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Advantage MDC Application,{2223/04/00098573.DOC; 1}
MD Care, Inc. Enrollment Procedure
E F E C T I V E D A T E O F C O V E R A G E
Member Services Department: Receives MDC Enrollment Election (Application)
Application is NOT Complete
Application is Complete
Application is date stamped
ESR processes elections in chronological order by date of receipt
ESR may call member within 1 business day after eff date
to explain MDC rules
Info NOT received within 21
days
Letter sent within 5 days onBeneficiaries status
MDC receives reply listing from CMS
ESR will send Acceptance / Denial Letter to member within 7 business days
ESR documents efforts to obtain addl info Info rcvd
ESR sends Enrollment Info to member no later than 7 business days
after receipt
ESR submits info to CMS within 14 calendar days
MDC denies Enrollment
ESR sends denial letter within 7 bus
w/letter
ESR determines proper effective date according to applicable election period
Initial Coverage Election Period
Open Enrollment Period
Special Election Period
Annual Election Period
1st day of the month of Part A / B
entitlement
1st day of the month after MDC rcvs completed
enrollment election
January 1 of the following year a30.4 CMS
Medicare Advantage MDCplication, {2223/04/00098573.DOC; 1}
MD Care, Inc.Involuntary Disenrollment Procedure
Member Services Department:Receives Information for possible cause
for Involuntary Disenrollment
ESR maintains documentation leading to decision to involuntarily
disenroll member
ESR sends letter to member advising of
upcoming involuntary disenrollment, incl info on
grievance rights
Member Engages in Disruptive Behavior
ESR sends member letter confirming effective date of
disenrollment within 7 business days of receipt of
CMS reply listing
MDC submits documentation of member’s disruptive behavior to CMS
CMS makes determination within 14 business days after info is rcvd; notifies
MDC of decision within 5business days after making
decision
Premiums Not Paid
ESR will send notice of non-payment within 1
Month + proper notice delinquent premiums
were due
ESR sends member letter confirming effective date of disenrollment within 7 business days of receipt
of CMS reply listing
Change of Address
ESR determines disenrollment status/sends disenrollment
letter w/lock-in restrictions
ESR will send letter to member advising of upcoming involuntary disenrollment, incl info on grievance rights within 7 business days of MDC learning of member’s change of
address
MDC submits documentation of member’s change of address outside
MDC Service Area to CMS
Permanent Temporary
Notice rcvd from member
Notice rcvd from outside
source
ESR attempts to confirm member's Permanent Change of Address
NOT Confirmed
after 6 months
Confirmed
ESR will initiate disenrollment after
6 months have passed from date MDC learned of
address change
ESR sends member letter confirming effective date of disenrollment within 7
business days of receipt of CMS reply listing
Medicare Advantage MDC Application, 1/21/05 {2223/04/00098573.DOC; 1}
MD Care, Inc. Voluntary Disenrollment Procedure
Member Services Department:Receives Disenrollment Form for
Voluntary Disenrollment
Disenrollment Form is NOT Complete
Disenrollment Form is Complete
Disenrollment Form is date stamped
ESR processes elections in chronological order by date of receipt
ESR determines if Disenrollment Form is complete
ESR documents efforts to obtain addl info
Info rcvd ESR determines that requests apply to
member’s election period Allowable
Disenrollment Effective Date
Disenrollment Effective Date NOT
allowed
ESR calls/writes member to select
Allowable Disenrollment Effective Date
Member cancels request
Member selects Allowable
Disenrollment Effective Date
MDC submits Disenrollment
transactions to CMS within 30 calendar
days of receipt
ESR sends signed copy of completed Disenrollment
form, and acknowledgement letter w/ effective date of
disenrollment
ESR sends member letter confirming effective date of
disenrollment within 7business days of
receipt of CMS reply listing
Medicare Advantage MDC Application,{2223/04/00098573.DOC; 1}
Incoming Paper Claims
Sorting / Date Stamp Claims
1. CMS 1500 Claims Forms Part B2. CMS 1450 (UB-92) Claims Forms Part A 3. Mis-Directed Claims4. Provider Dispute Letters 5. Other Correspondence
Forward mis-directed claims timely: Must forward within 10 working days from date of receipt
Claims to be processed will be sorted by Date of Receipt and by Claims Type NOTE: Claims acknowledgement: provider of service must be able to verify that the claim was received by the payer within a specific time frame:
Paper Claims to be acknowledged within 15 working days of receipt Electronic Claims to be acknowledged within 2 working days of receipt
Scanning Claims Batching Process:- 50 claims per batch per date of received (CMS 1500 & CMS 1450)
Scanning Verification Process: 1. Member 2. Provider3. Diagnosis4. Details Lines
Claims cannot be Scanned
In-load to EZ Link system
Claims Accepted by EZ Link: - Create crystal report to process
Create crystal report to process
Claims coming through FAX
Adjudication Process
MD Care, Inc Medicare Paper Claims Processing Workflow
Check & EOB Run weekly and Sign Mail out within 24 hours
MIS rejected: Claims rejects must be corrected
with in 24 hours & re-in load back to MIS.
