2021 Administrative Manual Network Provider

1

Network Provider Administrative Manual

2021

3MediGold is a registered trade name of Mount Carmel Health Plan, Inc., Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc.

Table of Contents

SECTION 1: Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 6a. Welcomeb. Introductionc. Important News & Updatesd. Provider Communications

SECTION 2:How to Contact MediGold . . . . . . . . . . . . . . Pg 7-8 a. Case Managementb. Compliance c. Contracting & Provider Relationsd. Member Grievance and Appealse. Member Servicesf. Pharmacy Benefit Managerg. Provider Service Center h. Quality Managementi. Risk Adjustmentj. Special Investigations Unit (SIU)k. Utilization Managementl. Stars and HEDIS

SECTION 3:Eligibility and Enrollment . . . . . . . . . . . . . . . . .Pg 9a. Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 9b. Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 9c. The Member’s Primary Care Provider . . . . .Pg 10d. Membership Identification Card . . . . . . . . .Pg 10

SECTION 4:Provider Policies and Protocols . . . . . . . . . . .Pg 12a. Compliance with Policy/Protocol . . . . . . . .Pg 12b. Provide Timely Notice of

Demographic Changes . . . . . . . . . . . . . . . .Pg 12c. Prohibited Billing Practices . . . . . . . . . . . . .Pg 13i. Balance Billing . . . . . . . . . . . . . . . . . . . . . . .Pg 13d. After Hours Care . . . . . . . . . . . . . . . . . . . . .Pg 14e. Delay in Service . . . . . . . . . . . . . . . . . . . . . .Pg 14f. Medical Record Requirements . . . . . . . . . .Pg 14i. Follow Medical Record Standards . . . . . . .Pg 14ii. General Documentation Guidelines . . . . . . .Pg 15iii. Demographic Information . . . . . . . . . . . . . . Pg 16iv. Member Encounters . . . . . . . . . . . . . . . . . . Pg 16v. Clinical Decision and Safety Support . . . . . Pg 16g. Risk Adjustment Information . . . . . . . . . . . . Pg 16

i. Risk Adjustment Process System and Encounter Data Processing System . . . . . . . . . . . . . Pg 17 ii. Improper Payment Measures . . . . . . . . . . Pg18h. Informing Members of Advance Directives . . . . . . . . . . . . . . . . . . . Pg 18i. Referrals/Prior Authorization Requests . . . . . . . . . . . . . . . . Pg 18j. MediGold Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . Pg 19

SECTION 5:Quality Management . . . . . . . . . . . . . . . . . . .Pg 20a. Regulatory Requirements . . . . . . . . . . . . . .Pg 20b. Healthcare Effectiveness Data and Information Set (HEDIS®) . . . . . . . . . . .Pg 20c. What are Medicare Star Ratings? . . . . . . . .Pg 21d. Program Goals . . . . . . . . . . . . . . . . . . . . . .Pg 21e. Program Activities . . . . . . . . . . . . . . . . . . . .Pg 22f. Risk Management/Quality Concern Reporting . . . . . . . . . . . . . . . . . . .Pg 22g. Outcomes, Evaluations and Member-Based Studies . . . . . . . . . . . . . . .Pg 22h. Access and Availability . . . . . . . . . . . . . . . .Pg 23i. Member and Provider Satisfaction . . . . . . .Pg 23

SECTION 6:Utilization Management . . . . . . . . . . . . . . . . .Pg 24a. Utilization Management . . . . . . . . . . . . . . . .Pg 24 i. Overview . . . . . . . . . . . . . . . . . . . . . . . .Pg 24 ii. Medical Necessity . . . . . . . . . . . . . . . . .Pg 25 iii. Prior Authorization . . . . . . . . . . . . . . . . .Pg 25 iv. Prior Authorization Process . . . . . . . . . .Pg 26 v. Prior Authorization Decision- making Process . . . . . . . . . . . . . . . . . . .Pg 26 vi. Referral Policies . . . . . . . . . . . . . . . . . . .Pg 26 vii. Hospital Notifications . . . . . . . . . . . . . .Pg 27 vii. Concurrent Review . . . . . . . . . . . . . . . .Pg 27 ix. Readmission Reimbursement . . . . . . . .Pg 28 x. Urgent Care and Emergency Services . .Pg 29 xi. Notifications to Members . . . . . . . . . . .Pg 29 xii. When to Deliver the NOMNC . . . . . . . . .Pg 30 xiii. Notice Delivery to Representatives . . . .Pg 30 xiv. Exceptions . . . . . . . . . . . . . . . . . . . . . . .Pg 31 xv. Alterations to the NOMNC . . . . . . . . . . .Pg 31 xvi. When to Deliver the DENC . . . . . . . . . .Pg 31

MediGold is a registered trade name of Mount Carmel Health Plan, Inc., Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 4

Table of Contents

xvii. Hospital Discharge Notices . . . . . . . . . . . . Pg 31 1. An Important Message From

Medicare About Your Rights (IM). . . . . . Pg 31 2. Detailed Notice of Discharge . . . . . . . . .Pg 32xviii. Availability of Utilization Management Staff . . . . . . . . . . . . . . . . . . .Pg 32b. Skilled Nursing Facilities (SNF) . . . . . . . . .Pg 32 i. Prior Authorization . . . . . . . . . . . . . . . . .Pg 32 ii. Concurrent Review . . . . . . . . . . . . . . . .Pg 33 iii. MediGold Tier

Reimbursement Model . . . . . . . . . . . . .Pg 34 iv. Benefit Period . . . . . . . . . . . . . . . . . . . .Pg 34

SECTION 7:Case Management . . . . . . . . . . . . . . . . . . . . .Pg 35a. Case Management . . . . . . . . . . . . . . . . . . .Pg 35 i. Transitions of Care Program . . . . . . . . .Pg 35 ii. Disease Management Program . . . . . . .Pg 36 iii. Behavioral Health Program . . . . . . . . . Pg. 36 iv. Chronic Care Improvement

Program – Chronic Obstructive Pulmonary Disease . . . . . . . . . . . . . . . .Pg 36

v. Complex Case Management Program . .Pg 37 Nurse Advice Line

SECTION 8:Medicare-Covered Drugs . . . . . . . . . . . . . . . .Pg 38a. Medicare Part B Drugs: . . . . . . . . . . . . . . .Pg 38i. Definitionii. Benefitb. Medicare Part D Drugs: . . . . . . . . . . . . . . .Pg 39i. Definitionii. Benefitc. The Formulary . . . . . . . . . . . . . . . . . . . . . .Pg 39d. Tiered Drug Benefit . . . . . . . . . . . . . . . . . .Pg 39e. Medicare Part D Benefit Stages

and Total Out-of-Pocket Costs . . . . . . . . .Pg 40f. Vaccines Covered Under

Medicare Part D . . . . . . . . . . . . . . . . . . . . .Pg 40g. Provision of and Billing

for Zostavax© and SHINGRIX© . . . . . . . . .Pg 40h. Part D Utilization

Management Requirements . . . . . . . . . . . .Pg 40 i. Prior Authorization . . . . . . . . . . . . . . . . .Pg 40 ii. Quantity Limits . . . . . . . . . . . . . . . . . . . . Pg 41

iii. Part B Benefit versus Part D benefit (B/D) . . . . . . . . . . . . . . . . Pg 41

i. Diabetic Glucose Monitors, Test Strips, and Supplies . . . . . . . . . . . . . . Pg 41

j. Self-Administered Drugs in an Outpatient Setting . . . . . . . . . . . . . . .Pg 42

k. Non-Covered Part D Utilization Management Requirements . . . . . . . . . . . .Pg 42

SECTION 9:Claims Processing Procedures and Guidelines . . . . . . . . . . . . . .Pg 43a. Copayment and Coinsurance . . . . . . . . . .Pg 43b. Submission of Charges

(Claims and Encounters) . . . . . . . . . . . . . .Pg 44 i. Essential Documentation . . . . . . . . . . . .Pg 44 ii. Tips for Submitting Paper Claims . . . . . .Pg 44c. Remittance Advice . . . . . . . . . . . . . . . . . . .Pg 45d. Corrected Claims Submission . . . . . . . . . .Pg 45e. Request for Claims Review Form . . . . . . . .Pg 45f. Claims Timely Filing Limitations . . . . . . . . .Pg 46g. Provider Portal . . . . . . . . . . . . . . . . . . . . . .Pg 46h. Transfer of Claims from Medicare

Part B Carrier/MAC to MediGold . . . . . . . . Pg 47i. Coordination of Benefits . . . . . . . . . . . . . . Pg 47j. Secondary Payor . . . . . . . . . . . . . . . . . . . .Pg 48k. Medicaid as a Secondary Payor . . . . . . . .Pg 48l. Subrogation and

Workers’ Compensation. . . . . . . . . . . . . . .Pg 48

SECTION 10:Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 49a. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 49b Monitoring and Auditing First Tier,

Downstream and Related Entities (FDR) . .Pg 49c. Annual Compliance Attestation by FDRs . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 49d. Compliance Reporting . . . . . . . . . . . . . . . .Pg 49


Table of Contents

SECTION 11:Special Investigations Unit . . . . . . . . . . . . . . .Pg 49a. Fraud, Waste and Abuse . . . . . . . . . . . . . .Pg 49 i. What is Medicare FWA? . . . . . . . . . . . .Pg 49 ii. Examples of Provider, Pharmacy,

or Vendor FWA . . . . . . . . . . . . . . . . . . .Pg 50 iii. Disclosure of Ownership, Exclusion

and Criminal Conviction . . . . . . . . . . . .Pg 50 iv. How to Report FWA. . . . . . . . . . . . . . . .Pg 50

SECTION 12: Network Participation Responsibilities . . . . Pg 51a. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 51b. How to Become a Participating

Provider with MediGold . . . . . . . . . . . . . . . Pg 51c. MediGold’s Code of Conduct . . . . . . . . . . Pg 51d. Credentialing Process . . . . . . . . . . . . . . . . Pg 51 i. Physician Credentialing . . . . . . . . . . . . . Pg 51 ii. Initial Credentialing . . . . . . . . . . . . . . . .Pg 52 iii. Recredentialing . . . . . . . . . . . . . . . . . . .Pg 52 iv. Facility Credentialing

and Recredentialing . . . . . . . . . . . . . . . .Pg 52 v. Summary Suspension . . . . . . . . . . . . . .Pg 52e. Provide Official Notice . . . . . . . . . . . . . . . .Pg 54f. Transition of Member Care Following

Termination of Your Participation . . . . . . . .Pg 55g. Performance Assessment . . . . . . . . . . . . .Pg 55h. Provisions of Access to Your Facility . . . . .Pg 55i. Physician Incentive Plan

Regulation Compliance . . . . . . . . . . . . . . .Pg 55j. Remediation Policy . . . . . . . . . . . . . . . . . .Pg 55k. Medicare Advantage

Participation Provisions . . . . . . . . . . . . . . .Pg 56

SECTION 13:Member Grievance and Appeal Process . . . .Pg 61a. General Information on

Medicare Appeals Procedures . . . . . . . . . .Pg 61b. Who May File an Appeal . . . . . . . . . . . . . .Pg 62c. Support for the Appeal . . . . . . . . . . . . . . .Pg 62d. Assistance with Appeals . . . . . . . . . . . . . .Pg 62e. Medicare Standard Organization

Determination and Appeals Procedures . .Pg 62f. Medicare Expedited/72-Hour

Determination and Appeal Procedure . . . .Pg 65g. Types of Decisions Subject to

Expedited/72-Hour Review . . . . . . . . . . . .Pg 65h. How to Request an

Expedited/72-Hour Review . . . . . . . . . . . .Pg 65i. How an Expedited/72-Hour

Determination/Review Request will be Processed . . . . . . . . . . . . . . . . . . . .Pg 66

j. MediGold Grievance Procedures . . . . . . . .Pg 67k. Quality Improvement Organization

Immediate Review of Hospital Discharges . . . . . . . . . . . . . . . . . . . . . . . . .Pg 68l. Quality Improvement Organization

Quality of Care Complaint Process . . . . . .Pg 69


SECTION 1: Welcome

WelcomeWelcome and thank you for participating in the MediGold Provider Network. We appreciate your partnership in delivering high-quality care and better outcomes for our members-your patients. Communication is key to any successful relationship, so we hope you find the contents in this manual helpful and let us know if we can do anything to make working with us easier.

IntroductionMediGold is a Medicare Advantage plan founded in 1997. We are a provider-sponsored organization dedicated to providing exceptional coverage, customer service and access to high quality and cost-effective care.

We are a not-for-profit organization that is a part of the Trinity Network and are contracted with the Centers for Medicare & Medicaid Services (CMS) to participate in the Medicare Advantage program offering HMO and PPO products with, and without, Part D drug coverage to Medicare beneficiaries.

You can find details on our products at: MediGold.com.

We are committed to partnering with our providers to build strong relationships and make working with us easier. We developed this manual to guide you through MediGold policies, procedures and processes. Great effort has been made to ensure the information in these pages is accurate. If there is any conflict between the contents of this manual and your provider agreement, the provider agreement will prevail. Please contact provider services if you have any questions.

Note: Throughout this manual we refer to “the Plan” and “MediGold” interchangeably

Important News and Updates tothis ManualIn accordance with your agreement, providers must abide by all provisions contained in this manual, as applicable. Revisions to this manual constitute revisions to MediGold’s policies and procedures. Such revisions and other updates to policies and procedures may be communicated to network providers via the monthly MediGold Provider Update, but may also be communicated multiple methods that may include mail, internet, email, telephone, and in person.

Provider CommunicationsWe want to be a great partner and developmutually beneficial partnerships with our providers. Communication is essential to successful relationships and sharing information with you is very important to MediGold. We distribute a monthly “MediGold Provider Update” to all our participating providers. It shares key information to stay current on matters that may affect your work with MediGold and our members.

If you are not currently receiving this communication, please go to MediGold .com/For-Providers to sign up.

http://MediGold.com

http://MediGold.com/For-Providers


SECTION 2:How To Contact MediGold

Case Management1-800-240-3870, option 48 – 4:30 p.m. Monday – FridayToll Free Fax: 1-833-263-4870Email: [email protected]

Compliance Toll Free: 1-833-263-4862 Toll Free Fax: 1-833-976-0037 Email: [email protected]

Contracting & Provider RelationsToll Free: 1-800-991-9907 (TTY 711) Toll Free Fax: 1-833-900-0608Email: [email protected]

Member Grievance and AppealsToll Free: 1-888-898-6129 (TTY 711) Toll Free Fax: 1-833-802-2495 Email: [email protected]

Member ServicesToll Free: 1-800-240-3851 (TTY 711) Toll Free Fax: 1-833-900-0606

Pharmacy Benefit ManagerCVS Caremark Part D Services, LLC P.O. Box 52066 Phoenix, AZ 85072-2000 Phone: 1-866-785-5714

Provider Service CenterToll Free: 1-800-991-9907 (TTY 711) Toll Free Fax: 1-833-900-0606

Quality ManagementEmail: [email protected]

Risk AdjustmentEmail: [email protected] Toll Free Fax: 1-833-978-1756

Department Phone Numbers

Address: 6150 East Broad St ., EE320, Columbus, OH 43213

Website: MediGold .com

Provider Portal: MediGold.com/For-Providers/Provider-Portal

Current Provider Administrative Manual: MediGold.com/For-Providers/Tools-and-Resources/

Current Member Evidence of Coverage: MediGold.com/Members/Member-Materials

mailto:MediGoldCompliance%40mchs.com?subject=

http://MediGold.com

http://MediGold.com/For-Providers/Provider-Portal

http://MediGold.com/For-Providers/Tools-and-Resources/

http://MediGold.com/Members/Member-Materials


Special Investigations Unit (SIU) For Fraud, Waste, and Abuse ConcernsVoicemail: 1-833-263-4863 ......................We are committed to partnering with you! If you suspect

someone of committing fraud, please report any suspicious Email: [email protected] fraudulent activity in one of these ways. Toll Free Fax: 1-833-900-0606 Anonymous: MediGold.com/SIU

Utilization ManagementToll Free: 1-800-240-3870 ........................To obtain prior authorization or notify us of the procedures Toll Free Fax: 1-833-263-4869 or listed on the Prior Authorization List, services concurrent review, or to make a referral. Stars and HEDISLocal: 1-888-898-6129 Toll Free Fax: 1-833-263-4823 Email: [email protected]

TruHearing Toll Free: 855-286-0550 ...........................Contact for audiology and hearing aid services.

MediGold Vision1-866-253-8963 ........................................8 a.m. - 8 p.m., 7 days a week.

SECTION 2:How To Contact MediGold

Department Phone Numbers Continued

mailto:SIU.MediGold%40mchs.com?subject=

http://MediGold.com/SIU


SECTION 3: Eligibity And Enrollment

Enrollment

There are limits to when and how often Medicarebeneficiaries can change the way they receivetheir Medicare benefits:

Between Oct. 15 and Dec. 7 each year, anyone can make any type of change, including adding or dropping Medicare prescription drug coverage.

From January 1 through March 31, anyone enrolled in a Medicare Advantage Plan (except those with an MSA plan) has an opportunity to change plans or return to Original Medicare.

Anyone who disenrolls from a Medicare Advantage plan during this time can join a stand-alone Medicare Prescription Drug Plan during the same period.

Generally, you may not make changes at other times unless you meet certain special exceptions; such as if you move out of the plan’s service area, want tojoin a plan in your area with a 5-Star Rating or qualify for extra help with your prescription drug costs.

In general, Medicare beneficiaries are only able to change the way they receive Medicare benefits two times a year (as noted above).

