2014 Provider Manual - Coventry Medicare: Advantage

2014 Provider Manual

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Table of Contents 1 About Us .......................................................................................................................................... 6

2 Administrative Procedures ............................................................................................................... 7 2.1 - Participating Providers ........................................................................................................... 7 2.2 - Provider/Member Relationships ............................................................................................. 8 2.3 - Credentialing of Providers ...................................................................................................... 8 2.4 –Member Number and Identification Cards ............................................................................. 9

2.5 - Provider News (Provider Newsletter) and Other Provider Communications ......................... 9 2.6 - Monthly Member Listing...................................................................................................... 10 2.7 - On-Call Providers ................................................................................................................. 10 2.8 - Copayment/Coinsurance/Deductible Collection .................................................................. 10 2.9 - No-Show Appointments ....................................................................................................... 11

2.10 - Noncovered Services .......................................................................................................... 11

2.11 - Dismissal of Patients from a Practice ................................................................................. 11

2.12 - Termination and Restrictions.............................................................................................. 11

2.13 - Use of Nonparticipating Providers ..................................................................................... 12 2.14 - Ancillary Personnel Performing Services ........................................................................... 12 2.15 - Advanced Directives ........................................................................................................... 12

2.16 - Translation Services ........................................................................................................... 14 3 Preauthorization ............................................................................................................................. 15

3.1 - Overview .............................................................................................................................. 15 3.2 - Guidelines for Inpatient Preauthorization............................................................................. 17 3.3 -Definition of Preauthorization Types .................................................................................... 18

3.4 - Emergency Room (ER) Visits .............................................................................................. 18 3.5 -Maternity Notification Forms ................................................................................................ 19

3.6 - Preauthorization for Out-of-Network Services to Be Considered as In-Network ................ 19 3.7 - OB/GYN Treatment ............................................................................................................. 20

3.8 - Injectables ............................................................................................................................. 20 3.9 - Advanced Technologies ....................................................................................................... 21

3.10 - Utilization Management (UM) Decisions .......................................................................... 21 4 Reimbursement & Claims .............................................................................................................. 22

4.1 - Compensation ....................................................................................................................... 22 4.2 - Immunizations and Injectables ............................................................................................. 22 4.3 - Claims Filing Procedures...................................................................................................... 23 4.4 - Electronic Claims ................................................................................................................. 25 4.5 Request for Notes/Invoices ............................................................................................... 26

4.6 - Timely Filing Policy ............................................................................................................. 26 4.7 -Adjustment Requests ............................................................................................................. 27

4.8 - Remittance ............................................................................................................................ 27 4.9 - Status of Claims .................................................................................................................... 28 4.10 - Coordination of Benefits (COB)......................................................................................... 29 4.11 – Systems Affecting Preauthorization and Claims Payment ................................................ 33 4.12 - Subrogation/Recovery ........................................................................................................ 34

4.13 - Payment Policy Program .................................................................................................... 35 4.14 - Provider Reimbursement Fee Schedule .............................................................................. 37 4.15 - Noncovered Services .......................................................................................................... 38

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4.16 – Fraud and Abuse ................................................................................................................ 43

5 Pharmacy Benefits ........................................................................................................................ 50 6 Laboratories ................................................................................................................................. 56

6.1 - Lab Services ......................................................................................................................... 56

7 Plan Options ................................................................................................................................... 57 7.1 -Types of Benefit Plans ........................................................................................................... 57

8 Physician Participation Information .............................................................................................. 59 8.1 - General Guidelines ............................................................................................................... 59 8.2 - Coventry Health Care Access and Availability Standards ................................................... 61

8.3 -Office Survey and Medical Record Review .......................................................................... 62 8.4 - Maternity .............................................................................................................................. 62 8.5 - Malpractice ........................................................................................................................... 63 8.6 - Members’ Rights and Responsibilities ................................................................................. 63

8.7 - Preventive Care Guidelines .................................................................................................. 67 9 Participation Appeal Process ....................................................................................................... 68

9.1 - Guidelines Grievance/Hearing ............................................................................................. 68 9.2 - Reporting to the National Practitioner Data Bank ................................................................ 71

9.3 - General Comments ............................................................................................................... 71 10 Provider Appeal Procedures ..................................................................................................... 73

10.1 -Definitions ........................................................................................................................... 73

10.2 - Peer-to-Peer Reviews ......................................................................................................... 74 10.3 - Submission of Additional Clinical Information after a Pre-Service Denial ....................... 75

10.4 - Post-Service Claim Reviews and Provider Appeal Processes ............................................ 76 11 Health Management Programs ..................................................................................................... 78

11.1 - Preventive Health Guidelines ............................................................................................. 78

11.2 - Disease Management Programs.......................................................................................... 78

11.3 - Diabetes Disease Management Programs ........................................................................... 79 11.4 - Asthma Disease Management Program .............................................................................. 79 11.5 - Cardiac Disease Management Program .............................................................................. 79

11.6 - Maternity Management Program ........................................................................................ 80 11.7 - Chronic Obstructive Pulmonary Disease (COPD) Disease Management Program ........... 80

11.8 - Case Management Programs .............................................................................................. 80 12 Quality Improvement ................................................................................................................... 82

12.1 - Introduction ........................................................................................................................ 82 12.2 - Purpose ............................................................................................................................... 82 12.3 - Goals and Objectives .......................................................................................................... 83 12.4 -Confidentiality ..................................................................................................................... 84 12.7 - Quality Management Program Activities ........................................................................... 84

12.8 - HEDIS® ............................................................................................................................. 84 12.9 - Patient Safety ...................................................................................................................... 85

12.10 - Demographics, Epidemiology & Health Disparities ........................................................ 87 12.11 - Medical Continuity and Coordination of Care ................................................................. 87 12.12 - Behavioral and Medical Continuity and Coordination of Care ........................................ 87 12.13 - Medical Record Documentation and Monitoring Compliance......................................... 88 12.14 - Delegated Activities ......................................................................................................... 88 12.15 - Health Plan Accreditation Compliance & Annual Ranking ............................................. 88

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12.16 - Medicaid Program Compliance ........................................................................................ 89

12.17 - Annual Quality Improvement Program Evaluation, Review and Approval ..................... 89 13 Clinical Standards of Care ......................................................................................................... 90

13.1 - Preventive Health Guideline Development Policy ............................................................. 90

13.2 - Clinical Practice Guidelines ............................................................................................... 91 14 CoventryCares Medicaid ............................................................................................................ 99

14.1 - Member Numbers, ID Cards and PCP Panel ...................................................................... 99 14.2 - Management of After-Hours Access To Service ................................................................ 99 14.3 - Copayment Collection ...................................................................................................... 100

14.4 - Coinsurance and Deductibles ........................................................................................... 100 14.5 - Preauthorized Care ........................................................................................................... 100 14.6 - Patient Self-Determination Act ........................................................................................ 100 14.7 - Customer Service/Member Eligibility/Claims Status....................................................... 101

14.8 - Members’ Rights and Responsibilities ............................................................................. 101 14.9 - Loss of Eligibility for Medicaid ....................................................................................... 102

14.10 - Communication Standards .............................................................................................. 102 14.11 - Special Needs Populations.............................................................................................. 104

14.12 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) ............................... 104 14.13 - Transportation ................................................................................................................. 106 14.14 - Maternity ........................................................................................................................ 107

14.15 - Abortions ........................................................................................................................ 107 14.16 - Sterilization/Hysterectomy ............................................................................................. 107

14.17 - Division of Surveillance and Disease Control Reporting ............................................... 108 14.18 - Routine Childhood Immunizations ................................................................................. 108 14.19 - Claims Filing Procedures................................................................................................ 108

14.20 - Electronic Claims ........................................................................................................... 110

14.21 -Adjustment Requests ....................................................................................................... 111 14.22 - Noncovered Services ...................................................................................................... 111 14.23 - Encounter Claims and Other Electronic Data Submission ............................................. 112

14.24 - Status of Claims .............................................................................................................. 113 14.25 -Coordination of Benefits ................................................................................................. 113

14.26 - Maternal/Child Case Management ................................................................................. 114 14.27 - Providers Excluded from Participation in Federal health Care Programs ...................... 114

14.28 - Mountain Health Choices .................................................. Error! Bookmark not defined. 16 Coventry Health Care, Inc. ...................................................................................................... 117 17 Pharmacy Services-Coventry Cares of WV ............................................................................. 118 18 Medicare .................................................................................................................................. 120

18.1 What is Medicare? ............................................................................................................. 120

18.1.1 What is Advantra HMO? ................................................................................................ 120 18.1.2 What is Advantra PPO? .................................................................................................. 120

18.2 Medicare Advantage’s Member Rights & Responsibilities ............................................... 121 18.3 Member Identification ....................................................................................................... 124 18.4 Unique Services ................................................................................................................. 124 18.4.1 Emergent/Urgent Care/Renal Dialysis Services/Clinical Trials ..................................... 124 18.5 Referrals/Prior Authorization ............................................................................................. 125 18.5.1 Mental Health/Substance Abuse Services Prior Authorizations ...................................... 125

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18.6 Member Input in Treatment Plan ........................................................................................ 126

18.7 Advance Directives ............................................................................................................. 126 18.10 Provider Appeals Process ................................................................................................. 127 18.11 Member Grievance OR Medicare Appeals Process for Medical Coverage ..................... 127

18.11.1 Notice of Discharge and Medicare Appeal Rights ........................................................ 129 18.12 Quality Improvement Organization Review ..................................................................... 131 18.13 Claims and Encounter Submission ................................................................................... 131 18.14 Mediare Advantage (MA) Risk Adjustment ..................................................................... 132 18.15 Special Status Medicare Members .................................................................................... 137

18.16 Privacy of Medical Records .............................................................................................. 139 18.17 CMS Requirements ........................................................................................................... 139 18.19 Medicare Provider Training and Education ...................................................................... 143

Attachment A – Commercial and Medicare Preauthorization List ................................................. 146

Attachment B - Maternity Notification and Risk Screen ................................................................ 149 Attachment C - Claim Inquiry/Adjustment Request Form ............................................................. 151

Attachment D – Provider Reimbursement Fee Schedule ............................................................... 152 Attachment E: Carelink Medicaid Services Requiring Preauthorization ....................................... 153

Attachment F – Advance Directives ............................................................................................... 156 Attachment G – Provider Change in Information Form ................................................................. 158 Attachment H – Quick Reference Guide ........................................................................................ 159

Attachment I – HEDIS Measures – Tips for Providers .................................................................. 160 Attachment J- Advantra Member ID Card……………………………………………………….. 196

Attachment K- Coventry Cares of WV ID Card…………………………………………………. 198

Carelink Health Plans, Inc., a licensed HMO, and its affiliates are collectively referred to herein as “Coventry Health

Care” unless otherwise noted. Coventry Health Care has offices in Charleston, WV and Wheeling, WV.

HMO products are underwritten by Coventry Health Care of West Virginia, Inc. PPO products are underwritten by

Coventry Health and Life Insurance Company and administered by Coventry Health Care of West Virginia, Inc.

Coventry Health Care Customer Service can be reached during normal business hours by calling 800-348-2922.

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1 About Us

Coventry Health Care of West Virginia, Inc. is a West Virginia domiciled HMO with offices in

Charleston and Wheeling, WV.

Coventry Health Care of West Virginia, Inc. makes available a variety of products to its members

including traditional HMO plans, POS plans, and a Medicaid product.

HMO products are underwritten by Coventry Health Care of West Virginia, Inc. PPO products are

underwritten by Coventry Health and Life Insurance Company and administered by Coventry

Health Care of West Virginia, Inc.

PPO products include both local and national provider network products and CoventryOne, a group

trust offering health coverage to individuals and families. Throughout this document, Carelink

Health Plans, Inc., Coventry Health Care of West Virginia, Inc., and Coventry Health and Life

Insurance Company are referred to as “Coventry Health Care,” “We,” “Us,” or “Our.”

Coventry Health Care is committed to working with provider practices in order to achieve mutual

success. We share the common goal of preserving the quality of care for patients who seek benefits

from a managed care plan within the traditional physician/patient relationships.

We recognize the important role each provider plays in the administration of the plan. This

Provider Manual is designed to serve as a guide for the administrative procedures required by

Coventry Health Care and is referenced as part of the Provider Agreement between you and us. We

hope that most of your day-to-day questions are addressed in this manual. Please call us if you have

any questions. Our Customer Service Representatives are available to help you Monday through

Friday, between 8:00 a.m. and 6:00 p.m.

Customer Service Representatives can be reached by calling 800-348-2922 or 888-348-

2922.

Medicaid Customer Service Representatives can be reached at 800-3482922 or 888-348-

2922, Monday through Friday between 8:30 a.m. and 5:00 p.m.

Your Network Management Representative can also assist you with policies and procedures

such as reimbursement, contractual, or participation issues.

You can also refer to our website, www.chcwv.com, for updated information.

The utilization management staff is available to discuss specific cases or utilization management

questions by phone between 8:00 am and 5:00 pm by calling the Customer Service number at

800.348.2922. The ability to receive faxed information is available 24 hours per day, 7 days per

week at 866.373.0274.

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2 Administrative Procedures

2.1 - Participating Providers

Participating providers include those health care providers that have a contract with Coventry

Health Care. Coventry Health Care members enrolled in HMO plans must utilize participating

providers to be eligible for covered services, unless Coventry Health Care has specifically

preauthorized the use of nonparticipating providers before services are rendered or in the case of

emergency services. Members may use nonparticipating pharmacies for prescription drugs

prescribed for emergency services only for a quantity sufficient to treat the acute phase of the

illness/injury. POS and PPO products allow members to receive covered services from

nonparticipating providers usually at a reduced level of coverage. If a participating provider sees a

POS, HMO or PPO member for a service that requires preauthorization, but does not get the service

authorized the member cannot be billed for the service.

You should be aware that the Preferred Provider Directory and the online provider search at

www.chcwv.com are subject to change. You should verify the participation status of a provider

with Coventry Health Care’s Customer Service Department before referring a patient/Coventry

Health Care member. Please call Customer Service at 800.348.2922.

Primary Care Providers

Primary Care Providers (PCPs) are those physicians and other health care providers, such as Nurse

Practitioners, who accept the responsibility of providing and/or coordinating the health care needs

of any Coventry Health Care member who chooses that provider. This applies only to benefit plans

that require the member to select a PCP. It is important that all PCPs ensure 24hour coverage and

accessibility for members.

Any participating provider that is listed as a Coventry Health Care PCP may see a member

regardless of whom the member has chosen as their PCP. Primary Care Providers fall within the

following types of medical specialties:

Internal Medicine

Family Practice

General Practice

Pediatrics

Osteopaths

Nurse Practitioners

OB/GYN Physicians

Coventry Health Care benefit plans allow members to have open access to an OB/GYN provider

for covered services.

Specialty Care Physicians

A specialty care provider is a provider who provides care to Coventry Health Care members within

the scope of a specific medical specialty.

Please check our website on a regular basis for new

information: www. chcwv.com.

