Provider Manual - SummaCare

IRevised May 2016
I. Office Staff Reference Claim Data Element Claims Submission Directory Electronic Data Interchange (EDI) Submission Member ID Cards Member’s Rights and Responsibilities Notice of Privacy Practices Prior Authorization Drug List for Commercial Members Prior Authorization Drug List for Medicare Members Prior Authorization Services List (Medicare & Commercial Members) Prior Authorization Request Form for Drugs Covered Under Medical Benefit Prior Authorization Request Form for Services Provider Claim Adjustment Request Provider Support Services SummaCare Mission Statement Summary of SummaCare Plans SummaCare Website Take Back Process
II. Quality Management Quality Management Program Summary III. Medical Management Clinical Management Department Summary
Genetic Testing Request Form Prior Authorization by Fax
Prior Authorization Request Form IV. Pharmacy Management MedImpact Request Form
TransactRX Vaccine Manager Pharmacy Management Department Summary
V. Policies & Procedures CLAIMS Claims – Denials (Medicare)
Claims Submission of Never Events Hospice Interest Payments (Fully-Insured & Self-Funded Groups)
Interest Payments (Medicare) Medicare Explanation of Benefits Medicare Member Claim Reimbursement Medicare Remittance Advice/Notice for Non Contracted Providers Overpayment Recovery Procedures Overpayment Refund Receipt, Reconciliation and Recording Process Pended Claims Plan Directed Care Prompt Payment of Claims (Medicare)
Subrogation CLINICAL MANAGEMENT Access to Board-Certified Physician Consultant for Utilization Decisions
Care Coordination and Complex Case Management Program Continuity & Coordination of Care Between Medical & Behavioral Health Practitioners Coverage of Emergency Services Disease Management Medicare Pre-Service Organization Determinations Physician Proposal for Policy/Criteria Modification Transition to Other Care When Benefits End
Utilization Management COMPLIANCE Antifraud Policy Audit Coordination
Corporate Confidentiality of Member, Practitioner and Payor Information Policy Physician/Practitioner Code of Conduct Policy Prompt Payment of Claims
CREDENTIALING Appeals Process for Physicians/Practitioners Failing to Meet Recredentialing Criteria Confidentiality of Physician/Practitioner Information
Credentialing/Recredentialing of Advance Practice Nurses Credentialing/Recredentialing of Audiologists
Credentialing/Recredentialing of Behavioral Health Physician/Practitioner Credentialing/Recredentialing of Genetic Counselors Credentialing/Recredentialing of Occupational Therapists
Credentialing/Recredentialing of Optometrists Credentialing/Recredentialing of Physicians, Oral Surgeons, Podiatrists and Chiropractors
Credentialing/Recredentialing of Speech Pathologists Disruptive Physician/Practitioner Policy
Office Site Visit and Medical/Treatment Record-Keeping Physician/Practitioner Appeals Process for Adverse Peer Review and Determinations
Physician/Practitioner Leave of Absence Physician/Practitioner Office Site Visit
Physician/Practitioner Performance Improvement Process Physician/Practitioner Rights and Responsibilities for Credentialing/Recredentialing
Required Criteria for Participation Types of Individuals Credentialed/Recredentialed
PHARMACY Coverage for Injectable Drugs Drug Recalls Drug Utilization Review Information Collection for Pharmacy Benefit Management Decision Making Lost, Stolen, and Destroyed Prescriptions
Medicare Part D Compound Drugs Medicare Part D Coverage Determinations Medicare Part D Coverage Determination Exceptions Medicare Part D Effect of Failure to Provide Timely Notice to Medicare Enrollees Medicare Part D Formulary Development Management Maintenance Communication Medicare Part D Medically Accepted Indication Medicare Part D Medication Therapy Management Program Medicare Part D Out-of-Network Pharmacy Access Medicare Part D Opiate APAP Overutilization Monitoring Medicare Part D OTC Covered Drugs Medicare Part D Quantity Limits Medicare Part D Request for Reimbursement Medicare Part D Transition Process Off-label use of Prescription Drugs Pharmacy Benefit Tier Exceptions Pharmacy Prior Authorizations Prescription Access during Public Health Emergencies
Step Therapy Protocols Vacation Overrides QUALITY MANAGEMENT/APPEALS Assessment of New Technology Clinical Practice Guidelines Confidentiality of Medical Records – Physician/Practitioner Sites Continuity and Coordination of Medical Care
Medical Record Review Documentation Preventative Health Guidelines
VI. Miscellaneous Acknowledgement of Service (Waiver) Changing Contact Information Form EDI Provider Registration
Health Education Materials Request Form Informed Consent to Coordinate of Care Form
Office Staff Reference
CLAIMS DATA ELEMENT (1 of 2)
HCFA Current/Updated National Uniform Claim Committee (NUCC) claim form A separate claim for each patient (member) Member’s (patient’s) identification number from their ID card Member’s (patient’s) name Member’s (patient’s) date of birth and gender ICD10 diagnosis code(s) Indicate if member (patient) has other insurance coverage. Date(s) of service (if rental item, it must include rental date span). DOS must be within member’s
term of coverage. We do not process future dates of service. Place of service codes and/or modifiers CPT/HCPCS code(s) Charge for each line of service Claim should not exceed 99 lines of service Provider Tax ID number NPI # in box 24j and 33b Physician’s name/signature (unless contracted as a “pay to group”). Correct total charges If “late or corrected” claim, they should note this somewhere on the claim. (Prefer box 19) All information on the entire document MUST BE LEGIBLE
UB A separate claim for each patient (member) Member’s (patient’s) identification number from their ID card Member’s (patient’s) name Member’s (patient’s) date of birth and gender Member’s (patient’s) account number Type of Bill Discharge code Provider’s tax ID number DRG number (if any – it could be located in 3 to 4 different locations on claim but must be an
accurate and active DRG number) Date(s) of service Revenue codes CPT/HCPCS codes and/or modifiers (if any) Charge for each line of service Correct total charges If the patient is a Medicare member, the attending physician’s NPI# and name must be in boxes
82 thru 83. All information on the entire document MUST BE LEGIBLE NPI# in box 56
Claims Data Element
CLAIMS DATA ELEMENT (2 of 2)
ADA (Dental claim form) Claim should be identified as “actual claim or pre-determination”. A separate claim for each patient (member) Member’s (patient’s) identification number from their ID card Member’s (patient’s) name) Member’s (patient’s) date of birth and gender Member’s (patient’s) account number (if any) Indicate if member (patient) has other primary dental coverage. Date(s) of service (if pre-determination, there will not be any DOS). Tooth number(s) Tooth surface code(s) If prosthesis, date of initial visit If orthodontics, date of placement of appliance (this date is vital because in most cases many
dentists bill the patient in monthly installments) Provider should not submit any x-rays with a claim unless requested by us and/or for appeals. We
will not be returning any x-rays, they will be recycled. X-rays cannot be scanned however, some pictures can be scanned.
Dental HCPCS code for each service Unless indicated otherwise, all dental charges are performed in the office so no location code is
required on dental claims. Charge for each line of service Correct total charges Provider tax ID # Provider’s name/signature If “late or corrected” claim, they should note this somewhere on the claim. All information on the entire document MUST BE LEGIBLE NPI# in correct designated box
CLAIMS SUBMISSION (1 of 1)
Claims can be submitted through Electronic Data Interchange (EDI) SummaCare Payor ID number is 95202. Apex Payor ID number is 34196. Please send completed paper claim forms and supporting documentation to: SummaCare P.O. Box 3620 Akron, Ohio 44309-3620 Plan Central Claim Entry Provider offices who do not have the capability to submit claims via EDI, can submit claims through SummaCare’s online provider web portal – Plan Central. Claim submission is available under the “Updates” menu option.