There are special exceptions, for example: ifbeneficiaries move out of a plan’s service area,are institutionalized or have ‘Medicaid’ benefits.

Eligibility

Generally, a Medicare beneficiary is eligible to enroll in MediGold if the following two conditions are satisfied:

He or she is entitled to Medicare Part A and is enrolled in Medicare Part B as of the effective date of enrollment in MediGold.

He or she lives in the service area covered by MediGold.

There are some exceptions to the general rule, and some other eligibility rules. Please contact Member Services for additional information.At each office visit your office staff should:

Ask for the member’s ID card. Copy both sides of the ID card and keep the copy

with the patient’s file. Determine if the member is covered by another

health plan to record information for coordination of benefits purposes.

Refer to the member’s ID card for the telephone number to verify eligibility, deductible, coinsurance, copayments and other benefit information. To view a member’s specific plan benefits, use the Plan number located on the ID card to find the Evidence of Coverage on our website at MediGold.com/Members/Member-Materials.

Participating providers must admit patients to a participating facility unless an emergency situation exists that precludes safe access to a participating facility or if the admission is approved for a non-participating facility.

The member will receive in-network benefits onlywhen services are performed at a participating MediGold provider.

http://MediGold.com/Members/Member-Materials



The Member’s Primary Care Provider

Each member of MediGold who enrolls in one of our HMO products is required to choose his or her own primary care provider (PCP) from a list of network providers. Each PPO member must choose his or her own PCP from a list of our network providers or an out-of-network provider.

Members have the option to change their PCP at any time upon request to MediGold. Changes in PCPs are effective on the first day of the month after the request is processed by MediGold. MediGold will monitor the frequency and reasons members change PCPs. When MediGold determines that frequent changing of a PCP interferes with a PCP’s ability to effectively manage a member’s care, MediGold may limit the ability of a member to change his or her PCP.

To request a PCP change, members must call Member Services Department at toll-free 1-800-240-3851 (TTY 711), or submit a written request to:

MediGold Enrollment Department

Attention: PCP Change Request6150 East Broad Street, EE320 Columbus, OH 43213

You may request a listing of MediGold members assigned to you by contacting provider services.

Membership Identification Card

MediGold issues an identification (ID) Card to each member. Members are required to present their ID cards for medical, hospital, and other covered services. The MediGold ID card will identify MediGold members to you and your staff and provides quick access to pertinent information such as applicable copays, contact numbers to coordinate medical care, hospitalization or other covered services, as well as claims submission information. MediGold members are instructed to put their Medicare cards away for safekeeping and present only their MediGold ID cards at the time of service.

Be sure to check the member’s ID card at each visit, especially the first visit of each year when the information is most likely to change.

MediGold is a registered trade name of Mount Carmel Health Plan, Inc., Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 11

Front of card

Back of card

MediGold’s member ID card was revised to include logos for MediGold and information specific to each of MediGold’s products . For reference purposes, a sample copy of the card follows:

SAMPLE

SAMPLE



SECTION 4: Provider Policies And Protocols

Compliance With Policy/Protocol

According to your provider agreement, you will comply with and be bound by MediGold’s policies and protocols, including those contained in this manual. Failure to comply with such policies and protocols will be reviewed by MediGold and may result in appropriate action in accordance with your provider agreement, such as denial of payment, financial penalties and modifications to your reimbursement or other terms of your agreement with us, or ineligibility to participate in recognition programs.You are not permitted to bill our members for any amounts not paid due to your failure to comply with our policies and protocols .

Provide Timely Notice of Demographic Changes

You must notify us within 30 days of any changes to demographic and participation information that differs from the information reported with your executed provider agreement. These include, but are not limited to: tax ID changes (W9 required), office or remittance address changes, phone numbers, suite

numbers, additions or departures of health care providers from your practice, ability of individual practitioners to accept MediGold members or any other changes that affect availability to MediGold members and new service locations.

If a provider is associated with a group that is delegated for credentialing, please verify that credentialing is not affected by contacting the Provider Service Center at 1-800-991-9907.

If a provider is associated with a group that is delegated for credentialing, please reach out to your group’s point of contact for credentialing.Demographic changes must be completed by submitting a Provider Information Change Form. Provider terminations must be completed by submitting a Provider Termination Request Form.

Forms are available online at MediGold.com/For-Providers/Tools-and-Resources/Forms.


(CONTINUED ON NEXT PAGE)


Prohibited Billing PracticesBalance Billing

Prohibited Billing of Qualified Medicare Beneficiary (QMB) Individuals and Medicare Assignment:

Medicare-covered services, also covered by Medicaid, are paid first by Medicare because Medicaid is generally the payor of last resort. Medicaid may cover the cost of care that Medicare may not cover or may partially cover (such as nursing home care, personal care, and home- and community-based services).

Federal law prohibits all Medicare providers from billing QMB individuals for all Medicare deductibles, coinsurance or copayments. All Medicare and Medicaid payments the provider receives for furnishing services to a QMB individual are considered payment in full. The provider is subject to sanctions if you bill a QMB individual for amounts above the sum total of all Medicare and Medicaid payments, even when Medicaid pays nothing.

In addition, all Medicare providers must accept assignment for Part B services furnished to dual eligible beneficiaries. Assignment means that the Medicare-allowed amount (Physician Fee Schedule amount) constitutes payment in full for all Part B-covered services provided to beneficiaries.

What to do: Ensure that you are checking the eligibility

of your patients. Some Medicare enrollees may qualify for both Medicare and Medicaid services. These members are called Dual Benefits Members.

You may confirm a MediGold member’s eligibility for Medicaid through Medicaid Information Technology System (MITS).

What not to do: The QMB program is a state Medicaid benefit that covers Medicare deductibles, coinsurance and copayments, subject to state payment limits.

Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the state reimburses providers for the full Medicare cost-sharing amounts.

Further, all Original Medicare and MA providers—not only those that accept Medicaid—must refrain from charging QMB individuals for Medicare cost- sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions. Federal law bars Medicare providers from balance billing a QMB beneficiary under any circumstances. See: Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997 .

Non-Covered and/or Not Medically Necessary Services, Integrated Denial Notice (IDN) Required

If you have any reason to believe that MediGold will not cover a service, in whole or in part, and wish to bill the member for such a service, you must contact MediGold’s Utilization Management team prior to performing the services. The utilization management team will review the request and, if the service is not covered under the member’s benefit plan and/or “medically not necessary,” issue an IDN to the member. The member must receive the IDN in advance of receiving the service and must have sufficient time to decide if they want to proceed with the non-covered and/or “medically not necessary” service.

1

2




Meeting the member at your office.

Directing the member to your pre-arranged, network PCP on-call.

Delay in Service

Facilities that provide inpatient services must maintain appropriate staff, resources and equipment to ensure that covered services are provided to our members in a timely manner. A delay in service is defined as a failure to execute a physician order in a timely manner that results in a longer length of stay. A delay in service may result for any of the following reasons:

Equipment needed to execute a physician’s order is not available.

Staff needed to execute a physician’s order is not available.

A facility resource needed to execute a physician’s order is not available. Facility does not discharge the patient on the day the physician’s order is written. Payment to facilities may be affected for delays in service.

Medical Record Requirements

Follow Medical Record Standards

Medical record requests may be made by MediGold and/or its designated vendor for a variety of reasons. Requests for medical records may be necessary in any of the following circumstances:

Additional information is required before MediGold can process a claim.

A complaint or allegation of possible fraud, waste or abuse of the Medicare program which requires investigation.

Any complaint alleging possible quality of care, service or access to care.

Review of an established or new physician or practitioner is warranted, before or after a claim is paid, based on analysis of data.

Non-Covered Services, Integrated Denial Notice (IDN) Required (continued)

Failure to obtain an IDN for a non-covered and/or “not medically necessary” service will result in an administrative denial, for which you may not seek any reimbursement from MediGold or the member.

You should know or have reason to know that a service may not be covered if:

The service is expressly excluded from coverage in the member’s Summary of Benefits and Evidence of Coverage.

We have provided general notice either that we will not cover a particular service or that particular services are only covered under certain circumstances.

We have made a determination that planned services are not covered and/or “not medically necessary” services and have communicated that determination to you.

Member Responsibility: Nothing herein or in your agreement with MediGold prohibits you from collecting any coinsurance, deductible, or copayments specifically identified in the member’s Evidence of Coverage, available online at: MediGold .com/Members/Member-Materials .

You may not bill our members for non-covered services if you do not comply with this policy.

After Hours CareMediGold members are instructed to contact their PCP before any form of care is rendered. Therefore, the PCP may receive telephone calls outside routine office hours. It is incumbent upon you to determine whether the requested care is of an emergency nature. Every reasonable and medically appropriate attempt should be made to give advice and arrange for the member to be seen during regular office hours. As the provider, you should consider:

Meeting the member at the emergency room or directing the member to the nearest urgent care center or emergency room, where appropriate.

https://medigold.com/Members/Member-Materials




Medical Record Requirements (continued)

Payment retraction.

Data collection for HEDIS.

Risk adjustment purposes that include, but are not limited to: verifying the accuracy of coding, ensuring all diagnosis codes are properly supported by relevant medical records, medical record review to identify any conditions not captured through claims or encounter data, and to comply with CMS requests for records when conducting any risk adjustment data validation audits.

CMS request for records (MediGold performs health care operations for CMS).

Additional information is required to support delegation oversight monitoring and auditing activities to ensure compliance with CMS guidelines.

In all cases, it is extremely important that requested records are provided to the proper entity within the timeframe specified.

It is understandable that there are concerns about patient confidentiality, but the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits disclosure of protected health information without a patient’s authorization when the information is necessary to carry out treatment, payment or health care operations.

When Medicare Beneficiaries enroll in MediGold, they are informed of MediGold’s use of their protected health information to carry out health care operations. Providing the requested documentation does not violate HIPAA and does not require additional beneficiary authorization.

Your cooperation is a legal obligation as outlined in the Social Security Act, the law governing Medicare (Section 1842), as well as a contractual requirement of your participation in MediGold. CMS requires MediGold, as one of its contractors, to report suspected fraud. Failure to forward records that substantiate service may force MediGold to consider this action.

If you choose to charge the Plan for medical records, Plan shall reimburse physician for records requested by the Plan at the Medicare rate, plus postage when applicable. Payment shall be made by the Plan to physician upon the Plan’s receipt of the requested records.

General Documentation Guidelines

We also expect you to follow these commonly accepted guidelines for medical record information and documentation:

Date all entries and identify the author.

Make entries legible. If signatures are illegible, you may be required to provide an attestation or signature log.

Cite medical conditions and significant illnesses on a problem list.

Give prominence to notes on medication allergies and adverse reactions. Also note if the member has no known allergies or adverse reactions.

Make it easy to identify the medical history and include chronic illnesses, accidents and operations.

For medication records, include name of medication and dosages. Also, list over-the-counter drugs taken by the member.

Code all ICD-10 codes to the highest specificity.

Document these important items:

All member conditions that are currently being treated or monitored.

Blood pressure.

Height/weight and body mass index (BMI).

Tobacco items, including advice to quit.

Alcohol use and substance abuse.

Immunization record.

Family and social history.

Preventive screenings and services.



Demographic Information

The medical record for each MediGold member should include:

Member name and/or ID number on every page.

Gender.

Age or date-of-birth.

Address.

Marital status.

Occupational history.

Home and/or work phone numbers.

Name and phone number of emergency contact.

Name of spouse or relative.

Insurance information.

Member EncountersWhen you see MediGold members, document the visit by noting:

Member’s complaint or reason for the visit.

Physical assessment.

Unresolved problems from the previous visit(s).

Diagnosis and treatment plans consistent with your findings.

Member education, counseling or coordination of care with other providers.

Date of return visit or other follow-up care.

Review by the primary physician (initialed) on consultation, lab, imaging, special studies andancillary, outpatient and inpatient records.

Consultation and abnormal studies are initialed and include follow-up plans.

Clinical Decision and Safety Support Tools in Place to Ensure Evidence-Based Care is Provided

Examples of clinical decision and safety supporttools include, but are not limited to:

ALT/AST laboratory test done if member taking statins.

Immunization tracking sheet.

Flow sheet for chronic diseases.

Member reminder system.

Electronic medical records.

E-prescribing.

Risk Adjustment InformationIn 1997, CMS created a new payment methodology for Medicare Advantage plans. The new methodology uses the health status of Medicare beneficiaries to determine accurate payment rates.Physicians and other health care providers play an important role in risk adjustment because CMS looks at provider encounter data (extracted by MediGold from claims) to determine payment rates.Encounter data you submit to MediGold must be accurate and complete.

Risk adjustment is based on ICD-10 diagnosis codes, not CPT codes. Therefore, it is critical for your office to refer to an ICD-10-CM coding manual and code accurately, specifically and completely when submitting claims to MediGold.

Diagnosis codes must be supported by the medical record. If it is not documented in the medical record, MediGold won’t recognize it as an existing condition. Medical records must be clear and complete.

Never use a diagnosis code for a ‘probable’ or ‘questionable’ diagnosis. Instead code only to the highest degree of certainty.




Risk Adjustment Information (continued)

Be sure to distinguish between acute vs. chronic conditions in the medical record and in coding. Only choose diagnosis code(s) that fully describe the member’s condition and pertinent history at the time of the visit.

Be sure that the diagnosis code is appropriate for the member’s gender.

Always carry the diagnosis code all the way through to the correct digit for specificity. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character where applicable. (Where place holders exist, ‘X’ must be used for the code to be valid).

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.

CMS will conduct an encounter data validation study on an annual basis by reviewing a sample of provider medical records to ensure coding accuracy. You may be contacted by MediGold requesting medical records for data validation . In order for a chart to be valid the following criteria must be met:

Complete patient demographic information

Date of Service

Valid Signature

Illegible provider signature will require a signature attestation per CMS guidelines

Documentation must indicate the diagnoses are being monitored, evaluated, assessed/addressed, or treated (MEAT).

Risk Adjustment Processing System (RAPS) & Encounter Data Processing System (EDPS)

MediGold is required to submit accurate diagnosis

information on all of its members to CMS through

the Encounter Data Processing System (EDPS).

For EDPS submissions, CMS will filter claims data

according to their risk adjustment guidelines. This

filtering logic may prevent some claims that have

traditionally been paid by MediGold from being

accepted by CMS for risk adjustment purposes.

Because of this, there may be instances where

MediGold will need to reach out to a provider to

obtain missing or incomplete data that would be

needed for Risk Adjustment submissions. Below are

the CMS websites that provide technical information

on EDPS guidance.

Medicare Encounter Data System—Institutional Companion Guide

Medicare Encounter Data System—Professional Companion Guide

Medicare Encounter Data System—DME Companion Guide

https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Downloads/5010A2837ACG.pdf

https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Downloads/5010A1837BCG.pdf

https://www.csscoperations.com/internet/cssc3.nsf/files/Jul2016_CG_837P-DME_v2_5CR_081016.pdf/$FIle/Jul2016_CG_837P-DME_v2_5CR_081016.pdf



Improper Payment Measure (IPM)

In accordance with risk adjustment requirements, CMS performs risk adjustment data validation (IPM) audits to validate the MediGold members’ diagnosis data that was submitted by MediGold drawn from provider claims submissions. These audits are typically performed annually. If MediGold is selected by CMS for a IPM audit or to validate submitted diagnosis information, you are required, as a participating provider to comply and timely submit requested medical records to substantiate the diagnosis data submitted.

Informing Members of Advance Directives

The federal Patient Self-Determination Act (PSDA) gives individuals the legal right to make choices about their medical care in advance of incapacitating illness or injury through advance directive.

Under this federal act, physicians and other professional providers, including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to members on state laws about advance treatment directives, about members’ rights to accept or refuse treatment and about your own policies regarding advance directives.

To comply with this requirement, we also inform members of laws on advance directives through our Member Agreement and other communications. We encourage these discussions with your patients.

As long as the member can speak for him/herself, you must honor his/her wishes. If the member becomes so sick that he/she cannot speak for him/herself, then this directive will guide you in treating the member and will save the member’s family, friends and other providers from any guesswork as to what course of treatment, if any, the member would have wanted.

There may be several types of advance directives to choose from, depending on state law. Most states recognize:

Durable Power of Attorney for Health Care (DPAHC): DPAHC form allows the member to appoint an agent (family, friend or other person) whom he/she trusts to make treatment decisions for him/her should there come a time the member is unable to make them for him/herself.

Living Wills: The living will is a document through which a member may inform his/her physician that, if the member has a terminal condition (no chance of recovery) and death will occur in a relatively short period of time, the member only wants a desired level of care provided. This document goes into effect only when a member is permanently unconscious or terminally ill and can no longer speak for him/herself.

Rights of the Terminally Ill Act: Members have the right to control decisions relating to their medical care when they are terminally ill. This includes the decision not to undergo procedures that extend life in case of a terminal illness. To do this, the member must make a written notice advising his/her physician to withhold or withdraw procedures that continue life in the event of a terminal condition. The member is encouraged to give this form to his/her physician and closest relative and it should be kept on file should the event ever occur. You must document in a prominent part of the member’s medical record whether or not the member has executed an advance directive.

Referrals/Prior Authorization RequestsAll referrals and prior authorization requests for MediGold members for out-of-network services must be made by a network provider. Prior authorization is not required for referrals for in-network services however, all referrals and prior authorization requests for out-of-network services should be made by a network provider.




Referrals/Prior Authorization Requests (continued)

You are responsible for the care of your members whether you provide the care directly or indirectly. Medical care, including diagnostic testing, sought out-of-network (excluding emergent or urgent care) at your direction but not prior authorized, will be subject to MediGold’s Remediation Policy. Prior authorization requests received after the date of service will not be processed.