Process and Pay
Process and Denied
Refer to Claims Denial
Flowchart 1. Contracted provider must process within 60 calendar days 2. Non Contracted Provider must process within 30 calendar days
Pending Claims
Refer to Pending Claims
Flowchart
Claims Acceptance
Scanning Rejected
Rejected
Medicare Advantage MDC Application, {2223/04/00098573.DOC; 1}
90
MD Care, Inc.Medicare Electronic Claims Workflow
Received E claims through
Web Site
Received E Claims through FTP Site
Received E Claims through
Email with Encryption
Image Capture & Scrubs Process
Acknowledgement Letter sent out to Provider within 24 hours:1. Number of claims accepted2. Number of claims rejected
Claims to be processed will be sorted by Date of Receipt and by Claims Type NOTE: Claims acknowledgement: provider of service must be able to verify that the claim was received by the payer within a specific time frame:
Paper Claims to be acknowledged within 15 working days of receipt Electronic Claims to be acknowledged within 2 working days of receipt
All contracted health care providers are permitted to connect through the Plan’s secure Web System. It permits real time verification of claims status.
In-load to EZ Link system
Claims Accepted by EZ Link: - Create crystal report to process
Create crystal report to process
Claims Report will be distributed to processor based on date of receipt
Check & EOB Run weekly and Sign Mail out within 24
hours
MIS rejected: Claims rejects must be corrected within 24 hours & re-in load back
to EZ link.
Process and Pay
Process and Denied
Refer to Claims Denial
Flowchart
Claims Accepted In load to EZ link
1. Contracted provider must process within 60 calendar days 2. Non Contracted Provider must process within 30 calendar days
Medicare Advantage MDC Application, {2223/04/00098573.DOC; 1}
91
MD Care, Inc.Medicare Pending Claims Workflow
Pending for Additional Information
(Unclean Claims)
Pending for Internal
Eligibility Verification
Process(48 hrs Turn Around time)
Utilization Process (48 hrs Turn
Around Time)
Pending for External
1St Attempt: Follow-up Within 5 -10
days
Request Information from
Provider / Hospital(Send Letter out)
Return back to claims adjudicator
2nd Attempt: 11 to 25 days
Made phone call to follow-up
Final Decision: 25 to 30 days
After performed 1st and 2 nd trials, there is no
response
Either Partial Pay or Denial
Unclean Claims are considered to be claims received with insufficient information necessary to determine the Plan’s liability. Contested Unaffiliated and Affiliated claims will be completed (paid or denied) within sixty (60) calendar days of receipt.
Refer Back to Medicare Flowchart
Medicare Advantage MDC Application, {2223/04/00098573.DOC; 1}
MD Care, Inc.Medicare Claims Denial Workflow
Medicare Paper /
Electronic Claims
Workflow
Member Claims Denial Process
Medicare Timeliness: 95% of all member denials must be mailed within 60 calendar days from earliest receipt date to be considered compliant.
Medicare Accuracy: 95% of all member denials must be considered accurate based on the 19 criteria listed on the
Claim Denial Letter Audit Tool
Eligibility Denials:1. Predated with plan 2. Postdated with plan (NOTE: Denials that read “not eligible” with IPA or medical group at the time of service are inappropriate denials.)