Claims Submission
Provider Support Services For questions about benefits, plan limits, authorizations, eligibility and claim status please login to Plan Central. If you are unable to locate the answer to your question on Plan Central, please call Provider Support Services. Phone: 330-996-8400 or 800-996-8401 (Hours of business 8:00am – 5:00pm) Fax: 330-996-8490 (please do not fax claims or medical records) Email: mailto:[email protected] Plan Central Registration: Click on the Plan Central button on www.summacare.com. Health Service Management* Prior Authorization, Inpatient Concurrent Review, Case Management Phone: 330-996-8710 or 888-996-8710 Fax: Outpatient: 234-542-0815
Inpatient: 234-542-8805 *Providers - Please fax forms to Benefits Determination Unit. Call Benefits Determination Unit
for emergent prior authorization. *Facilities - Please contact Benefits Determination Unit with notification of hospitalization
within 24 hours of admission. Pharmacy To obtain prior authorization and/or step therapy drug information, please contact Pharmacy or visit our website at www.summacare.com for the latest versions of SummaCare’s Drug Formulary and Medicare Part D Formulary. Phone: 888-783-1780
To obtain prior authorization for prescription drugs, please contact our Pharmacy Benefit Manager (PBM), MedImpact, at the number listed below. Please also visit our website at www.summacare.com for the latest versions of the SummaCare Commercial Drug Formulary documents and the Medicare Part D Comprehensive Formulary. Phone: 800-788-2949 Fax: 858-790-7100 Durable Medical Equipment Phone: 330-996-8428 or 866-728-8797 Fax: 330-996-8904 or 234-542-0815 SummaCare Administration Phone: 330-996-8410 or 800-996-8411
PROVIDER CLAIM ADJUSTMENT REQUEST (1 of 1)
Providers may submit their claims electronically through one of our contracted Trading Partners or they can directly submit their HIPPA Compliant electronic claim files to us. Our Payor ID’s are SummaCare 95202 and Apex 34196. Contact EDI Support- [email protected] for a complete list of Trading Partners or how to become a direct submitter. Professional Electronic Claims must include BUT not limited to:
• The Billing Providers NPI and TAX ID Number are required to submit electronic claims to us. Loop 2010AA
• Multiple claims can be sent on the same electronic file • Member name • Member’s date of birth and sex • Member’s 11 digit ID Number • Valid ICD10 diagnosis code
Institutional Electronic Claims must include BUT not limited to:
• The Billing Providers NPI and TAX ID Number are required to submit electronic claims to us. Loop 2010AA
• Multiple claims can be sent on the same electronic file • Member name • Member’s date of birth and sex • Member’s 11 digit ID Number • Valid ICD10 diagnosis code
Companion Guides and EDI documents can be found on our website:
• SummaCare – EDI • Apex – EDI
Providers who submit their claims electronically are encouraged to participate in Electronic Remittance Advice (ERA) and Electronic Transfer of Funds (EFT).
ERA/EFT documents can be found: • SummaCare – ERA/EFT • Apex – ERA/EFT
Electronic Data Interchange (EDI) Submission
Electronic Data Interchange (EDI) Submission
________________________________________________________________________________
A – Plan type: This is the type of health insurance plan the member has. Examples of plan types include Group PPO, Individual PPO, Self Funded PPO, etc. B – Name of the Plan: This is the name of the benefit plan the member has. Examples include Plan 5620A, Plan 3700A, Qualified Plan Q1501A, etc. C – Network Name: This is the name of the provider network. Questions? Please call Provider Support Services at 800-996-8401 or e-mail [email protected].
Member ID Cards
Member Rights & Responsibilities
Upon enrollment and at least annually thereafter, SummaCare informs our members that they have the following rights and responsibilities. SummaCare employees and all of our contracted providers are updated on these statements annually as well. These statements help to ensure that members are treated with fairness and respect. Equally important, they inform members of their responsibilities as a health plan member.
These statements promote a mutually respectful relationship between SummaCare, plan members and their healthcare providers. It is important that members understand their responsibilities as a SummaCare member. If they don’t follow these responsibilities, they may not receive all the services or coverage to which they might otherwise be entitled.
As a SummaCare member you have the right to:
1. Receive timely and accurate information about SummaCare including its services, its practitioners and providers, and its members’ rights and responsibilities;
2. Be treated with fairness, respect and dignity;
3. Be assured your medical records and personal health information will be handled confidentially and your privacy protected. Please refer to SummaCare’s NOPP (Notice of Privacy Practices) for a complete description of your privacy rights;
4. Participate with your healthcare professional in making decisions about your healthcare;
5. A candid discussion of appropriate or medically/surgically necessary treatment options for your conditions, regardless of cost or benefit coverage;
6. Voice complaints or appeals about SummaCare or the care provided;
7. Provide advance directives that would inform your doctor of your wishes should you have a terminal illness or lose your ability to make decisions for yourself;
8. A safe, secure, clean and accessible medical environment;
9. Get information about your coverage and costs as a member of SummaCare that is easy to understand;
10. Obtain information about SummaCare and our contracted provider’s financial arrangements and qualifications;
11. To see plan providers, get covered services and get your prescriptions filled within a reasonable period of time;
12. Make recommendations regarding SummaCare's "Member Rights and Responsibilities" statement and policy;
MEMBER RIGHTS & RESPONSIBILITIES (1 of 2)
As a SummaCare member you have the responsibility to:
1. Provide to the extent possible, information that SummaCare and its healthcare professionals need in order to care for you;
2. Understand (to the degree possible) your health problems and participate in developing and following mutually agreed upon treatment goals;
3. Follow the guidelines and instructions for care that you have agreed on with your healthcare professional;
4. Keep medical appointments. If you cannot keep an appointment, you should notify the healthcare professional’s office;
5. Identify yourself via your membership card, to use the card appropriately and to assure that other people do not use your card;
6. Respect SummaCare employees and your healthcare professional and refrain from using threatening or abusive language or mannerisms;
7. Act in a way that supports the care given to other patients and helps the smooth running of your doctor’s office, hospitals and other offices;
8. Familiarize yourself with your coverage and the rules you must follow to get care as a SummaCare member;
9. Pay in full any plan premiums, co-payments, co-insurance amounts or deductibles required by your specific SummaCare benefit plan;
10. Call SummaCare Customer Service if you have any questions, suggestions or problems with your care or payment.
How to get more information about your rights and responsibilities: If you have questions or concerns about your rights and protections, please call Customer Service at the number listed on your SummaCare ID card. You can also get free help and information from the Ohio State Health Insurance Information Program (OSHIP) at 1-800-686-1578 (or TTY 1-614-644-3745). Medicare members may get additional information by calling 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), or by visiting the Medicare website at www.medicare.gov.
What you can do if you think you have been treated unfairly or your rights are not being respected: If you think you have been treated unfairly or your rights have not been respected, you should call SummaCare Customer Service. Customer Service will ensure that your issue is addressed, and give you additional information on the complaint and appeal processes available to you. If you have been treated unfairly due to your race, color, national origin, disability, age or religion, please let SummaCare know. You can also call the Office for Civil Rights in your area.
MEMBER RIGHTS & RESPONSIBILITIES (2 of 2)
SUMMARY
You have the right to: • Get a copy of your health and claims records • Correct your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated
Your Rights
Your Choices
You have some choices in the way that we use and share information as we: • Answer coverage questions from your family and friends • Provide disaster relief • Market our services
Our Uses and
Disclosures
We may use and share your information as we: • Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical
examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions
Privacy Officer: Michael Frye Phone: 330-996-8912 email: [email protected]
SummaCare 10 North Main Street Akron, OH 44308 www.summacare.com
Get a copy of health and claims records
• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us. • You can file a complaint with the U.S. Department of Health and Human Services
Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in payment for your care
• Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes • Sale of your information
Help manage the healthcare treatment you receive
• We can use your health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization • We can use and disclose your information to run our organization and contact you when necessary.
• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.
Pay for your health services We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your plan We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
Our Uses and
Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/ privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues We can share health information about you for certain situations such as:
• Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic
violence • Preventing or reducing a serious threat to anyone’s
health or safety
Do research We can use or share your information for health research.
Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:
• For workers’ compensation claims • For law enforcement purposes or with a law
enforcement official • With health oversight agencies for activities authorized
by law • For special government functions such as military,
national security, and presidential protective services
Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities • We are required by law to maintain the privacy and
security of your protected health information. • We will let you know promptly if a breach occurs that
may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/ understanding/consumers/noticepp.html.
Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
Effective date: September 23, 2013
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Medical Prior Authorization List (For Drugs Administered in an Office, Home or Outpatient Setting)
Effective September 7, 2015
THIS LIST APPLIES TO ALL COMMERCIAL FULLY-INSURED MEMBERS
Certain drugs require prior authorization in order to be covered under your health plan. Prior authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment (including prescribed drug intervention) relative to approved criteria. Prior authorization is required to ensure that the drug is medically necessary and you will receive the benefits to which you are entitled.
Requests for prior authorization must be received before the services or drugs are provided/administered. Failure of a network provider to contact SummaCare for required authorization of items covered under your benefit plan will relieve the health plan and you from any financial responsibility for the service if those services are rendered before notifying the plan.
NOTE: Your in-network providers are responsible for obtaining authorization 48 hours prior to administering these prescription drugs. If you use a provider that is not in your network, it is your responsibility to obtain any required prior authorization.
For Providers: Network providers are responsible for obtaining authorization at least 48 hours before rendering these prescription drugs.
How to request prior authorization for drugs covered under the medical benefit: o Fax submission of requests for prior authorization should be used for nonurgent requests. o Routine requests: Fax 234-231-7082 o Urgent requests: Call 330-996-8710 or 888-996-8710
SummaCare provides coverage under the medical benefit for many drugs that are administered in an office, home or outpatient setting. We require certain drugs to receive prior authorization before being administered. The following drugs may require prior authorization:
ABILIFY MAINTENA (aripiprazole) ACTEMRA (tocilizumab) ACTHAR GEL (corticotropin) ADAGEN (pegademase) ALDURAZYME (laronidase) ALPHANATE (antihemophilic factor) ALPROLIX (factor product) ARALAST (alpha proteinase inhibitor) ARCALYST (rilonacept) ARZERRA (ofatumumab) AVONEX (interferon beta-1a) BEBULIN/BEBULIN VH (factor product) BELEODAQ (belinostat) BENEFIX (factor product) BENLYSTA (belimumab)
BIVIGAM (immune globulin) BLINCYTO (blinatumomab) BONIVA IV (ibandronate) BOTOX (onabotulinumtoxin A) CARIMUNE (immune globulin) CAYSTON (aztreonam) inhalation CEREZYME ( imiglucerase) CIMZIA (certolizumab pegol) CINRYZE (C1 inhibitor) CORIFACT (factor product) CYRAMZA (ramucirumab) DYSPORT (abobotulinumtoxin A) ELAPRASE (idursulfase) ELELYSO (taliglucerase---alfa) ENTYVIO (vedolizumab)
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PROLIA (denosumab) PROVENGE (sipuleucel-T) QUTENZA (capsaicin 8% patch) RECLAST (zoledronic acid) RELISTOR (methylnaltrexone bromide) REMICADE (infliximab) RISPERDAL CONSTA (risperidone LA) RITUXAN (rituximab) RIXUBIS (factor product) SIGNAFOR LAR (pasireotide pamoate) SIMPONI ARIA (golimumab) SOLIRIS (eculizumab) STELARA (ustekinumab) SUPPRELIN LA (histralin) implant SYLVANT (acyclovir) SYNAGIS (palivizumab) SYNRIBO (omacetaxine mepesuccinate) TEFLARO (ceftaroline fosamil) TEMODAR (temozolomide) TESTOPEL (testosterone pellets) TRETTEN (factor product) TYSABRI (natalizumab) TYVASO (treprostinil) VECTIBIX (panitumumab) VENTAVIS (iloprost) VORAXAZE (glucarpidase) VPRIV (velaglucerase) XEOMIN (incobotulinumtoxin A) XGEVA (denosumab) XIAFLEX (collagenase) XOFIGO (radium Ra 223 dichloride) XOLAIR (omalizumab) XYNTHA (antihemophilic factor) YERVOY (ipilimumab) ZALTRAP (ziv-afilbercept) ZEMAIRA (alpha proteinase inhibitor)
IMPORTANT INFORMATION: 1. This document is not intended to interfere with urgently needed care. Urgent care is any request for medical care or
treatment in which the time periods for SummaCare to make nonurgent care determinations (within 14 days) could result in the following circumstances:
o Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment; or
o In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
If in the judgment of the rendering provider the care is of an emergency or urgent nature, the plan will review for medical necessity after the care has begun.
2. All services, even if authorized, are subject to your benefit plan contract coverage and exclusions, eligibility and network design. Approvals are not a guarantee of coverage, as your benefit plan contract may retroactively terminate at a future date.
3. Services not listed on this document may not be covered because they are listed as exclusions on your plan contract. Your benefit plan contract exclusions and current status of eligibility may be verified online at www.summacare.com. Call the customer service number on your member identification card to inquire about eligibility and coverage.
4. Providers may visit Plan Central at https://SummaCare.myplancentral.com to view eligibility and benefits or register for a user account. For additional questions, please email [email protected].
3
To find the most current list of services, surgeries, durable medical equipment or drugs covered under your medical benefit requiring prior authorization, please visit www.summacare.com or call the customer service number located on your member identification card. If you are unsure as to what requires prior authorization, please call customer service.
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Medical Prior Authorization List (For Drugs Administered in an Office, Home or Outpatient Setting)
Effective September 7, 2015 - PROVIDER COPY THIS LIST APPLIES TO ALL MEDICARE MEMBERS
Certain drugs require prior authorization in order to be covered under your health plan. Prior authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment (including prescribed drug intervention) relative to approved criteria. Prior authorization is required to ensure that the drug is medically necessary and you will receive the benefits to which you are entitled.
Requests for prior authorization must be received before the services or drugs are provided/administered. Failure of a network provider to contact SummaCare for required authorization of items covered under your benefit plan will relieve the health plan and you from any financial responsibility for the service if those services are rendered before notifying the plan.
NOTE: Network providers are responsible for obtaining authorization at least 48 hours before administering these prescription drugs. If the provider is not in the plan network, it is the member’s responsibility to verify that prior authorization has been obtained.