See the Utilization Management Section in this manual for more details . MediGold Member Rights and Responsibilities

We tell our members that they have the following rights and responsibilities, all of which are intended to help uphold the quality of care and services they receive from you.

MediGold Members’ Rights

To be treated with dignity, respect and fairness at all times by MediGold and network providers.

Privacy of your medical records and personal health information.

To see network providers and get covered services within a reasonable period of time and within a reasonable distance from your home.

To know your treatment choices and to participate in decisions about your health care.

To use advance directives (such as a living will or a power of attorney).

To make complaints if you experience problems or have concerns related to your coverage or your care.

To obtain information about your health care coverage and costs.

To obtain information about MediGold and network providers.

MediGold Members’ Responsibilities

Be familiar with your coverage and the rules to follow to obtain care as a member.

Give your physician and other professional providers the information they need to care for you, and to follow the treatment plans and instructions that you and your providers have agreed upon.

Act in a way that supports the care given to other patients and does not prevent the provider or MediGold office from running smoothly.

Pay your plan premiums and any copayments/coinsurance you may owe for covered services received.

Contact us with any questions, concerns, problems or suggestions.


SECTION 5: Quality Management

Regulatory Requirements

An effective Quality Management (QM) program must comply with the applicable federal and state standards. Compliance requires the collaborative efforts of MediGold and all network providers. MediGold must meet all regulatory requirements of the MA program, including required quality improvement projects, Stars and HEDIS, enrollee satisfaction surveys and surveys to assess enrollees’ understanding of their health outcomes.

The requirements MediGold must comply with regarding quality are published in the Medicare Managed Care Manual, Chapter 5. This chapter describes how MediGold must operate and perform quality measurement and improvement related to the delivery of health care and enrollee services. The chapter’s purpose is to assist MA organizations in developing quality assurance and performance improvement programs, as well as to provide CMS with a road map for monitoring the MA Plan’s Quality Management program.

The requirements in Chapter 5 include:

Formal QM program with participation by network providers.

Chronic Care Improvement Program (CCIP).

Minimum performance levels in studies.

Annually reported standard quality-related measures including Healthcare Effectiveness Data & Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcome Survey (HOS).

Maintenance of a health information system that integrates all data necessary to implement the QM program.

Identification and correction of significant systemic problems.

Contract with the independent Quality Improvement Organization (QIO)

Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is a set of standardized performance measures. The purpose of HEDIS is to provide members with a means to assess the value they receive for their health care dollar and to hold health plans accountable for their performance. As a network provider, you may, at times, be required to assist in medical record data collection.

Currently, there are 91 measures across seven (7) domains of care .

These domains are:

1 Effectiveness of care .

2 Accessibility/availability of care .

3 Experience of care .

4 Relative resource use .

5 Utilization and risk-adjustment utilization .

6 Health plan descriptive information .

7 Measures collected using electronic clinical data systems .



What are Medicare Star Ratings?

The CMS uses a 5-Star quality rating system to measure how well providers and Medicare Advantage health plans are delivering care to members. Successful collaboration with our providers and quality patient care for our members is very important to us. Ratings range from 1 to 5 stars, with 5 being the highest and 1 being the lowest.

The Star measures are made up of performance measures from HEDIS, CAHPS, HOS (measures comparison of members health plan assessment over 2 years), prescription drug program and CMS administrative data.

Star Ratings include measures applied to the following five broad categories:

1 Outcomes: measures that reflect improvements in a member’s health .

2 Intermediate outcomes: measures that reflect actions taken with patients that assist in improving a member’s health status, i .e . controlling blood pressure .

3 Patient experience: measures that reflect the member’s perspectives of the care they receive .

4 Access measures: measures that reflect processes and issues that could create barriers to receiving needed care, i .e ., Plan makes timely decisions about appeals .

5 Process measures: those that capture the health care services provided to members who can assist in maintaining, monitoring or improving their health status .

Program Goals

The MediGold QM program is a comprehensive program designed to comply with regulatory requirements to monitor the quality of care and services provided by the MediGold delivery system. This includes administrative activities of the Plan and its contracted providers.

The program’s purpose is to pursue opportunities for improving medical care, service and the well-being of MediGold members. The focus is on continuous quality improvement with a constant eye on how care and services can be provided at a higher level of quality. Dedicated MediGold resources are allocated to conduct ongoing quality assessment of performance toward goals with problem resolution, as necessary.

The QM program focuses on three dimensions of health care delivery:

1 Delivery system structure itself .

2 Processes involved in delivering health care .

3 Results of care delivery .

By continuously monitoring and evaluating these three dimensions of health care delivery, MediGold constantly strives to provide the highest quality care in the most appropriate setting in the most efficient manner to attain the utmost satisfaction of MediGold members.



Program Activities

A variety of activities are involved in implementing the MediGold QM program including, but not limited to, the following:

Risk management/quality concern reporting.

Monitoring of member service activities, including complaints, appeals and grievances.

HEDIS data collection/monitoring.

Member satisfaction surveys.

Member-based performance improvement projects/studies.

Provider-based performance improvement.

Physician access and availability surveys.

Review of quality concerns for each physician at the time of recredentialing.

Required data reporting to CMS, such as hospital acquired conditions and serious reportable adverse events.

Risk Management/Quality Concern Reporting

The goal of Risk Management, a component of the QM program, is to control and minimize possible risks arising in the direct provision of care, as well as risks associated with administration of the Plan. The Risk Management/Quality Concern Reporting Form provides a reporting mechanism for contracted providers to report risk management cases or quality concerns. This reporting mechanism is used to identify cases/incidents with potentially serious, undesirable and/or unexpected occurrences that may include loss of life, limb or function or has the potential to adversely affect MediGold’s reputation. If there is a risk management or quality concern issue in your office regarding a MediGold member, please contact MediGold’s QM Department at the email listed in the Contact Us section of this manual.

Outcomes, Evaluations and Member-Based Studies

The outcomes of clinical care are measured in the following terms: improved health, illness and death reduction, whether the treatment or therapy improved outcome as planned, whether the medical action positively altered the course of the disease’s natural history and whether clinical actions taken provided positive outcomes. Outcomes evaluation identifies potentially adverse events resulting from quality issues. Adverse outcomes identified in significant number or scope are investigated and member-based studies are conducted to improve measurable outcomes.



Access and Availability

An additional measure of quality is the access to care and availability for MediGold members. Access means that medically necessary care is available in a timely manner and that members are able to schedule appointments and obtain any required referrals, as indicated, based on clinical needs. Availability means that MediGold has made arrangements for the provision of all covered services to members by the proper types, mix and number of network providers. The standards for measuring the adequacy of access and availability are stipulated in the MediGold Provider agreement and MediGold’s Network Practitioner’s Access and Availability Standards.

The access and availability requirements which have been approved by MediGold’s Quality Management Committee are as follows:

Telephone coverage service 24 hours a day, seven (7) days a week.

Member calls returned within 24 hours. This includes attempts made to members by leaving voice mail messages, leaving verbal messages with other relatives, etc.

Urgent appointments scheduled with the PCP or a network PCP acting on your behalf within three days of the request. Urgent appointments are identified as any convolution of persistent symptoms which are perceived urgent by a prudent layperson or that may endanger members not seen within 48 hours.

Routine appointments are scheduled by the PCP or a network PCP acting on your behalf within ninety (90) days of request.

Members with a concern they view as needing medical attention prior to routine appointments, under the assistance of health plan case management, may be requested for access within the 90-day timeframe.

Covered services are provided in a culturally competent manner to all members including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds and physical or mental disabilities.

Members have timely access to copies of pertinent information from their medical records.

Compliance with standards is evaluated by reviewing medical records, claims and encounter history, scheduling systems and records, complaints and grievances, and member satisfaction and disenrollment surveys.

Member and Provider Satisfaction

MediGold monitors members’ perceptions of the quality of care and services received. Member satisfaction is considered an indicator of the success of an organization in providing quality care.

MediGold assesses member satisfaction using the following sources of information: member complaints and grievances, PCP change requests, and random sampling by CMS through use of standardized disenrollment surveys and member satisfaction surveys. MediGold may also periodically conduct independent provider and member satisfaction surveys to assess provider access and availability, members’ perception of access to care and services, wait times, referrals, explanations of care, members’ education and members’ participation in the decision-making process to meet their health care goals.

MediGold also monitors providers’ perceptions of the quality of administrative services provided by MediGold. Network provider surveys are periodically conducted to evaluate provider satisfaction and identify areas for improvement.


SECTION 6: Utilization Management

Utilization Management

Overview

The purpose of MediGold’s Utilization Management Program is to ensure the delivery of medically necessary, optimally achievable, quality care through appropriate utilization of resources in a cost effective and timely manner to all members. To ensure this level is achieved and/or surpassed, programs are consistently and systematically monitored and evaluated.

Utilization management is performed to ensure an effective and efficient medical and behavioral health care delivery system. It is designed to evaluate the cost and quality of medical services provided by participating physicians, hospitals and other ancillary providers.

The goal of utilization management is to assure appropriate utilization and to achieve the following objectives for all members to:

Assure effective and efficient utilization of facilities and services through an ongoing monitoring and educational program. The program is designed to identify patterns of utilization, such as overutilization, underutilization and inefficient scheduling of resources.

Assure fair and consistent utilization management decision-making.

Educate medical providers and other health care professionals on appropriate and cost-effective use of health care resources. MediGold works cooperatively with its participating providers to assure appropriate management of all aspects of the members’ health care.

Continually improve the quality of care and resource allocation within the organization.

Evaluate advancing medical technologies to determine the level of coverage provided to members.



Medical Necessity

The utilization management process will assess, direct and efficiently control health care resources in a cost-effective manner while maintaining high-quality care. This process is accomplished through comprehensive interdisciplinary utilization and case management programs.

MediGold utilizes evidence-based medicine in its decision-making process. Utilization management review is applied in the determination of medically necessary services, ensuring that the criteria are applied consistently and fairly to all members. Criteria is reviewed and updated on an annual basis and is available to providers as requested.

Resources utilized by MediGold in determining medically necessary services include, but are not limited to:

Medicare National and local coverage determinations.

MCG Rapid Recover Guidelines.

National Comprehensive Cancer

MediGold policies and procedures.

Attending practitioner exam.

Recommended treatment plans.

Medical records (hospital and office).

Board-certified practitioner who is a peer of the attending practitioner.

Member contract (benefits/criteria related to the request).

Practitioner contacts (consultations and/or information).

Medical literature.

According to Plan policy, medical necessity is defined as those services determined by MediGold or its designated representative to be:

Preventive, diagnostic and/or therapeutic in nature.

Specifically relates to the condition which is being treated/evaluated.

Rendered in the least costly medically appropriate setting (e.g., inpatient, outpatient, office), based on the severity of illness and intensity of service required.

Not solely for the member’s convenience or that of his or her physician.

Supported by evidence-based medicine.

The information needed will often include the following:

Patient name, MediGold ID#, age, gender.

Brief medical history.

Diagnosis, co-morbidities, complications.

Signs and symptoms.

Progress of current treatment, including results of pertinent testing.

Providers involved with care.

Proposed services.

Referring physician’s expectations.

Psychosocial factors, home environment.

Prior Authorization

Prior authorization is conducted to determine if the:

Requested treatment is a covered service.

Service is medically necessary and appropriate.

Service is performed by an appropriate provider.

Please refer to the MediGold Prior Authorization List through the MediGold website at:

MediGold.com/For-Providers/Tools-and-Resources/Utilization-Management/Prior-Authorization-MediGold

https://www.medigold.com/For-Providers/Tools-and-Resources/Utilization-Management/Prior-Authorization-MediGold




A complete list of procedure codes requiring prior authorization is available online at: MediGold.com/For-Providers/Tools-and-Resources/Utilization-Management/Prior-Authorization-MediGold

Prior Authorization requests may be submitted to MediGold as follows:

Online: Currently, SNF and Oncology Services can submit the prior authorization request and upload clinical support documentation using the Essette Provider Portal. There will be future services added to this submission process in the future. The link is available on our website at: https://provider.medigold.com/AuthPortal/Login.aspx

You will be asked a series of clinical questions

If Milliman Care Guidelines criterion are met, you will receive an approval along with authorization number for your records.

If you do not receive an approval upon submission, the request will be reviewed by our Plan nurses and medical directors for determination.

Email: All services may submit an email authorization request, along with clinical supporting documentation to:

Hospital Admission and Concurrent Review: [email protected]

Skilled Nursing Admission and Concurrent Review: [email protected]

All other preservice requests: [email protected]

Fax: You may submit a prior authorization request, along with clinical support documentation, using our form by faxing to 1-833-263-4865 (Toll Free).

Our form can be found on our website at https:// medigold.com/For-Providers/Tools-and- Resources/Forms

The request will be reviewed by our Plan nurses and medical directors for determination.

Phone: All services may submit an authorization request via phone. Please call 1-800-240-3870 and follow the prompts to load an authorization.

Turnaround Time for Pre-Service Organizational Determinations:

CMS allows up to 14 calendar days for standard organizational determinations. MediGold goal, if all information is submitted timely, is 3-5 calendar days.

CMS allows up to 72 hours for standard Part B drugs.

CMS allows up to 72 hours for expedited organizational determinations.

CMS allows up to 24 hours for expedited Part B drugs

Prior Authorization Decision-Making Process

Utilization review nurses determine medical necessity following the hierarchy of these guidelines, as applicable:

1. Medicare NCD-LCDs.

2. MCG (Milliman Care Guidelines).

3. National comprehensive cancer network (NCCN).

4. MediGold clinical policies.

5. MediGold medical director clinical judgement.

Services requiring prior authorization, for which prior authorization is not obtained, will not be covered by MediGold. If the ordering network provider does not obtain the required prior authorization they will be subject to MediGold’s Remediation Policy.

Utilization patterns are monitored by MediGold and could lead to corrective action plan recommendations. Utilization data is included in physician profiling and may be considered at the time of re-credentialing.

When MediGold denies a prior authorization request for payment or services, we must issue a written integrated denial notice (IDN) to an enrollee, an enrollee’s representative, or an enrollee’s physician. See the Policies and Provider Protocol section for more details.

Referral Policies

The referring provider or his/her designee is responsible for communicating the information, limitations and terms (authorization number, approved number of visits, approved services, and effective dates) of the referral/authorization to the referred-to provider by mail, fax or telephone. It is important for the referred-to provider to document the referral authorization number in the member’s medical record (or log book as appropriate) for future reference to facilitate appointment scheduling and claims submittal.






Referrals to out-of-network providers are authorized when a covered service is not available within the existing network of MediGold network providers. The referral must be requested by a network provider. Please attach referral to the prior authorization request form and include any documentation explaining the circumstances under which the member’s medically necessary need for covered services cannot be addressed by a MediGold network provider. Circumstances may include the existence of an ongoing treatment plan and/or a specific covered service that is not available from a MediGold network provider.

Services requiring prior authorization for which prior authorization is not obtained will not be covered by MediGold. If the ordering network provider does not obtain the required prior authorization they will be subject to MediGold’s Remediation Policy.

Utilization patterns are monitored by the MediGold Utilization Management Committee, which may recommend corrective action plans.

Utilization data is included in physician profiling and may be considered at the time of re-credentialing.

Hospital Notifications

Notifications are communications to MediGold regarding a member’s admission to or discharge from a hospital. Admission notification must be made within 2 business days and can be submitted by faxing a completed Hospital Admission Notification Form toll free at 1-833-263-4866 . This form can be found at MediGold .com/For-Providers/Tools-and-Resources/Forms . Notification of the members discharge date must be provided within 2 business days.

Concurrent Review

MediGold ensures the oversight and evaluation of members when admitted to hospitals, rehabilitation centers, and skilled nursing facilities (SNF). This oversight includes reviewing continued inpatient stays to ensure appropriate utilization of health care resources and to promote quality outcomes for members.

MediGold provides oversight for members receiving acute care services in facilities mentioned above to determine the initial/ongoing medical necessity, appropriate level of care, appropriate length of stay, and to facilitate a timely discharge.

Concurrent review is initiated as soon as MediGold’s utilization review nurses are notified of the admission. Subsequent reviews are based on the severity of the individual case, needs of the member, complexity, treatment plan and discharge planning activity. The authorization will occur concurrently based on guidelines for appropriateness of continued stay to:

Ensure that services are provided in a timely and efficient manner.

Make certain that established standards of quality care are met.

Implement timely and efficient transfer to a lower level of care when clinically indicated and appropriate.

Complete timely and effective discharge planning.

Identify referrals appropriate for case management (CM) or quality-of-care review.

Identify cases appropriate for follow up by the CM/service coordinator.

Concurrent review decisions are made utilizing the following criteria:

Medicare National and local coverage determinations.

MCG Rapid Recovery Guidelines.

MediGold clinical judgement.

Medicare guidelines.


https://www.medigold.com/For-Providers/Tools-and-Resources/Forms

https://www.medigold.com/For-Providers/Tools-and-Resources/Forms



Readmission Reimbursement

It is the policy of MediGold to reimburse facilities at outpatient/observation payment rate (this applies to contracted and non-contracted providers) for 30-day readmissions. This is based upon claims payment policies and is not based on medical necessity.

A readmission is defined as an admission to the same facility within 30 days from discharge of the original admission.

Exclusions include:

Admissions for chemotherapy or immunotherapy treatment.

Admissions to a psychiatric or substance abuse facility.

Admissions to an inpatient rehabilitation unit.

Elective admissions or procedures.

Readmission after a member is discharged from the hospital against the physician’s medical advice.

Transfers of patients to receive care not available at the first facility.

Catastrophic cases defined as members receiving intense services for a prolonged period of time and as determined by a plan medical director.

If during the concurrent utilization review process it is determined that the readmission criteria was met then the case is approved for payment at an observation level of care.

These review criteria are utilized as a guideline. Decisions will take into account the member’s medical condition and co-morbidities. The review process is performed under the direction of the MediGold medical director.

Frequency of review will be based on the clinical condition of the member. The frequency of the reviews for extension of initial determinations is based on the severity/complexity of the patient’s condition, necessary treatment and discharge planning activity, including possible placement in a different level of care. Clinical information is requested to support the appropriateness of the admission, continued length of stay, level of care, treatment and discharge plans

As a Medicare Advantage Plan, MediGold is not required to follow original Medicare billing and claims processing procedures (Medicare Managed Care Manual Chapter 4- Section 10.2). As such, MediGold does not follow the CMS Inpatient Only List, nor do we utilize the 2 Midnight Rule to determine and or assign inpatient level of care.

STEP-BY-STEP LEVEL OF CARE REVIEW PROCESS In cases where the hospital case manager and MediGold utilization review nurse do not agree on the decision:

Step 1: Hospital case manager sends additional clinical information to the MediGold Utilization Nurse to review. If a consensus cannot be reached at the Nurse level, please move to step 2.

Step 2: Physician-to-physician (peer-to-peer) A physician involved with the patient’s care or physician advisor may request a Physician to Physician (peer to peer) discussion with a medical director by calling Utilization Management at 1-800-240-3870 within two business days of receiving the notice of determination. (If P2P is post-discharge, it is considered a request for review in step 3.)

Step 3: Request for Review of Inpatient Status. All post-discharge requests for review must be submitted within 90 days from the date of discharge. This is a final review of level of care and a decision will be provided within 7-10 business days of submission.




Urgent Care and Emergency Services

Urgently needed services are covered services provided in- and out-of-network when such services are medically necessary and immediately required:

As a result of an unforeseen illness, injury, or condition.

It is not reasonable, given the circumstances, to obtain the services through network providers.

Emergency services are covered inpatient and outpatient services that are furnished by a qualified provider needed to evaluate or stabilize an emergency medical condition as defined below:

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in serious:

Jeopardy to the health of the individual or in the case of a pregnant woman, her unborn child.

Impairment to bodily functions. Dysfunction of any bodily organ or part.

For emergency services:

Members are instructed to proceed to the nearest health care facility, whether or not that facility is a MediGold network provider. Members may contact their PCP if uncertain about their clinical condition or how to proceed. When calling the PCP, the member may be instructed to proceed to the nearest facility or to dial 911.

When a MediGold member presents to a network hospital emergency room for care and is admitted as an inpatient, the network hospital is required to notify MediGold within two business days.

For emergency services obtained from out-of- network providers, the member, the member’s family member or attending physician is responsible for notifying the member’s PCP within 48 hours.

MediGold reserves the right to transfer members whose condition is stable to network providers when the transfer can take place without harm to the member. MediGold also reserves the right to retrospectively review emergency room and urgent care records and may subsequently determine that the care was not a medically necessary emergency or an urgently needed service. This retrospective review may occur at the point of claims adjudication and/or upon UM audit of ER/urgent care services. MediGold will consider the perception of a ‘prudent layperson’ when reviewing urgently needed or emergency services.

Notifications to Members

CMS has developed standardized notices and forms for use by plans as described below:

Required Notification to Members for Observation Services: In compliance with the Federal Notice of Observation Treatment and Implication for Care Eligibility Act, contracted hospitals and critical access hospitals must deliver the Medicare Outpatient Observation Notice (MOON) to any member who receives observation services as an outpatient for more than 24 hours. The MOON is a standardized notice to a member informing them that they are an outpatient receiving observation services and not an inpatient of the hospital or critical access hospital and the implications of such status. The MOON must be delivered no later than 36 hours after observation services are initiated, or sooner upon release.

Integrated Denial Notice (IDN): MediGold must issue a written notice to an enrollee, an enrollee’s representative, or an enrollee’s physician when it denies a request for payment or services. The IDN combines

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and replaces the standardized Medicare Part C denial notices entitled ‘Notice of Denial of Payment’ and ‘Notice of Denial of Medical Coverage.’ See the Policies and Provider Protocol section for more details.

Notice of Termination of Services for SNF, HHA, CORF: When MediGold has authorized coverage of services, MediGold is responsible for determining a member’s coverage termination date and providing a detailed explanation of termination of services as described in section 100 of the Medicare Managed Care Manual. MediGold will coordinate with skilled nursing facilities (SNFs), home health agencies (HHAs) and comprehensive outpatient rehabilitation facilities (CORFs) by providing a termination of services date as early in the day as possible to allow for timely delivery of the NOMNC. If the SNF, HHA or CORF assesses a member to be appropriate for discontinuation of services or discharge, the provider will reach out to MediGold three days before the targeted termination date (also known as last covered day). MediGold will review the case with the provider to determine if services will continue or be terminated. If a member files an appeal, the plan must deliver a detailed explanation of why services should end. The two notices used for this purpose are:

Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123-NOMNC.

Detailed Explanation of Non-Coverage (DENC) Form CMS-10124-DENC.

When to Deliver the NOMNC

Providers must deliver a completed copy of the NOMNC to members receiving covered SNF, HHA, (including psychiatric home health), CORF and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process of the Medicare Claims Processing Manual and Chapter 13, Sections 100.2 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed.

Completed SNF and Part B therapies NOMNC’s should be faxed to MediGold Health Services at: Toll Free 1-833-263-4865 and a copy placed in the medical record. All other NOMNC’s should be placed in the medical record.

Notice Delivery to Representatives

The CMS requires that notification of changes in coverage for an institutionalized beneficiary/ enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee’s representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee’s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date.

When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative’s address signs (or refuses to sign)

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the receipt is the date of receipt. Place a dated copy of the notice in the enrollee’s medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee’s liability starts on the second working day after the provider’s mailing date.

Exceptions

The following service terminations, reductions or changes in care are not eligible for an expedited review. Providers should not deliver a NOMNC in these instances, when:

Services are being reduced (e.g., an HHA providing physical therapy and occupational therapy discontinues the occupational therapy).

Beneficiaries are moving to a higher level of care (e.g., home health care ends because a beneficiary is admitted to a SNF).

Beneficiaries exhaust their benefits (e.g., a beneficiary reaches 100 days of coverage in a SNF, thus exhausting their Medicare Part A SNF benefit).

Beneficiaries end care on their own initiative (e.g., a beneficiary decides to revoke the hospice benefit and return to standard Medicare coverage).

A beneficiary transfers to another provider at the same level of care (e.g., a beneficiary transfers from one SNF to another while remaining in a Medicare-covered SNF stay).

A provider discontinues care for business reasons (e.g., an HHA refuses to continue care at a home with a dangerous animal or because the beneficiary was receiving physical therapy and the provider’s physical therapist leaves the HHA for another job).

Alterations to the NOMNC

The NOMNC must remain two pages. The notice can be two sides of one page or one side of two separate pages, but must not be condensed to one page. Providers may include their business logo

and contact information on the top of the NOMNC. Text may not be moved from page 1 to page 2 to accommodate large logos, address headers, etc. Providers may include information in the optional ‘Additional Information’ section relevant to the beneficiary’s situation.

When to Deliver the DENC

A provider must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered SNF, HHA, CORF and hospice services upon notice from the Quality Improvement Organization (QIO) that the beneficiary/enrollee has appealed the termination of services in these settings. The DENC must be provided no later than close of business of the day of the QIO’s notification.

Hospital Discharge Notices: As under original Medicare, a hospital must issue to members, within two days of admission, a notice describing their rights in an inpatient hospital setting, including the right to an expedited QIO review at their discharge. (In most cases, a hospital also issues a follow- up copy of this notice a day or two before discharge.) If an enrollee files an appeal, then the plan must deliver a detailed notice stating why services should end. The two notices used for this purpose are:

An Important Message From Medicare About Your Rights (IM) Form CMS-R-193.

Detailed Notice of Discharge (DND) Form CMS-10066.

An Important Message From Medicare About Your Rights (IM): Hospitals must issue the IM within two calendar days of admission, obtain signature of the patient or the signature of their authorized representative and provide a signed follow-up copy to the patient as far in advance of discharge as possible, but not more than two calendar days before discharge. This letter will include the process to request an immediate review with the appropriate QIO. Members who desire an immediate review must:




Submit a request to the QIO, in writing or by telephone, by midnight of the day of discharge.

The request must be submitted before the member leaves the hospital.

If the member fails to make a timely request to the QIO she or he may request an expedited reconsideration by MediGold.

Upon notification by the QIO that a member has requested an immediate review, MediGold will contact the facility, request all relevant medical records, a copy of the executed IM and evaluate for validity.

Detailed Notice of Discharge: If the patient appeals, the Detailed Notice of Discharge must be:

Issued as soon as possible after notification by the QIO that an appeal was filed.

Issued no later than noon of the day after the QIO’s notification.

A copy must be included with the packet of medical records submitted to the QIO for their review determination.

Availability of Utilization Management Staff

MediGold’s Health Services Department provides medical and support staff resources, including a medical director, to process requests and provide information for the routine or urgent authorization/pre-authorization of services, utilization management functions, provider questions, comments or inquiries. We are available 8:00 a.m. to 4:30 p.m. Monday through Friday. See ‘Contact Us’ in this manual for more information.

Skilled Nursing Facilities (SNF)

Inpatient SNF care includes room and board, skilled nursing care and other customarily provided services in a Medicare Plan.

Three-Day Hospitalization: The Original Medicare requirement of a three (3) consecutive day hospital stay before transferring to a SNF is waived for MediGold members.

Prior Authorization

SNF stays will require prior authorization before admitting a MediGold member. Milliman Care Guidelines, along with clinical judgment and the following coverage factors will be used to determine medical necessity:

The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by, or under the supervision of, professional or technical personnel are ordered by a physician.

These skilled services are required on a daily basis.

As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF.

The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

Prior Authorization requests may be submitted to MediGold following directions listed above on page 26



Concurrent Review

Concurrent reviews are due on scheduled dates provided by your utilization review nurse. Failure to provide timely updates may result in denied reimbursement for days when skilled criteria is not met. The facility is to notify MediGold of any change in member status or treatment.

MediGold Tier Reimbursement Model

MediGold will utilize 4 Tiers when assigning a daily skilled nursing facility reimbursement rate. Tiers will be assessed and assigned using the 5 Day MDS documenting functional status, active diagnoses, current health conditions, swallowing and nutritional status and special treatments, procedures and programs. Attributes of the individual Tiers are described below. Examples are not all inclusive. Tier assignments are dependent upon the severity of illness and complexity of care of each member:

Tier 1 and Tier 2 are low to moderately complex stays. Clinical documentation used to assign Tier 1 and Tier 2 reimbursement is derived from Sections G, I, J, and O of the 5 Day MDS.

Tier 1 Examples

Low complexity cases such as uncomplicated Hip and Knee Replacements

Debility, requiring supervision or limited assistance for performance of ADLs.

Stable, active diagnoses within the last 7 days such as Stroke and stable neurologic conditions with minimal to no residual effects

Stable cardiorespiratory diagnoses such as Pneumonia, CHF, CAD, Hypertension, PVD

Anemia

UTI

Diabetes

CVA with minimal or no residual affects/deficits


Tier 2 Examples

Moderate complexity cases such as a Stroke with residual effects/deficits

Active Orthostatic Hypotension

Debility, requiring extensive assistance or full staff performance of ADLs at every occurrence

Cases in which members have had major surgery during the prior inpatient hospital stay and require surgical wound care such as surgery involving the spinal cord or major spinal nerves, some neurosurgery procedures, major cardiac surgery, repair of deep ulcers, bone marrow or stem cell harvest or transplant

Septicemia

Viral Hepatitis

Neurogenic Bladder

Isolation and or quarantine for active, infectious disease (does not include standard body/fluid precautions)

Tier 3 are high complexity stays with high cost treatments such as IV medications, tube feedings, complex wound care, trach care. These cases are currently assigned Per Diem rates, based on the treatment type. Clinical documentation used to assign Tier 3 reimbursement is derived from Section K, M, and O of the MDS and must be active, while a resident.

Tier 3 Examples

Tube feedings: NG or PEG

Complex Wound Care (includes Wound Vacs)

Tracheostomy care (not on invasive mechanical ventilator support)

High cost IV medications

Transfusions

Chemotherapy and or Radiation

Paraplegia, Hemiplegia or Hemiparesis


Tier 4 stays are members requiring ventilator support. These cases are currently assigned Per Diem rates, based on treatment type. Clinical documentation used to assign Tier 4 reimbursement is derived from Section O of the MDS and must be active, while a resident.

Tier 4 Example

Invasive Mechanical Ventilator Support: Weaning, continuous and or nocturnal only ventilation

Benefit Period

Inpatient skilled care and services are covered for up to 100 days per benefit period. If a member’s coverage begins while in a SNF, any SNF days used in that benefit period prior to the member’s effective date will apply toward the 100-day benefit. While an inpatient in a SNF, should the member be admitted to an acute care hospital for an illness related to the original problem or a new diagnosis, the consecutive days will stop temporarily until the member is transferred back to the SNF.

If a member is discharged from a SNF, and within 60 days requires readmission to the SNF, the member must use the existing benefit period.

It is important to note that a benefit period cannot end while a beneficiary is an inpatient of a hospital, even if the hospital does not meet all necessary for starting a benefit period. Similarly, a benefit period cannot end while a beneficiary is an inpatient of a SNF (meaning a new benefit period cannot be started) as defined below.


For a member to have a new benefit period

To end a benefit period, a beneficiary cannot have been an inpatient of a hospital or a SNF for at least 60 consecutive days. SNF is defined as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission. The stays need not be for related physical or mental conditions.


Case Management

Our case managers are available to assist our members by coordinating services for easy access to medical care through a variety of services, such as:

Health and Wellness Referral.

Complex Case Management.

Behavioral Health.

Transition of Care.

Disease Management.

Case managers are also in charge of administering the Centers for Medicare & Medicaid Services (CMS) required programs such as:

Chronic Care Improvement Program – Chronic Obstructive Pulmonary Disease.

MediGold’s knowledgeable and caring case managers provide education and medical and emotional support for members. They refer members to health and wellness resources in their community. For members who are “high risk,” they collaborate with a treatment team to create member-specific, cost-effective health care options to share with the member and their family. Targeted members may have chronic conditions such as chronic obstructive pulmonary disease, congestive heart failure, diabetes or an acute illness requiring coordination of multiple services, short-term intensive intervention or long-term education and monitoring. The goal of case management is to facilitate maximum functional levels at the most appropriate intensity of service.

Case management is conducted by telephone and includes a needs assessment, development of a care management plan, on-going monitoring and case closure. All case management program processes are documented in standardized formats and closely coordinated with aspects of utilization management, including prior authorization and concurrent review.

If you identify a MediGold member who is at risk for high utilization of services or who needs assistance in coordinating health care services, please submit a Case Management Referral Form. You can find this form at: MediGold .com/For-Providers/Tools-and-Resources/Forms.

Transitions of Care Program

Our program is focused on evaluating and coordinating post-hospitalization needs for members who may be at risk of readmission. MediGold case managers are involved with care transitions, such as discharge from inpatient hospital to home and assessment and updates of the member’s care plan, as needed. Case managers also help ensure members see their primary care provider within seven to 10 days after discharge and work with them through any problems they may have adhering to their post-discharge medications.

SECTION 7: Case Management

http://MediGold.com/For-Providers/Tools-and-Resources/Forms

http://MediGold.com/For-Providers/Tools-and-Resources/Forms



Disease Management Program

The goal of our DM program is to improve the member’s quality of life by helping them better manage and monitor their chronic disease through the development of a collaborative treatment plan with their primary care provider.

We work with members to help with their chronic conditions and how to monitor those by developing a treatment plan in coordination with their primary care provider.

Condition monitoring: Work with the member to ensure they are monitoring their conditions, e.g., getting labs done and medication adherence.

Medical behavior comorbidities and other health conditions: coordination of care as they are generally delivered by multiple providers and may include other medical and behavioral conditions.

Health behaviors: The DM program content addresses health behaviors that may impede a member’s ability to manage a condition and encourage members to develop healthy behaviors.

Psychosocial issues: This program addresses psychosocial issues that may be barriers for the member in meeting treatment goals and identifies how the program modifies interventions to address the issues that arise from:

Cultural, religious and ethnic beliefs concerning the condition of treatment options.

Perceived barriers to meeting treatment requirements.

Education.

Access, transportation and financial barriers to obtaining treatment.

Behavioral Health Program

Our program offers services provided by a Licensed Independent Social Worker. Services included but not limited to referrals to inpatient facilities, outpatient providers and community support groups. Our program will start with a thorough psychosocial assessment and followed by a plan of care development that it is individualized to meet the needs of our members. Included in these services are psychosocial support, resources linkage and behavioral health education at not no cost to our members.

Chronic Care Improvement Program – Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death and disability in the United States. COPD is generally caused by cigarette smoking It may also be caused by exposure to or inhalation of noxious stimuli. It is a disease characterized by airflow obstruction. Symptoms include shortness of breath, chronic cough, and excessive phlegm/sputum production. Symptoms may cause severe physical disability and death. While COPD is preventable, there is no cure. Emphysema and chronic bronchitis are the two most common forms of COPD.

MediGold has established the following goals as measures of success for the program:

Enhance member self-management skills through education, Case Management coaching and written material.