Emergency and Urgently Needed Services Denials:1. In-Area (non-emergent; presenting circumstances fail test)2. In-Area (Records not received)3. In-Area (partial denial of inappropriate services) 4. Out-of Area (Not urgently needed) 5. Out-of Area (Records not received)
Maximum Allowable Benefit
Not a Covered Benefit
Verify all Denials Prior to Sending Out
All Denials must have documentation in the system All phone calls made must documented in the system
Perform Claims Denial Audit Tool prior to sending out denial letter
Checking denial letter format and
language
Checking denial detail
Checking decision to deny is correct
Checking denial was issue timely
Checking system documentation
Medicare Advantage MDC Application, {2223/04/00098573.DOC; 1}
MD Care, Inc. MEMBER GRIEVANCE RESOLUTION
GRIEVANCE RECEIVED
CLINICAL
GRIEVANCE
ADMINISTRATIVE
GRIEVANCE
GRIEVANCE REVIEW BY QM SPECIALIST
CONTACTS GROUP
CONTACTS PROVIDER FOR A RESPONSE
GRIEVANCE REVIEW BY MEMBER SERVICES
CONTACTS GROUP
CONTACTS PROVIDER FOR A RESPONSE
PLAN QM DEPT RECEIVES PROVIDER & GROUP
RESPONSE
REVIEWED BY QM SPECIALIST
MEMBER SERVICES RECEIVES PROVIDER &
GROUP RESPONSE
REVIEW RESPONSE
REVIEW OF GRIEVANCE BY GRIEVANCE & APPEALS COMMITTEE
FOR RESOLUTION
WITH QUALITY OF CARE ISSUE
NO QUALITY OF CARE ISSUE
PROVIDE RESOLUTION
REPORT SUMMARY TO QUALITY
IMPROVEMENT COMMITTEE
MEDICAL DIRECTOR
REVIEW
PEER REVIEW
PROVIDE RESOLUTION
GRIEVANCE REVIEWED BY
GRIEVANCE & APPEALS COMMITTEE
Medicare Advantage MDC Application,{2223/04/00098573.DOC; 1}
94
MD Care, Inc. GRIEVANCE PROCEDURE
Member Services Department:
Oral Grievance Written Grievance
MSR assists member in documenting issue on Grievance Form: MPR
Document is date stamped
Administrative
MSR enters incident in EZ-CAP; creates member case file
MSR conducts thorough investigation
MSR sends 3rd letter notifying MG/IPA
MSR sends ack letter within 5 working days
Clinical
MSR sends resolution/closure letter
MSR forwards copy of member’s case file and EZ-CAP incident to Quality Management
Department
MSR will send up to 2 letters requesting any needed info
QM makes Determination/Final Disposition within 30 days
Info NOT RCVD
Info RCVD
Determination / Final Disposition made within 30 days; entered into EZ-CAP
QM sends resolution/closure letter
MSR determines if issue is Admin or Clinical
QM conducts thorough investigation
QM enters Determination/Final Disposition into EZ-CAP; closes EZ-CAP incident
QM forwards case file to Member Services Department
Medicare Advantage MDC Application, {2223/04/00098573.DOC; 1}
MD Care, Inc. APPEAL (RECONSIDERATION) PROCEDURE
Member Services Department: Notice of Appeal rcvd via CMP, SSA, RRD
Written Appeal
Document is date stamped
MSR enters issue in MIS; creates case file
QM makes determination within 60 days
QM makes determination within 30 days
MSR sends ack letter within 5working days
QM conducts thorough investigation of Appeal
QM documents / closes incident in MIS
QM sends written notification of determination to member within specified timeframes
Member Services Department stores case file
Appeal: Rqst for Service
Appeal: Rqst for Payment
QM forwards case file to Member Services Department
QM tracks / maintains Appeal in MIS
MSR forwards case file / MIS incident to QM
Medicare Advantage MDC Application, {2223/04/00098573.DOC; 1}
MD Care, Inc.
NOTICE OF NONCOVERAGE OF INPATIENT HOSPITAL CARE
Notifying Enrollees of Non-coverage of Inpatient Hospital Care
Upon admission to the hospital, enrollees will receive “Important Message From
Medicare” that will inform them of their appeal rights.
The enrollee may submit a request for an immediate QIO review by noon of the first
business day following receipt of the “Notice of Non-Coverage.”
If the enrollee disagrees with the decision, a detailed “Notice of Non-Coverage” will be
issued one day before the enrollee’s hospital coverage ends.
The enrollee is notified of CHMP’s decision to end coverage of a hospital stay
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