How to request prior authorization for drugs covered under the medical benefit:
o Fax submission of requests for prior authorization should be used for nonurgent requests. o Routine requests: Fax 234-231-7082 o Urgent requests: Call 330-996-8710 or 888-996-8710
SummaCare provides coverage under the medical benefit for many drugs that are administered in an office, home or outpatient setting. We require certain drugs to receive prior authorization before being administered. The following drugs may require prior authorization:
ACTEMRA (tocilizumab) ACTHAR GEL (corticotropin) ALPHANATE (antihemophilic factor) ALPROLIX (factor product) ARZERRA (ofatumumab) AVONEX (interferon beta-1a) BEBULIN/BEBULIN VH (factor product) BELEODAQ (belinostat) BENEFIX (factor product) BENLYSTA (belimumab) BIVIGAM (immune globulin) BLINCYTO (blinatumomab) BONIVA IV (ibandronate) BOTOX (onabotulinumtoxin A) CARIMUNE (immune globulin) CIMZIA (certolizumab pegol) CINRYZE (C1 inhibitor) CORIFACT (factor product)
CYRAMZA (ramucirumab) DYSPORT (abobotulinumtoxin A) ELELYSO (taliglucerase---alfa) ENTYVIO (vedolizumab) ERBITUX (cetuximab) FLEBOGAMMA (immune globulin) FLOLAN (epoprostenol) GAMASTAN (immune globulin) GAMMAGARD (immune globulin) GAMMAKED (immune globulin) GAMMAPLEX (immune globulin) GAMUNEX-C (immune globulin) GAZYVA (obinutuzumab) GLASSIA (proteinase inhibitor) HALAVEN (eribulin mesylate) HEMOFIL M (antihemophilic factor) HERCEPTIN (trastuzumab) HIZENTRA (immune globulin) HYQVIA (immune globulin)
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PROVIDER COPY
XIAFLEX (collagenase) XOFIGO (radium Ra 223 dichloride) XOLAIR (omalizumab) XYNTHA (antihemophilic factor) YERVOY (ipilimumab) ZALTRAP (ziv-afilbercept)
PROVIDER COPY
IMPORTANT INFORMATION: 1. This document is not intended to interfere with urgently needed care. Urgent care is any request for medical care or
treatment in which the time periods for SummaCare to make nonurgent care determinations (within 14 days) could result in the following circumstances:
o Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment; or
o In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
If in the judgment of the rendering provider the care is of an emergency or urgent nature, the plan will review for medical necessity after the care has begun.
2. All services, even if authorized, are subject to your benefit plan contract coverage and exclusions, eligibility and
network design. Approvals are not a guarantee of coverage, as your benefit plan contract may retroactively terminate at a future date.
3. Services not listed on this document may not be covered because they are listed as exclusions on your plan contract.
Your benefit plan contract exclusions and current status of eligibility may be verified online at www.summacare.com. Call the customer service number on your member identification card to inquire about eligibility and coverage.
4. Providers may visit Plan Central at https://SummaCare.myplancentral.com to view eligibility and benefits or register
for a user account. For additional questions, please email [email protected].
3
To find the most current list of services, surgeries, durable medical equipment or drugs covered under your medical benefit requiring prior authorization, please visit www.summacare.com or call the customer service number located on your member identification card. If you are unsure as to what requires prior authorization, please call customer service.
Effective September 7, 2015 - PROVIDER COPY
THIS LIST APPLIES TO ALL COMMERCIAL FULLY-INSURED & MEDICARE MEMBERS
Certain services require prior authorization in order to be covered under the member’s health plan. Prior authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment (including prescribed drug intervention) relative to approved criteria. Prior authorization is required to ensure that the service is medically necessary and that the member will receive the benefits to which the member is entitled.
Requests for prior authorization must be received before the services are provided. Failure of a network provider to contact the health plan for required authorization of items covered under the member’s plan will relieve the health plan and the member from any financial responsibility for the service, if those services are rendered before notifying the plan.
NOTE: Network providers are responsible for obtaining authorization at least 48 hours before provision of services.
How to request prior authorization for services:
Medical Prior Authorization List (For Services and Equipment)
SERVICES SummaCare provides coverage for medically-necessary healthcare services. SummaCare requires prior authorization before the provision of select services. The list of services below may change. The most up-to-date listing of services needing prior authorization is maintained at www.summacare.com.
The following services require prior authorization: • Referrals to a surgeon for back pain • Ambulance
Transport by fixed-wing plane Elective (nonemergency) transportation by ground
ambulance • Applied behavioral analysis (ABA) • CardioMEMS system • Cochlear device and/or implantation
• Cosmetic or potentially cosmetic surgery or procedures • Dental care that is non-routine and is needed for the
purpose of treating illness or injury • Experimental medical and surgical procedures and new
technology • Genetic testing • Hyperbaric oxygen therapy • Infertility diagnostic and treatment services • Infusions of ketamine, lidocaine for pain • Inpatient confinements
Acute care hospital Behavioral health hospital Long-term acute care hospital Rehabilitation facility Residential treatment center Skilled nursing facility, sub-acute or
transitional care facility
Type of Service 24/7 Online Requests* Routine Requests Urgent Requests Ambulance N/A 330-996-8791 or
866-996-8791 330-996-8791 or 866-996-8791
Inpatient N/A Fax 234-542-0811 330-996-8710 or 888-996-8710
All other requests N/A Fax 234-542-0815 330-996-8710 or 888-996-8710
*Fax submission of requests for prior authorization should be used for nonurgent requests.
(CONTINUED) 1
Computed Tomography (except CT of the sinus) Gastrointestinal imaging through capsule
endoscopy Magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) Magnetic resonance spectroscopy (MRS) Nuclear medicine scans Positron Emission Tomography (PET) Single-Photon Emission Computed Tomography
(SPECT) • Transplant services
transplants
OUTPATIENT SURGERIES SummaCare provides coverage for medically necessary outpatient surgeries. SummaCare requires certain outpatient surgeries to receive prior authorization before the provision of services. The list of surgeries below may change. The most up-to-date listing of outpatient surgeries needing prior authorization is maintained at www.summacare.com.
The following outpatient surgeries require prior authorization:
• Bariatric surgery • Implanted cardioverter defibrillator • Orthognathic surgery procedures, bone grafts,
osteotomies and surgical management of the temporomandibular joint
• Spinal/back surgery • Spinal cord stimulator • Stereotactic radiosurgery (e.g. Cyberknife, Gammaknife) • Uvulopalatopharyngoplasty
DURABLE MEDICAL EQUIPMENT & PROSTHETICS SummaCare provides coverage for medically necessary durable medical equipment. SummaCare requires certain durable medical equipment receive prior authorization before the provision of services. The list of items below may change. The most up-to-date list of durable medical equipment needing prior authorization is maintained at www.summacare.com.
The following durable medical equipment requires prior authorization:
• Bone growth stimulator • Cardioverter defibrillator (wearable), including AED
garment • Electric transport devices (e.g. wheelchairs, scooters) • Home oxygen therapy • Insulin pump, ambulatory • Negative pressure wound therapy • Noninvasive airway assistive devices and accessories • Orthopedic or therapeutic shoes (Medicare Only) • Orthotic devices (Medicare Only) • Orthotic shoe inserts (Medicare Only) • Pneumatic compression device • Prosthetics/prosthetic devices • Scooter, electric or motorized • Speech generating device • Wound products (e.g. platelet gels, human allograft
products, matrix products, skin replacement products) • Ventilator (portable/home)
(CONTINUED) 2
PROVIDER COPY
IMPORTANT INFORMATION 1. This document is not intended to interfere with urgently needed care. Urgent care is any request for medical care or
treatment in which the time periods for SummaCare to make nonurgent care determinations (within 14 days) could result in the following circumstances: • Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment; or • In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. If in the judgment of the rendering provider the care is of an emergency or urgent nature, the plan will review for medical necessity after the care has begun.
2. All services, even if authorized, are subject to the member’s benefit plan contract coverage and exclusions, eligibility and network design. Approvals are not a guarantee of coverage, as the member’s benefit plan contract may retroactively terminate at a future date.
3. Services listed on this document may not be covered because they are listed as exclusions on the member’s plan contract. Benefit plan contract exclusions and current status of eligibility may be verified online at www.summacare.com.
