home care
  service is to work with enrollees, their families
  and community providers to treat challenging
  behaviors that interfere with a youth's
  successful functioning at home and in the
  community. In-home services are delivered by a
  trained Behavior Specialist and a supervising
  licensed behavioral health professional.
•  
• The HSCSN Behavioral Health Home Services
  Referral Form must be submitted for all
  home-based behavioral health service requests.
  The form will improve and expedite referrals,
  reviews and authorizations. It is important that
  the provider supply all relevant clinical
  history. The completed HSCSN Behavioral Health
  Home Services Referral form can be faxed to
  202-721-7190. The requests are reviewed by the
  Home Health Unit and referred to an independent
  licensed social worker to conduct an assessment
  and provide recommendations for services.
  Behavioral health home services are authorized
  based on the recommendation. The services will
  be reassessed every 6 months within the Home
  Health Unit for continued medical necessity.
•  
• Please call HSCSN at 202-467-2737 and request to
  speak with the Home Health Review Nurse if you
  need assistance.

25
Authorizations

• Durable Medical Equipment (DME), Orthotics,
  Prosthetics and Assistive Technology
• The documentation required for the authorization
  is dependent on the type of equipment requested.
  The following are standard requirements
•  
• Physician Order for the Service
• Certificate of Medical Necessity (CMN) or
  Physician Letter
•  
• A pended authorization is generated after receipt
  of the CMN and the physician order. Delivery
  confirmation receipt from the vendor is required
  before an authorization can be approved. Please
  fax receipt to the DME Review Nurse within 24
  hours of delivery (or next business day if after
  hours) at 202-467-0978. Receipt should include
  the following information
•  
• Signature of person taking possession of
  equipment at time of delivery
• Delivery date
• Documentation of education conducted and
• Brand name, model number, quantity,
  serial/identification number(s) of equipment
  delivered
•  
• HSCSN verifies all new and replacement durable
  medical equipment, prosthetics, orthotics, and
  assistive technology delivered to the enrollees
  in the home.

26
Authorizations

• Inpatient Admissions
• Non-emergent (elective) medical/surgical
  inpatient admissions and outpatient surgical
  procedures must receive prior authorization from
  the UM Department. The PCP or specialist should
  contact the UM Department at least 3 business
  days prior to the scheduled admission or
  procedure to obtain authorization.
• All emergent/urgent inpatient admissions must be
  reported to the UM Department within 24 hours of
  the admission. Please fax admission information
  to 202-635-5590. The following information is
  needed for the admission
•  Enrollee Name
• ID Number
• Admitting Physician
• Hospital Name and Address
• Admission Date
• Diagnosis and clinical information
• Name and Telephone Number of Contact Person
•  
• If notification is not received within 24 hours
  of the admission, the days prior to notification
  will be denied unless there are documented
  extenuating circumstances.

27
Medical Necessity Guidelines

• A service is Medically Necessary for an
  individual if a physician or other treating
  health Provider, exercising prudent clinical
  judgment, would provide or order the service for
  a patient for the purpose of evaluating,
  diagnosing or treating illness, injury, disease,
  physical or mental health conditions, or their
  symptoms, and that is
•  
• In accordance with the generally accepted
  standards of medical practice
• Clinically appropriate, in terms of type,
  frequency, extent, site and duration
• considered effective for the patients illness,
  injury, disease, or physical or mental health
  condition
• Not primarily for the convenience of the
  individual, Care giver, treating physician, or
  other treating healthcare provider
• More cost effective than an alternative service
  or sequence of services, and at least as likely
  to produce equivalent therapeutic or diagnostic
  results with respect to the diagnosis or
  treatment of that individuals illness, injury,
  disease or physical or mental health condition.
• Refer to HSCSNs Provider Manual for more detail
  regarding medical necessity criteria.
• Pages 83-86.