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Hospitals and Ancillary Providers

Coventry Health Care maintains contracts with hospitals and ancillary providers within the service

area to fulfill the health care needs of all members. Please note that each participating provider may

not be a participating provider for all products or services for which he or she is licensed.

2.2 - Provider/Member Relationships

Coventry Health Care requires all participating providers to discuss treatment options with patients

who are our members. This allows a member to make an informed decision about their course of

treatment with knowledge of both the possible benefit limitations and treatment options.

Information discussed between the physician and the member is to be kept confidential.

2.3 - Credentialing of Providers

Any new provider that is joining your practice/organization must first be credentialed by Coventry

Health Care prior to being able to render services to Coventry Health Care members, unless

Coventry Health Care determines the provider does not need to complete the credentialing process

as described below. If Coventry Health Care receives a claim from a non-credentialed provider in

your practice/organization, the claim will be returned to the provider and denied as the provider

would be considered a “non-participating provider.” The member will not be responsible for the

charges.

Please notify Coventry Health Care as far in advance as possible when adding a new provider to

your practice. Coventry Health Care will then make the determination as to whether or not the

provider must complete the credentialing process. If the provider is required to complete the

credentialing process, an application will be provided. Once a clean application and all supporting

material are received by Coventry Health Care, the credentialing process will begin. This process

can take up to 120 days. Please note: A site visit may be required prior to the processing of your

application.

Procedures that require conscious sedation will not be approved to be performed in a provider’s

office unless the following are met:

Provider must have received training in specific procedures.

Provider must be approved by credentialing prior to performing the procedure on any

Coventry Health Care member.

Provider’s office must pass an initial site review.

If your practice will be performing procedures that require conscious sedation, please contact your

Provider Relations Representative to schedule a review. Coventry Health Care will not cover

procedures performed in the office if the Provider has not received preauthorization to perform the

procedure.

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Coventry Health Care does not credential the following types of physicians:

Pathologist

Radiologist

ER Physician

Anesthesiologist (Pain Management specialists and anesthesiologists who practice in-office

conscious sedation require credentialing.)

Neonatologist

Hospitalist

2.4 –Member Number and Identification Cards

Coventry Health Care Member ID Numbers are system-generated, unique 11 digit identification

numbers followed by a suffix for each family member. Subscriber’s suffix is 01 and the spouse and

dependents’ numbers are 02 through 99. Always verify the Member ID and submit it exactly as it

appears on the ID card or on the electronic eligibility responses.

The entire number, including the suffix, must be used for billing and inquiries. Each family

member receives a card listing their name, their member number, the effective date of the ID card,

and the subscriber’s group name and group number. The plan type indicates whether the member is

a fully insured HMO or POS member with Coventry Health Care, a fully insured PPO member

with CHLIC, or a member of a self-funded plan. The effective date on the ID card reflects the most

recent benefit change by the member’s group.

If the member has a prescription benefit through Coventry Health Care, the pharmacy Customer

Service telephone number will be listed at the bottom of the identification card. If the member has

behavioral health care and substance abuse coverage through Coventry Health Care, the member

may self-refer or be referred by their PCP for most benefit plans. The telephone number for

behavioral health and substance abuse services is on the member’s ID card.

For Coventry Health Care Medicaid Members, please refer to Section 15.

2.5 - Provider News (Provider Newsletter) and Other Provider Communications

Coventry Health Care regularly publishes a provider newsletter entitled Network News (formerly

Connection). This is the main source of mass communication to participating providers, and is

located on the website at www.chcwv.com. Network News may include Provider Manual

amendments. The Provider Manual amendments are part of the provider’s contract.

Network News is intended to explain amendments and keep participating providers abreast of

issues, including but not limited to, Coventry Health Care programs, policy and procedure

changes/updates, network changes, changes in the Schedule of Allowances, billing information,

and general topics of interest. These notices should be considered part of this manual and kept for

further reference. Network News clarifies changes to policies and procedures that amend the

http://www.chcwv.com/

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provider’s agreement with Coventry Health Care. Provider news, announcements and contract

amendments are posted on our website at www.chcwv.com » Providers » Document Library. Be

sure to review Network News for important messages.

To ensure proper receipt of Network News, please contact your Coventry Health Care’s Provider

Relations department immediately if your fax number changes.

Coventry Health Care also communicates regularly with its participating providers by sending

broadcast faxes. Please be sure to contact your Provider Relations representative immediately if

you change your fax number.

2.6 - Monthly Member Listing

Because WV Medicaid members are allowed to change managed care organizations on a monthly

basis, PCP practices who participate with the Medicaid program upon request will receive a listing

of all members who have designated the physician(s) in that practice as their Primary Care

Physician. Practices may verify eligibility by contacting Customer Service or by utilizing

www.directprovider.com. Please remember that for all fully-insured plans, members can access any

participating PCP, not just the designated PCP.

2.7 - On-Call Providers

As a participating provider, you are responsible for providing access for members 24 hours a day, 7

days a week. Referring patients directly to the emergency room for nonemergent services when you

are unavailable is not acceptable and is a violation of your Participating Provider Agreement.

Physician may arrange for a physician who is a Participating Provider to furnish coverage on

Physician’s behalf (a “Covering Physician”) so long as Physician retains primary responsibility for

Members’ care. When a physician is taking calls for you, he or she is responsible for coordinating

any necessary care for those patients in your absence. In order for Coventry Health Care to

reimburse your on-call physician, you must provide Coventry Health Care with information

regarding your on-call physician in advance. Otherwise, the claims could be denied or delayed

awaiting this information. To facilitate claims processing, please notify your Provider Relations

Representative of the current on-call information for your practice.

2.8 - Copayment/Coinsurance/Deductible Collection

The Member ID card has information regarding the member’s financial responsibility for some

types of services; however, for specific benefit information, the member should refer to his/her

Schedules of Benefits, which vary among groups. Therefore, it is important to verify the correct

deductible, copayment, and/or coinsurance amount information on the member ID card or

Schedule of Benefits by calling Customer Service or through www.directprovider.com. Copayments, Coinsurance and Deductibles can be collected at time of service. Customer Service is

available to provide the most up to date coinsurance and/or deductible information.

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2.9 - No-Show Appointments

If your office has an established policy on prior notification of canceled appointments that includes

a charge for no-shows, you may charge Coventry Health Care members directly should they violate

this policy. Please note that this must be an established policy communicated to and applied to all

patients. Coventry Health Care members may not be charged for a canceled appointment at a rate

greater than what would be charged to a non-Coventry Health Care member.

2.10 - Noncovered Services

As stated in your Provider Agreement with Coventry Health Care, you may not bill the member for

services that are not covered by Coventry Health Care unless you notify the member before you

provide and/or order the non-covered service and the member indicates in writing their willingness

to pay out-of pocket. You also must require that the member execute a form to the effect that

the services are not a covered benefit, and the form must clearly identify the specific service that is

not covered. A general acknowledgement of liability for non-payment is not an acceptable form.

You may be held responsible for the charges associated with the non-covered service if you do not

have an executed form indicating that the member understands the service is non-covered and is

willing to pay out-of-pocket.

2.11 - Dismissal of Patients from a Practice

It is recommended that your practice have an established policy for dismissing patients from the

practice. Coventry Health Care members should be seen and treated in the same manner as any

other patient you see. Services or appointments cannot be refused in emergency or urgent care

situations unless you have provided a member with at least 30 days notice and requested that they

select another physician. In the event of a member dismissal from your practice, the member should

be notified in writing. It is recommended that the practice submit a copy to Coventry Health Care

of the dismissal notification letter sent to the member. If requested, Coventry Health Care can assist

the member in selecting a new physician. This policy is to be used for special situations with

specific patients only where just cause exists for dismissing the patient. If you are wishing to close

your practice to new patients please notify Coventry Health Care in writing with the effective date

of the change.

2.12 - Termination and Restrictions

Participating providers may terminate their participation with Coventry Health Care. Providers

wishing to terminate must notify Coventry Health Care in writing. Please refer to your Provider

Agreement for detailed requirements about the termination process.

Providers who wish to restrict their practice in any way also must restrict their practice to all

carriers and must give Coventry Health Care written advance notification as stated in your Provider

Agreement. The Provider Agreement has provisions regarding the necessary timing.

Provider Agreements will not be terminated by Coventry Health Care to penalize provider in the

event Provider: (a) advocates in good faith on behalf of a member; (b) files a complaint against

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Coventry Health Care; (c) appeals a decision made by Coventry Health Care; or (d) treats a

substantial number of patients who require expensive or uncompensated care; or (e) requests and

expedited appeals resolution or supports an enrollees appeal.

2.13 - Use of Nonparticipating Providers

Unless otherwise preauthorized by Coventry Health Care, participating providers must be utilized

for services arranged or coordinated by participating providers. Examples of these services are lab

procedures, DME supplies, and use of assistant surgeons. If a participating provider sends

specimens to a nonparticipating provider for interpretation, provides DME or supplies from a

nonparticipating vendor, or uses the services of a nonparticipating assistant surgeon, the

participating provider will be held responsible for the nonparticipating provider’s charges. In the

event that a nonparticipating provider is recommended, it is the responsibility of the participating

provider to obtain a preauthorization for these services. Prior to being held liable, you will receive

written notification in the form of a Pay and Educate letter for the first offense. A copy of this letter

is sent to Provider Relations for recruitment of the nonparticipating provider. After the initial

warning, it will be your responsibility to verify the provider’s participation status.

2.14 - Ancillary Personnel Performing Services

For any health care professionals employed by, under contract with, or otherwise supervised by the

provider when such professionals are not required to be credentialed directly by Coventry Health

Care, the provider must implement peer review and credentialing of such health care professionals

who provide covered services to members on behalf of, or under the supervision of, the provider.

These personnel are defined as:

Nurse Practitioners (unless they are credentialed)

Physician Assistants

Certified Nurse Midwives

Physical, Occupational and Speech Therapists

Certified Registered Nursing Assistants (CRNAs)

2.15 - Advanced Directives

Advance directive is a written document or an oral statement in the presence of the attending

physician and two (2) witnesses by an adult member who has been diagnosed by his/her attending

physician as being in a terminal condition voluntarily executed by an adult member (or by another

on behalf of and at the direction of the adult member), and, witnessed by two (2) individuals each

of whom is eighteen (18) years of age or older.

Witnesses cannot be a spouse or blood relative of the patient. Employees of health care facilities

and physicians’ offices, who act in good faith, may serve as witnesses.

The written or oral statement may also appoint an agent to make health care decisions for the adult

member if the adult member is determined to be incapable of making an informed decision.

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The adult member is responsible for notifying his/her Coventry Health Care participating provider

if an advance directive has been made or if he/she has any moral or religious belief that prohibits

the making of an advance directive. Coventry Health Care shall require the adult member’s

participating provider to promptly make the advance directive or the objection to an advance

directive or a copy of such, if written, or the fact of such if oral, a part of the adult member’s

medical records.

Participating Providers shall be required to remind adult members that the directive applies only to

care received from that particular participating provider and does not guarantee that it will be

implemented by another provider since providers can refuse to implement a directive as a matter of

conscience. The participating provider shall be responsible for advising the adult member that it is

the adult member’s responsibility to notify other participating providers authorized to treat the adult

member of the advance directives or to their objection of an advance directive and to furnish them

copies.

Participating providers shall, review the written directive and determine if he/ she is willing to

honor the request as written or orally presented.

A Coventry Health Care participating provider shall only be expected to implement an advance

directive when:

A written copy of the advance directive has been provided to and accepted by a

participating physician. If the adult member is comatose, incapacitated, or otherwise

mentally or physically incapable of communication, any other person may notify the

participating provider of the existence of the advance directive.

For any competent adult member who has been diagnosed by his/ her attending

participating physician as being in a terminal condition, the attending participating

physician shall, in the presence of two (2) witnesses, receive an oral statement by the adult

member authorizing the providing, withholding, or withdrawing of life-prolonging

procedures or the appointment of an agent to make health care decisions for the adult

member under the circumstances stated in the advance directive if the adult member is

determined to be incapable of making an informed decision.

Coventry Health Care recognizes that an advance directive can be revoked at any time by the adult

member (i) by a signed and dated written revocation from the member or person acting at his/her

direction; (ii) by physical cancellation or destruction of the advance directive by the adult member

or another in his/her presence and at his/her direction; or (iii) by oral expression of intent to revoke.

Any revocation of an advance directive shall be effective when communicated to the participating

physician.

For additional documentation regarding advance directives, please see Attachment K.

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For more information on advance directives, visit the American Medical Association website at

www.ama-assn.org.

2.16 - Translation Services

If a language barrier prevents you communicating effectively with our members, we have

translation services available to assist. Our language line provides interpreter services at no cost to

you. Please contact our Customer Service Center. Let the Customer Service representative know

that you need an interpreter and what language is needed. They will make the connection for you.

Our translation service provides interpreters for more than 140 languages and is available during

the Customer Service hours of 8 a.m. to 6 p.m. Eastern. Call Customer Service toll-free at

800.348.2922.

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3 Preauthorization

3.1 - Overview

Preauthorization (prior approval) is required for nonemergent inpatient and outpatient hospital

admissions; certain medical, surgical or diagnostic procedures, Rehabilitative Services, durable

medical equipment (DME) under specific conditions; and, for HMO members, care by

nonparticipating providers. The preauthorization list is periodically updated by Coventry Health

Care, and if changes are made you will be notified through our newsletter, Provider News or

through a fax blast. Preauthorization must be obtained even if Coventry Health Care is not the

primary payer. If the provider is unsure about a particular procedure or needs more information,

contact Health Services at 888.348.2966. Providers may also consult directprovider.com to look

up codes that require preauthorization.

The provider ordering the care or the provider performing the service must contact Coventry Health

Care to obtain preauthorization. Specific medical information is required to determine medical

necessity and the availability of benefits. If the service/procedure is suspected of being cosmetic in

nature, preauthorization is required regardless of the location performed. If the date of the

preauthorized service changes, the provider must contact Coventry Health Care prior to performing

the service in order to update the preauthorization. In order to allow sufficient time for the

preauthorization process, please contact Coventry Health Care for preauthorization a minimum of 3

working days prior to when the service is needed for elective, scheduled procedures, and diagnostic

testing. Procedures on the preauthorization list require preauthorization even when performed in an

office setting (e.g., MRIs, sleep studies, cosmetic procedures, etc.).

Even if Coventry Health Care is not the primary carrier, preauthorization must be obtained prior to

any nonemergent services (listed as requiring preauthorization), being performed or for services for

which someone else may be determined liable and noncovered by Coventry Health Care (i.e.,

Medicare primary or other commercial coverage is primary). Coventry Health Care requires that

you provide the diagnosis code as well as the CPT code and/or the HCPC code for durable medical

equipment, to be performed when requesting preauthorization. The clinical information provided

and the plan of treatment will be evaluated and completed by the Preauthorization Nurse within 3

working days of receipt of all necessary information to make a determination for elective

procedures or testing for non-urgent requests. For urgent procedures or testing, the determination

will be made within 24 hours upon receipt of all clinical information. If the 24-hour deadline falls

on a weekend or holiday, preauthorization will be given on the next working day, but in no event

more than 72 hours after the request is received. Evaluation using Coventry Health Care-approved

criteria will be performed and a decision will be made on the requests. For concurrent review, the

Concurrent Review Coordinator will review the information the next working day after

notification.