4. Providers may visit Plan Central at https://SummaCare.myplancentral.com to view eligibility and benefits or register for a user account. For additional questions, please email [email protected].
3
To find the most current list of services, surgeries, durable medical equipment or drugs requiring prior authorization, please visit www.summacare.com.
PROVIDER COPY
PRIOR AUTHORIZATION REQUEST FOR DRUGS COVERED UNDER THE MEDICAL BENEFIT
(ie. Drugs given via IM or IV administered in an office, home, or outpatient setting) Please fax to 234-231-7082
*For urgent requests only, please call 330-996-8710
DATE
MEMBER ID # MEMBER DOB
PHONE # FAX #
NEW REQUEST REAUTHORIZATION REQUEST
PLACE OF SERVICE/FACILITY OUTPT PROVIDER OFFICE
IS THE PROVIDER BUYING AND BILLING FOR THE MEDICATION? YES NO
CLINICAL INFORMATION - PERTINENT TO DRUG BEING REQUESTED (ATTACH
COPIES OF PERTINENT CLINICALS)
Include symptoms/findings, labs, tests, imaging, and conservative treatment, if any.
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, you are hereby notified that you have received this communication in error and any review, disclosure, distribution, or copying of it or its contents is prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at 10 N. Main St., Akron, OH 44308 via the USPS. If this was an email received in error, please notify the sender and delete it.
AUTHORIZATION #
INPATIENT 234-542-0811 RADIOLOGY 800-540-2406 All Other 234-542-0815 *For urgent requests only, please call 330 996-8710 or 888 996-8710
DATE MEMBER NAME LAST FIRST MI
MEMBER ID # MEMBER DOB ___________
PROCEDURE ORDERED DATE OF SERVICE DIAGNOSIS
CPT CODE(S) ICD-9 DX CODE
ELECTIVE ADMISSION GENETIC TESTING Patient Counseling Completed
OUTPATIENT SURGERY Basic Elements of Informed Consent for Genetic Testing IMAGING Basic Elements of Informed Consent for Cancer Susceptibility OUT OF NETWORK REFERRAL By signing, I certify that the member above has been NEW TECHNOLOGY counseled according to guidelines checked above.
OTHER Physician’s Signature _______________________________
CLINICAL INFORMATION - PERTINENT TO PROVIDER SERVICE (ATTACH COPIES OF PERTINENT
CLINICALS)
_________________________________________________________________________________________________
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, you are hereby notified that you have received this communication in error and any review, disclosure, distribution, or copying of it or its contents is prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at 10 N. Main St., Akron, OH 44308 via the USPS. If this was an email received in error, please notify the sender and delete it.
AUTHORIZATION # CONTACT
Please complete each section of this form. Print clearly, using black or blue ink only. Incomplete or illegible information may delay your response or cause your request to be returned.
Date:________________
Are you submitting a corrected claim? Please submit your corrected claim electronically with the appropriate indicator. If you are submitting a paper claim, please write ‘corrected claim’ in box 19. The adjustment request form should not be used for corrected claims. Fee/Contract Pricing Dispute Itemized Bill Enclosed (if requested by the plan) Unlisted Procedure Code/Modifier 22 Denial
Are you submitting the Primary EOP? Please indicate the claim number below and mail this adjustment request form with the primary EOP. Overpayment Correspondence (Check Enclosed) Refund checks should be submitted with a copy of the overpayment letter in order to process the refund timely and accurately. Timely Filing Proof of timely filing must be submitted in order for the adjustment request to be considered.
Not a Duplicate Charge (Denied CB) My claim denied as a duplicate, but it is not a duplicate. Provide explanation in the space provided below. Medical Necessity Dispute (EX 87,88,89) Additional clinical information must be submitted)
Overpayment Correspondence (No Check Enclosed) You are submitting an explanation as to why you are not submitting a refund that has been requested OR you are requesting that we request a refund on a duplicate or incorrect payment. Medical Records Enclosed (if requested by plan) Please do not submit medical records unless the plan requests them. This will save you the time of submitting medical records that are not necessary to consider your claim.
Requester/Contact Name: Email Address:
Provider Name: Fax Number:
Provider Claim Adjustment Request
Type of Request
Send completed form to: SummaCare, Attn: Mailroom, P.O. Box 3620, Akron, OH 44309-3620
PROVIDER CLAIM ADJUSTMENT REQUEST (2 of 2)
If the claim does not fall into one of the above outlined categories, please contact the Provider Support Service Unit at 330-996-8400 or 800-996-8401.
1. If there are multiple claims that fall under the same “Type of Request”, please submit one form with an attached spreadsheet containing all of the requested information for each individual claim.
2. Instructions for submitting the completed form are found at the bottom of the form.
3. This form can be copied for future use. This form is also available at: www.summacare.com on
the Provider Homepage.
Provider Support Services For questions about benefits, plan limits, authorizations, eligibility, claim status, and all other general inquiries; please visit our website at www.summacare.com to login to Plan Central. Phone: 330-996-8400 or 800-996-8401 Email: mailto:[email protected]
Click Before You Call In order to improve efficiencies and eliminate lengthy hold times, SummaCare is directing providers who call for basic plan information to use Plan Central – our secure provider web portal. Plan Central is the provider’s source for day-to-day operations for efficient, real time answers to basic plan inquiries. Effective December 15, 2013, providers who call Provider Support Services for basic plan information will be advised to use Plan Central. This new process eliminates calls for basic inquiries, which allows Provider Service Representatives to be available to answer complex calls which require our assistance. If your office uses a billing company, please make sure your billing company is also aware of this new process and obtains access to the site so the workflow in your office is not interrupted.
If you do not have a username and password, please visit www.SummaCare.com, click the Provider tab then Resources and Self Services and select Plan Central to register for a user account. To Help Us Serve You Better When contacting Provider Support Services, please select the appropriate prompt and have detailed information available as outlined below: Eligibility, Benefits and Authorizations Physician/Provider Tax ID Number Name of the person calling Date of service (if applicable) Member name and member I.D. number Name of the procedure/CPT code Setting where service performed (Inpatient/outpatient/office)
Claims and All Other General Inquiries Physician/Provider Tax ID Number Name of the person calling Member name and member I.D. number Name of the physician/provider of service Total charges billed Date of service (if applicable) Contracting questions
Provider Support Services
SUMMACARE’S VISION, MISSION AND VALUES (1 of 1)
Our Vision: Providing access to the highest quality of service, products, and education for our internal and external customers in the communities that we serve. Our Mission: Providing our customers with comprehensive, community-focused health care choices priced to reflect quality, value, and service. Our Value: Our values provide the framework for each of us to support the mission in our day-to-day work by emphasizing the beliefs and attitudes, which govern the operations of the system. They are an affirmation of what is most important for the success of our organization and reflect a belief that success is a personal standard compelling us to strive to reach our highest potential as individuals in service to our community. We believe in the highest standards of personal and organizational integrity. Honesty and fairness
are expected from all of us. We believe in preserving a quality, caring organizational environment. Each of us will take
responsibility for continuously improving the quality of service he or she provides. We believe in excellence in leadership throughout the organization. All who lead must also
facilitate the efforts of our employees in best serving our customers, as well as service in a mentoring and educating role to support all employees in achieving their full potential.
We believe in valuing one another. Each of us will value the knowledge, experience and ability of
other employees and the contribution that each makes to Summa. We believe that we all deserve respect and fair treatment. Each of us will support these
fundamental premises by being an example of this positive behavior. We believe in open communication. Each of us will continually strive to remove communication
barriers. Group participation is encouraged in the resolution of issues. We believe in teamwork. We value the participative process and consensus building. It is through
cooperation that our greatest successes will be derived. We believe in community service. We encourage all of our employees to be good community
citizens and seek opportunities of service to others. We believe in individuality. We value diversity in experience and perspectives at all levels of our
work force. Differing points of view will be sought and respected.