28
Appealing a Clinical Decision

• Provider Rights to Appeal a Clinical Denial
  Decision
•  
• Providers have the right to
•  
• Discuss denial decisions with the licensed
  clinical reviewer
•  Speak with the physician reviewer who issued the
  denial (or designee)
•  Obtain an explanation of appeals process,
  including timeframes for appeal decision
•  Appeal decision by submitting written comments,
  documents or any relevant information
•  
• To File an Appeal
•  
• There are two ways to file an Appeal
•  
• Telephone the Utilization Review Line at 202
  721-7162 Mon. Friday 830am 500pm
•  
• Health Services for Children with Special Needs,
  Inc.
• 1101 Vermont Avenue, NW - Suite 1200
• Washington, DC 20005
• Attn Utilization Management Department - Appeals

29
Outpatient Mental Health Services

• Authorizations for medication management and
  therapy services (individual, group, family) are
  provided by the enrollees Care Manager in
  accordance with the table below.
•  
• The behavioral health treatment plan or
  outpatient treatment report must be received by
  the Care Manager within 30 days of initiating
  services and every six (6) to twelve (12) months
  for continued authorization, depending on the
  authorized service (see table). HSCSN does not
  accept psychotherapy notes.
•  
• See HSCSNs Provider Manual Pages 76-79 for
  further information.

Type of service requested Benefit Initial Authorization Requirement Continued Authorization Requirement
Medication Management Plan allows 16 visits/year Submit initial treatment plan Updated treatment plan or submitted treatment report - required every 12 months
Individual, Group and Family Therapy Plan allows 90 visits/six months Submit initial treatment plan Updated treatment plan or submitted treatment report required every 6 months
30
HealthCheck/EPSDT Participation

• Medicaid's Early and Periodic Screening,
  Diagnostic, and Treatment (EPSDT) Program is a
  preventive primary health care program for
  eligible low-income children and teens ages birth
  to 21. EPSDT emphasizes preventive care,
  especially screening services, to promote good
  health and identify and treat problems early and
  effectively.
• EPSDT is a joint federal-state partnership
  program administered by the Centers for Medicare
  Medicaid Services (CMS). The program has two
  operational components
• Assuring the availability and accessibility of
  required health care resources
• Helping Medicaid recipients and their parents or
  guardians to effectively use these resources
• CMS, state Medicaid agencies, and EPSDT providers
  have a shared obligation to ensure comprehensive
  pediatric preventive care for eligible children
  and teens, and to support their families in
  accessing the health services available through
  EPSDT.

31
HealthCheck/EPSDT Participation

• The DC Department of Health Care Finance (DHCF)
  in partnership with Georgetown University has
  developed the free, online HealthCheck Provider
  Education System.
• Please take a minute to REGISTER at
  http//dchealthcheck.net to review the
  curriculum. Your registration ensures that your
  training is recorded by DHCF. This is necessary
  so that you get credit for fulfilling the
  training obligations required to be a Medicaid
  provider. Please note that this training will
  fulfill your obligations for all Medicaid Managed
  Care Organizations (MCOs) with which you are
  paneled
• Chartered Health Plan
• Health Services for Children with Special Needs
• UHC Community Health Plan (Unison)
• In addition, you will receive 5 CMEs upon
  completion of the curriculum.

32
Blood Lead Screening

• All Medicaid eligible children are to receive
  blood lead screening by ages 12 months and 24
  months of age to be in compliance with the
  requirements of 42 U.S.C. 1396d (r) (1) (B)
  (iv) and the CMS State Medicaid Manual, section
  5123.2D.
• This testing is reported annually as part of the
  CMS Form 416 report on Health Check services.
• Blood lead screenings are also required for those
  children greater than 24 months (2 years) of age,
  up to 72 months (6 Years) of age, for whom blood
  lead screenings cannot be documented.

33
Individuals with Disabilities Education Act
(IDEA)

• Individuals with Disabilities Education Act
  (IDEA) Federal law governing the rights of
  infants and toddlers to receive early
  intervention (Part C) and the educational rights
  of school-age children and youth with
  education-related disabilities (Part B).
• The early intervention system is designed to
  serve children from birth through three years of
  age (36 months) who are DC residents. In order
  for the child to receive services he/she must be
  found eligible. Children are eligible if they
  were born with a disability or health condition
  that affects their development or are functioning
  at half their age (greater than 50 delay) in one
  or more areas of performance such as
• Physical development
• Cognitive development
• Communication, language speech development
• Social/emotional development
• Adaptive/self-help skills
• Early intervention may include speech, physical,
  occupational and family therapists, developmental
  educators, assistive technology, nursing.
• Infants and Toddlers with Disabilities (ITDD) of
  the Department of Health and the MCOs coordinate
  the needed services.

