Provider Orientation - PowerPoint PPT Presentation

1 / 46
About This Presentation

Provider Orientation


Provider Orientation * HEDIS What can HSCSN s network physicians do? Monitoring of BMI and associated components of good health In order to target Obesity and ... – PowerPoint PPT presentation

Number of Views:270
Avg rating:3.0/5.0
Slides: 47
Provided by: Jacqueli111


Transcript and Presenter's Notes

Title: Provider Orientation

Provider Orientation
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

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.

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
  • 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.

  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.

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
  • 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

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).

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
  •  Physical disability
  •  Mental disability
  •  Family background
  •  Language
  •  Diet and nutrition
  •  Race and ethnicity
  •  Cultural Beliefs

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
  • Governance The goal-setting, policy-making, and
    other oversight vehicles an organization uses to
    help ensure the delivery of culturally competent
  • 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//

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
  • What are the Care Managers role and
  • 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
  • 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
  • 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

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
  • 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
  • Communicate with the HSCSN Care Manager about
    concerns (risks, noncompliance, overutilization,
    underutilization, health education needs, etc.)
    and progress

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
  • Providers have the option of submitting claims
    electronically through EMDEON or via mail.
    HSCSNs payor ID is 37290. Claims should be
    mailed to
  • PO Box 29055
  • Washington, DC 20017

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.

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
  • HSCSN PAYOR ID 37290

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.

  • These services DO NOT require authorization
  • Specialty office visits (except behavioral
  • 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) 

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

  •  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
  • Residential Treatment Facility
  • Intermediate Care Facility for Mental Retardation

  • 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.

  • 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.

  • 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
  • HSCSN verifies all new and replacement durable
    medical equipment, prosthetics, orthotics, and
    assistive technology delivered to the enrollees
    in the home.

  • 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.

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
  • 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.

Appealing a Clinical Decision
  • Provider Rights to Appeal a Clinical Denial
  • 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,
  • 1101 Vermont Avenue, NW - Suite 1200
  • Washington, DC 20005
  • Attn Utilization Management Department - Appeals

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
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
  • 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

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// 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
  • 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.

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
  • 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.

Individuals with Disabilities Education Act
  • 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.

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.

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
  • 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_
  • The Clinical Guidelines may also be found in your
    HSCSN Provider Manual on pages 102-103.

Healthcare Effectiveness Data and Information Set
  • 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.

  • 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
  • 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

  • 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

  • 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.

  • What can HSCSNs network physicians do?
  • Timeliness of Prenatal Care and of Postpartum
  • 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
  • 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.

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

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
  • 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
  • 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

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
  • Department of Health (202) 727-6408
  •  Immunizations, Dept. of Health (Vaccine for
  • (202) 576-7130
  •  Lead Levels, DC Lead Registry (202) 535-1398
  •  Developmental Delay DC Early Intervention
  • (202) 727-3665 or visit

Health Insurance Portability and Accountability
  • 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
  • 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.

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)
  • Claims and Billing
  • CMS 1500
  • UB04

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

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
  • Adult Care
  • Vaccines
  • Dental
  • Clinical Practice Guidelines
  • Advance Directives
  • Mandatory Reporting
  • Clinical conditions

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

  • 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.

Write a Comment
User Comments (0)