SummaCare’s Vision, Mission and Values
SUMMARY OF SUMMACARE PLANS (1 of 1)
Fully-Insured SummaCare PPO – a self-referral system. This plan is not PCP driven and members may choose to stay in-network with higher levels of coverage or go out-of-network incurring greater out-of-pocket expenses in the form of deductibles and/or coinsurance amounts. Medicare Medicare Advantage Plans – Corporate (employer) and individual plans are available. Service area includes Summit, Stark, Portage, Medina, Cuyahoga, Wayne, Lake, Ashtabula, Trumbull, Mahoning, Columbiana, Tuscarawas, Geauga, Holmes, Lorain, Ashland, Richland, Morrow, Huron, Erie, Crawford, Marion, Wyandot, Seneca, Sandusky, Ottawa, Lucas, Wood, Hancock, Hardin, Auglaize, Allen, Putnam, Henry, Fulton, Williams, Defiance, Paulding, Van wert, Mercer and Carroll Counties. Supplemental Solutions – a comprehensive health plan option for individuals and families. This product is a PPO plan. Members can choose to stay in-network with higher levels of coverage or go out-of- network incurring greater out-of-pocket expenses in the form of deductibles and/or coinsurance. Self-Funded A wide variety of self-insured plans are offered through SummaCare’s third-party administrator, Apex Benefits Services. The type of plan (i.e., PPO, EPO, etc.) is listed on the member’s ID card. For questions, please call Provider Support Services at (800) 996-8401 or email mailto:[email protected]
Summary of SummaCare Plans (Fully-Insured and Self-Funded)
SummaCare Web-based Services SummaCare offers its members and providers a great deal of information that can be accessed through our website at www.summacare.com.
On the SummaCare website, the Providers tab along the menu bar allows access to the web-based services and programs designed for use by SummaCare’s providers.
When clicking the Provider Tab from the main menu, you will see the following:
Resourced & Self Services - Quickly find the tools you need! Access SummaCare’s online provider manual, forms, prior authorization lists, patient eligibility (Plan Central) and more.
Become a Network Provider- Learn more about becoming part of SummaCare’s network of quality providers and print or submit an online application.
News & Updates - Find the latest provider updates, seminar information and archived Provider Press newsletters.
Clinical Management - SummaCare has several disease management programs, case management services and wellness services to help our members live healthier, happier lives. Learn how to refer your patients!
Quality Management - The objectives of our quality management program include promoting and building quality into the structure and processes of our organization and monitoring and working to improve outcomes.
SummaCare Plans & Benefits - Learn about SummaCare’s full line of health insurance products.
Find a Doctor or Hospital
Compliance Training - All providers who contract with SummaCare Medicare Advantage services are expected to abide by CMS rules and regulations. Annual Compliance training is provided on Summacare.com
Provider Support Services – Provides information on when and how to contact Provider Services for assistance or plan education.
SummaCare Website
TAKE BACK PROCESS ON OVERPAYMENT (1 of 1)
If a provider office prefers take backs be done on all overpaid claims, a signed letter on office letterhead agreeing to take backs across the board should be submitted to SummaCare. This would apply to all overpayments pending and in the future. Providers are not notified in advance of the take back. A refund request letter will be sent in the event the overpayment is not recouped within 90 days. Please send the above mentioned letter of agreement to:
SummaCare Insurance Company Attention: Recovery 10 N. Main St. Akron OH 44308 Any questions regarding the take back process should be directed to Provider Support Services at 330- 996-8400 or 800-996-8401. Providers may also email questions to [email protected] .
Take Back Process on Overpayment
QUALITY MANAGEMENT PROGRAM SUMMARY (1 of 1)
SummaCare’s mission is to work with providers, members and employers to provide a comprehensive, community-focused health plan that maximizes service and choice while minimizing cost. The SummaCare Quality Management Program supports our mission by assessing performance, identifying opportunities for improvement and facilitating change to improve the quality and safety of care and service provided and to promote member management of their health. Review activities encompass the following: Quality and utilization of all medical and behavioral healthcare services in all care settings provided to
all enrolled demographic groups, including inpatient and outpatient services provided by physicians, practitioners, hospitals and other providers
Continuity and coordination of care, under-utilization and over-utilization Review of health plan clinical and business operations including Utilization Management, Quality
Management, Risk Management, Customer and Provider Services, Credentialing, Claims Processing, Eligibility Processing, Appeals, Sales, Human Resources, Training, etc.
Member and provider satisfaction information Trending and evaluation of complaints, grievances and appeals. Oversight of the quality of non-clinical aspects of service such as availability and access, claims
timeliness, call answer timeliness, call abandonment, etc. Special clinical studies for the Medicare population as specified and required by the Centers for
Medicare and Medicaid Services Ongoing assessment of the scope, content and performance of the Quality Management Program to
ensure compliance with all regulatory and NCQA accrediting standards o This includes annual HEDIS data collection, analysis and improvement activities o The annual Quality Management Program Description and Quality Management Program
Evaluation documents are available for review on the SummaCare website www.summacare.com
Oversight of the Quality Management Program is provided by the SummaCare Board of Directors and is directly accountable to the SummaCare Executive Quality/Compliance Council (EQCC). The President and Chief Medical Officer sit on the Board. Other committees support the work of the Quality Program and report to the EQCC. Please see the Quality Management Program Description on www.summacare.com. You are encouraged to direct questions or concerns about SummaCare’s quality management program to the Director of Quality Management at 330-996-8421.
Resources: Quality Management Program Description
Quality Management Program Summary
Responsibility:
• Authorization and Medical Necessity Review • Enhanced Care Management Programs
o Chronic Disease Self-Management Programs o “Bridge-to-Home” Transitional Care o “Bridge Units” for skilled nursing stays o “SummaCare Physicians House Calls Program” o “Comprehensive At Home Care Program” for end of life o “Intense Case Management”
• Case Management/Care Coordination • Complex Case Management
Goals:
• Member support and education for effective healthcare self management • Provider support and assistance with helping members find needed and coordinated, appropriate
care • Health plan benefit management that maximizes the members’ benefits for receiving quality care
in clinically appropriate settings Achievements:
• Updated disease management programs for diabetes, heart failure, asthma, chronic kidney disease, and depression
• Enhanced Care Management programs targeted at frail elders with multiple co-morbidities • Case management programs targeted at catastrophic illness and high-risk members
Clinical Management Department Summary
Please fax to 330-996-8605 / 330-996-8904 or call 330-996-8710 / 888-996-8710 for urgent requests
Member Last Name:
Member First Name:
Requesting Physician First & Last Name:
Practice/Group Name:
Physician Contact Name:
Facility/Place of Service:
Patient Counseling Completed: Basic Elements of Informed Consent for Genetic Testing Basic Elements of Informed Consent for Cancer Susceptibility
By signing this form, I certify that the member above has been counseled according to the guidelines checked above. ______________________________________________________ Physician Name (print) ______________________________________________________ Physician Signature
SummaCare Use Only
You will be notified if your request is not approved.
GENETIC TESTING REQUEST FORM (1 of 1)
In order for us to respond to you quickly, please:
Prior Authorization By Fax
1. Complete the request form in its entirety (see following page—make copies for your use).
2. Include any supporting information and chart notes with your request.
3. To allow for medical necessity review, please send requests at least 48 hours prior to rendering service.
4. Complete clinical information will help to facilitate a quicker authorization decision.
5. SummaCare will provide prior authorization within 48 hours of receipt of request.
After a determination has been reached, an authorization specialist will telephone you at your office to notify you of the determination outcome. If you should have questions regarding the above process, please call the Benefits Determination Unit at 330-996-8710 or 888-996-8710.