Increase number of members using appropriate medications

Increase number of members correctly using medications

Establish and maintain communication with Primary Care Provider (PCP) and Specialist Providers

Reduce the number of inpatient admissions and Emergency Department (ED) utilization

Decrease length of stay when hospitalized

Reduce morbidity and mortality

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Nurse Advice Line

Expert answers to your health care questions are just a phone call away, with the MediGold 24-Hour Nurse Advice Line. Registered nurses are available 24x7 to answer your questions, assess your symptoms and help you decide whether you should call your doctor, head to the urgent care or treat your symptoms at home.

Complex Case Management Program

MediGold aims to take care of members who have experienced a critical event or diagnosis that requires extensive use of resources. They may need help navigating the system to facilitate appropriate delivery of care and services. This program goes beyond providing case management for one complex condition, e.g., transplant member or members already enrolled in MediGold disease management programs. The scope of services provided by complex case manager to the members include:

Initial assessment of health status.

Education about the case management program.

Development of a member-specific care plan with goals, task, barriers, opportunities and self-management skills.

Reassessment of progress against the member care plans and evaluation of adherence.

Based on acuity, regularly scheduled contact with the case manager.

Assistance in navigating and collaborating with practitioners and community resources regarding treatment.

Supporting transitional care between inpatient to other facilities or home.

Discussion with interdisciplinary team to review treatment plan and interventions.


SECTION 8: Medicare-Covered Drugs

Medicare Part B Drugs

Definition:

Medicare Part B drugs fall into five major categories:

1 Drugs billed by physicians and typically provided in physicians’ offices or outpatient facility, ‘incident to’ a physician’s service.

2 Drugs billed by pharmacy suppliers and administered through durable medical equipment (e.g., nebulizer solutions).

3 Drugs billed by pharmacy suppliers and self-administered by the patient (e.g., immunosuppressive drugs and some oral anti-cancer drugs).

4 Separately-billable drugs provided in hospital outpatient departments, covered as ‘supplies’ or ‘integral to a procedure.’

5 Separately-billable End Stage Renal Disease (ESRD) drugs.

Part B drugs are not usually self-administered (except in the instance listed above); therefore, coverage is usually limited to drugs or biologicals administered by infusion or injection.

Despite the general limitation on coverage for outpatient drugs under Part B, there are some notable exceptions to this limitation. In addition to the drugs mentioned above, the following drugs or classes of drugs are considered payable under Medicare Part B:

Antigens.

Hemophilia clotting factors.

Hepatitis B vaccine.

Influenza vaccine.

Oral anti-cancer drugs.

Oral anti-emetic drugs.

Pneumococcal vaccine.

Injectable osteoporosis drugs.

Certain drugs for home dialysis.

This is not an exhaustive list.

Benefit:

Drugs classified as Part B drugs are subject to a coinsurance determined by the member’s MediGold policy. Please see the Summary of Benefits, available at MediGold .com or by contacting provider services, for specific coinsurance amounts.

The Part B coinsurance amount does not count toward a member’s Part D coverage limit, initial coverage limit or total out-of-pocket amount.

http://MediGold.com



Medicare Part D Drugs

Definition:

A Part D drug is available only by prescription, approved by the Food and Drug Administration (FDA), used and sold in the United States and used for a medically accepted indication. Covered Part D drugs include prescription drugs, biological products, insulin and some vaccines.

Medical supplies associated with the injection of insulin (syringes and needles) are also included under Part D.

There are some drugs, prescription or otherwise, that are not covered by either Medicare Part B or Part D.

Benefit:

For all questions related to Part D drug benefits, and coverage requirements, please consult the member’s Evidence of Coverage available at: MediGold .com or call provider services.

Most providers are not contracted to dispense Part D drugs as network providers (except for vaccines). In the event that you do dispense these drugs, you have 2 options for claims submission:

1 Bill MediGold’s Pharmacy Benefit Manager, CVS Caremark.

2 Supply the required and necessary information to the member to submit a Member Reimbursement Claim to MediGold’s Pharmacy Benefit Manager.

The Formulary

A formulary is a listing of drugs covered by MediGold to meet its members’ needs.

MediGold members have access to a formulary. If any formulary changes are made that will limit members’ ability to fill their prescriptions, MediGold will notify the members before the change is made. At least 30 days notice will be given. The formulary is available at MediGold .com/formulary.

Tiered Drug Benefit

Under MediGold’s Part D drug benefit, covered drugs fall into one of five tiers. The copay or coinsurance amount assigned to each tier varies between products. The five tiers are:

Tier 1 - Preferred generic

Tier 2 - Generic

Tier 3 - Preferred brand

Tier 4 - Non-preferred drug

Tier 5 - Specialty tier

Any drug covered by Medicare but not found in the formulary is treated as if it were a non-formulary drug and is subject to the tier 5 coinsurance amount upon review and approval.

Members may incur extra cost for drugs obtained at an out-of-network pharmacy.

For a list of pharmacies in your area visit MediGold .com/Find-a-Pharmacy .

http://MediGold.com

https://medigold.com/formulary

http://MediGold.com/Find-a-Pharmacy



Medicare Part D Benefit Stages and Total Out-of-Pocket Costs

Medicare Part D benefits include four stages of coverage. Stage one, the yearly deductible stage, may apply to MediGold members depending on which plan is chosen. Stage two is the Initial Coverage Limit where members are only responsible for the tier copay or coinsurance associated with the prescription drug. Stage three is where members generally are responsible for 100 percent of the Medicare covered drug charges. This period is commonly referred to as the coverage gap or ‘donut hole.’ This stage is supplemented by the Medicare Coverage Gap Discount Program which provides a manufacturer discount on brand name drugs and also reduced cost for generic drugs. In addition to this program, MediGold plans offer additional gap coverage. Please refer to the member’s Evidence of Coverage at MediGold .com .

Members stay in the coverage gap stage until they have reached the annual Part D total out-of-pocket amount. Members then move into stage four, the Catastrophic stage.

At the Catastrophic stage, the Plan will pay most of the cost of the drugs and the member will have a greatly-reduced copay or coinsurance.

MediGold members receive monthly statements advising them of the amounts applied toward these limits.

Vaccines Covered Under Medicare Part D

If not in the Point of Care (POC) Network, claims for Part D vaccines and the administration must be billed on a CMS-1500 to MediGold’s Pharmacy Benefit Manager, CVS Caremark. CVS Caremark will send your office an Explanation of Payment which will include the member’s cost share. CVS Caremark’s address:

CVS Caremark Medicare Vaccine ProcessingP .O . Box 52193 Phoenix, AZ 85072-2193

Provision of and Billing for ZOSTAVAX© and SHINGRIX©

If your office has chosen to offer the ZOSTAVAX©

and SHINGRIX© vaccine to your MediGold patients, MediGold has contracted with POC Network Technologies for its TransactRx Vaccine Manager to allow you to submit claims directly to CVS Caremark for reimbursement.

To verify SHINGRIX availability, please use website located at https://www.shingrix.com/shingles-vaccine-locater.html

For more information or to enroll, please visit enroll.mytransactrx.com or call 1-866-522-3386.

Part D Utilization Management Requirements

The MediGold formulary has Utilization Management requirements that include prior authorization (PA), quantity/dosage limits (QL), Part B benefit versus Part D benefit determinations (B/D), as well as non-formulary exception criteria. Prior Authorization: For a select group of drugs the plan requires the member or their physician to get prior approval before we will agree to cover the drug. The approval or denial is based on the plan design and focuses on safety and proper medication use.


http://MediGold.com

http://enroll.mytransactrx.com

https://medigold.com/formulary

https://medigold.com/Resources/Drug-Benefits/Utilization-Management/2019-Prior-Authorization-Forms



Quantity Limits: For certain drugs, we limit how much of a drug can be obtained within a specific period of time. Quantity limits are based on approved FDA maximum daily limits.

Part B benefit versus Part D benefit (B/D): Some drugs may be paid either under Part B benefit or the Part D benefit depending on the circumstances. Information may need to be submitted describing the use or setting of the drug to make the determination.

Coverage determinations (also known as formulary exceptions) are used to determine if a drug meets specific exception criteria in order to be covered even though it is not on the plan’s formulary.

For drugs in tier 2, 3 (generic only) and 4 (brand and generic), a provider can ask the plan to make an exception in the cost-sharing tier for the drug if the member has medical reasons justifying an exception to the rule.

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Some key points regarding these Part D Utilization Management requirements:

Most prior authorizations must be done annually per member per prescription.

A temporary (30)-day override may be requested by the prescribing physician, pharmacist or member while the prior authorization is completed.

Prior authorizations and coverage determinations can be requested proactively in one of three ways:

Call MediGold’s Pharmacy Benefit Manager CVS Caremark to initiate a prior authorization or coverage determination over the phone.

Utilize the Part D prior authorization forms or coverage determination request form online at: https://medigold .com/Tools-and-Resources/Drug-Benefits/Utilization-Management and fax the form to CVS Caremark. Call MediGold’s Pharmacy Benefit Manager CVS Caremark to request a general prior authorization form or download from https://medigold .com/Tools-and-Resources/Drug-Benefits/Utilization-Management

Providers shall not impose a fee upon or charge a MediGold member or the Plan for completion of prior authorization or other administrative forms required by Plan.

Diabetic Glucose Monitors, Test Strips, and Supplies

Diabetic supplies and glucose monitors are not covered under the Medicare Part D prescription benefit and may be provided at no cost to MediGold members when obtained through MediGold’s network supplier. Please contact provider services for additional details on this benefit.

NOTE



Self-Administered Drugs in an Outpatient Setting

Self-administered drugs provided to MediGold members during an outpatient hospital encounter are reimbursable under Part D benefits if the drug is a Medicare Part D-covered medication. In order for members to receive reimbursement for this benefit, they must be provided with the appropriate detail to submit a member reimbursement claim to MediGold’s Pharmacy Benefit Manager. The required information is as follows:

National Drug Classification Number (NDC).

Full name of medication.

Dosage.

Strength.

Dispense date.

As an out-of-network outpatient cost of drug pharmacy, MediGold requests that you comply with the above information request in order to facilitate member reimbursement requests.

Non-Covered Part D Utilization Management Requirements

There are some drugs that are excluded from Medicare coverage by law. These include:

Drugs for:

Anorexia, weight loss or weight gain (except to treat physical wasting caused by AIDS, cancer or other diseases).

Fertility.

Cosmetic purposes or hair growth.

Relief of the symptoms of colds, like a cough and stuffy nose.

Erectile dysfunction may be covered as a supplemental benefit under certain plans.

Prescription vitamins and minerals may be covered as a supplemental benefit under certain plans. (except prenatal vitamins and fluoride preparations).

Non-prescription drugs may be covered as a supplemental benefit under certain plans (over-the-counter drugs).

Prescription drugs used for the above conditions will not be covered by Medicare Part D. However, they may be covered if they are being prescribed to treat other conditions. For example, prescription medications for the relief of cold symptoms may be covered by Part D if prescribed to treat something other than a cold—such as shortness of breath from severe asthma—as long as they are approved by the United States FDA for such treatment.

If you prescribe a non-cancer medication on the formulary for a reason other than the use approved by the United States FDA, the drug will probably not be covered unless the use is listed in one of three Medicare-approved drug compendia (medical encyclopedias of drug uses). For anti-cancer drugs, the drug plan should accept indications of drug use from additional compendia and other peer-review medical literature.

A patient may also receive a denial from a Part D plan stating that their drug does not meet DESI standards. The FDA’s Drug Efficacy Study Implementation (DESI) evaluates the effectiveness of those drugs that had been previously approved on safety grounds alone. Drugs that are found to be less than effective by DESI evaluation are excluded from coverage by Part D.

NOTE


SECTION 9: Claims Processing Procedures And Guidelines

Copayment and Coinsurance

Copayments and coinsurance are designed to encourage MediGold members to seek appropriate medical care. The copayment is a flat amount that the member pays when covered services are rendered in the provider’s office.

Coinsurance is the percentage of the cost of the service that the member pays. Each MediGold member may have a different copayment level, based on his or her benefit plan. The office visit copayment may be different for PCP, specialist or facility visits.

These copayment amounts are specified on the member’s ID card. If necessary, call provider services to verify the copayment or coinsurance amount or coverage. When calling, please be prepared to supply the member’s name and member number (found on the MediGold ID card) to the MediGold representative.

You have the responsibility to collect the copayment or coinsurance.

If a copayment is required for office medical care, it will apply to professional fees only. Fee-for-service payments issued by MediGold will be accompanied by a remittance advice to the provider indicating the payment amount from MediGold, minus applicable copayments that are the member’s responsibility, for submitted expenses.

If a copay is required for medical care rendered in an outpatient hospital clinic setting, it will be applied to the facility claim based on the clinic type revenue code submitted by the facility. MediGold recognizes industry standard revenue codes as outlined in the Uniform Billing Editor.

The facility must bill the appropriate revenue code that reflects the type of clinic services rendered in order for the correct copay to be administered by MediGold.

0510 - General (specialist clinic visit) 0517 - Family Practice (pcp clinic visit)

A member may not be billed for non-covered and/or “not medically necessary” services unless an Integrated Denial Notice (IDN) is obtained prior to the service being rendered. Please refer to Provider Policies and Protocols in this manual.

MediGold follows Medicare Claims Processing and Coding guidelines. Physicians and other healthcare professionals are encouraged to remain current with CMS policies, coding, and/or billing requirements. Please refer to the guidelines published annually by CMS. Please refer to your provider agreement for any exceptions that may apply.

CMS Claim Processing Manual 100-04

Please contact MediGold’s Provider Services Team at 1-800-991-9907 with any questions. Claims status inquiries can be obtained by accessing our Provider Portal at MediGold .com/For-Providers/Provider-Portal .

Providers could experience delays in claims processing if a claim is not completed correctly. An improperly completed claim may be denied or returned for correction and resubmission.

Annual Women’s Exam

Gynecologist must bill the coded PREVE (along with pap and pelvic exam) for the annual women’s exam. The applicable copay will apply.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending



There are processes and data elements that are essential for prompt claim payment and encounter processing:

General Form Submissions Claims can be submitted to MediGold on paper or electronically. Faxed claims are not accepted and will not be processed.

MediGold accepts the current versions of CMS Forms 1500 (HCFA) and 1450 (UB-04). Form CMS-1500 Data Set Form CMS-1450 (UB) Data Set

Except as otherwise noted, providers should follow National Standard practices for form completion and CPT/HCPC/ICD coding standards.

Claims requiring additional documentation (e.g., medical records, operative reports, primary carrier’s EOBs) must be sent to the address provided below.

Essential MediGold Data Elements Required:

Member (patient) name.

Member (patient) date of birth.

Insured/subscriber name.

Insured/subscriber ID number.

Name of other health benefits coverage available for the member. Name of insured/ covered person for other health benefits coverage. Attach a copy of the other health plan’s Explanation of Benefits for the listed charges, if applicable.

Indicate if member’s condition is related to patient’s occupation or an accident.

Name of the referring provider and the NPI (National Provider Identifier) of the referring provider, if applicable.

Charge for each service and treatment. Do not subtract any copayment amounts; the charge should reflect the actual fee for services.

Signature of treating physician or provider.

Treating provider’s tax identification number for 1099 purposes.

Name and address of treating provider (please print or type).

NPI of treating provider.

Electronic Claim Submissions

Electronic claims (also known as 837I and 837P) can be submitted to MediGold’s clearinghouses Claimsnet and Change Healthcare (formerly Emdeon).

MediGold’s payor ID numbers: HMO Plans/Medical Only: 95655 PPO Plan: 13123

Clearinghouse contact information:

• Claimsnet: Telephone #: 1-800-356-0092 Website: Claimsnet.com

• Change Healthcare (previously Emdeon): Telephone #: 1-877-363-3666 Website: Changehealthcare.com

Paper Form Submissions

Hardcopy claims must be legible and should be submitted to our processing center at: MediGold P .O . Box 830697 Birmingham, AL 35283

Tips for submitting paper claims:

Verify the member’s unique MediGold ID number is correct and is located in box 1a on form CMS-1500 or field 60 on CMS-1450.

Type or print claim forms. DO NOT ALTER FORMS in any manner.

Ensure form and print are dark enough to read.

Ensure data is aligned in the proper fields.

Make sure the corporate name to which the federal tax ID belongs appears in box 33 and the corporate (group) NPI appears in box 33a of the CMS-1500 form.

*Please work with your vendor or clearinghouse to ensure you are receiving your confirmation and/or error/rejected claims reports. You are responsible for making sure you are receiving and addressing all claim submission errors and resubmitting them in a timely manner.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf


NOTE


Corrected Professional: 1500 Claim Submission Complete a new claim form and be sure to insert the following in box 22:

Resubmission Codes:

7 – To indicate it is a replacement

8 – To void/cancel the prior claim.

Original Ref . No .: Enter the original MediGold 12 digit claim/reference number you are correcting or cancelling

Corrected Claims can be submitted either electronically or *paper . See below

*When submitting on paper, please mail the corrected claim at the address below, along with the Corrected Claim Cover Sheet that can be found at MediGold.com/For-Providers/ Tools-and-Resources/Forms

MediGold P .O . Box 830697 Birmingham, AL 35283

Corrected Facility: UB-04 Claim Submission

Complete a new claim form with the correct type of bill (TOB) code in FL 04

Example: (see UB04 billing manual for the TOB that pertains to your type of facility)

TOB 117-replacement or corrected claim for a previously submitted hospital inpatient claim

TOB 118- void/cancel prior inpatient claim claim

TOB 137-replacement or corrected claim for a previously submitted hospital outpatient claim

TOB 138- void/cancel prior inpatient claim claim

Request for Claims Review Form

You will find a Request for Claim Review Form in the Claims section at MediGold.com/ For-Providers/Tools-and-Resources/Forms or by contacting Provider Services at 1-800-991-9907. It should be used in the following situations: If you believe a claim was processed incorrectly. You are submitting additional information at the request of MediGold to complete processing of a claim. An underpayment or overpayment was made by MediGold.