Participating providers may be held responsible for the cost of service(s) where preauthorization is

required but not obtained. The member may not be billed for the applicable service(s).

16

The preauthorization number will be given to the ordering provider verbally, thereby creating a

paperless preauthorization system. The member will receive written documentation of the approved

procedure/service. You may also access www.directprovider.com for the preauthorization process.

The preauthorization number should be included on the claim form when submitting the claim to

Coventry Health Care. Specialty care providers are expected to forward appropriate reports of

consultations or treatments, and/or plans for future evaluation and treatment to the member’s

primary care provider.

If a member is admitted to the hospital in an emergency, Coventry Health Care must be notified

within 24 hours or by the end of the next working day if the 24-hour deadline falls on a weekend or

legal holiday. Earlier notification greatly facilitates the utilization review process and allows

Coventry Health Care to determine during the stay whether or not medical criteria for coverage is

met.

Unless the patient has received preauthorization from Coventry Health Care for out-of-network

care or is a member of a plan with out-of-network benefits, all nonemergent care must be received

within the contracted provider network in order for services to be eligible for coverage. Should the

provider refer such a member for care outside of the network without preauthorization, you may be

held responsible for the charge(s) of the service(s) rendered and the member may not be billed.

Please note that participating providers may not be participating for all products or services.

Please call Coventry Health Care to verify participation status.

Coventry Health Care uses clinical guidelines to determine if services are medically necessary as

defined in the member’s Evidence of Coverage, Certificate of Insurance, or Plan Document.

Coventry Health Care will ask the provider questions about the member’s symptoms, other

indications, and what types of treatment and/or tests have already been utilized. This information

will be compared with clinical guidelines to determine appropriateness. If the indicators are

present, the procedure will be preauthorized as medically necessary. If appropriateness indicators

are not present, the case will be referred to the Medical Director who may discuss this case with the

member’s attending physician.

Preauthorization only verifies that the requested service meets the benefit plan’s definition of

medical necessity and is not a guarantee of payment. Whether the requested service is

covered by Coventry Health Care is subject to all of the terms and conditions of the

member’s benefit plan, including but not limited to, member eligibility and benefit coverage

at the time the services are provided.

Examples of the procedures where Coventry Health Care utilizes the medical review criteria may

include, but are not limited to, hysterectomies, cholecystectomies, laminectomies, and

septoplasties. When submitting clinical notes for review, please mail them to:

Coventry of West Virginia

Attn: Health Services

3721 Tec Port Drive

P.O. Box 67103

17

Harrisburg, PA 17111

Notes may also be faxed to 888-247-4791. They may also be submitted through

www.directprovider.com, through the authorization function.

Medical Services Requiring Preauthorization for 2013: Please see Attachment A.

3.2 - Guidelines for Inpatient Preauthorization

Coventry Health Care must be informed prior to a member’s nonemergent hospitalization. Before

calling Coventry Health Care, please be prepared to provide us with the information contained in

the list below which will reveal the severity of illness and/or intensity of service. This information

will be used to determine whether or not the care meets Coventry Health Care’s criteria for

coverage as an inpatient stay.

General information such as the member’s name and ID number, the admitting provider, the

Primary Care Provider, diagnosis, and procedure code.

Severity of illness including a history of the current illness and the diagnosis (es),

description of symptoms (frequency/severity), physical findings and outpatient treatment

attempted (if applicable). Coventry Health Care may request lab results (if applicable), x-

ray findings, and other significant medical information.

Plan of treatment such as the medications (IV, IM), invasive procedures, tests monitoring/

observation, consultation (If needed during admission, has it been scheduled?), other

services (e.g., respiratory treatments, therapies, wound care), activity level (if relevant to

treatment plan), and diet (if relevant).

Anticipated duration of inpatient hospital stay.

Alternative treatment available such as IV therapy, skilled nursing, and physical therapy.

Hospitalization and the continued stay can be preauthorized only when the severity of the

member’s illness and/or the intensity of the required services meet the established criteria for acute

inpatient care. Coventry Health Care Concurrent Review Coordinators are available to work with

the provider and the hospital staff to coordinate the care a member may need following discharge

from the hospital. Concurrent review is performed after the initial preauthorization and while the

member is still inpatient. If the Concurrent Review Coordinator needs information in addition to

that in the member’s chart, he or she may contact your office. If the member does not appear to

meet or continue to meet medical criteria for an inpatient stay, the Concurrent Review coordinator

will discuss alternative care that may be covered. The medical director will be involved in

Please be aware of the services that

require preauthorization.

18

the final decision when a coverage denial appears necessary. The hospital and/ or attending

physician and the member will be notified if medical criteria is not met, and benefits are no longer

available for coverage of additional inpatient days.

For HMO members, preauthorization to a nonparticipating provider for a nonemergent service is

approved only when medically necessary and when Coventry Health Care does not have a

participating provider who can provide the needed service. Coventry Health Care has the right to

determine where the covered services can be provided when a participating provider cannot provide

the service for in-network coverage. Only those visits made after approval is given will be covered.

Coventry Health Care must be notified of an emergency admission within 24 hours or by the end of

the next working day if the 24-hour deadline falls on a weekend or legal holiday. However, earlier

notification greatly facilitates the utilization review process and allows Coventry Health Care to

determine during the stay whether or not medical criteria for coverage is met.

If you are unsure regarding the necessity for preauthorization, please call Health Services at

888.348.2966.

For weekend or after-hours admissions, you can call Health Services on the next working day at

888.348.2966 or fax to 888-247-4791.

3.3 -Definition of Preauthorization Types

Inpatient

Approval of coverage of an inpatient stay will be contingent upon each day meeting medical

necessity criteria. Inpatient stays require preauthorization.

Outpatient

A procedure (for example, vasectomy) or a service/test (for example, cystogram) that requires less

than six (6) hours of post-procedure observation is considered outpatient. The requirement for

preauthorization depends upon the type of procedure or service rendered. Please call Customer

Service or Health Services to determine if preauthorization is required. If the observation period

extends beyond six hours, contact Health Services for preauthorization (See below for definition for

Observation).

Observation

Observation is defined as an admission to an acute care hospital where the length of stay is greater

than six (6) hours and up to 48 hours. Observation does not include an admission to an intensive

care unit, an extended stay in the Emergency Department, or routine observation following an

outpatient procedure, service, or that is less than six (6) hours. Observation stays require

preauthorization.

3.4 - Emergency Room (ER) Visits

Preauthorization is NOT required for a member to be treated for an emergency condition; however,

patients are instructed to contact their Primary Care Provider for medical advice prior to seeking

care, if possible. Follow-up visits to the emergency room are not covered under most

19

circumstances. If you take a call from a member after hours and advise them to go to the ER, please

contact Health Services at 888.348.2966 on the next working day to inform us of your action.

3.5 -Maternity Notification Forms

The Maternity Notification Form can be found as Attachment B. Use of the Maternity Notification

Form is recommended as it assists in determining potential high-risk cases. Please notify Coventry

Health Care of any potential high risk maternity cases after the initial visit confirming the

pregnancy. Notifications should be faxed to Health Services at 866.373.0274. You may

also utilize www.directprovider.com to complete and submit the Maternity Notification Form.

When using the form, please complete all pertinent information. A copy should be kept in the

member’s file for your records. If you need additional Maternity Notification Forms, you can print

the form from our website at www.chcwv.com » Providers » Document Library. You also may

contact your Provider Relations Representative.

For pregnant individuals seeking non-maternity care, preauthorization should be obtained by

calling Health Services at 888.348.2966. The preauthorization number will be given to the member

and/ or specialty care office verbally. An approval letter will also be mailed to the member.

3.6 - Preauthorization for Out-of-Network Services to Be Considered as In-Network

For HMO members and certain self-funded plans that do not have out-of network benefits,

Coventry Health Care will preauthorize services rendered by

nonparticipating providers or facilities only when the member’s medical

needs require specialized or unique services which Coventry Health Care

considers unavailable within the existing network. For POS, PPO

members, and certain self-funded plans that do have out-of-network

benefits, Coventry Health Care will preauthorize as in-network, certain

services rendered by nonparticipating providers or facilities only when the

member’s medical needs require specialized or unique services which Coventry Health Care

considers unavailable within the existing network. Retroactive requests for consideration at the In-

Network benefit level will not be considered.

While final treatment decisions remain the responsibility of the provider and member, when

discussing treatment options with your patients, your cooperation in fully explaining this process is

appreciated.

Coventry Health Care must be notified via phone, fax or www.directprovider.com and

preauthorization obtained before care is rendered, except in emergency cases. Please allow 3

working days after all requested information has been received, for the evaluation of the

preauthorization request.

You and the member will be notified of the approval or denial of care at the in-network level of

benefits. Preauthorization for out-of-network services to be considered at the in-network level of

benefits will be given for a designated level of service for a specified length of time. Open-ended

Preauthorization is

not required for a

member to be treated

for an emergency

condition.

20

preauthorizations will not be granted. Subsequent care by the out-of-network provider will require a

separate, preauthorization for coverage at the in-network level of benefits.

If an HMO member sees a nonparticipating provider or is admitted to a nonparticipating hospital in

an emergency situation, Coventry Health Care will work with the attending provider to have the

member’s care transferred to participating providers as soon as medically possible.

In the course of an out-of-network evaluation, any services, tests, or procedures which can be

provided within the network must be performed by participating providers in order to obtain

coverage as described above. The referring provider is asked to monitor the care of out-of-network

providers and assist in case management by helping coordinate lab, x-ray, etc., through

participating facilities.

3.7 - OB/GYN Treatment

Most of our benefit plans which require the selection of a Primary

Care Provider also allow female members to choose an OB/GYN

provider in addition to her Primary Care Provider. Female members,

age 13 or older, whether or not they are in a plan where they choose an OB/GYN provider may

receive obstetrical/gynecological care directly from a participating provider. The specialist copay

will apply for female members to see their designated OB/GYN provider. OB/GYNs performing

annual exams should bill with the appropriate preventive medicine CPT code.

3.8 - Injectables

All therapeutic office-based injectables covered under the member’s medical benefit require

preauthorization before the service is rendered. You may call Health Services at 888.348.2966 to

obtain preauthorization for these types of injectables. Injectables are reimbursed according to

national rates negotiated by Coventry Health Care with various national vendors. These rates are

updated quarterly and notification is done through the provider newsletter. Examples of injectables

covered under the member’s medical benefit include (but are not limited to):

Remicade

Aranesp

Neulasta

Natalizumab Q4079

Unlisted or miscellaneous drug codes such as (but are not limited to) J9999, J3490, J3590

When self-administered injectable drugs are covered by Coventry Health Care, they may be

covered under the member’s pharmacy benefit. These drugs require preauthorization before the

service is rendered. You may call Pharmacy Services at 877.215.4100 to obtain preauthorization for

these types of injectables. These self-administered injectables are obtained through Coventry

Health Care contracted providers. Pharmacy injectable forms and criteria are available on our

website at www.chcwv.com » Providers » Prescription Documents.

Female members age

13 or older can choose

an OB/ GYN in

addition to a PCP.

21

Examples of self-administered injectable drugs covered under the member’s pharmacy benefit

include (but are not limited to):

Avonex

Procrit

Neupogen

Enbrel

Insulin does not require preauthorization.

Certain self-funded benefit plans where Coventry Health Care administers the benefits may require

that self-administered injectables be obtained through the members pharmacy benefit.

Communication will occur with providers notifying them of these certain plans.

3.9 - Advanced Technologies

Please be advised of the following guidelines for these specific advanced technologies:

Robotics: Reimbursement for charges related to Robotics assistance during surgery will be

based solely on the base standard procedure. There will be no additional reimbursement for

the use of robotics. Members shall not be held responsible.

When a claim is submitted for 3-D Imaging Coventry Health Care does not issue additional

reimbursement for the Advanced Technology rendering component. Such component is

incidental and reimbursement will be based solely on the base standard imaging

study/procedure. Members shall not be held responsible.

3.10 - Utilization Management (UM) Decisions

UM decision making is based on appropriateness of care, service, and existence of coverage. We do

not specifically reward practitioners or other individuals for issuing denials. Financial incentives

for UM decisions do not encourage decisions that result in under-utilization.

22

4 Reimbursement & Claims

4.1 - Compensation

Physician

Allowances are set by CPT code. Please include any applicable modifiers to ensure proper

payment. Payment may be reduced depending on the modifier billed. Physicians must submit

claims Coventry Health Care for covered services rendered to Coventry Health Care members in

order to receive reimbursement. Claims submitted to Coventry Health Care should include your

usual fee for services rendered by CPT code. Proper coding remains the responsibility of the billing

provider. Fees billed for services provided to Coventry Health Care members should be the same as

those charged to non-Coventry Health Care members for the same services.

Unless directed otherwise by Coventry Health Care, claims should be billed in accordance with the

billing instructions applicable to Medicare and industry standards.

Facility

Allowances are set by certain methodologies dictated by contract. Examples of these are per diems,

case rates, DRGs, etc. Payment may be reduced depending on the modifier billed. Facilities must

submit claims to Coventry Health Care for covered services rendered to Coventry Health Care

members in order to receive reimbursement. Claims submitted to Coventry Health Care should

include your usual fee for services rendered. Proper coding remains the responsibility of the billing

provider. Fees billed for services provided to Coventry Health Care members should be the same as

those charged to non-Coventry Health Care members for the same services. Unless directed

otherwise by Coventry Health Care, claims should be billed in accordance with the billing

instructions applicable to Medicare and industry standards.

Ancillaries

Allowances are set by certain methodologies dictated by contract. Examples of these are per diems,

case rates, fee for service, etc. Payment may be reduced depending on the modifier billed.

Ancillaries must submit claims to Coventry Health Care for covered services rendered to Coventry

Health Care members in order to receive reimbursement. Claims submitted to Coventry Health

Care should include your usual fee for services rendered. Proper coding remains the responsibility

of the billing provider. Fees billed for services provided to Coventry Health Care members should

be the same as those charged to non-Coventry Health Care members for the same services. Unless

directed otherwise by Coventry Health Care, claims should be billed in accordance with the billing

instructions applicable to Medicare and industry standards.

4.2 - Immunizations and Injectables

Coventry Health Care reimburses immunizations and injectables based on a list of rates developed

by Coventry and adopted by Coventry Health Care. These rates are updated quarterly and will be

given to providers through the newsletter.

23

Please reference the Immunization Chart on our website at www. chcwv.com.

Rabies Vaccinations

Rabies Vaccinations are a covered benefit for Coventry Health Care members. A PCP or specialist

who elects to provide this service in their office can contact Health Services to obtain the vaccine.

Health Services will order the vaccine from our preferred pharmacy vendor and it will be sent

directly to the provider’s office. There is NO COST to the provider for the vaccine and

the provider should not bill Coventry Health Care for the vaccine. Effective 8/1/2010 members can

receive the Rabies vaccine at the pharmacy by a vaccinating pharmacist. The member is required to

have a prescription from their Doctor to present at the pharmacy. The pharmacy vendor will bill

Coventry Health Care directly. Members may also be directed to the nearest participating hospital

emergency room or the local Health Department for the vaccine. Claims will pay in accordance to

the member’s benefit and the corresponding place and/or provider of service.

4.3 - Claims Filing Procedures

Physician

Submit charges on a CMS 1500 Health Insurance Claim form (or UB92 or UB04 if applicable) or

its successor directly to the Claims department.

Use a separate claim form for each provider.

Use a separate claim form for each member.

Please submit one claim for all services provided in the same day and same place of service.

Coventry Health Care reserves the right to retract claims paid where split billing (using two

claim forms for the same date of service) is used.

Submit original form to Coventry Health Care; keep a copy for your files.

Submit a complete and correct claim form.

When applicable, include other insurance information on the claim form. When Coventry

Health Care is secondary, please attach the primary carrier’s Explanation of Benefits (EOB)

to the claim (if filing electronically, please see Electronic Claims Submission Process).

Include all pertinent diagnosis information.

Include the complete provider number, National Provider Identifier (NPI), and member

number including the two-digit suffix.

When applicable, include the valid ICD-9 diagnosis code up to the fourth or fifth digit.

Please note any special circumstances, and/or include office notes with claims submitted for

services that require special consideration.

Remember to include:

Preauthorization number for hospitalization, outpatient hospital services, and other services

or procedures requiring preauthorization as stated in this manual.

CPT Procedure Codes - unlisted codes must be accompanied by description of service, test,

or procedure before payment will be considered.

Valid Place of Service code.

24

Facility

Submit charges on a UB92 or UB04 claim form or its successor directly to the Claims department.


Please submit one claim for all services provided in the same day/ same admission and

same place of service. Coventry Health Care reserves the right to retract claims paid where

split billing (using two claim forms for the same date of service) is used.

Submit original form to Coventry Health Care; keep a copy for

your files.


When applicable, include other insurance information on the claim

form.

When Coventry Health Care is secondary, please attach the

primary carrier’s Explanation of Benefits (EOB) to the claim.

Include all pertinent diagnosis information.

Include the complete provider number, National Provider Identifier (NPI), and member

number including the two-digit suffix.

Include the valid ICD-9 diagnosis code up to the fourth or fifth digit.

Please note any special circumstances, and/or include medical records with claims

submitted for services that require special consideration.

Remember to include:

Preauthorization number for hospitalization, outpatient hospital services, and other services

or procedures requiring preauthorization as stated in this manual.

CPT Procedure Codes - unlisted codes must be accompanied by description of service, test,

or procedure before payment will be considered.

ICD-9-CM Diagnosis Code, (four or more digits must be used).

Valid Place of Service code.

Submission of Claims for Coventry Health Care Commercial and Coventry Health Care Medicaid

should be sent to:

Coventry Health Care

Attn: Claims Department

P.O. Box 7373

London, KY 40742-7373

Customer Service

can be reached

during normal

business hours by

calling 800-348-

2922.

Information on electronic claims

submission is available on our

website: www.chcwv.com.

25

4.4 - Electronic Claims

If submitting electronically, the Commercial payer ID number is 25133 and the Medicaid number is

25140. The regulations promulgated pursuant to the Health Insurance Portability and

Accountability Act (HIPAA) requires that Coventry Health Care comply with Electronic Data

Interchange (EDI) standards for health care as established by the Secretary of Health and Human

Services.

In support of HIPAA and its goal of Administrative Simplification, Coventry Health Care

encourages physicians and medical providers to submit claims electronically. Electronic claims

submission can have significant, positive impact on the productivity and cash flow of your practice

because:

EDI reduces the paperwork and costs associated with printing and mailing paper claims.

EDI reduces the time it normally takes for Coventry Health Care to receive a claim by

eliminating mailing time.

EDI reduces the delays due to incorrect claim information by returning these errors directly

to you through the same electronic channel. These claims can be corrected and re-

submitted.

Electronic claim submission improves claim accuracy by decreasing the chance for

transcription errors and missing/incorrect data.

EDI claims can be tracked and monitored through claim status reports received

electronically.

Electronic claim submission to Coventry Health Care is easy to establish. Providers can submit

directly to Emdeon. Electronic claim submissions will be routed through Emdeon who will review

and validate the claims for HIPAA compliance and forward them directly to Coventry Health Care.

Please contact Emdeon directly and Emdeon can provide the electronic requirements and setup

instructions. Providers should call 800.215.4730 for information on direct submission to Emdeon or

for problems with EDI filing.

EDI claim submitters should review Coventry Health Care’s EDI Exclusion List and Electronic

Claim Submission Requirements. Coventry Health Care uses the ANSI X12N 837 V4010 or V5010

and V4010A1 or V5010A1 implementation guides that have been established as the standard claim

transactions for HIPAA. The official implementation guides for claim transactions are available

electronically from the Washington Publishing Company website: www.wpc-edi.com.

Coventry Health Care encourages and recommends regular review of all EDI Acknowledgement

and Reject Reports returned to you to ensure timely filing of resubmissions or claim adjustment

requests when necessary.

For more information on electronic claims submission, please visit our website at www.chcwv.com

» Providers » Claims Information.

26

4.5 Request for Notes/Invoices

Certain procedures may require the submission of additional documentation before payment is

made. In cases of this nature, the claim will be closed, and we will request notes or an invoice.

Providers must then submit notes or an invoice in order for the claim to be reviewed. These must be

submitted within 1) 90 days of the date of the request or, 2) the original timely filing period

applicable to the claim as described in Section 4.7 or the claim will be denied for timely filing.

4.6 - Timely Filing Policy

Coventry Health Care strictly enforces its timely filing clause in the provider contracts. Claims

must be filed within the timely filing period specified in the provider contract.

COB claims in which Coventry Health Care is the secondary carrier should be filed with the

Explanation of Benefits (EOB) within the timely filing period specified in the provider contract.

Global charges must be submitted within the timely filing period specified in the provider contract

of the date of the primary service (i.e., charges for pregnancy should be submitted within one year

of the delivery). Any charges outside of the global charges must be billed within the timely filing

period specified in the provider contract.

Proof of Timely Filing

Providers must submit proof of timely filing within 90 days after the timely filing limit or the claim

will remain denied. Providers requesting reconsideration of claims denied for timely filing should

submit an acceptable form proving timely filing to the Coventry Health Care adjustment request

address. Some acceptable forms of proof of timely filing are:

A copy of the EDI report from Emdeon showing that the electronic

carrier accepted the claim within the timely filing limits.

If the claim was submitted to another insurance carrier, the other carriers EOB must be

submitted. If there is no EOB, supporting documentation must include claims information

from the other insurance carrier.

Substantiated documentation of follow up contacts with the Customer Service

Organization’s (CSO) representatives regarding the claim submission. This documentation

should include the dates of all contacts within the timely filing limit, and the CSO

representative’s name.

Coventry Health Care will make every effort to work with a physician’s office having a billing

problem. We suggest you contact Customer Service at 800.348.2922 as soon as possible should this

be a concern or problem.

Please also refer to Section 10 for Post-Service Claim Review

27

4.7 -Adjustment Requests

When filing an adjustment or a corrected claim, please use the address listed below. Adjustment

requests must be received by Coventry Health Care within the timeframe specified in the contract.

Information and Adjustments

A Claim Inquiry/Adjustment Request Form should be used whenever resubmitting a claim. The

form allows you to put in writing your inquiry about a claim. Attaching this form to resubmitted

claims helps us process and/ or review requests in a timely manner. Please see Attachment C for a

Claim Inquiry/Adjustment Request Form.

Corrected Claims

All corrected claims should be marked “Corrected Claim.” When submitting a Corrected Claim on

a UB92 or UB04 form, the claim should be submitted using a billing type that ends in 5.

Handwritten changes on your claim form will only be accepted if written in ink, initialed, dated and

must be accompanied by a Claim/Inquiry Adjustment Request Form. In instances where a provider

wishes to appeal, the provider should follow the process defined in

Section 10 of this manual.

To send your corrected or replacement claims to Coventry Health Care electronically, use Claim

Frequency Type Code (CLM05-3) value equal to “7” to indicate a corrected or replacement claim

for professional claims. For institutional claims use the loop and segment CLM05 value equal to

“7” to indicate a corrected or replacement claim submission to Coventry Health Care, please use

the following links from your health plan’s website: Provider/EDI Documents/EDI Claims.

Late Charges

When submitting a claim for additional or late charges, you should submit the entire claim again

with the additional charges included and use a billing type that ends in 7. Any submission of claims

of this nature must occur within the timeframe specified in your contract. These claims should be

sent to the address below.

All requests listed in this section should be mailed to:


Attn: Adjustments

P.O. Box 7373

London, KY 40742-7373

4.8 - Remittance

Providers may receive remittances electronically. For information and requirements, please contact

your Provider Relations Representative. It is your responsibility to verify remittances. If the

provider wishes to dispute a payment, the provider must contact Coventry Health Care within the

time period specified in your contract. If the provider does not notify Coventry Health Care within

that time period, payment is considered final.

28

Schedule of Payment

Checks are scheduled to run on a weekly basis. Checks are usually received by provider offices

within ten (10) working days after a check run.

Method of Payment

For participating providers, payments are made to the provider. The check sum includes payment

for all services processed for that practice during the payment cycle.

Should a remittance include denied charges or payments requiring adjustment, an explanation of

the denial or adjustment code will be given on the remit.

Out-of-Pocket Maximums

Most copayments, deductibles, and coinsurance are applied to the member’s benefit year out-of-

pocket maximum. The actual amount of the maximum varies among benefit plans. When a member

meets their out-of-pocket maximum, they are instructed to present their letter from Coventry Health

Care stating that they have reached the out-of-pocket maximum on all subsequent provider visits

for the remainder of the benefit year.

4.9 - Status of Claims

You may call the Customer Service Department to check the status of claims. Customer Service

representatives are available to answer any claim inquiries Monday through Friday between 8:30

a.m. and 5:00 p.m. The number is 888.348.2922. You can also check the status of claims online by

using www. directprovider.com or Emdeon, including multiple claim submissions at one time. If

you do not have access to www.directprovider.com or Emdeon and you need to verify the status of

numerous claims, please fax your inquiries to 724.778.4299 (Commercial) and 302.283.6586

(Medicaid), Attention: Claims.

Coventry Health Care recommends that claims status inquiries not be made unless it has been at

least 45 days since the date of submission.

It is the responsibility of the provider to maintain an updated record of their accounts receivable.

Coventry Health Care recommends that you check your accounts receivable monthly to determine

if there are any outstanding claims. In the event that there are, the provider should contact

Customer Service or access www.directprovider.com to determine if the claim was received.

Coventry Health Care will not be responsible for claims that were never received and the

date of service exceeds the timely filing limit.

For providers who submit claims electronically, reports are provided to the provider after each

submission detailing the claims that were sent and received. It is the provider’s responsibility to

track this list to ensure that claims were received by Coventry Health Care. Coventry Health Care

will not be responsible for claims that were never received when the date of service

exceeds the timely filing limit and an EDI report showing acceptance of the claim is not provided.

29

4.10 - Coordination of Benefits (COB)

The coordination of benefits (“COB”) provision applies when a member has health care coverage

under more than one payer.

Until a coordination of benefits determination is made, the member shall not be held liable for the

cost of covered services provided. Coventry Health Care will close any claim where other

insurance is confirmed. Coventry Health Care will re-open claims for payment once all required

information is received.

Coordination of Benefits when Coventry Health Care is Secondary

1. If the primary insurance requires an authorization and authorization is obtained, and the

services is covered by the primary insurance and CL, we will honor the EOB and coordinate

benefits.

2. If the primary insurance does not require an authorization, and the service is a covered

service by the primary insurance and by CL we will honor the EOB and coordinate benefits.

3. If we receive an EOB with a covered service denied for no authorization and this service

requires preauthorization with CL, that authorization will be required to coordinate the

claim.

4. If we receive an EOB with a covered service denied for no authorization, and the service

does not require an authorization for CL, we will process as primary.

5. If we receive an EOB for non-covered services from the primary payer, and it is a covered

service that requires an authorization from CL, we will only pay the claims with a CL

authorization in place.

6. If we receive an EOB for non-covered services from the primary insurance, and it is non-

covered with CL, it will be denied.

7. If we receive an EOB for an HMO member and the provider is Non-Participating,

authorization will be required even if CL is secondary.

Scenario

Number

Preauthorization

Required

Preauthorization

Obtained

Covered

Service

Coordinate

Benefits

Primary Carrier 1 Y Y Y

CL Secondary N Y Y

Primary Carrier 2 N Y

CL Secondary Y N Y Y

Primary Carrier 3 Y N Y

CL Secondary Y N Y N

Primary Carrier 4 Y N Y

CL Secondary N Y Y

Primary Carrier 5 N

CL Secondary Y Y Y Y

Primary Carrier 6 N

CL Secondary N N

30

Coordination of Benefits with Commercial Carriers

The charts on the following pages show when Commercial Carriers are primary or secondary.

The provider is prohibited from balance billing as long as:

(1) The combined payment from Coventry Health Care and the primary payer equals Coventry

Health Care’s allowed amount under our provider contract, or

(2) The member had no liability after the primary payer paid, or if the member had liability,

Coventry Health Care paid the member responsibility.

If our allowed amount (amount Coventry Health Care would have paid as the primary carrier) is

LESS THAN the other carrier’s paid amount, Coventry Health Care will pay nothing. If Coventry

Health Care’s allowed amount is more than the primary carrier’s paid amount, Coventry Health

Care will pay the difference from our allowed amount and the other carrier’s paid amount for

covered services.

Allowed Amount that a participating provider has agreed to accept as payment in full, or in the

absence of a fee schedule, the default amount that Coventry Health Care will base payment on. It is

this amount that Coventry Health Care would pay before taking out any member responsibility.

This is the same calculation used when Coventry Health Care is the primary carrier.

Coordination of Benefits with Medicare

The charts on the following pages show when Medicare is primary or secondary. Coventry Health

Care will always use Medicare’s allowable charges for processing.

When a Member is covered by 2

group plans, and

Then Primary

If one plan does not contain a COB

provision

The plan without COB provision is

The plan with COB provision is

The Member is the subscriber under one

plan and dependent under the other

The plan covering the Member as the

subscriber is

The plan covering the person as a

dependent is

The Member is the subscriber under a

retiree plan and dependent under an

active plan

The plan covering the Member as the

subscriber is

The plan covering the person as a

dependent is

The Member is a subscriber in two active

group plans

The plan that has been in effect longer is

The plan that has been in effect the shorter

amount of time is

The Member is a subscriber under both

an active employee plan and a retiree

plan

The plan which the subscriber is an active

employee is

The retiree plan is

The Member is an active employee on

one plan and enrolled as a COBRA

The plan which the subscriber is an active

employee is

31

subscriber

The COBRA plan is

The Member is covered as a dependent

child under both plans

The plan of the parent whose birthday

occurs earlier in the calendar year (known

as the birthday rule) is The plan of the

parent whose birthday is later in the

calendar year is

NOTE: If the parents have the same

birthday (MM/DD), the plan that has

been in effect longer is primary


child under both a group plan and

Medicaid

The Group Plan is

Medicaid is


child and coverage is specified in a court

decree

The plan of the parent primarily

responsible for health coverage under the

court decree is

The plan of the other parent is


child and coverage is not specified in a

court decree

The custodial parent or spouse of custodial

parent’s plan is

The non-custodial parent’s plan is


child and the parents share joint custody

The plan of the parent whose birthday

occurs earlier in the calendar year is

The plan of the parent whose birthday is

later in the calendar year is

NOTE: If the parents have the same

birthday (MM/DD), the plan that has

been in effect longer is primary

32

Benefits with Medicare for Members 65 and Over:

Member is covered by Coventry is Medicare

a group plan, and Then Primary is Primary Who is qualified for coverage due solely to

ESRD

For the first 30 months after

Medicare becomes effective

Upon completion of the 30

months after Medicare becomes

effective

Subscriber who is an active If the employer employs 100

employees or more

If the employer employs fewer

than 100 employees

Spouse or dependent child

full-time Subscriber

If the employer employs 100

employees or more

If the employer employs fewer

than 100 employees

Who becomes qualified for overage due to

ESRD after enrolled in Medicare due to

If Medicare had been secondary

to the group plan before ESRD

entitlement, then for the first 30

months following ESRD

entitlement

If Medicare had been primary to

the group plan before ESRD

entitlement

Subscriber not actively covered by

the employer group

Member is covered by a group plan, and Then Coventry

is Primary

Medicare is

Primary age 65 or over, and is the Subscriber’s spouse,

and is actively working for Group

If the employer group has less

than 20 employees

If the employer group has 20 or

more employees

becomes qualified for coverage due to ESRD

after enrolled in Medicare due to

If Medicare had been secondary

to the group plan before ESRD

entitlement, then for the first 30

months following ESRD

entitlement

If Medicare had been primary to

the group plan before ESRD

entitlement

Age 65 or over, is

The Subscriber’s spouse and by working for the

group

33

4.11 – Systems Affecting Preauthorization and Claims Payment

The systems noted below contain licensed or copyrighted material. Due to the licensing agreements

and copyright law, Coventry Health Care cannot distribute the detailed logarithms, policies, or rules

used in these systems to its providers. Coventry Health Care shall reply to any provider’s specific

inquiry about a rule or policy affecting the provider within 10 working days of receipt of a written

request. Requests should involve specifics of the preauthorization or claims payment issue for

which information is needed. To ensure proper handling of requests for system or policy

information, please send requests to the address below and reference the ten-day response time

requirement.

Coventry Health Care Provider Relations Department

500 Virginia Street East, Suite 400

Charleston, WV 25301

Utilization Management Guidelines

Coventry Health Care utilizes clinical criteria to determine medical necessity of inpatient stays,

outpatient surgeries, home health, DME, outpatient therapies, and diagnostic services that require

preauthorization. The criteria consist of objective, measurable, clinical indicators.

Also included are parameters of patient stability indicating readiness for discharge from the

hospital and options for alternative settings. It addresses appropriateness of admission to and

continued stay in and discharge from general and special units within the hospital. Coventry Health

Care will provide the medical criteria used in the decision making process with a written, faxed, or

telephone request by the provider. Criteria may be reviewed on site at the Coventry Health Care

office, read to the provider over the phone, or viewed on www.directprovider.com.

Health Services will provide the information within ten (10) days of the request. A provider may

call Customer Service or Preauthorization department to initiate request.

Coventry Health Care supplements its policies with proprietary utilization management guidelines.

These guidelines are traditionally developed with the involvement of providers in the affected

specialty and often are formally approved by the Coventry Health Care Utilization Review

Committee before use.

Medically Necessary/Medical Necessity

Those services, supplies, equipment, and facilities charges that have been determined by Coventry

Health Care to be: (i) medically appropriate, which means that the expected health benefits (such

as, but not limited to, increased life expectancy, improved functional capacity, prevention of

complications, relief of pain) exceed the expected health risks by a sufficiently wide margin;

(ii) necessary to meet the basic health needs of the member as a minimum requirement; (iii)

rendered in the most cost-efficient manner and setting appropriate for the delivery of the health

service; (iv) consistent in type, frequency, and duration of treatment with scientifically-based

guidelines of national medical research, professional medical specialty organizations, or

governmental agencies that are accepted by Coventry Health Care; (v) consistent with the diagnosis

of the condition; (vi) required for reasons other than the comfort or convenience of the member or

his or her physician; and (vii) of demonstrated value based on clinical evidence reported by Peer

Reviewed Medical Literature and by generally recognized academic medical experts; this is, it is

34

not Experimental or Investigational or unproven. Coventry Health Care will provide the medical

criteria used in the decision making process with a written, faxed, or telephone request by the

provider. Criteria may be reviewed on site, read to the provider over the phone, or viewed on

www.directprovider.com. Health services will provide the information within ten (10) days of the

request. A provider may call Customer Service or Preauthorization Department to initiate request.

Preauthorization

Some services may be noncovered or only partially covered if they are not preauthorized through

the Coventry Health Care Health Services Department. You may contact the Health Services

Department at 888.348.2966.

4.12 - Subrogation/Recovery

Coventry Health Care, along with its affiliates, have contracted with third party vendors (Recovery

Vendor) to recover monies paid to providers that should not have been paid to such providers

(Ineligible Payments). Ineligible Payments may occur for numerous reasons, including, but not

limited to, late notice to Coventry Health Care of an ineligible member; a Member failing to

provide correct coordination of benefits information to Coventry Health Care or its self-funded

clients; or a provider failing to disclose all information related to the service or item requested for

payment by Coventry Health Care. The recovery parameter is twelve (12) months from the last paid

date of the claim(s).

Coventry Health Care shall identify Ineligible Payments and litigation matters that are appropriate

to refer to the appropriate Vendors. A recovery letter is then generated requesting the overpayment

and the provider is given 30 days (unless otherwise specified in the provider contact) to refund the

overpayment. After 30 days, if the refund has not been received, the claim will be adjusted to

recover the overpayment.

Coventry Health Care, along with its affiliates, also has contracted with one or more third party

vendors (Subrogation Vendors) to supervise its clients’ interests in litigation with third parties that

may lead to a subrogation payment to these clients. (The Recovery Vendor and Subrogation vendor

are hereinafter collectively referred to as the Vendors and individually as a Vendor.)

35

If you believe you received a refund letter in error or have any pertinent information that may not

have been considered in making the determination, please contact our Customer Service

Department at 1-800-348-2922, Monday through Friday 8:00 a.m. to 5:00 p.m. EST.

All refunds should be mailed to:

Coventry Health Care Bank One

PO Box 714665

Columbus, Ohio 43271-4665

All Return Checks should be mailed to:


The Recovery Dept.

120 East Kensinger Dr.

Cranberry Twp, PA 16066

4.13 - Payment Policy Program

Coventry Health Care utilizes software packages to improve business processes. This software is

used in auditing pre-payment claims submitted to Coventry Health Care. The program aligns our

payment policies and claims adjudication system with nationally accepted coding standards and

guidelines of the Centers for Medicare and Medicaid Services (CMS) and the American Medical

Association (AMA). These software packages provide auditing capability for current claims

received as well as historical claims for the same patient, same date of service, and same provider.

The following are some of the edits utilized by these software packages:

Medical Visit

Duplicate

Pre-operative

Post-operative

Incidental

Mutual Exclusive

Assistant Surgeon

Re-bundling

New Visit

Multiple Surgical Reduction

Invalid modifier/procedural code combination

In addition to these software packages, Coventry Health Care supplements its claims policies with

proprietary claims payment guidelines. These guidelines are generally developed on a national

level by the medical management staff at Coventry’s corporate headquarters and then approved at

the local Coventry Health Care level prior to use. Examples of areas of care where proprietary

claims payment guidelines exist include, but are not limited to, spinal manipulation, payment of

supplies, and policies on the applicability of copayments.

36

Edit Description

Multiple Units

identifies claims with an excessive number of units submitted either on the

same line or on separate lines of the same claim. When used appropriately,

certain modifiers can override a multiple unit edits

Duplicates

logic detects where duplicate submissions of a service were submitted on

separate claims. The analytics examine codes that, by definition, cannot be

billed more than once on the same date of service, within a defined date

range, or over the lifetime of the patient.

CCI

The National Correct Coding Initiative is a compilation of CMS bundling

edits that are comprised of two categories: 1) comprehensive and

component procedures; and 2) mutually exclusive procedures.

Global Surgery-

E/M

CMS has defined specific time periods during which the Evaluation and

Management (E/M) services related to a surgical procedure, furnished by

the physician who performed the surgery, are to be included in the payment

of the surgical procedure code. This is referred to as the Global Surgical

Package. E/M services billed on the same day as the procedure or during the

defined global period for the procedure will be denied.

New Visit

The AMA and CPT-4 defines a new patient as one “who has not received

any professional services from the physician or another physician of the

same specialty who belongs to the same group practice within 3 years.” The

term “professional services” applies to any face-to-face visit with a

provider. This includes procedures as well as E/M visits.

Multiple Surgeon

The American College of Surgeons and CMS both evaluate the need for an

assistant surgeon, co-surgeons and team surgeons for all surgical

procedures, defining procedures for which an assistant surgeon, co-surgeon,

or team surgeon is not allowed and procedures for which an assistant

surgeon, co-surgeon, or team surgeon may be allowed.

Incidentals

CMS has established services and procedures that are considered incidental

to other services or procedures provided on the same date of service. These

are status B,P,T,N codes.

Lab NCD

CMS sets national coverage policy for diagnostic laboratory tests, and the

determination of medical necessity for those tests, through national

coverage determinations (NCDs). ConVergence Point evaluates the

diagnosis submitted and the testing performed to determine whether the

diagnosis codes supports the necessity of the test in accordance with the

CMS policy.

Lab Panels

If all of the component codes are submitted for a panel, ConVergence Point

will deny all of the component codes and replace them with the appropriate

panel code.

E/M

Correct coding of E/M services stipulates only one E/M code may be

reported per day for the same patient/provider. However, the 25 modifier

“significant separately identifiable evaluation and management service by

the same physician on the same day of the procedure or other service,” can

override an E/M edit where appropriate

Add-On

Add-on codes are designated in the CPT-4 book with a “+” symbol and

frequently contain descriptions such as “each additional” or “list separately

in addition to primary procedure.”

37

Multiple Procedure

Reduction

Multiple Procedure Reduction (MPR), that identifies when more

than one surgical or medical procedure is performed on the same patient on

the same day and ranks all eligible procedures based on the RVU

amount, billed amount, or allowed amount for each procedure.

Invalid Modifier to

Procedure

Correct coding based on AMA, CMS guidance to allow identified modifiers

with certain procedures.

Advanced

Technology

Coventry based policy that bundles Advanced Technology codes into

Radiological and Surgical procedures. Many of these bundling rules are

captured in CCI, and these CMS sourced CCI edits will fire first and have a

CCI defense. Coventry specific bundling rules will fire when there is no

existing CCI rule. These rules will be defended by a Per Payer Policy

defense.

Edit Description

Payment Policy Program Review

Payment Policy Program is an automated claim auditing system, used to ensure that claims are paid

correctly based on clinical patterns. It also checks for the use of inappropriate CPT codes,

modifiers, and for duplicate claims.

Payment Policy Program reviews do not follow the appeal process and cannot be appealed. To

request a Payment Policy Program review, please complete and mail the form that is attached as

Attachment C and include applicable documentation within the time period specified in your

contract.

Requests should be sent to:

Adjustments Department

Attn: MCRN Review for Payment Policy

P.O. Box 7373

London, KY 40742-7373

*There is not a fax option for a Payment Policy Program review request.

To check on the status of a Payment Policy Program review request please contact Customer

Service at 888.348.2922. A Medical Review Nurse (MCRN) will review the documentation and

consult with the Medical Director to reach a decision. Notice of the decision is provided on the

remittance advice. Decisions are considered to be final and are not subject to appeal.

4.14 - Provider Reimbursement Fee Schedule

Coventry Health Care providers are generally notified of any change in fees at least 60 days in

advance of any change. Please see Attachment D to request CPT specific fee information. Coventry

Health Care shall reply to written requests from providers for specific allowances within 30

working days of receipt. Requests should be limited to frequently billed services offered by the

provider. A form to request specific fees is attached as Attachment D.

38


Certain services and supplies are noncovered and/or specifically excluded by Coventry Health

Care. Different Coventry Health Care products may have a different list of exclusions. The most

common exclusions for the fully insured products are listed at the end of this section. This list may

be reduced or expanded for self-funded groups. The Medicaid product has exclusions involving

specific state regulations. In addition to those items specifically listed as a noncovered service in

the member’s Evidence of Coverage, Certificate of Insurance, or Plan Documents, any service

which is not medically necessary will be considered noncovered.

Benefits are described in detail in the member’s Evidence of Coverage, Certificate of Insurance, or

Plan Documents which each subscriber receives at the time of enrollment. Covered benefits and the

member’s payment responsibility may vary among employer groups. Members are advised that

their Evidence of Coverage, Certificate of Insurance, or Plan Documents, the member website and

the Customer Service Department should be their sources of information regarding coverage status.

If you have questions about the coverage for a certain service, please call the Customer Service

Department number located on the back of the member’s ID card. Be sure to have the member’s ID

number so you can get accurate information.

If patients come to you with their benefit questions, please instruct them to call the Customer

Service Department number located on the back of their ID card.

Fully Insured Non-Covered Services

Coventry Health Care does not cover (i) any service or supply that is not medically necessary; (ii)

any service or supply that is not listed as a covered service; or (iii) any service or supply that is a

direct result of receiving a non-covered service. In addition the following services are specifically

excluded:

Administrative Examinations/Immunizations: examinations or immunizations for employment,

travel, school, camp, sports, licensing, insurance, adoption, marriage or those ordered by a third

party.

Administrative Services: charges made to Coventry Health Care members by providers for failure

to appropriately cancel a scheduled appointment, telephone calls, completion of forms, transfer of

records, copying of medical records or generation of correspondence. Annual or monthly

administrative fees.

Alternative Medicine: services or supplies related to alternative or complementary medicine.

Services in this category may include, but are not limited to: hypnotherapy; acupuncture; sleep

therapy; behavior training; recreational therapy (dance, arts, crafts, aquatic, gambling and nature

therapy); hair analysis; holistic medicine; homeopathy; aroma therapy; massage therapy; herbal,

vitamin, or dietary products or therapies.

39

Behavioral Health and Substance Abuse:

Long term behavioral health care

Residential Treatment

Psychiatric evaluation or therapy when related to judicial or administrative proceedings or

orders, when employer requested, or when required for school

Educational testing or psychological testing, unless part of a treatment program for covered

services

Marriage or relationship counseling; vocational or employment counseling

Treatment of mental retardation and learning disabilities are not covered under behavioral

health and substance abuse benefits

Any other services listed in the member’s Evidence of Coverage, Certificate of Insurance,

or Plan Documents as noncovered services that could be considered Behavioral Health

services.

Blood drawing, preparation and storage of umbilical cord blood.

Braces and supports needed for athletic participation or for employment.

Charges which are in excess of any benefit limitations, or benefit maximums (e.g., number of days,

etc.)

Contraceptive (birth control): oral contraceptives unless the employer has elected a Prescription

Drug Rider.

Cosmetic treatment and surgery that is a service performed mainly to improve a member’s

appearance or for psychological benefits.

Custodial care, including inpatient or outpatient custodial care, nursing home care, respite care,

rest cures, domiciliary or convalescent care along with all related services.

Dental services or related expenses incurred as a result of the provision of dental services

including those performed in a hospital or outpatient care facility, including:

Dental or oral appliances or devices, including but not limited to, bite guards for teeth

grinding, dental implants, dentures, and oral appliances for snoring or sleep apnea

regardless of medical necessity.

Dental services or related expenses incurred as a result of the provision of dental services

including those performed in a hospital or outpatient care facility and treatment of diseases

of the teeth or.

Oral surgery which (1) is part of an orthodontic treatment program, (2) is required for

correction of an occlusal defect, or (3) is not specifically covered in the member’s Evidence

of Coverage, Certificate of Insurance, or Plan Documents.

Wisdom tooth extraction.

Orthognathic surgery

Anesthesia administered in conjunction with a dental procedure, unless it is specifically

covered in the member’s Evidence of Coverage, Certificate of Insurance, or Plan

Documents.

40

Donor: procedures involving a member’s organ and tissue donors, unless the recipient is a covered

Coventry Health Care member. Charges for tests and procedures related to donor searches.

Educational classes, programs, and support groups including, but not limited to, prenatal courses,

marital counseling, self-help training and other nonmedical self care and those dealing with

lifestyle changes.

Experimental/Investigational: medical, surgical or other health care procedures, services or

supplies are considered Experimental or Investigational if any of the following applies:

Any drug not approved for use by the Food and Drug Administration (FDA); any FDA

approved drug prescribed for an off-label use whose effectiveness is unproven based on

clinical evidence reported in peer-reviewed medical literature; or any drug that is classified

as an

Investigational New Drug (IND) by the FDA. As used herein, off-label prescribing means

prescribing prescription drugs for treatments other than those in the labeling approved by

the FDA.

Is under clinical investigation by health professionals or are undergoing clinical trials by

any governmental agency, including but not limited to, the Department of Health and

Human Services or the Food and Drug Administration.

Any health product or service that is subject to Institutional Review Board (IRB) review or

approval. Any health product or service that is the subject of a clinical trial that meets

criteria for Phase I, II or III as set forth by FDA regulations, except as specifically defined

in the “Clinical Trials” section of the member’s Evidence of Coverage, Certificate of

Insurance, or Plan Document.

Does not have required final federal regulatory approval for commercial distribution for the

specific indications and methods of use assessed or has not been approved by the CMS for

coverage by Medicare.

Any health product or service whose effectiveness is unproven based on clinical evidence

reported in Peer-Review Medical Literature.

Eye:

Routine vision exams, refractions for eyeglasses or contact lenses, and all services

associated with eyeglasses or contact lenses, unless the employer has elected a Vision

Rider.

Services for, or related to, eye surgery for the purpose of correcting refractive errors such as

radial keratotomy, LASIK, and other refractive and laser eye surgeries or vision correction

procedures; eye exercises.

Visual augmentation devices

Vision Therapy

Foot:

Services for weak, strained, flat, unstable, or unbalanced foot or for a metatarsalgia or

bunion. This does not apply to an open cutting operation.

Routine foot care including trimming of hyper keratotic lesions, calluses, and nails, except

for foot care for Coventry Health Care members who have Diabetes or Peripheral Vascular

Disease.

41

Foot orthotics, arch supports, corrective shoes, shoe inserts, heel elevations and fittings for

such devices, except for Coventry Health Care members with diabetes or peripheral

vascular disease.

Genetic Testing/Counseling: parental screening and related genetic counseling for genetic

predisposition either before or after conception, except for genetic testing for cystic fibrosis; pre-

implantation genetic testing.

Growth Hormone, unless the employer has elected a Prescription Drug Rider. Growth Hormone

for idiopathic short stature or for individuals over age eighteen (18) is not covered.

Hearing Aids: Hearing aids, ear plugs, cochlear implants and augmentative communicative devices

such as TTDY.

Infertility: egg or sperm donation; gamete intrafallopian transfer (GIFT) and zamete intrafallopian

tube transfer (ZIFT) procedures; cryopreservation and storage of sperm, eggs, embryos, supplies,

drug therapies and drugs, unless the employer has elected an Infertility Rider.

Medical Equipment, Appliances, Devices and Supplies. Coverage does not include benefits for

medical equipment appliances devices and supplies that have both a therapeutic and non-

therapeutic use. These include but are not limited to: air conditioners; batteries and batter chargers,

unless utilized as part of a covered service (e.g., insulin pumps, infusion pumps); bedliners; breast

pumps; canes; cervical collars; convenience items including, but not limited to, telephone,

television, guest meals and accommodations; corsets; cranial helmets; dehumidifiers; elastic or

leather braces or supports; exercise equipment; expenses incurred at a health spa, gym or similar

facility; filters; grab or tub bars; heating pads; home improvement items including, but not limited

to, escalators, elevators, ramps, stair glides or emergency alert equipment; humidifiers; mattress

covers; office chairs; office visits for the purpose of fitting a noncovered device or supply; over-

the-counter medical supplies which do not require a prescription including, but not limited to,

Band-Aids, antibiotic cream, Vita lights and magnetic mats; rental or purchase of TENS units;

splints; sun or heat lamps; take home medications; traction apparatus; tub benches; or whirlpool

baths.

Newborn: For fully insured HMO and POS members, hospital and physician charges for newborns

for the birth and inpatient stays or any subsequent services when the newborn is not enrolled in the

HMO or POS benefit plan within 31 days of birth.

Nutritional counseling and training except as stated in the member’s Evidence of Coverage,

Certificate of Insurance, or Plan Documents.

Nutritional formula or supplements, tube feeding and medical foods even if provided as the sole

source of nutrition.

Orthognathic Surgery.

Pregnancy: Implantation services for any reason.

42

Prescription drugs, including self-administered injectable, unless the employer has elected a

Prescription Drug Rider.

Private duty nursing.

Private room, unless medically necessary or if a semi-private room is not available.

Rehabilitation: long-term rehabilitation therapy.

Research: services for medical research.

Services or Supplies. Coverage does not include benefits for services or supplies if they are:

The result of injuries sustained during the commission of an illegal act

Services rendered as a result of a Temporary Detention Order

Service or supplies related to care for conditions which state or local law require be treated

in a public facility; care for military service connected disabilities for which the Coventry

Health Care member is legally entitled to services when facilities are reasonably available

to the Coventry Health Care member

Service and supplies for smoking cessation and nicotine addiction, unless required by state

or federal law.

Services received following the effective date of the termination of the Coventry Health

Care member’s coverage with Coventry Health Care.

Services rendered outside the scope of a participating or nonparticipating provider’s license,

rendered by a provider with the same legal residence as the member, or rendered by a

person who is a part of the member’s family including a spouse, brother, sister, parent, step-

parent, child or step-child.

Sexual Dysfunction, Sexual Aids or Sex Transformation: treatment for sexual dysfunction,

sexual aids, or sex transformation or the reversal thereof. This includes medical and behavioral

health services. Treatment of sexual dysfunction is limited to pharmacologic therapy under the

member’s Prescription Drug Rider.

Sterilization: the reversal of Sterilization.

Stockings: elastic hose, graduated compression (TED) hose, Jobst stockings unless covered for the

treatment of lymphedema.

Testicular Implants.

Therapy. The following types of rehabilitative therapy are not covered, although this list is not

meant to be exclusive:

Physical or Occupational Therapy for the purpose of behavior

modification or for improving performance in school or sports

Occupational Therapy for the purpose of treating sensory hypersensitivity

Sensory Integration Therapy

43

TMJ/TMD: Services or supplies for the treatment of Temporomandibular Joint Disease or

Disorder, unless purchased as a Rider by the employer Travel and Transportation other than

medically necessary transportation from one facility to another facility that has been preauthorized

by Coventry Health Care.

Weight Reduction: dietary supplements or programs for weight reduction. Medical or psychiatric

services, office visits, and associated charges for procedures primarily performed for the treatment

of obesity or weight reduction, including but not limited to, gastric bypasses, “mini” gastric

bypasses, stomach stapling, gastric balloons, jejunal bypasses, gastric banding, gastroplasty,

Biliopancreatic Diversion Duodenal Switch (BPD-DS), and bariatric specialist services. Some of

these services may be covered if the member’s employer chose a rider that covers the long term

treatment of morbid obesity. Please consult Customer Service for the specific services covered by

these riders.

Work-related injuries or illnesses, including those injuries that arise out of or in any way result

from an illness or injury that is work-related; provided the employer provides, or is required to

provide, workers’ compensation or similar type coverage for such services.

4.16 – Fraud and Abuse

As a West Virginia Medicaid managed care organization receiving state and federal funding for

payment of services provided to its members, Coventry Health Care is bound by all federal and/or

state anti-fraud and abuse laws and regulations. Therefore, participating Providers of Coventry

Health Care are subject to the same applicable federal and/or state anti-fraud and abuse laws and

regulations relating to this program.

Coventry Health Care is dedicated to eradicating fraud and abuse from its programs and cooperates

with the Bureau of Medical Services (BMS), the Medicaid Fraud Control Unit (MFCU), the Office

of the Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) to

administer effective fraud and abuse practices. Organizations, including providers, suffer

tremendous costs as a result of fraud and abuse, including higher premiums, higher costs to provide

care and compromising in quality of care. Providers are in the best position to detect characteristics

of fraud and abuse, which leads to the minimization of fraud loss.

Fraud is the intentional deception or misrepresentation made by a recipient or a provider with the

knowledge that the deception could result in some unauthorized benefit to the recipient or provider

or to some other person. Abuse is practices that are inconsistent with sound fiscal, business, or

medical practices, and result in unnecessary costs to the Medicaid program, or in reimbursement for

services that are not medically necessary or that fail to meet professionally recognized standards for

health care.

Some common examples of member fraud are:

Letting someone else use their insurance card

Using multiple physicians to acquire abusive drugs

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Some common examples of provider fraud are:

Billing for services not provided

Billing for more expensive services than actually provided

Federal Deficit Reduction Act of 2005

As required by the Deficit Reduction Act of 2005, it is Coventry’s policy to provide

detailed information to Coventry employees, vendors or other subcontractors, and other

persons acting on behalf of Coventry, about the Federal False Claims Act, administrative

remedies for false claims and statements established under 31 U.S.C. §§ 3801 et seq.,

and applicable State laws pertaining to civil or criminal penalties for false claims and

statements, and whistleblower protections under such laws (collectively, “False Claims

Acts”). The False Claims Acts assist the Federal and State Governments in preventing

and detecting fraud, waste and abuse in Federal health care programs, such as

Medicare and Medicaid. Please refer to the summary of the Federal False

Claims Act and West Virginia False Claims Act.

Special Investigation Unit (SIU)

By understanding fraud and abuse, we can work together to try and eliminate the effects of

fraudulent and abusive behaviors. Coventry Health Care, Inc. Coventry Health Care of West

Virginia’s parent company, has an SIU designed to monitor and investigate suspicious activities

within its health plans. It is staffed with clinical professionals, claims investigators, and data

analysts trained to detect fraudulent activities who work closely with state and federal law

enforcement agencies, other insurance companies and the provider community to detect and

prevent health care fraud and abuse.

If you believe you have information relating to health care fraud or abuse, please contact our SIU.

They will review the information provided and will maintain the highest level of confidentiality as

permitted by law. The SIU has a dedicated hotline for reporting fraud, waste, and abuse – call the

Hotline at (866) 806-7020. You will be prompted to leave a message. You may also report

suspected Fraud, Waste and Abuse by sending an e-mail to [email protected] or a fax to

(724) 778-6827.

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5 Pharmacy Benefits

Overview

Pharmacy coverage is optional and certain Groups may not have drug coverage through Coventry

Health Care. Please access www.directprovider.com or contact Customer Service to determine if a

member has drug coverage through Coventry Health Care.

The Prescription Drug List is based on the recommendations of the Pharmacy and Therapeutics

(P&T) Committee. The criteria used by this committee in formulating the Prescription Drug List

include, but are not limited to, the following:

Safety of the medication

Comparison to other currently approved medications in regard to the effectiveness of the

new medication

Cost compared to other currently approved medications

As a participating physician, you should prescribe medications that are preferred on the

Coventry Health Care Prescription Drug List if medically appropriate for your patient. Changes to

the Prescription Drug List are printed in the Connection newsletter after the P&T Committee

meetings. In addition, an updated Prescription Drug List is posted on Coventry Health Care’s

website www.chcwv.com.

There are two versions of the printed Prescription Drug List: an alphabetical listing and a tiered

version. In either case, Tier 1 includes preferred generic drugs and select OTC drugs. Tier 2

includes preferred brand drugs and Tier 3 includes non-preferred brand and generic medications.

Members with a Tier 4 benefit design have coverage for self-administered injectables on Tier 4

level. Self-administered injectables are listed in the Specialty Medications section of the

Prescription Drug List. When you prescribe drugs from preferred tiers 1 and 2, members will have

the lowest out of pocket costs. In some cases, dosage limitations and prior authorization

requirements apply for certain drugs.

Subject to the exclusions, deductibles, and copayments and coinsurance, benefits are available for

outpatient prescription drugs when the prescription is written by a provider licensed to prescribe

prescription drugs and when the member uses a participating pharmacy. The benefit described

includes a mail-order option, as well as an option to obtain up to a 90-day supply of maintenance

drugs at participating pharmacies. A copayment and/or coinsurance applies to each covered

prescription or refill. Most prescription drug benefits include one copayment and/or coinsurance for

preferred generic drugs, one copayment and/or coinsurance for preferred brand drugs, and one

copayment and/or coinsurance for non-preferred drugs. Some members may have a separate

coinsurance on Tier 4 for self-administered injectables.

Some plans have a prescription drug deductible; under those plans members must first meet their

prescription drug deductible before Coventry Health Care makes any payment for covered

prescription drugs. These deductibles apply to each benefit year.

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In order to receive this benefit, a member must present his or her Coventry Health Care Member ID

card at the time the prescription is filled. Prescriptions filled at participating pharmacies must be

submitted through the online claims adjudication process. The pharmacy will then charge the

member the lesser of: 1) the applicable copayment, coinsurance, or deductible, 2) the negotiated

contract amount for the drug, or 3) cost of the drug. Coventry Health Care will not reimburse

members who fail to follow this procedure.

Except as otherwise indicated, the quantity of a prescription dispensed by a retail pharmacy for

each prescription or refill is limited to the lesser of the following and will be considered a

prescribing unit:

The amount prescribed in the prescription order or prescription refill.

A 31-day supply as defined by Coventry Health Care.

The amount necessary to provide 31-day supply according to the maximum dosage

approved by the Food and Drug Administration for the indication for which the drug was

prescribed.

Depending on the form and packaging of the product, the following:

480 ml of oral liquids.

A sufficient amount to provide the prescribed dosage for four weeks (for drugs prescribed

based on the number of doses per week).

One inhaler or one commercially prepackaged set of doses (for inhaled drugs).

One commercially prepared or packaged tube of topical medications including salves,

creams, ointments, suppositories or patches.

The number of vials of one type or strength of insulin needed to provide the prescribed

dosage for 31 days.

One commercially prepackaged set of doses, (i.e. tablets, capsules).

Coverage for certain drugs, established by Coventry Health Care’s Pharmacy and Therapeutics

Committee, is subject to specific quantity or dosage limits. You can get information about specific

quantity limits from the Coventry Health Care website at www.chcwv.com or by contacting the

Pharmacy Help Desk at 800.378.7040. If a drug is non-covered dosage or quantity is medically

necessary, then the physician may request payment for the non-covered dosage or quantity by

contacting Coventry Health Care. If Coventry Health Care, after reasonable investigation and

consultation with the prescribing physician, approves an exception, the prescription will be covered

at the applicable drug copayment and/or coinsurance once the member has satisfied any applicable

deductibles for the benefit year. Such an exception will be acted on within two working days of

Coventry Health Care’s receipt of the request.

For a patient with intractable cancer pain, the member’s physician may request a dosage that is in

excess of the recommended dosage of a pain relieving agent.

The physician should provide information to Coventry Health Care to confirm that the drug is for

intractable cancer pain and that the drug is FDA approved for that use. A decision will be made

within 24 hours of receiving the request and communicated by telephone to the requesting

physician. If a physician prescribes a medication in a dose that requires two separate strengths and

a pharmacy must dispense two separate prescriptions to accommodate the prescribed dose, the

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member will be required to pay the required copayment or coinsurance for each pharmacy

prescription dispensed. The pharmacy department may require two separate strengths for cost-

effectiveness. Any covered medication that has a duration of action extending beyond one month

shall require the number of copayments that is equal to the anticipated duration of the medication.

For example: Depo-Provera is effective for three months. It is covered and will require three

copayments.

Mail-order Benefit

The copayment and/or coinsurance applies to each initial and refill prescription for up to a 90-day

supply of maintenance drugs once any applicable deductibles have been satisfied for the benefit

year. The member will need to allow at least a 14-day turnaround time to receive their mail order

prescription. Only maintenance drugs, as defined by Coventry Health Care, are available through

mail order. Controlled substances are not available through the mail order program. Please refer to

the Mail Order Exclusion List on our website for additional information.

Retail Maintenance Drug Benefit

In addition to the mail order benefit, the member also has the option to obtain up to a 90-day supply

of maintenance drugs from a participating pharmacy. The member will pay one copayment and/or

coinsurance for each prescribing unit in a 90 day supply. Only the maintenance drugs defined by

Coventry Health Care will be available at the retail maintenance drug benefit. Controlled

substances are not available at the retail maintenance drug benefit.

Specialty Medications

Specialty Medications are available through our preferred Specialty Pharmacy Provider.

Specialty Medications as defined by Us are typically high-cost drugs, including but not limited to

the oral, topical, inhaled, inserted or implanted, and injected routes of administration. Included

characteristics of Specialty Medications are drugs that:

are used to treat and diagnose rare or complex diseases

require close clinical monitoring and management

frequently require special handling

may have limited access or distribution

Except in urgent situations, all Specialty Medications are distributed by a Specialty Pharmacy

approved by Us and are limited to no more than a 31 day supply per fill. Specialty Medications

require Prior Authorization, unless specified elsewhere and are subject to quantity limits.

General Information

Coventry Health Care requires mandatory generic substitution. If a brand name prescription drug is

dispensed, FDA-approved AB-rated and an equivalent generic prescription drug is available, the

member shall pay an ancillary charge directly to the pharmacy in addition to the non-preferred

brand name copayment and/or coinsurance once any applicable deductibles have been satisfied for

the benefit year. The ancillary charge is the difference between the price of the brand name drug

and the generic drug and does not apply to any deductible.

Certain drugs require prior authorization by Coventry Health Care prior to coverage. Participating

physicians and Coventry Health Care’s Customer Service Department have a current list of these

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medications. If the member needs to take a drug that requires prior authorization, the prescribing

physician must contact Coventry Health Care with the medical indications for prescribing the

medication. Prior authorization is determined using criteria developed by Coventry Health Care’s

Pharmacy and Therapeutics Committee, based on FDA approved uses and laws of the state of West

Virginia. In addition, high dollar claims will be reviewed by Coventry Health Care for efficacy and

cost effectiveness in conjunction with FDA standards of care.

Because there may be more than one therapeutically equivalent brand name of a prescription drug,

not all therapeutically equivalent brands of prescription drugs (i.e., those produced by different

manufacturers) may be included in Coventry Health Care’s Prescription Drug List. In some

instances, for the same drugs (i.e., drugs with the same active ingredients) made by two different

manufacturers, Coventry Health Care may only put one of the drugs on its Prescription Drug List

and the other drug will be excluded from coverage.

In certain situations, Coventry Health Care can, upon written notification to the member, give

notice that the member’s prescription drug benefit is in jeopardy. These situations include, but are

not limited to, a member using medications in a manner that contradicts his/her prescription or

standard prescribing practices, consistently using multiple pharmacies, or obtaining prescriptions

for the same medication from multiple physicians. Continued abuse of this nature can result in

termination, upon 31-day written notice to the member, of prescription drug benefits for the

member and all covered dependents.

What is covered

∙ Medically Necessary drugs:

-- Obtained from a participating pharmacy (including mail order)

-- For which a prescription is required by federal or state law

-- Which are not specifically excluded

∙ Self-administered injectable drugs.

∙ Diabetic supplies, including insulin, syringes, blood glucose strips, lancets, and glucose monitors.

∙ Compounded prescriptions when all of the following apply:

--No suitable commercially available alternative is available.

--The main active ingredient is a covered prescription drug.

--The purpose is solely to prepare a dose form that is medically necessary and is

documented by the prescribing doctor.

--And, when the claim for the prescription is submitted electronically.

Depo-Provera is covered through our pharmacy benefit. Physicians are to write

a prescription for the medication and the patient is to obtain the medication from a participating

pharmacy. Depo-Provera will not be covered if supplied by the physician’s office.

Coverage for preventive drug products

will be provided at 100% of the Allowable Charge/Allowed Amount in a manner consistent with

Section 2713 of Federal H.R. 3590. This includes over-the-counter aspirin, folic acid, iron and

fluoride tablets. Members will need a written prescription in order for these to be covered.

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What is not covered

• Drugs which are not medically necessary.

• Drugs obtained from nonparticipating pharmacies in a non-emergency situation when such

pharmacies have not previously notified Coventry Health Care, by facsimile or otherwise, of

their agreement to accept as payment in full reimbursement for their services at rates available to

pharmacies that are participating providers, including any copayment, coinsurance and/or

deductible consistently imposed by Coventry Health Care.

• Any prescription drug which is to be administered, in whole or in part, while a member is in a

hospital, medical office, or other health care facility.

• Travel prophylaxis.

• Growth hormone for adults.

• Any prescription drug that is being used or abused in a manner that is determined to be furthering

an addiction to a habit-forming substance.

• Drugs which do not require a prescription by federal or state law, with the exception of over-the-

counter (OTC) programs sponsored by Coventry Health Care. For example: Legend drugs for

which there is a non-prescription drug alternative (such as over-the-counter), over-the-counter

drugs (like aspirin, antacids, herbal products, medicated soaps, food, food supplements, food

replacements, and bandages) or over-the counter equivalents, behind-the-counter drugs,

nutraceuticals or medical foods.

• Contraceptive implant systems and intrauterine devices (IUDs).

• Dietary supplements, appetite suppressants, drugs used to treat obesity or assist in weight

reduction or weight gain, and malabsorption agents.

• Drugs and products for smoking cessation, including prescription drugs such as Zyban, with the

exception of OTC programs sponsored by Coventry Health Care.

• Medications prescribed for cosmetic purposes, including but not limited to, tretinoin for aging

skin and minoxidil lotion.

• Drugs and products used to treat infertility (unless covered by a rider).

• Injectable medications, except self-administered injectable drugs.

• Refill of prescriptions resulting from loss or theft or resulting from damage by the member.

• Medications for treatment of diseases of teeth and gums, except fluoride

tablets or drops.

• Devices or supplies of any type, regardless of having a prescription order, unless specifically

listed as covered in the member’s pharmacy rider. These include, but are not limited to tubing

for insulin pumps; ostomy supplies, including bags, adhesives, tubing, therapeutic devices,

support garments, corrective appliances, non-disposable hypodermic needles, or other devices

regardless of their intended use. The member’s prescription drug coverage does not extend to

drugs or products that are not FDA approved prescription medications, such as those without an

approved FDA application (NDA, ANDA or BLA).

• Allergy supplies, including syringes.

• Experimental and investigational drugs; products not approved by the FDA; drugs with no FDA-

approved indications, medications prescribed at dosages in excess of FDA approval; drugs

prescribed for purposes other than the FDA approved use, unless a drug is recognized for

treatment of the covered indication in one of the standard reference compendia or in substantially

accepted peer-reviewed medical literature. Cancer drugs that are FDA approved for a certain

cancer type may be used for treatment of other types of cancer, provided the drug has been

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recognized as safe and effective for treatment of that specific type of cancer in any of the standard

reference compendia. Any drug approved by the FDA for use in the treatment of cancer pain shall

not be denied for coverage on the basis that the dosage is in excess of the recommended dosage

of the pain relieving agent, if the prescription in excess of the recommended dosage has been

prescribed in compliance with Virginia law for a patient with intractable cancer pain.

• Vitamins and minerals (both OTC and legend), except legend prenatal vitamins for pregnant and

nursing females, liquid or chewable legend pediatric vitamins for children under age 13, and

potassium supplements to prevent/treat low potassium.

• Biological sera, and Hemophilia blood factors with the exception of programs sponsored by

Coventry Health Care.

• Medications used to enhance athletic performance, including but not limited to, anabolic steroids.

• Medications related to sexual transformation or transgender.

• Medications for a condition or injury related to a Worker’s Compensation claim.

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6 Laboratories

6.1 - Lab Services

LabCorp is the preferred outpatient laboratory for Coventry Health Care. All non-emergent

laboratory services should be sent to LabCorp for processing. It is Coventry Health Care’s policy

that laboratory services should be provided by a contracted vendor for lab services if the lab

services are not provided in the provider’s office. When a participating provider sends a lab to a

vendor that Coventry Health Care has not contracted with to perform lab services, the provider is

responsible for the charges per Section 2.13.

Physicians may be reimbursed for certain laboratory services in the office if immediate results of

the tests will affect the care of the patient or course of therapy. Please refer to your specific contract

with Coventry Health Care in order to determine the lab services that you are contracted to

perform.

Genetic Testing

Some lab procedures may require preauthorization such as Genetic testing. For a complete listing

of services requiring preauthorization, see Attachment A.

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7 Plan Options

7.1 -Types of Benefit Plans

Health Maintenance Organization (HMO), Point-of-Service (POS), and Preferred Provider

Organization (PPO) products are available to both large and small groups with as few as two

employees. The specific benefits provided and premium required depends upon the product and

benefit plan selected. The product descriptions are only summaries of benefits, exclusions and

limitations and are not contracts. The complete benefits, limitations, exclusions and

procedural requirements of a plan can be found in the coverage documents for each product.

HMO Products

Coventry Health Care of West Virginia’s HMO plans require members to select a primary care

physician to assist in coordination of their health care. Female members age 13 and older have the

option of selecting an OB/GYN in addition to a PCP. Members receive services from Coventry

Health Care’s network of quality health care professionals. Members can access participating

specialists directly for covered services without a referral. Participating PCPs as well as

participating specialists are able to obtain directly from Coventry Health Care any required

preauthorization needed.

HMO benefit plans with low to high levels of member responsibility are available.

POS Products

In 2011, Coventry Health Care of West Virginia began offering POS benefit plans to its members.

These benefit plans require a member to select a primary care physician. Members have the choice

of receiving care from a participating provider (in network) while receiving a higher level of

benefit, or the member may go to a nonparticipating provider (out-of-network) at a reduced level of

benefit.

Referrals from the PCP for office visits to other participating providers are not required. POS

members may access any participating specialist directly and receive covered services at the in-

network level. Participating and nonparticipating PCPs and specialists are able to obtain directly

from Coventry Health Care any required preauthorization needed.

POS benefit plans with low to high levels of member responsibility are available.

PPO Products

Coventry Health Care of West Virginia administers PPO products that are underwritten by its

affiliate, Coventry Health and Life Insurance Company. There is no PCP selection required for

PPO products. Members have the choice of receiving care from a participating provider (in

network,) while receiving a higher level of benefit, or the member may go to a nonparticipating

provider (out-of-network) at a reduced level of benefit. PPO benefit plans with low to high levels of

member responsibility are available. Some of these benefit plans may also be coupled with either a

FSA (Flexible Spending Account), HRA (Health Reimbursement Arrangement), or HSA (Health

Savings Account), or any combination thereof.

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Employers have the option to purchase PPO benefit plans that use a local network of providers that

is nearly identical to the HMO provider network or to purchase PPO benefit plans that use a

national network of providers through Coventry Health Care National Network. The PPO benefit

plans may have different Directories of Health Care Providers from the HMO and POS plans.

CoventryOne

This product is a PPO product offered to individuals and families through a Non-Employer Group

Trust. Please refer to Section 16 for more information about the CoventryOne product.

Employer Self-Funded Benefit Plans

Coventry Health Care arranges the provider network for benefit plans funded by employer groups.

These benefit plans are administered by Coventry Health Care. In these plans, the employer, not

Coventry Health Care, has the ultimate payment responsibility to the provider.

Coventry Health Care Medicaid Program

Coventry Health Care offers a Medicaid HMO product, to eligible Medicaid recipients and to

children who qualify for health care coverage through the West Virginia Medicaid Program, the

Mountain Health Trust. The physician network and reimbursement methodology for providers may

vary from our commercial products. For a Coventry Health Care Medicaid fee schedule, please

contact your Provider Relations Representative. Please refer to the Administrative Procedures for

Coventry Health Care Medicaid for more information. For more information about participation in

the Coventry Health Care Medicaid network, please contact your Provider Relations

Representative.

Product Options

Coventry Health Care providers have the ability to opt-out of certain networks. In the event a

provider wishes to opt-out of a network, notice must be given pursuant to the provider’s agreement.

To obtain specific benefit information about one of your Coventry Health Care patients,

please refer to www.directprovider.com or call Customer Service.

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8 Physician Participation Information

8.1 - General Guidelines

A provider must complete an application, sign two Participating Provider Agreements and be fully

credentialed by Coventry Health Care, or by a specifically delegated entity, in order to be approved

for participation. Once the Participating Provider Agreements have been executed, an original copy

will be returned to the provider for his/her records.

.

Providers/Patient Relationships

Providers will be solely responsible for the treatment and medical care provided to a member and

the maintenance of their relationship with a member. Coventry Health Care will neither exercise

control or direction over, nor be liable for, the manner or method by which the provider provides

professional services under the Provider Agreement. Providers can and must freely communicate

with members regarding appropriate treatment alternatives and/or the treatment options available to

them, including alternative medications, regardless of benefit coverage limitations. Coventry

Health Care is entitled to deny payment for provider services to a member which it determines are

not covered services. A coverage denial does not absolve providers of their professional

responsibility to provide appropriate medical care to members.

Committee Activity

Provider input is an important element of the management structure of Coventry Health Care.

There are several committees where external professionals are essential. These committees allow

our participating providers a voice in the policy and procedure-making process and in the clinical

and medical/utilization management studies. If you are interested in joining any of these

committees, please contact your Coventry Health Care Network Management Representative.

Minimum Initial and Recredentialing Standards

All practitioners applying for initial and continued participation in the Coventry Health Care

network must meet the minimum credentials criteria, unless an exception is made by the

Credentialing Committee. If the applicant does not meet criteria and an exception is not made,

he/she may reapply to the network after six months from the determination.

All practitioners applying for initial and continued participation in the Coventry Health Care

network must meet all applicable criteria as outlined below:

have completed an application and a signed attestation statement.

have a current, unrestricted state license in the state in which they are applying to provide

services.

have a current, unrestricted Drug Enforcement Agency (DEA) certificate. An exemption is

made for applicants who do not prescribe medications.

Please be sure to submit a complete

credentialing application when

applying for participation

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have current malpractice insurance issued by an insurance carrier domiciled in the U.S. and

in accordance with the coverage requirements as stated in Coventry Health Care policies

and Section 8.5 of this manual.

have no significant liability claims history and fully disclose all judgments, settlements, or

pending claims in professional liability cases, imposed and pending sanctions including but

not limited to Medicare, Medicaid, or DEA and criminal conviction(s) for the past five

years.

have no Medicare/Medicaid sanctions.

the physical and mental health status of the applicant must permit him/her to practice

medicine in an unrestricted manner.

the applicant must be free of impairment due to chemical/substance abuse.

have a work history for the five years previous, with no gaps greater than six months, unless

gaps can be explained, either verbally or in writing. A gap in work history that exceeds one

year must be clarified in writing.

for PCPs only, office hours availability at least 25 hours a week and perform the functions

of a primary care provider by meeting one of the following conditions: a) performs the

functions of a primary care provider at least 50% of the time in which he/she engages in the

practice of medicine, or b) has limited their practice for at least two years prior to

association with Coventry Health Care to general practice, internal medicine, pediatric, or

family medicine.

For initial credentialing, PCPs, OB/GYNs, and high-volume behavioral health care

practitioners must pass the on-site review and demonstrate compliance with medical record

keeping standards.

At the time of recredentialing, PCPs must perform adequately when information pertaining

to member complaints, member satisfaction, utilization management, and/or results of

quality improvement activities is evaluated.

State and/or Medicare/Medicaid sanctions or licensure restrictions identified regarding a

participating provider shall be reviewed by the Credentialing Committee. Recommendations

for action will be communicated to the identified provider by the Credentialing Committee

Chairperson. The provider has the right to appeal.

The provider has the right to review and to correct erroneous information. The provider will be

notified by Coventry Health Care via phone, fax or letter and will have 15 days to comply with the

request, in writing or verbally. Upon receipt of the corrected information, the provider’s file will be

amended. The provider will be provided all necessary policies and procedures pertaining to their

right to review and correct erroneous information in the event the credentialing information

obtained from other sources varies substantially from that provided by the provider.

Recredentialing is required

within three years of

initial credentialing.

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Additional criteria for Credentialing Midwives:

The applicant must have an unrestricted license as a Registered Nurse and Nurse- Midwife.

The applicant must have staff membership in good standing at the network hospital for

which he/she is applying. “Staff membership” refers to any designation adopted by the

hospital where the Nurse Midwife can provide services permitted by his/her licensure and

certification.

The applicant will have a formal working relationship with a network obstetrician/

gynecologist.

8.2 - Coventry Health Care Access and Availability Standards

Coventry Health Care utilizes accessibility/availability standards based on requirements from

NCQA, state and federal regulations. The Access Standards are communicated to physicians and

members by newsletters and the Coventry Health Care website and are part of the Provider Manual.

Practitioners that do not meet Coventry Health Care’s access standards are provided

recommendations for improvements in order to meet the set standard. The Credentialing

Committee reviews the information as part of the initial and reappointment process.

Office appointments for medical/surgical care

Initial new member appointment: < 12 weeks

Preventive care appointments: < 30 days

Routine primary care (non-urgent, symptomatic conditions) appointments: < 72 hours

Urgent care appointments: < 48 hours

Emergency care appointments: immediately

Initial prenatal visits: < 14 days of pregnancy confirmation

After Hours

Access to after-hours care by a network PCP is available to members 24 hours a day, 7 days

a week. (Emergency Room physicians and Urgent

Care Centers are not considered “network physicians for routine call

duty”.)

After hours calls to the answering service for urgent problems are returned immediately.

After hours calls to the answering service for non-urgent problems are returned within 30

minutes.

Number of patients routinely scheduled to be seen per hour

Adult patients: no more than six should routinely be scheduled per hour.

Pediatric patients: no more than eight should routinely be scheduled per hour.

Policy for no show or cancellations are in place.

Office telephone standards

The telephone caller should not be placed on hold > 2 minutes.

The telephone staff members should clearly identify the name of the office.

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Hours of Operation for facilities

Surgical Centers

Services are available a minimum of 40 hours per week

Rehabilitation Centers

Services are available a minimum of 40 per week

Home Health Agencies

Services are available 24 hours a day/ 7 days a week

Durable Medical Equipment

Services are available a minimum of 40 hours per week

8.3 -Office Survey and Medical Record Review

To ensure and evaluate the accessibility of services and the quality of care, Coventry Health Care

performs on-site reviews of physician offices. There are two aspects of the review: 1) a survey

addressing office policies and procedures, and 2) a medical record review. Coventry Health Care

may use a third-party vendor to conduct these surveys.

The office survey is completed by a Coventry Health Care reviewer and the office manager or

physician in the practice. Coventry Health Care surveys the office policies and procedures, such as

those to schedule appointments, handle emergencies, and ensure patient confidentiality. The

Quality Improvement (QI) Reviewer conducts the medical record review. Prior to the medical

record review, a list of names is sent to the practice for medical records to be pulled for the

Coventry Health Care QI Reviewer to check for documentation and coding accuracy.

Coventry Health Care considers these reviews educational and works with the

office to improve areas in which there is a deficiency. Information, including

sample problem lists, is available to those practices that request follow-up.

Offices will be revisited as determined by the results of the review. Generally an office may be

revisited every one to three years.

More information about the office survey and medical record review, including Coventry Health

Care’s required standards, may be obtained by contacting your Network Management

Representative.

8.4 - Maternity

The minimum length of stay for a vaginal delivery is 48 hours, and the minimum length of stay for

a cesarean section is 96 hours. If the physician believes the mother’s medical condition warrants a

longer stay, the physician must contact Coventry Health Care for preauthorization of such

additional services. Shorter stays shall occur where patient and physician agree. For all expectant

Coventry Health Care members, the physician is strongly encouraged to complete the Maternity

Notification Form listed as Attachment B in this manual. This form assists Coventry Health Care in

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identifying high risk pregnancies and in providing additional support and services for pregnant

members.

Benefits for inpatient care are determined in accordance with applicable federal and state law and

the criteria outlined in the most current version of the Guidelines for Perinatal Care prepared by the

AAP and ACOG, or the Standards for OB/GYN Services prepared by ACOG. Coventry Health

Care is allowed a six-month period to incorporate any changes in these guidelines or standards in

its procedures.

Each expectant mother is mailed information during her pregnancy that includes a request to notify

Coventry Health Care of the baby’s physician. In addition, Coventry Health Care sends mothers-to

be a Baby Matters packet which includes information on the stages of pregnancy and eating smart

for two, and provides a list of community classes and resources.

8.5 - Malpractice

All providers must have the Coventry Health Care-required malpractice insurance coverage limits.

Only the Credentialing Committee has the ability to make exceptions to such coverage

requirements.

8.6 - Members’ Rights and Responsibilities

Coventry Health Care is committed to treating members in a manner that respects their rights as

members, including those members with diverse cultural and ethnic backgrounds and those with

physical and mental disabilities.

For HMO and POS Members:

The member has the right to a description of their rights and responsibilities, plan benefits,

benefit limitations, premiums, and individual cost-sharing requirements.

The member has the right to a description of the HMO’s grievance procedures and the right

to pursue grievance and hearing procedures without reprisal from the Health Maintenance

Organization (HMO).

The member has the right to a description of the method in which they can obtain a list of

the plan’s provider network, including the names and credentials of all participating

providers, and the method by which they may choose providers within the plan.

The member has the right to choose an available participating Primary Care Provider (PCP),

and with proper referrals, the right to a participating specialist.

The member has the right to privacy and confidentiality with regard to their personal

information.

The member has the right to full disclosure from their health care provider of any

information relating to their medical condition or treatment plan and the ability to examine

and offer corrections to their own medical records.

The member has the right to be informed of plan policies and any charges for which they

will be responsible.

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The member has the right to a description of the procedures for obtaining out-of-area

services.

The member has the right to a description of the method by which they can obtain access to

a summary of the plan’s accreditation report.

The member has the right to have medical advice or options communicated to them without

any limitations or restrictions being placed upon the provider or PCP by the HMO.

The member has the right to have all coverage denials reviewed by appropriate medical

professionals consistent with the HMO’s review procedure.

The member has the right to have coverage denials involving medical necessity or

experimental treatment reviewed, after exhaustion of the HMO’s internal grievance

procedure, by appropriate medical professionals who are knowledgeable about the

recommended or requested health care service, as part of an external review.

The member has the right to emergency services without prior authorization if a prudent lay

person acting reasonably would have believed that an emergency medical condition existed,

and the right to a description of procedures to obtain emergency services.

A female member has the right to direct access, annually, to her OB/ GYN for the purpose

of a well woman examination without a referral from her PCP, and no female member shall

be required to obtain a referral from her PCP as a condition to coverage of prenatal or

obstetrical care.

A female member whose plan provides coverage for surgical services in an inpatient or

outpatient setting has the right to reconstruction of the breast following mastectomy and

reconstructive or cosmetic surgery required as a result of an injury caused by the act of a

person convicted of a crime involving family violence.

A female member whose plan provides coverage for laboratory or x-ray services has a right

to the following when performed for cancer screening or diagnostic purposes: (1) a baseline

mammogram for women age thirty-five to thirty-nine, inclusive; (2) a mammogram for

women age forty to forty-nine, inclusive, at least every two years; (3) a mammogram every

year for women age fifty and over; (4) a pap smear at least annually for women age 18 and

over.

A nonsymptomatic member over 50 years of age and a symptomatic person less than 50

years of age has the right to colorectal cancer examinations and laboratory tests for

colorectal cancer.

The member has the right to rehabilitation services.

The member has the right to child immunization services, which shall not be subject to

payment of any deductible, per-visit charge and/or copayment.

A diabetic member whose health benefits policy includes eye care benefits, has the right to

direct access to an optometrist or ophthalmologist of their choice from the panel without

referral from their PCP for an annual diabetic retinal examination. When the diabetic retinal

examination reveals the beginning stages of an abnormal condition, access to future

examinations shall be subject to prior authorization from a primary care provider.

The member who has a prescription drug rider has the right to obtain prescription drugs

from a retail pharmacy and not be required to obtain prescription drugs from a mail-order

pharmacy.

The member has the right any combination of blood pressure testing, urine albumin or urine

protein testing and serum creatinine testing as recommended by the National Kidney

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Foundation when performed for kidney disease screening or diagnostic purposes at the

direction of a person licensed to practice medicine and surgery by the board of medicine.

The member has the right to general anesthesia for dental procedures and associated

outpatient hospital or ambulatory facility charges provided by appropriately licensed health

care individuals in conjunction with dental care if the member is:

o seven years of age or younger or is developmentally disabled and is an individual for

whom a successful result cannot be expected from dental care provided under local

anesthesia because of a physical, intellectual or other medically compromising

condition of the member and for whom a superior result can be expected from dental

care provided under general anesthesia; or

o a child who is twelve years of age or younger with documented phobias, or with

documented mental illness, and with dental needs of such magnitude that treatment

should not be delayed or deferred and for whom lack of treatment can be expected to

result in infection, loss of teeth, or other increased oral or dental morbidity and for

whom a successful result cannot be expected from dental care provided under local

anesthesia because of such condition and for whom a superior result can be expected

from dental care provided under general anesthesia.

For All Members:

The member has the right to:

be provided with accurate information about Coventry Health Care’s services, benefits,

their rights and responsibilities, and participating providers.

participate with their provider in decisions made regarding their health care.

have access to Coventry Health Care’s Customer Service Department.

discuss appropriate or medically necessary treatment options for medical conditions,

regardless of the cost or benefit coverage.

be treated with respect and recognition of his/her dignity and need for

privacy and confidentiality.

voice complaints and appeals about this organization or the care provided by participating

providers and to have a clear, documented method for addressing any complaints and

appeals.

to make recommendations regarding Coventry Health Care’s member rights and

responsibility policy.

Members’ Responsibilities to Providers

Coventry Health Care members have the responsibility for cooperating with providers of health

care services by:

Cooperating with health plan representatives and acting in a nonthreatening manner.

Providing information needed by health care professionals.

Informing office and facility staff of their coverage with Coventry Health Care and

notifying office and facility staff if their coverage ends.

Following instructions and guidelines given by health care providers. Failure to comply

with recommended treatment is an option for members. However, when a member fails to

comply with the recommended treatment, Coventry Health Care will have no further

liability to pay for treatment for the particular condition until such time that the member

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later decides to follow the prescribed treatment, assuming the prescribed treatment is a

covered service. