Enrollment Procedure

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


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


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


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


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


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

Documents

Enrollment Procedure