In the instance of an overpayment, please do not send a check for the overpayment to MediGold. MediGold will reduce future payments by the amount of the overpayment directly through the claims system.

Completed forms should be faxed to the number indicated on the form. It is the intent of MediGold to process all requests within two weeks of receipt.

Remittance Advice

You will receive a remittance advice along with claim payments. The remittance advice will provide detailed information about all encounters and claims received and processed by MediGold. The remittance advice is intended to assist with reconciling your claim submissions and payments.

Electronic Payment and Remittance Enrollment

To apply for Electronic Payment and Remittance, please complete the enrollment form. Providers must proactively contact the financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements necessary for successful reassociation of the EFT payment with the ERA remittance advice.

Corrected Claims Submission

When a claim submission error is identified, either by receipt of a MediGold remittance advice or through your internal review, a corrected claim may be sent directly to MediGold’s claims processing.

Requests for corrections/adjustments to claims must be submitted within 180 days from the date of the original remittance advice or as specified in your provider agreement .

NOTE



Claims Timely Filing Limitations Timely claim and encounter data submission is important to ensure prompt claims payment. The contracted claims filing time limit is specified in your provider agreement. MediGold strictly enforces these filing limits and is under no obligation to pay claims submitted beyond the limits of your provider agreement. Should extenuating circumstances prevent a claim from being submitted within the time limitations, those circumstances will be reviewed on a case-by-case basis. Please remember that in accordance with your provider agreement with MediGold, you may not bill the member for services denied as a result of not meeting claims filing limitations.

Provider Portal MediGold offers a convenient and secure web portal to ease administrative duties for:

Verifying member eligibility.

Viewing member specific plan information.

Viewing claim history and payment status.

Sending secure messages to our provider services team.



Transfers of Claims from Medicare Part B Carrier/MAC to MediGold Your practice may receive an Explanation of Medicare Benefits (EOMB) from Medicare administrators indicating claims have been forwarded directly to MediGold for processing. If the notation ‘transfer to MCHP’ appears on an EOMB, do not assume the claim was transferred. Please submit a separate claim directly to MediGold. This will prevent the possibility of the claim being denied for timely filing. As soon as the denial is received, please submit a claim to MediGold. ‘Timely filing’ begins with the date on the Medicare EOMB. Please refer to your provider agreement for your timely filing limit. Coordination of Benefits A MediGold member may have benefits available from more than one health plan. Coordination of Benefits (COB) determines which benefit plan is the primary payor and which is secondary. Members remain liable for payment of MediGold’s cost-sharing regardless of whether MediGold is the primary or secondary payor. You are encouraged to ask MediGold members about any changes to coverage and/or additional coverage on an ongoing basis. You are required to report additional insurance coverage information on claim and encounter forms to MediGold, and MediGold retains all rights to COB savings and recoveries.

MediGold will use the rules outlined below to determine primary payor responsibility in the following order:

1

2

3

The plan with no COB provision or non- duplication coverage exclusion will always be primary.

The plan covering a member as a subscriber will be primary for care rendered to that member. In addition, the benefits of a plan that covers an individual as an employee who is neither laid off nor retired (or as that employee’s dependent) are determined before those of a plan that covers that individual as a laid-off or retired employee (or as that employee’s dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this provision is ignored.

If none of the above rules determines the order of benefits, the benefits of the plan that covered an employee, member, or subscriber longer are determined before those of a plan that covered that individual for a shorter time.

Questions regarding COB may be directed to Provider Services at: Toll Free: 1-800-991-9907 (TTY 711) Toll Free Fax: 1-833-900-0606

COB enables MediGold to avoid and, in some cases, recover expenses related to members with multiple health insurance coverages. In NO CASE will more than 100 percent of the MediGold contracted rate be paid in total because of multiple health insurance coverages.

NOTE



Secondary Payor MediGold will coordinate coverage with commercial insurance, Medicare and Medicaid. MediGold can assist you in determining responsibility for a member’s primary coverage.

As a network provider you agree to supply MediGold with all available information for documentation regarding a member’s coverage by another health plan or insurer. This information may be provided in the appropriate section of the CMS 1500 or UB04 Form. When notice of payment or denial of payment is received, you may bill MediGold. Attach a copy of the other insurance carrier’s notification of payment or denial to the CMS 1500 or UB04 Form.

Medicaid as a Secondary Payor Medicaid is responsible for payment of Medicare cost-sharing expenses for Medicare beneficiaries who are eligible for Medicaid under the Qualified Medicaid Beneficiaries (QMB) definition, including those beneficiaries enrolled in a MA program. Cost-sharing includes copayments, coinsurance and deductibles.

Medicaid is not required to provide any payment for cost-sharing expenses to the extent that payment under Medicare for the service would exceed the payment amount that otherwise would be made under the Medicaid state fee schedule for such service if provided to an eligible recipient other than a Medicare beneficiary.

Subrogation Subrogation is based on the right of a MediGold member who suffered injury/illness caused or contributed to by a third party to recover damages from that party. MediGold’s recovery is for the value of services rendered to or the expense incurred in treating the member for those injuries/illnesses. Identification methods include medical record notations, examination of specific diagnoses that are often accident- related and others.

The MediGold member assigns his or her right of recovery to MediGold by operation of the Member Agreement or a signed lien form. MediGold has a responsibility to its members to first process claims that result from an accident, and then pursue reimbursement from the appropriate third-party payor. When treating a MediGold member for injuries stemming from an accident, bill MediGold as the primary payor. MediGold will process the claim, and then determine whether subrogation is required.

Subrogation issues typically take considerable time to resolve. In almost every case, the claim for a provider’s services will be paid before the subrogation process is initiated.

Workers’ Compensation The term ‘Workers’ Compensation’ is applied to claims expenses that, due to job-related injury or illness, are the responsibility of the member’s employer. Identification methods are the same as for subrogation.

As with COB, providers are required to report potential subrogation and Workers’ Compensation cases (using the appropriate spaces on the CMS 1500 or UB04 form) to MediGold, and MediGold retains all rights to any sums payable under such circumstances.


SECTION 10: Compliance

Overview The Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage (MA) Organizations, such as MediGold, to implement an effective compliance program that prevents, detects, and corrects Medicare Parts C and D program noncompliance, as well as fraud, waste, and abuse (FWA). The MediGold Compliance Department serves as the hub for all internal and external compliance concerns, compliance reporting, and compliance training. The MediGold Compliance Department also coordinates delegation oversight activities by business unit owners of first-tier, downstream and related entities (FDRs) that are delegated a Medicare Part C or D function.

Monitoring and Auditing First Tier, Downstream and Related Entities (FDR) MediGold may enter into contracts with FDRs to provide administrative or health care services to Medicare beneficiaries enrolled in the Plan, but MediGold remains ultimately responsible for fulfilling the terms and conditions of its contract with CMS. Medicare program requirements apply to FDRs and MediGold must monitor and audit FDRs to ensure compliance with all applicable federal and state laws, rules and regulations. FDRs that conduct their own audits should provide to the MediGold Compliance Department a summary of the audit work plan and also the audit results that relate to the services the FDR performs for MediGold. When FDR noncompliance with CMS regulations occurs, a Corrective Action Plan (CAP) will be requested by MediGold. Onsite audits may be conducted by MediGold when deemed appropriate by the Plan as the result of a risk assessment, tracking and trending

member complaints related to access, service or care provided, or if the FDR’s performance falls below established metrics or other service levels.

Annual Compliance Attestation by FDRs MediGold’s FDRs, including providers such as doctors, skilled nursing facilities, home health agencies, and medical groups, must satisfy certain compliance requirements each year. MediGold requires its FDRs to provide proof that they have satisfied these compliance requirements. This is easily done by the FDR completing and submitting an annual attestation to MediGold indicating that they have satisfied the compliance requirements. For your convenience, you can submit the annual attestation through our website at: Medigold.com/For-Providers/Tools-and-Resources/Compliance-Fraud-Waste-and-Abuse-FWA.

Compliance Reporting You can report compliance concerns, or fraud, waste, and abuse, related to MediGold as follows:

1. Email: [email protected].

2. Fax the Chief Compliance Officer Toll Free: 1-833-976-0037

3. If you prefer, you may make a report anonymously:

• Click on our online form at: Report Fraud or Compliance Matters.

or

• Call our parent company’s (Trinity Health) anonymous Integrity Hotline at 1-866-477-4661 . Indicate you want to make a report regarding MediGold.

https://medigold.com/For-Providers/Tools-and-Resources/Compliance-Fraud-Waste-and-Abuse-FWA



https://medigold.com/SIU

https://medigold.com/SIU


SECTION 11: Special Investigations Unit

Fraud, Waste and Abuse

In order to be good stewards of Medicare funds, as well as keep costs low for our members, MediGold is committed to program integrity efforts by early identification, correction and prevention of health care FWA through its Special Investigations Unit (SIU).

MediGold’s SIU utilizes various methods in its efforts to address FWA including, but not limited to, software and data analytics tools. These resources assist in detecting claim aberrancies, outlier behavior, over/under-utilization and potentially inappropriate billing practices.

Procedures are in place to promptly address non-compliance and potential FWA issues, as well as reporting identified issues to appropriate authorities. Investigative and corrective steps by the SIU may include things such as interviews, medical record reviews, verbal/written provider education, written and documented corrective action plans, recovery of funds, appropriate federal and state law enforcement/ MEDIC referrals or other legal action.

The provider shall give the SIU the right to audit, evaluate and inspect books, contracts, documents, papers, medical records, patient care documentation and any other records of provider, its downstream and related entities or its transferee, that pertain to any aspect of services performed for members, reconciliation of benefit liabilities and determinations of amounts payable under the contract between CMS and Plan or as the Secretary of Health and Human Services (HHS) may deem necessary for ten (10) years or the date of completion of an audit, whichever is later.

What is FWA?

Fraud

Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist.

Knowingly solicit, pay and/or accept payment to induce or reward referrals for items or services reimbursed by federal health care programs.

Making prohibited referrals for certain designated health services.

Requires intentional deception or misrepresentations made by someone with the knowledge that the deceptions could result in unauthorized benefits or payments that they would not have been otherwise entitled to. This could include a false statement, misrepresentation, deliberate omission of facts or information that is critical in making a determination of whether a benefit is payable.

Waste

Typically defined as the overutilization or misuse of services or practices which, either directly or indirectly, result in unnecessary costs.

Abuse

Practices that are inconsistent with sound fiscal, business or medical practices and result in unnecessary costs. These could include services which are not medically necessary or fail to meet professionally recognized standards of care or result in improper payments. In addition, abuse can involve charging excessively for services or supplies or up-coding for services provided. In such abuse situations, a knowing or intentional misrepresentation of statement or fact is not necessary to obtain the payment.


SECTION 11: Special Investigations Unit

Examples of Provider, Pharmacy or Vendor FWA

Prescribing medications or supplies which are not medically necessary.

Ordering medically unnecessary testing.

Billing for services not rendered.

Employing excluded individuals.

Engaging in kickback arrangements.

Misrepresenting services provided in order to receive higher reimbursement.

Dispensing drugs purchased outside the U.S.

Dispensing generic drugs but billing for brand.

Intentionally dispensing less than the prescribed quantity (shorting).

Billing for prescriptions not received by the member or not filled.

Disclosure of Ownership, Exclusion and Criminal ConvictionMediGold conducts monthly reviews of exclusion lists, including the HHS Officer of Inspector General, List of Excluded Individuals and Entities, the CMS Preclusion List of prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries, General Services Administration and the System for Award Management database of parties that are excluded from federal procurement, to ensure that no federal funds are used to pay for services, equipment, or drugs provided by a provider, supplier,

employee or FDR who is excluded. If a provider or supplier is found to be on an exclusion list, the Plan may take action, including termination as a participating provider with MediGold.

How to Report FWAWe are committed to partnering with you! If you suspect someone of committing fraud, please report any suspicious fraudulent activity in one of these ways:

Leave a voicemail for MediGold’s Special Investigations Unit at 1-614-546-4392 Toll free number: 1-833-263-4863

Email MediGold’s Special Investigations Unit directly at: SIU .MediGold@mchs .com.

Send a fax to MediGold’s Special Investigations Unit at: 1-833-900-0606.

If you prefer, you may report fraud anonymously:

Complete MediGold’s anonymous online Fraud/Compliance Matters form at MediGold.com/SIU.

Call our parent company’s (Trinity Health) anonymous Integrity Hotline at 1-866-477-4661. Please indicate you would like to report fraud, waste or abuse concerning MediGold.

Report fraud via U.S. Mail:

MediGold Special Investigations Unit 6150 East Broad Street, EE320

Columbus, Ohio 43213

mailto:SIU.MediGold%40mchs.com?subject=


SECTION 12: Network Participation Responsibilities

Overview MediGold contracts with a variety of physicians and other health care professionals to provide primary and specialty care, as well as ancillary services to members.

MediGold publishes and distributes a directory of network providers and is available online at: MediGold .com/Find-a-Provider. If you have any questions regarding the current Provider/Pharmacy Directory, please contact the Provider Service Center at 1-800-991-9907 (TTY 771).

How to Become a Participating Provider with MediGold To join MediGold, please visit our website at MediGold .com/For-Providers/Join-Our-Network or email MediGoldContracting@mchs .com .

MediGold’s Code of Conduct As part of MediGold’s Integrity and Compliance Program, MediGold has a Code of Conduct that describe expected behaviors and actions. While not intended to address all possible legal, regulatory or ethical issues, our Code of Conduct addresses the more common issues and questions that someone might encounter. It provides resources to assist you if you have questions or need further assistance and it explains your duty to speak up and report, without fear of retaliation, any matters you believe may be a violation of our Code of Conduct. The MediGold Code of Conduct can be found on the MediGold .com website.

Credentialing Process

Providers applying for network participation have the following rights regarding the credentialing process:

To review the information submitted to support your credentialing application.

To correct erroneous information.

To be informed of the status of your credentialing application, upon request.

Physician Credentialing

All credentialing activities are administered through MediGold’s credentials committee, which reports its activities to the MediGold Board of Directors. The credentials committee is comprised of network primary care providers (PCPs) and specialists, in addition to the physician chairperson. The committee has the responsibility to establish, adapt, and adopt, as necessary, MediGold Board of Directors-approved criteria for participation and termination of physician participation. The committee also directs credentialing and recredentialing policies and procedures, including participation, denial and termination of physician participation.

Credentialing is an ongoing process, where a provider must first complete initial credentialing and, at a minimum of every three years, undergo recredentialing. Therefore, initial credentials will be valid for a period of 36 months.

New physician and other professional provider applicants will be reviewed within 180 days of gathering and verifying all necessary information. Review of all terminations, denials and renewals of participation shall occur within thirty (30) days of gathering and verifying all necessary information. MediGold utilizes the Council for Affordable Quality


http://MediGold.com/Find-a-Provider

http://MediGold.com/For-Providers/Join-Our-Network

mailto:MediGoldContracting%40mchs.com?subject=

http://MediGold.com




Healthcare (CAQH) for all initial credentialing and recredentialing of physicians. Please ensure that your information is up to date and your attestation current before applying for participation.

Initial Credentialing

Initial credentialing is a process of evaluating and determining a provider’s qualifications for participation with MediGold. The process includes screening and verifying provider applicants’ credentials and investigating any areas of potential concern. An office site audit and medical record review may be performed within six (6) months after the initial credentialing process has been completed. The process of evaluating credentials is based on predetermined credentialing and recredentialing criteria that MediGold has established for review of provider applicants. The credentialing and recredentialing criteria are available upon request.

Recredentialing

Recredentialing is the re-evaluation, at a minimum of every three years, of network providers to ensure their credentials still meet approved standards for participation and that their MediGold utilization and quality performance is acceptable. The credentials committee and the quality management committee work together to monitor important aspects of quality related to access, satisfaction, medical record review activities and peer review activities. MediGold accesses CAQH’s Universal Provider Datasource® for credentialing and recredentialing purposes. As long as you meet the recredentialing criteria, you will be successfully recredentialed. In the event any of the recredentialing criteria has not been met, the credentials committee may impose adverse action, including termination of your participation with MediGold. Written notification, via certified mail, will be sent by the chief executive officer within thirty (30) days of any adverse action stating the reasons for termination,

the consequences thereof and your appeal rights pursuant to the MediGold Formal Appeals Process Plan for providers (policy available upon request).

Facility Credentialing and Recredentialing

Credentialing and recredentialing of network facilities plays an important part in the MediGold QM Program. Credentialing, as a structural aspect of QM, is an ongoing process. All network facilities must meet MediGold state and federal quality standards prior to entering into a contractual agreement. Ongoing assessments are completed every three (3) years. Reassessment will be done more frequently if problems are identified.

Summary Suspension

MediGold, including its board of directors and credentials committee shall have the authority to summarily suspend a provider from participation with MediGold. A summary suspension may only be imposed when you, the provider, willfully disregard MediGold policies, whenever your conduct requires that immediate action be taken by the Plan to protect the life of a member, or to reduce the substantial likelihood of immediate injury or damage to the health or safety of any member. The summary suspension shall become effective immediately upon imposition. Written notification will be sent via certified mail to your address of record with MediGold within thirty (30) days by the chief executive officer on behalf of the imposer of such suspension. The notification will detail the summary suspension decision and your appeal rights pursuant to the MediGold Formal Appeals Process Plan for providers.