34
Level of Care Criteria

• The medical and behavioral criteria approved for
  the use by HSCSN for clinical determinations is
  InterQual Level of Care Criteria. HSCSN is
  licensed to utilize the criteria by McKesson
  Health Solutions, LLC. All InterQual criteria
  sets are based on two major clinical components
• 1) Severity of Illness
• 2) Intensity of Service
• The sets are sub-grouped by body system, clinical
  findings, imaging findings, laboratory findings
  and daily treatment protocols.
•  
• See HSCSNs Provider Manual, Pages 83-84, for
  further information.

35
Clinical Guidelines

• HSCSN encourages the use of evidence-based
  Clinical Practice Guidelines to ensure that the
  best and most current quality of care is provided
  to enrollees.
• HSCSN reviews all Clinical Guidelines every two
  years.
• For a list of all clinical practice guidelines
  adopted and approved by HSCSNs Quality Council
  can be found on the Provider Resources page on
  the HSCSN Website _at_ www.hscsn-net.org.
• The Clinical Guidelines may also be found in your
  HSCSN Provider Manual on pages 102-103.

36
Healthcare Effectiveness Data and Information Set
(HEDIS)

• HEDIS is a program designed and Managed by the
  National Committee on Quality Assurance (NCQA).
  The program is designed to measure a set of
  quality indicators and then be able to make
  comparisons across the nation based on plan type.
  HSCSN posts our results on our website and in our
  Provider Newsletter annually. You as a provider
  may also receive information throughout the year
  on your personal provider status with these
  measures as well as our overall health plan
  status. These are tools to help us partner to
  improve outcomes with the care delivery system
  for our enrollees.
• For complete information see Pages 111-114 of the
  HSCSN Provider Manual.

37
HEDIS

• What can HSCSNs network physicians do?
• Diabetes Care
• Educate on the importance of eye exams, lipid
  control, blood pressure control, foot exams, and
  serum glucose control. Tight management of
  diabetic enrollees to assist in meeting HEDIS
  goals is recommended. The goals for good Diabetic
  Management are
• Lipid control LDL-C lt 100mg/dL
• HbA1C lt 7 good control, lt 8 control, gt 9
  poor control
• BP lt 130/80 good control, lt 140/90 poor
  control
• Annual medical attention for nephropathy
• Refer enrollees to ophthalmologists/optometrists
  at least every two years.
• Encourage enrollees to have ordered labs drawn.
• Contact HSCSN Care Management when enrollees
  cancel appointments.
• Ensure that diabetic patients receive a
  comprehensive examination annually.
• Code information on your claims to document care
  delivery

38
HEDIS

• What can HSCSNs network physicians do?
• Monitoring of BMI and associated components of
  good health
•  
• In order to target Obesity and malnutrition and
  begin interventions as early as possible for both
  of these conditions it is accepted that
  monitoring of BMI and tracking what percentile
  and enrollee falls in is the most reliable way to
  date of determining where an enrollee is in the
  growth cycle. HEDIS also looks for documented
  discussions surrounding nutrition and exercise
  between the physician and caregiver or enrollee.
  Coding can also be used for all of these measures
  to document your care

39
HEDIS

• What can HSCSNs network physicians do?
• Childhood Immunizations
• HEDIS looks at the Immunizations recommended by
  the CDC as an area of comparison for quality
  care. The Childhood immunization measure most
  specifically counts recommended immunizations
  that have been given PRIOR to the childs second
  birthday. Immunizations that have been
  recommended to be given prior to 24 months of age
  that are given after the childs second birthday
  are considered non-compliant.
• Rotavirus administration is low, this may be
  because you must document if you are giving the
  two doses or three dose vaccines. If there is no
  documentation it is assumed the three dose
  vaccine was used and one dose was missed.
• Rates of administration of the Influenza vaccine
  have been low in the last few years. This is a
  CDC recommendation that influenza vaccines be
  administered to children under two annually.
• Call the HSCSN care manager to be your partner in
  getting enrollees in to get their immunizations
  in the recommended time frame.
•  