The fax number to submit a prior authorization request is 330-996-8904.
PRIOR AUTHORIZATION BY FAX (1 of 1)
CONFIDENTIAL Date:
Please fax to 330-996-8605 / 330-996-8904 or call 330-996-8710 / 888-996-8710 for urgent requests.
Member Last Name:
Member First Name:
Requesting Physician First & Last Name:
Practice/Group Name:
Physician Contact Name:
Diagnosis:
SummaCare Use Only
SummaCare Contact:
You will be notified by telephone if your request is not approved.
PRIOR AUTHORIZATION REQUEST FORM (1 of 1)
Pharmacy Management
Revised: 09/03/14
SummaCare/Apex Medication Request Form SUM01, 02, 03 (Part D), 06, 07
Attn: Prior Authorization Department
Fax: 8587907100
REQUEST FOR EXPEDITED (URGENT) REVIEW: BY CHECKING THIS BOX, I CERTIFY THAT APPLYING THE STANDARD REVIEW TIME
FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION
Date: ______________ Time MRF was taken: ______________ Physician Signature: _____________________________________ Physician Cell Phone #: _____________
Medication Request Information (please complete each section of this form prior to transmittal): *Denotes Required Fields
Status

PHARMACY INFORMATION (If provided)
*Length of Treatment: (Please be specific.)
Comments Reason for Medication Request (Please be specific, give detail.): Other Medications Tried and/or Failed including OTC (Please be specific, give detail. Chart notes preferred): Other Pertinent History (Relative or pertaining to this request.): **Note: Specialty Vendor is Walgreens Specialty: 8883473416
SummaCare is now partnering with TransactRx™ Vaccine Manager, which is the nation’s leading solution for healthcare providers to overcome the billing and reimbursement challenges associated with administering vaccines covered by Medicare Part D. Providers no longer have to write prescriptions for their patients to have their Part D vaccines administered at a pharmacy or ask their patients to pay out-of-pocket and then try to get reimbursed.
Benefits of TransactRx™ By signing one contract and enrolling with TransactRx™ Vaccine Manager, you will be able to submit claims for any Medicare Part D covered vaccine administered to members who have a Part D plan that is contracted with TransactRx™. Other benefits: • NO COST TO YOU. • Simple online enrollment process. • Credentialing and acceptance into the network in less than 48 hours. • Simple web-based demonstration to learn how to utilize the TransactRx™ Vaccine Manager system. • TransactRx™ Vaccine Manager is contracted with Medicare Part D plans that represent over 80% of all Medicare Part D covered lives. • Includes ALL Medicare Part D covered vaccines. • Favorable negotiated reimbursement rates for all Part D covered vaccines. • Ability to check status for outstanding claims. • Payments are made to providers twice a month via check or ACH. • Complete reporting is available to track and manage claims and payments. How to Enroll Go to http://enroll.mytransactrx.com/ to enroll. The following information will be required, in addition to accepting TransactRx™ Vaccine Manager’s Agreement: • Tax Identification Number (TIN) • National Provider Identifier(s) (NPI) • Medicare ID number • Drug Enforcement Administration (DEA) number • State Medical License number For questions on enrollment and claims processing, call TransactRx™ Vaccine Manager’s customer support center at 866-522-3386. To enroll in the TransactRx™ Vaccine Manager program, view a web demo or for more information, go to http://enroll.mytransactrx.com/.
TRANSACT RX VACCINE MANAGER (1 of 1)
Utilization management restrictions include, but are not limited to, prior authorization, step therapy, and quantity limits. Our formulary and utilization management restrictions are developed, reviewed and approved by the SummaCare Pharmacy and Therapeutics Committee which is comprised of network physicians and pharmacists.
To view the SummaCare utilization management restrictions for the prescription drug benefits, visit www.summacare.com and click on the Providers Tab, Resources & Self Services, and Pharmacy Management.
Formulary documents can also be obtained on www.summacare.com for the Commercial benefits and www.medicare.summacare.com for the Medicare Part D Prescription Benefit. Click on the “Find Your Drug” tab to view the latest SummaCare formulary documents.
PHARMACY MANAGEMENT DEPARTMENT SUMMARY (1 of 1)
CLAIM DENIALS – MEDICARE (1 of 2)
APPLIES TO: ___X_ SummaCare, Inc. __X__ Apex Health Solutions PRODUCT LINE(S): (Check all that apply)
__X__Medicare ____Commercial Fully
_X___Medicare ____Self-Funded ____BPO
Policy: Medicare members, when liable for payment, will receive a detailed
explanation of the reason for the denial. Purpose: To ensure the reason for non-payment of a claim is clearly identified and
appeal rights are provided to the member.
PROCEDURES
1. The system is configured to deny or pend claims for Processor review for a number of reasons which include but are not limited to:
• Member was not eligible at the time the service was rendered • Benefits are not available for the services rendered • Services exceed policy maximums • Claim is duplicate of a previously processed claim • Unauthorized services (on applicable services) • Provider chose to opt-out of participation in Medicare
2. When a claim denial results in member liability, a letter of explanation is
generated. These letters include claim/service line information as well as the procedures for filing an appeal.
POLICY NAME: CLAIM DENIALS – MEDICARE POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 7/1/1996 APPROVED BY: Claude Vincenti
CLAIM DENIALS – MEDICARE (2 of 2)
The “Responsible Party” is the person responsible for ensuring that this policy is reviewed and updated according to the Policy Review Schedule.
COMPLIANCE STATEMENT: Enforcement: All employees are responsible for complying with this policy.
Failure to abide by the conditions of this policy may result in corrective action, up to and including termination. Employees are responsible for reporting any observed violations of this policy in according with the Compliance Communication and Reporting Policy.
Review Schedule: This policy will be reviewed and updated as set forth in the Policy Review Schedule.
Compliance Monitoring and Auditing:
• The Issuing Dept. is responsible for monitoring and enforcing compliance with this policy.
• Compliance will conduct periodic reviews to monitor and audit compliance with this policy.
Documentation: Documentation related to this policy must be maintained for a minimum of 10 years.
Standards: MMCM Definitions: N/A Replaces: N/A Review Date: 9/16/2004, 9/1/2011, 8/4/2015 Revised Date:
3/12/1998, 10/18/2000, 9/16/2004, 9/1/2011, 8/4/2015
Responsible Party:
Melissa Stoner
HOSPICE SERVICES – MEDICARE (1 of 3)
Policy: This policy describes the administration of hospice service benefits for
Medicare beneficiaries. Purpose: To provide a consistent process for the administration of the Hospice
benefit which are compliant with CMS guidelines.
PROCEDURES
1. When a beneficiary signs a Hospice Election Statement (provided by Medicare Hospice Providers), the beneficiary must select and use a Medicare certified hospice provider(s) for care related to the terminal illness.
a. As of the first of the month after the beneficiary elects hospice, the capitation from CMS to the client is reduced to an administrative management fee per beneficiary per month. CMS places the beneficiary in an administrative suspension status.
b. Care provided on or after the date of the hospice election, by the hospice provider as it relates to the terminal diagnosis is paid directly by CMS.
c. CMS is billed by non-hospice providers for care unrelated to the terminal illness, (with the exception of the supplemental plan benefits, e.g., eyeglasses, dental, prescription etc., which will continue to be directed, provided and paid for by the plan.)
d. When billing CMS, providers should follow CMS guidelines, using the appropriate modifiers.
e. Beneficiaries can revoke hospice elections at any time to resume curative care. If so revoked, the client will resume coverage for the
POLICY NAME: HOSPICE SERVICES - MEDICARE POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 9/16/2011 APPROVED BY: Claude Vincenti
HOSPICE SERVICES – MEDICARE (2 of 3)
according to his/her benefit plan, the first of the following month. The client will then begin receiving normal capitation payments from CMS. Prior to the first of the month and after revocation of the hospice benefit, beneficiary reverts to Original Medicare.