Within ten (10) days after such summary suspension, a meeting of the credentials committee shall be convened to review and consider the action taken. The committee may recommend modification, continuation, or termination of the terms of the summary suspension and any further or additional corrective action. This shall not constitute a hearing. You are entitled to an appeal pursuant to the formal appeals process plan policy, unless the credentials committee recommends immediate termination of the suspension or cessation of all further corrective action. The terms of the summary suspension, as sustained or as modified, shall remain in effect pending a final decision by the MediGold Board of Directors.

Immediately upon the imposition of a summary suspension, the medical director shall have the authority to provide for alternative medical coverage of your members who are in a hospital at the time of such suspension. The wishes of the member(s) shall be considered in the selection of such an alternate provider. In the case of an immediate suspension of a PCP, non-hospitalized members of the suspended PCP will be assigned to alternate network PCPs.

Provide Official Notice

You must immediately notify us, in writing, at the address in your provider agreement or located on the contact page of this manual of the following events:

Material changes in, cancellation or termination of liability insurance.

Bankruptcy or insolvency.

Any indictment, arrest or conviction for a felony or any criminal charge related to your practice or profession.

Any suspension, exclusion, disbarment or sanction from a state or federally funded health care program.

Loss or suspension of federal Drug Enforcement Administration registration.

Loss of Medicare participation status.

Loss of a medical license, certificate or other legal credential authorizing the ability to practice or provide care.

Loss, suspension or revocation of staff privileges in your specialty or medical staff membership with at least one MediGold network hospital (except chiropractors). In extenuating circumstances, MediGold may accept into the network physicians who do not have active hospital privileges. These physicians must indicate in writing the coverage arrangements with network physician(s) who will admit and follow MediGold patients on their behalf; or

Loss of board certification or board eligibility in your medical specialty.

MediGold, including its board of directors and credentials committee shall have the authority to automatically and immediately suspend a provider’s participation with MediGold for any of the above instances.

The chief executive officer will notify you in writing, via certified mail, within thirty (30) days of the automatic suspension decision and of your appeal rights, pursuant to the MediGold Formal Appeals Process Plan for providers.

All such official notices must be in writing and sent by certified or registered mail or personally delivered to MediGold at:

Attn: President & Chief Executive OfficerMediGold 6150 E . Broad St, EE320 Columbus, OH 43213


Transition of Member Care Following Termination of Your Participation

You must make a good faith effort to notify all affected members at least thirty (30) calendar days prior to your termination of participation. If your network participation terminates for any reason, you are required to participate in the transition of your patient with timely and effective care.

Performance Assessment

Principles for performance assessment are derived from MediGold’s philosophies and business strategies for improving the quality of clinical care and to support providers in their practice of evidence-based and efficient health care delivery. In general, evaluation of provider practices is based upon the comparison of observed practice patterns with expected published patterns. Our goal is to improve healthcare quality and efficiency and reduce variation in outcomes by promoting the practice of evidence-based medicine. The performance assessments include benchmarking to national data and peers.

We require cooperation with our performance assessments and improvement activities (including, but not limited to, requests for telephone or face-to-face discussions and requests for additional information).

Provisions of Access to Your Facility

In support of MediGold’s clinical and quality initiatives, including care coordination, and concurrent review activities, you will provide us access to your facilities, including the emergency room, our members and their medical records, as well as your hospital and medical staff for purposes of obtaining necessary clinical information regarding our member’s condition or treatment plan. In addition, you will participate in discharge planning activities.

Physician Incentive Plan Regulation Compliance

The purpose of the federal Physician Incentive Plan (PIP) regulation is to allow CMS to determine if contracted Medicare managed care plans are making payments to physicians as an inducement for limiting medically necessary covered services to members. To make this determination, MediGold is required to provide information to CMS on whether its contractual relationships place physicians at substantial financial risk for referral services. CMS has complicated regulations defining a PIP and for calculating substantial financial risk. These regulations require a physician group or individual physician who is placed at substantial financial risk to purchase stop loss insurance and conduct member satisfaction surveys.

Remediation Policy

It is the policy of MediGold to maintain an adequate provider network and enforce the terms and conditions of its provider agreements and operating documents. MediGold will implement progressive disciplinary steps with MediGold participating providers who do not comply with the contractual requirement to refer members to MediGold participating providers or fail to obtain prior authorization from MediGold for services listed on MediGold’s Prior Authorization List. These disciplinary steps include focused review, monetary penalties and adverse participation decisions.

The following delineates the disciplinary steps taken upon each occurrence during the previous rolling twelve (12) month time period:

Step one: The MediGold participating provider will be mailed the “First Warning Letter”, attached hereto and made a part hereof, along with a copy of this policy, the MediGold Prior Authorization List, instructions on how to access the provider directory and/or related provider communications.





Step two: The MediGold participating provider will be mailed the “Second Warning Letter”, attached hereto and made a part hereof, describing the potential for a reduction in reimbursement for a period of six (6) months upon another occurrence. A copy of the policy, the MediGold Prior Authorization List, instructions on how to access the provider directory and/or related communications may accompany this letter.

Step three: The MediGold participating provider will be mailed the “Payment Reduction Letter” notifying them that (i) the non-participating provider or the unauthorized services has been paid by MediGold and (ii) that the MediGold participating provider will be reimbursed at the lesser of (i) eighty percent (80%) of the current Medicare fee schedule on the date of service, or (ii) actual billed charges, less applicable copayments, deductibles and coinsurance, for a period of six (6) months from the date of the payment reduction letter. A copy of the policy, the MediGold Prior Authorization List, instructions on how to access the provider/pharmacy directory and/or related communications may accompany this letter. The participating provider will be re-evaluated by MediGold during the six (6) months to determine if the provider has come into compliance. Reduced reimbursement may continue beyond the six (6) months at the discretion of MediGold. A memo will be placed in the QMACS system to explain the reduction.

Step four: The MediGold participating provider will be mailed the “Final Warning Letter” indicating that the MediGold participating provider’s non-compliance with the MediGold provider agreement and operating documents will be brought to a MediGold Committee and/or the MediGold Board for an adverse participation decision or other corrective action as deemed appropriate.

Medicare Advantage Participation ProvisionsIf you are contracted to participate in the network for MediGold (referred to below as Plan), you are required to follow a number of Medicare laws, regulations and CMS guidelines and instructions. These program requirements are stated in your provider agreement with us and listed below.

You must provide covered health care services in a manner consistent with professionally recognized standards of health care.

You may not discriminate against Medicare beneficiaries in any way based upon health status.

You must cooperate with Plan in allowing MediGold members to directly access screening mammography and influenza vaccination services.

You must cooperate with Plan in not imposing cost-sharing on MediGold members for influenza vaccine or pneumococcal vaccine.

You must cooperate with Plan in providing female MediGold members with direct access to a woman’s health specialist for routine and preventive health care services.

You must assist us in providing our MediGold members with timely and adequate access to covered health services. You must ensure that your hours of operation are convenient, you do not discriminate against members and that medically necessary services are available to MediGold members 24 hours a day, 7 days a week. Arrangements for coverage after hours and while off duty (weekends, sick times, vacations, etc.) must be made with other network providers. A current listing of network providers is available on our website at MediGold .com/For-Providers or by calling provider services.


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http://MediGold.com/For-Providers



You must provide information regarding treatment options, including the option of no treatment, to MediGold members in a culturally competent manner, taking into account limited English proficiency or reading skills, hearing or vision impairment and diverse cultural and ethnic backgrounds. Members with disabilities must have effective means of communication to make informed decisions about treatment options.

You must abide by our procedures to ensure effective and continuous patient care and quality review including our procedures to ensure the performance of an initial health assessment within 90 days of a member’s effective date of enrollment.

You will cooperate with Plan’s efforts to maintain procedures to identify MediGold members with complex or serious medical conditions, assess those conditions using medical procedures to diagnose and monitor the conditions on an ongoing basis and establish, implement and periodically update treatment plans for those members. You will maintain procedures to inform MediGold members of follow up care or provide training in self-care as necessary.

You must document in a MediGold member’s medical record whether they have executed an advance directive.

You must comply with Plan’s medical policies, quality improvement programs and medical management procedures. Plan will consult with providers when developing, reviewing and communicating them to providers in accordance with federal and state laws and regulations.

You will continue to provide covered services to members in the event of Plan’s insolvency, discontinuance of operations or termination of its contract with CMS, for the duration of the contract period for which CMS payments have been made to Plan and, for MediGold members

who are hospitalized, until such time as the member is appropriately discharged from the hospital.

With respect to covered services which are not provided in a health care facility, notwithstanding anything herein to the contrary, you shall continue to provide covered services until the earlier of: (a) thirty (30) days following the entry of a liquidation order under under applicable state law; (b) the end of the member’s period of coverage for a contractual prepayment or Plan premium; (c) the date the MediGold member obtains equivalent coverage from an alternative payor; (d) the date the MediGold member or the member’s employer terminates coverage under its agreement with MediGold; or (e) the date MediGold’s obligations under the Participating Provider agreement are transferred by a liquidator pursuant to applicable state law.

You will maintain MediGold members’ medical and other records in an accurate and timely manner and in accordance with accepted industry professional standards and applicable federal and state laws and regulations. Members shall be given timely access to their medical records and information that pertains to them. Any charges to MediGold members for copies of the records shall not exceed the reasonable and customary charges in the professional community, or the maximum amount allowed by applicable law.

You must safeguard the privacy and confidentiality of all information that identifies a particular MediGold member and abide by all applicable federal and state laws and regulations regarding privacy, confidentiality and disclosure of mental health records, medical records, other health information and enrollment and member information.


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Information from, or copies of, medical, enrollment and other records may be released only to authorized individuals in accordance with applicable federal and state laws and regulations. When required by law, you must secure a signed release from a member prior to disclosure of the member’s medical records and health information. You also will take reasonable precautions to ensure that unauthorized individuals cannot gain access to or alter member records.

You must cooperate with Plan procedures for handling grievances, determination appeals and expedited determinations and expedited appeals. This includes complying with all final determinations made by Plan, CMS, CMS’ contracted independent agency or the local quality improvement organization (QIO) pursuant to grievance and appeals procedures. Members are entitled to appeal denial and discharge decisions to an independent entity contracted by CMS or to the QIO. Upon request by Plan, you will promptly deliver to a member any required denial letter and cooperate in the delivery of a notice of medicare non-coverage (NOMNC) or other materials from Plan containing members’ appeal rights and with the parties responsible for performing the review and reconsideration. In addition, you must notify Plan promptly of any decision not to furnish to a member a health care service requested by a member or to terminate or discontinue a health care service being provided to a member which termination or discontinuation is contrary to the member’s wishes and of any member grievances and appeals known to you. Plan and the QIO will review members’ grievances concerning quality of care. Upon request of Plan, you will investigate and respond promptly to all quality issues related to care provided to members and cooperate with the QIO and Plan to resolve such issues in the best interest of members.

You must provide requested records and documentation to the Plan or the QIO as requested no later than by close of business of the day that you are notified by Plan or the QIO if the member has requested a fast track or expedited appeal at no cost to the Plan.

You will cooperate with any QIO review and other QIO activities pertaining to the provision of services to members.

In the event that Plan suspends and/or terminates your participation, Plan will deliver to you written notice of the reason(s) for the suspension and/or termination including, if relevant, the standards and profiling data used to evaluate you and the number and mix of providers needed by Plan. If applicable, the notice will also include the right to appeal the action taken by Plan and the process and timing for requesting a hearing in accordance with Plan’s policies and procedures. You acknowledge that if Plan suspends and/or terminates your participation because of deficiencies in the quality of care, Plan is required by federal regulations to provide written notice of such action to licensing or disciplinary bodies or to other appropriate authorities.

You must cooperate with Plan’s processes for notifying MediGold members of provider agreement terminations.

You may not distribute marketing materials or forms to Medicare beneficiaries without CMS approval of those materials or forms. If approved by CMS, you must display the approval number at the bottom of the form.

You must follow CMS marketing guidelines found in the Medicare Managed Care Manual if you are marketing this Plan to your Medicare eligible patients.


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In no event, including, but not limited to, non-payment by the Plan, Plan’s insolvency or breach of your provider agreement, can you bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a MediGold member, or person other than Plan acting on a MediGold member’s behalf, for services provided pursuant to your provider agreement. You are not prohibited from collecting supplemental charges or copayments on Plan’s behalf made in accordance with the terms of any agreement between Plan and its members. Further, this does not prohibit the collection of charges for services rendered by you but not covered under the subscriber or member agreement and benefits schedule. You further agree that (1) this provision shall survive the termination of your contract, regardless of the cause giving rise to the termination and shall be construed to be for the benefit of Plan’s members and (2) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between you and the member or persons acting on the member’s behalf.

You may not hold any MediGold member liable for payment of any fees that are the legal obligation of the Plan.

You must contact MediGold Utilization Management before providing a service if you feel that such a service will not be covered by the Plan and wish to bill the member for that service. If the service is not covered by Plan, utilization management will issue an integrated denial notice (IDN). The member must receive this IDN with sufficient advance notice to make an informed decision on whether to receive the non-covered and/or not medically neccesary service. If you perform a non-covered service on a member without requesting an IDN sufficiently in advance for the member to make such a decision, then the service will be denied and you may not hold the member liable for the

non-covered and/or “not medically neccesary” service. For more details, see the Provider Policies and Protocols section in this manual for more details.

You will be paid by the Plan in a prompt manner according to the terms of your provider agreement with Plan and applicable federal and state laws and regulations. You must cooperate with Plan in ensuring that any payment and incentive arrangements with subcontractors are specified in a written contract, that such arrangements do not encourage reductions in medically necessary services and that any physician incentive plans comply with CMS standards.

You understand that you are subject to laws and regulations applicable to persons or entities receiving federal funds, and must notify all subcontractors that they are also subject to these laws and regulations.

You will comply with all applicable federal laws and regulations including Medicare, Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, the Rehabilitation Act of 1973, the False Claims Act, the Anti-Kickback statute and all other laws applicable to recipients of federal funds.

You will inform Plan immediately upon your exclusion from participation in the Medicare program. According to section 42 CFR 422.204(b)(4), an MA organization must follow a documented process with respect to providers and suppliers who have signed contracts or provider agreements that ensures compliance with the requirements at § 422.752(a)(8) that prohibit employment or contracts with individuals (or with an entity that employs or contracts with such an individual) excluded from participation under Medicare and with the requirements at § 422.220 regarding physicians and practitioners who opt out of Medicare.

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You understand and acknowledge that Plan is ultimately accountable to CMS for any functions and responsibilities described in the Medicare Advantage regulations. You will cooperate with Plan in prohibiting the use of Medicare excluded practitioners.

If you are delegated an administrative function by the Plan, you must adhere to all delegation requirements set forth in the Medicare Advantage regulations and your provider agreement. All delegated activities are routinely monitored by Plan. You may not delegate any function under your provider agreement with the Plan to a Medicare excluded practitioner.

You must cooperate with Plan processes to disclose to CMS all information necessary for CMS to administer and evaluate the MA program, and all information necessary for CMS to permit beneficiaries and prospective beneficiaries to exercise an informed choice in obtaining Medicare services.

You will cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance, enrollee satisfaction, health outcomes and disenrollment rates for beneficiaries enrolled in MediGold for the previous two years, and other indicators as specified by CMS.

Subject to applicable patient confidentiality laws and regulations, you must submit to Plan, upon our request, or the request of our designees, within fifteen (15) calendar days of the request, medical records necessary to characterize the content/purpose of each encounter with a member. In the event that you are paid under a capitated arrangement, you must submit to Plan or our designee, within fifteen (15) calendar days of the request, all encounter data including medical records necessary to characterize the content/purpose of each encounter with a member in such frequency, formats and type as

reasonably requested by Plan for compliance with reporting requirements of federal and state government agencies and Plan’s utilization programs. Upon request by Plan or CMS, you are required to certify to CMS the accuracy, completeness and truthfulness of the encounter data submitted to Plan or our designee.

You acknowledge and agree that, as a contractor of Plan, you give Plan, the U.S. Department of Health and Human Services, the comptroller general, the general accounting office, other federal agencies and state and local regulatory agencies and their designees the right to inspect, evaluate and audit any pertinent contracts, books, documents, papers and records involving any aspect of services performed for members for a period of ten (10) years from the final date of the contract between CMS and Plan or the date of completion of an audit, whichever is later. The right to audit your records may be extended if CMS determines there is a special need to retain a particular record or group of records for a longer period and notifies you at least thirty (30) days prior to the normal disposition date or if there is a reasonable possibility of fraud. Your obligations herein survive the termination or expiration of your provider agreement.

Your books, provider agreement, documents, papers, medical records, patient care documentation, and any other records that pertain to any aspect of services performed for members must be maintained for ten (10) years or the date of completion of any federal or state government audit, whichever is later. You must retain such records beyond such period upon direction from CMS or other government agency.

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SECTION 13: Member Grievance And Appeal Process

Members are encouraged to let MediGold know if they have concerns or experience any problems with the Plan or its network providers. MediGold has representatives available to help members with their questions and concerns.

The procedures described in this section may be used if a member has an appeal or grievance he/she wants to submit to MediGold for review and resolution. These procedures include:

General information on Medicare appeals procedures.

Medicare standard organization determinations and appeals procedures.

Medicare expedited / 72-hour organization determinations and appeals procedure.

MediGold grievance procedure.

QIO immediate review of hospital discharges.

QIO quality of care complaint procedure.

General Information on Medicare Appeals Procedures

MediGold members have the right to appeal any decision about payment for, or failure to arrange or continue to arrange for, what the member believes are covered services (including non-Medicare covered benefits) under MediGold. Coverage decisions that are commonly appealed include decisions with respect to:

Payment for emergency services, post-stabilization care, or urgently needed services.