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HEDIS

• What can HSCSNs network physicians do?
• Timeliness of Prenatal Care and of Postpartum
  Care
•  
• Schedule/provide initial prenatal care as soon as
  pregnancy is confirmed.
• Remind expectant enrollees to make appointments
  for prenatal care and postpartum care
• Educate enrollees about the importance of
  prenatal and postpartum care.
• Contact HSCSN Care Management when enrollees
  cancel/fail to show up for scheduled visits.
• Alert HSCSN Care Management to any needs for
  outreach
• Provide postpartum visits between 21 and 56 days
  after delivery
• Global billing is a tool for your office to use
  for ease of billing purposes but you may submit
  documentation of visits/care delivery by
  submitting the CPT II (Table 4) codes to document
  individual visits not captured in the global
  billing. Codes should be used with a zero charge
  as individual visit payments are already included
  in the global payment.
•  

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Fraud, Waste and Abuse

• Fraud - means an intentional deception or
  misrepresentation by a person with the knowledge
  that the deception could result in some
  unauthorized benefit to himself or to some other
  person. It includes any act that constitutes
  fraud under applicable Federal or State law.
•  
• Waste - means the over-utilization of services
  not caused by criminally negligent actions waste
  involves the misuse of resources.
•  
• Abuse - means provider practices that are
  inconsistent with sound fiscal, business, or
  medical practices, and that result in an
  unnecessary cost to the Medicaid program, or in
  reimbursement for services medically unnecessary
  or that fail to meet professionally recognized
  standards for health care. It also includes
  beneficiary practices that result in unnecessary
  cost to the Medicaid program
•  

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Fraud, Waste and Abuse

• What is your role concerning the FCA?
•  
• You are essential to your organizations
  compliance with the FCA.
• The codes your office/facility attaches to
  diagnoses and procedures, the documentation you
  keep for each patient, the bills you file even
  the dates you record when procedures occur are
  subject to the FCA. Therefore, your work must be
  clear, accurate and in compliance with all rules
  and regulations.
• Safeguard your organization by ensuring
• You document orders in the patients medical
  record
• Services are deemed medically necessary based on
  patients needs
• Medical necessity is documented in the patients
  medical record
• All billing, coding, and reimbursement rules are
  followed
• Services not rendered, are credited to the
  patients account
• Accountability for your actions and acting with
  integrity in all circumstances.
• You do not retain Medicaid funds that were
  improperly paid

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Reporting Requirements

• By law, providers must report all occurrences of
  sexually transmitted diseases, communicable
  diseases, vaccine preventable diseases,
  immunizations administered, lead levels and
  developmental delay in infants and children to
  the following organizations
• Sexually Transmitted Diseases, Communicable
  Diseases
• Department of Health [phone]
•  Immunizations, Dept. of Health (Vaccine for
  Children)
• [phone]
•  Lead Levels, DC Lead Registry [phone]
•  Developmental Delay DC Early Intervention
• [phone] or visit www.strongstartdc.com
•  

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Health Insurance Portability and Accountability
Act (HIPAA)

• The goals of the privacy standards are to protect
  the confidentiality of individually identifiable
  information obtained, restricts how it can be
  used and disclosed and to protect individual
  rights.
• Access to Enrollee Records
•   
• Permitted Uses and Disclosures
•  
• HSCSN may request Protected Health Information
  (PHI) for
• Treatment, payment or healthcare operations,
• The healthcare operations of another covered
  entity or healthcare provider, if each entity has
  or had a relationship with the individual who is
  the subject of the PHI being requested, and the
  disclosure is
• For a purpose listed in the definition of
  healthcare operations or
• For the purposes of healthcare fraud and abuse
  detection or compliance.
• Another covered entity that participates in an
  organized healthcare arrangement with The HSC
  System for any healthcare operation activities of
  the organized health care arrangement.
•  

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Always.

• Remember to always refer to your Provider Manual
• Contract your Provider Service Representative
  with any questions or concerns
• Refer to your important numbers (Page 5) of your
  Provider Manual
• Notify us of any changes in your practice
• Provider resigned
• New provider on staff
• Change of address
•  
• Read your voucher, post your payment and review
  the reason code description in a timely manner.

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Questions???