2. The client is only responsible for the following in relation to beneficiaries seeking
or receiving hospice care and services: a. Education for the beneficiary regarding availability of hospice care b. Referral to a Medicare hospice provider c. Pre-Hospice consultation/evaluation by either the medical director or
employee of a hospice provider for beneficiaries who has not yet elected hospice benefit (effective January 1, 2005) for complete criteria see: http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf
d. Covered care and services for conditions that are unrelated to the beneficaries terminal illness
i. Plan providers must bill Medicare Carriers and Intermediaries for the beneficiary's basic benefits, using fee-for-service mechanisms for those services (applicable copayments also apply). When billing CMS, providers should follow CMS guidelines, using the appropriate modifiers.
ii. To ensure beneficiaries are receiving their full benefit for non- hospice related services, basic benefits will be coordinated with CMS not to exceed what the plan would have paid if they had been the only payer. Appropriate co-pays and coinsurance will apply.
iii. The plan is responsible for covering the beneficiary's supplemental benefits (e.g., eyeglasses, prescription drugs), if any, as long as the beneficiary uses a plan provider and remains enrolled with the plan.
3. For assistance with payment determinations, refer to Appendix A – FCC Hospice
Grid Beneficiary Signs Hospice Election Statement or Appendix B – FCC Hospice Grid Beneficiary Revokes Hospice Election Statement.
4. For Medicare coverage guidelines for Hospice Services, refer to the Medicare Benefit Policy Manual (Pub.100-2), Chapter 9 - Coverage of Hospice Services under Hospital Insurance at: http://www.cms.hhs.gov/manuals/Downloads/bp102c09.pdf.
Also see the Medicare Claims Processing Manual (Pub. 100-4), Chapter 11 - Processing Hospice Claims at: http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdf.
5/20/2013, 7/17/2013, 8/4/2015
Responsible Party:
Melissa Stoner
INTEREST PAYMENTS – FI & SF (1 of 2)
__ __Medicare __X_Commercial Fully
___Medicare _X___Self-Funded __X__BPO
Policy: The outline the computation and payment of interest due per ODI and
state regulations for clean and unclean claims. Purpose: To comply with ODI and state requirements.
PROCEDURES
Fully Insured - Ohio Interest calculation is performed automatically by the claims payment system on all claims. The process uses the number of days late X 18%. Interest is paid at the time the claim is paid. Self-Funded and Fully Insured (outside of Ohio) The Legal Department will review the laws of the state in which the self-funded client does business. If the state law requires interest to be paid for late claims, interest will be paid. The interest calculation will vary depending on the specific rules of each state.
POLICY NAME: INTEREST PAYMENTS – FULLY INSURED AND SELF-FUNDED
POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 7/1/2006 APPROVED BY: Claude Vincenti
INTEREST PAYMENTS – FI & SF (2 of 2)
Standards: Ohio SB #4 Definitions: N/A Replaces: N/A Review Date: 8/4/2015 Revised Date:
8/4/2015
Responsible Party:
Melissa Stoner
INTEREST PAYMENTS – MEDICARE (1 of 2)
_X___Medicare ____Commercial Fully
Policy: To outline the computation and payment of interest based on Centers for
Medicare and Medicaid Services (CMS) requirements Purpose: CMS requires interest to be paid on any service not finalzied within thirty
days from the date of receipt of a clean claim from a non-participating provider
PROCEDURES
claim amount X days late X interest rate 365
1) Interest calculation is performed programmatically on all applicable services prior to the payable run. The process uses the number of days late times the interest rate. Interest is paid at the time the services are paid.
2) The interest rate is released twice a year and can be found at
http://www.fms.treas.gov/prompt/rates.html. a) Configuration is responsible for obtaining and updating the interest rate for
automated interest calculation within the claims processing system.
3) The Claims Area uses databases to review services paying interest when the amount of interest is over $10. This review is based on pre-payable reports.
POLICY NAME: INTEREST PAYMENTS – MEDICARE POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 4/28/1998 APPROVED BY: Dennis Pijor
3/13/2007, 7/17/2013
Responsible Party:
Melissa Stoner
MEDICARE EXPLANATION OF BENEFITS (1 of 2)
Policy: SummaCare will comply with Medicare beneficiary explanation of benefit
specificity requirements. Purpose: To ensure compliance with CMS requirements regarding beneficiary
communications.
PROCEDURES EOB Procedure
A detailed EOB will be generated for each member weekly and a summary EOB will be generated quarterly beginning 4/1/2014. Beneficiaries may opt out of the EOB mailings via Plan Central. EOBs will still be available for beneficiaries in Plan Central but will no longer be mailed. Appeal rights will be included in the weekly EOB when the member has a liability over and above coinsurance, deductible and copay.
• FQ (unauthorized service – bill patient) • FR (services provided are not considered medically
necessary) • FS (service is not a covered benefit, bill patient) • FT (services have exceeded benefit limits of plan) • WZ (deny opt out of Medicare Physicians and Practitioners)
POLICY NAME: MEDICARE EXPLANATION OF BENEFITS POLICY NUMBER: ISSUING DEPT.: Configuration EFFECTIVE DATE: 4/1/2014 APPROVED BY: Dennis Pijor
MEDICARE EXPLANATION OF BENEFITS (2 of 2)
• LK(submit to workers comp) • 90 (billed as maintenance care – not a covered benefit) • SU(subrogation claim – third party responsible)
Notice of denial letters will continue to be generated to further explain the reason for denial.
Standards: MMCM Chapter 4 Definitions: N/A Replaces: N/A Review Date: 8/4/2015 Revised Date:
N/A
Responsible Party:
Melissa Stoner
MEDICARE BENEFICIARY CLAIM REIMBURSE (1 of 2)
Policy: SummaCare will process claims submitted by Medicare beneficiaries for
services that are covered by the plan when the member submits a completed claim, including all necessary supporting documentation.
Purpose: To develop guidelines for processing claims which are submitted directly by Medicare beneficiaries requesting reimbursement.
PROCEDURES The plan will: Process Medicare beneficiary submitted claims for services when the beneficiary has submitted a complete claim (Form CMS – 1490S) and all supporting documentation associated with the claim. This includes:
• Date of service • Place of service • Description of illness or injury • Description of each service received • Charge for each service • The physician or suppliers name and address
If an incomplete claim or claim containing invalid information is received, SummaCare will return the claim to the Medicare beneficiary with a letter indicating specifically what information is needed.
POLICY NAME: MEDICARE BENEFICIARY CLAIM REIMBURSEMENT POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 2/18/2011 APPROVED BY: Claude Vincenti
MEDICARE BENEFICIARY CLAIM REIMBURSE (2 of 2)
A copy of the claim will be retained in the document management system. All covered services will be paid directly to the beneficiary. The allowed amount is either the contracted rate for contracted providers or the Medicare rate for non- contracted providers. All non-covered services will be denied and a notice of denial letter will be sent to the beneficiary. COMPLIANCE STATEMENT: Enforcement: All employees are responsible for complying with this policy.
Failure to abide by the conditions of

Provider Manual - SummaCare

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