Payment for any other health services furnished by an out-of-network provider or facility that the member believes should have been arranged for, furnished, or reimbursed by MediGold.

Services not received, but which the member feels MediGold is responsible to pay for or arrange.

Discontinuation of services that the member believes are medically necessary covered services.

Members should use the MediGold grievance procedure (discussed in this section) for complaints that do not involve coverage decisions such as those set forth. For questions about what type of complaint process to use, members should call MediGold’s Member Service department toll-free at 1-800-240-3851 (TTY 711).

Members are entitled to a report from MediGold that describes the number of quality of care grievances and appeals and their dispositions processed during the most recent calendar year. Members may contact the Member Services Department for a copy of this report.

As discussed in this section, MediGold has a standard determination and appeals procedure and an expedited determination and appeals procedure.



Who May File an Appeal

A member may file an appeal.

A member’s legally authorized representative such as a durable power of attorney or legal guardian may file the appeal for the member on his/her behalf. The member may also appoint an individual to act as his/her representative to file the appeal by following the steps below:

Complete and submit form CMS -1696, appointment of representative form.

The appellant must include this signed statement with the appeal.

An out-of-network provider who has furnished a service to a member may file a standard appeal of a denied claim if he/she completes a waiver of payment statement indicating he/she will not bill the member regardless of the outcome of the appeal.

Support for the Appeal

MediGold is responsible for gathering all necessary medical information relevant to the request for reconsideration (appeal). However, it may be helpful to include additional information to clarify or support the request. For example, a member may want to include in the appeal request information such as medical records or provider opinions in support of the request. To obtain medical records, the member may send a written request to his/her primary care provider. If medical records from a specialist are not included in the medical record from the primary care provider, the member may need to make a separate request to the specialist who provided medical services. It is the member’s responsibility to pay any fee charged by the health care provider for medical records.

The member has the opportunity to provide additional information in person or in writing. In the case of an expedited decision or appeal, the member or the member’s authorized representative may submit evidence in person, via telephone,

or in writing transmitted by fax to the address and telephone number referenced under the expedited/72-hour review procedure.

Assistance with Appeals

In some situations a member may want help or guidance from someone who is not connected with MediGold. The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state.

In Ohio, the SHIP is called Ohio Senior Health Insurance Information Program (OSHIIP). Members may contact OSHIIP toll-free at 800-686-1578 .

In Idaho, the SHIP is called Senior Health Insurance Benefit Advisors (SHIBA). Members may contact SHIBA toll-free at 1-800-247-4422 .

Medicare Standard Organization Determination and Appeals Procedures

If a member specifically requests a particular service from a health care provider, or if that health care provider specifically requests authorization for a service from MediGold, it is considered a request for an organization determination on the service.

If the request is made in writing to MediGold (at the address listed below) to make payment for a service a member has already received, this a request for a MediGold determination on the payment.

In the case of a standard determination, MediGold must make a determination (decision) on the request for payment or provision of services within the following time frames:

Request for Service . If a member requests services, or requires prior authorization of a referral for services, MediGold must make a decision as expeditiously as the member’s health requires, but no later than fourteen (14) calendar days




after receiving the request for service. An extension of up to fourteen (14) calendar days is permitted if the member requests the extension or if MediGold has a need for additional information and the extension of time benefits the member. An example of this would be if MediGold would need additional medical records from out-of-network providers that could change a denial decision.

Request for Payment . If a member requests payment for services already received, MediGold will usually make a decision on whether or not to pay the claim no later than thirty (30) calendar days from receiving the request, but in no case will this period exceed sixty (60) days.

MediGold must notify the member in writing of any adverse decision (partial or complete) within the time frames listed above. The notice must state the reasons for the denial and also must inform the member of his/her right to file an appeal. If the member has not received such a notice within fourteen (14) calendar days of the request for services, or within sixty (60) days of a request for payment, the member may assume the decision is a denial and may file an appeal.

To proceed with the Medicare Standard Appeals Procedure, the Following Steps Will Occur:

The member must submit a written request to MediGold, Attention: Appeals and Grievance Coordinator, 6150 East Broad Street EE320, Columbus, OH 43213. The written request must be submitted within sixty (60) calendar days of the date of the notice of the initial decision.

MediGold will conduct a reconsideration and notify the member in writing of the decision, using the following time frames:

Request for Service. If the appeal is for a denied service, MediGold must notify the member of the reconsideration decision as

expeditiously as the member’s health requires, but no later than thirty (30) days from receipt of the request. The time frame may be extended by up to fourteen (14) days if the member requests the extension or if MediGold needs additional information, and the extension of time benefits the member, for example, if additional medical records are needed from out-of-network providers that could change a denial decision. Again, MediGold must make a decision as expeditiously as the member’s health requires, but no later than the end of any extension period.

Request for Payment. If the appeal is for a denied claim, MediGold must notify the member of the reconsideration determination no later than sixty (60) days after receiving the request for a reconsideration determination.

The reconsideration decision will be made by a person or persons not involved in the initial decision. All reconsiderations of adverse organization determinations based on ‘lack of medical necessity’ must be made by a provider with appropriate expertise in the field of medicine appropriate for the services at issue. The member or the member’s authorized representative may present or submit relevant facts and/or additional evidence for review either in person or in writing to MediGold.

If MediGold decides fully in the member’s favor on a request for a service, MediGold must provide or authorize the requested service within thirty (30) days of the date the request for reconsideration was received. If MediGold decides fully in the member’s favor on a request for payment, MediGold must make the requested payment within sixty (60) days of the date the request for reconsideration was received.

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If MediGold decides to uphold the original adverse decision, either in whole or in part, MediGold will automatically forward the entire file to MAXIMUS for a new and impartial review. MAXIMUS is CMS’ independent contractor for appeal reviews involving Medicare Advantage managed care plans such as MediGold. MediGold must send MAXIMUS the file within 30 days of a request for services and within 60 days of a request for payment. MAXIMUS will either uphold MediGold’s decision or issue a new decision. If MediGold forwards the case to MAXIMUS, MediGold will notify the member of the decision as discussed above.

For cases submitted for review, MAXIMUS will make a reconsideration decision and notify the member in writing of their decision and the reasons for the decision. If MAXIMUS upholds the Plan’s decision, their notice will inform the member of rights to a hearing before an administrative law judge of the Social Security Administration (SSA) (see below for further levels of appeal). If MAXIMUS (or a higher appeal level) decides in favor of the member, MediGold must pay for,

provide or authorize the service as expeditiously as the member’s health condition requires, but no

later than 60 days from the date notice reversing the Plan’s decision is received.

If MAXIMUS does not rule fully in the member’s favor, there are further levels of appeal:

If there is at least $170.00 (2020 amount) in controversy, the member may request a hearing before an administrative law judge (ALJ) by submitting a written request to MediGold, MAXIMUS or the SSA within sixty (60) days of the date of MAXIMUS’ notice that the reconsideration decision was not in the member’s favor. This sixty (60) day notice may be extended for good cause. All hearing requests will be forwarded to MAXIMUS. MAXIMUS will then forward the request and the reconsideration file to the hearing office. MediGold will also be made a party to the appeal at the ALJ level.

Either the member or MediGold may request a review of an ALJ decision by the Medicare Appeals Council, which may either review the decision or decline review.

If the amount involved is $1,670.00 (2020 amount) or more, either the member or MediGold may request that a decision made by the Medicare Appeals Council, or the ALJ if the Medicare Appeals Council has declined review, be reviewed by a federal district court.

Any initial or reconsidered decision made by MediGold, MAXIMUS, the ALJ, or the Medicare Appeals Council can be reopened by any party (a) within twelve months, (b) within four (4) years for just cause, or (c) at any time for clerical correction of an error or in cases of fraud.

The reconsidered determination is final and binding upon MediGold. If there is a binding arbitration clause in the member’s contract or individual election form, it does not apply to disputes subject to CMS’ appeals process.



Medicare Expedited/72-Hour Determination and Appeal Procedure

Members have the right to request and receive expedited decisions affecting medical treatment in ‘time- sensitive’ situations. A ‘time-sensitive’ situation is one in which waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize the member’s life, health or ability to regain maximum function.

If MediGold decides, based on medical criteria, that a situation is ‘time-sensitive’ or if any provider makes the request for the member by calling or writing in support of the request for an expedited review, MediGold will issue a decision as expeditiously as the member’s health requires, but no later than seventy-two (72) hours after receiving the request. This time frame may be extended by up to fourteen (14) days if the member requests the extension or if the Plan needs additional information and the extension of time benefits the member; for example, if MediGold needs additional medical records from out-of-network providers that could change a denial decision. Again, MediGold must make a decision as expeditiously as the member’s health requires, but no later than the end of any extension period.

Types of Decisions Subject to Expedited/72-Hour Review

Expedited Determinations . If a member believes he/she needs a service, or continues to need a service, and believes it is a ‘time-sensitive’ situation, the member or any provider (including a provider with no connection to MediGold) may request that the decision be expedited. If MediGold decides that it is a ‘time-sensitive’ situation, or if any provider states that it is one, MediGold will make a decision on the request for a service on an expedited/72-hour basis (subject to an extension as discussed above).

Expedited Appeals . If a member wants to request a reconsideration (appeal) of a decision by MediGold to deny a service requested or to discontinue a service the member is receiving that he/she believes is a medically necessary covered service and the member believes it is a ‘time-sensitive’ situation, the member may request that the reconsideration (appeal be expedited. If a provider wishes to file an expedited appeal for the member, the member must give him or her authorization to act on the member’s behalf. If MediGold decides that it is a ‘time-sensitive’ situation, or if any provider states that it is one, MediGold will make a decision on the appeal on an expedited/72-hour basis. This time frame may be extended by up to fourteen (14) days if the member requests the extension or if MediGold needs additional information, and the extension of time benefits the member; for example, if MediGold needs additional medical records from out-of-network providers that could change a denial decision.

Again, MediGold must make a decision as expeditiously as the member’s health requires, but no later than the end of any extension period.

Examples of service decisions which members may appeal on an expedited basis, when believed to be a ‘time-sensitive’ situation, include the following:

Denial of a service requested.

Services discontinued too soon, according to the member, for example:

Being discharged from a skilled nursing facility too soon and missing the deadline for a QIO review.

Home health care is being discontinued too soon and missing the deadline for a QIO review.

The procedures for requesting and receiving an expedited determination or an expedited appeal (an expedited decision) are described in the following sections.



How to Request an Expedited/72-Hour Review

To request an expedited/72-hour review, a member or the member’s authorized representative may call, write or visit MediGold. Members must specify an expedited/72-hour review when making the request.

How an Expedited/ 72-Hour Determination/ Review Request Will be Processed

Upon receiving a request for an expedited decision, MediGold will determine whether the request meets the definition of ‘time-sensitive’:

If the request does not meet the definition, it will be handled within the standard review process. The member will be informed by telephone or in person whether the request will be processed through the expedited seventy-two (72) hour review or the standard review process. The member will also be sent a written confirmation within two (2) working days of the telephone call or personal contact. If the member disagrees with MediGold’s decision to process the request within the standard time frame, the member may file a grievance with MediGold. The written confirmation letter will include instructions on how to file a grievance. If the request is ‘time-sensitive,’ the member will be notified of MediGold’s decision as expeditiously as the member’s health requires but no later than seventy-two (72) hours after receipt of the request.

An extension up to fourteen (14) calendar days is permitted for a 72-hour request for determination/appeal, if the member asks for the extension or MediGold needs more information and the extension of time benefits the member; for example, a member may need time to provide additional information, or MediGold may need to have additional diagnostic testing completed.

The request must be processed within seventy-two (72) hours if any provider calls or writes in support of the request for an expedited/72-hour review, and the provider indicates that applying the standard review time frame could seriously jeopardize the life or health of a member or the member’s ability to regain maximum function.

If an out-of-network provider supports the request, MediGold will have 72 hours from the time it receives all the necessary medical information from that out-of-network provider it needs to make a decision.

MediGold will make a decision on the request for determination/appeal and notify the member within 72 hours of receipt of the request. If MediGold decides to uphold the original adverse decision, either in whole or in part, the entire file will be forwarded by MediGold to MAXIMUS for review as expeditiously as the member’s health requires, but no later than 24 hours after the decision. MAXIMUS will send the member a letter with their decision within 72 hours of receipt of the case from MediGold.

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When requesting an expedited determination/appeal, if a member does not hear from MediGold within 72 hours of the request, the member can assume that the request has been denied. MediGold’s failure to notify the member in a timely manner – within 72 hours – constitutes a denial which may be appealed.

MediGold Grievance Procedures

MediGold members have the right to file a complaint—formally called a grievance—about problems observed or experienced, including:

Complaints about the quality of services received.

Complaints regarding such issues as office waiting times, provider behavior, adequacy of facilities, or other similar member concerns.

Involuntary disenrollment situations.

Disagreement with MediGold’s decision to process a request for a service or to continue a service under the standard 14-day time frame rather than the expedited/72-hour time frame.

Disagreement with MediGold’s decision to process an appeal request under the standard 30-day time frame rather than the expedited/72-hour time frame.

MediGold will attempt to resolve any complaint the member might have. MediGold will write to the member to let them know how the Plan has addressed the concern within thirty (30) days of receiving the grievance. In some instances, MediGold will need additional time to address the concern. If additional time is needed, MediGold will keep the member informed regarding the status of the grievance. MediGold is required to track all appeals and grievances in order to report cumulative data to CMS and to members, upon request.

Complaints about a decision regarding payment for or provision of, covered services that a member believes are covered by Medicare and should be provided or paid for by MediGold must be appealed through MediGold’s Medicare Appeals Procedure (see earlier in this section)

There are four possible dispositions to a request for expedited determination/appeal. They are:

The request to expedite the determination/appeal decision is approved, a decision is made in 72 hours and the member is notified that MediGold will cover or continue the service.

The request to expedite the determination/appeal decision is approved, MediGold makes a decision in 72 hours and notifies the member that the Plan will not cover or continue the service.

The request to expedite the determination/appeal decision is not approved, and MediGold tells the member that his/her request will be handled under the standard determination/appeal process.

The request to expedite the determination/appeal decision cannot be made in 72 hours, and MediGold lets the member know that the Plan will need up to an additional 14 days to process the request.

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Quality Improvement Organization Immediate Review of Hospital Discharges

Members have the right to receive all the hospital care that is necessary for the proper diagnosis and treatment of illness or injury. According to federal law, discharge date must be determined solely by medical needs. When being discharged from the hospital, members will receive a written notice of explanation called a Notice of Medicare Non-Coverage (NOMNC). This document outlines member rights, and a member does not have to disagree with the non-coverage determination in order to receive it. Hospitals participating with Medicare are required to issue this notice.

Members have the right to request a review by a QIO of any written NOMNC received from MediGold or from the skilled nursing facility or home health agency on MediGold’s behalf stating that the Plan will no longer pay for a member’s care. Such a request must be made by noon the day before covered services end. Members cannot be made to pay for the care or a service received before the QIO makes its decision and notifies the member.


If receiving inpatient care from a hospital, members have the right to request a review by a QIO of any written NOMNC from MediGold or the hospital on MediGold’s behalf stating that the Plan will no longer pay for a member’s care. Such a request must be made by midnight on the day of discharge. Members cannot be made to pay for the care or services received before the QIO makes it decision and notifies the member, if the notice is timely.

QIOs are groups of physicians who are paid by the federal government to review medical necessity, appropriateness, and quality of hospital treatment furnished to Medicare patients, including those enrolled in a managed care plan (like MediGold).

The telephone number and address of the QIO for Ohio is: Livanta LLCBFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701-1105 1-888-524-9900 TTY 1-888-985-8775 https://www .livantaqio .com The telephone number and address for Idaho is: KEPRO, INC. 5201 W. Kennedy Blvd, Suite 900 Tampa, Florida 33609 1-855-408-8557

Members should review the NOMNC to verify the address and telephone number of the QIO responsible for the facility in which they are a patient.

If a member asks for immediate review by the QIO by noon on the workday following a NOMNC, the member will be entitled to this process instead of the standard appeals process that is described in this section. The member will also be protected from liability for facility services received before the QIO makes its decision. Instead of QIO review, a member may appeal the notice of

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https://www.livantaqio.com



NOTE

non-coverage/notice of discharge and medicare appeal rights within 60 days as discussed above by requesting that MediGold reconsider the decision. The advantage of the QIO review is that members will get the results within three working days if requesting the review on time.Also, members are not financially liable for facility charges incurred during the QIO review process. This same protection does not apply in the case of MediGold’s reconsideration process.

Members may file an oral or written request for an expedited/72-hour MediGold appeal only if they have missed the deadline for requesting the QIO review. If a member does not seek QIO review, however, and seeks an expedited reconsideration of the organization determination, the member will be financially responsible for the facility costs incurred from the date the NOMNC is issued if the original determination to discharge is upheld through the appeal process. The member must specifically state that he/she has missed the immediate QIO review deadline, he/she wants an expedited

(or 72-hour) Appeal and he/she believes his/her health could be seriously harmed by waiting for a standard appeal.

Members may still request a review by the QIO after the deadline of midnight on the day of discharge for NOMNC appeals. However, the QIO is permitted 2 days to review the case and make a decision if the member is still inpatient but missed the deadline or 30 days if the member has since been discharged. No financial liability protection is extended to the member.

If the member receives an immediate review by the QIO, he/she will not be entitled to a MediGold expedited reconsideration or standard appeal of the discharge decision.

Quality Improvement Organization Quality of Care Complaint Process

For concerns regarding the quality of care received, a member may also file a complaint with the QIO in his/her state.

2021 Administrative Manual Network Provider

Documents

Transcript of 2021 Administrative Manual Network Provider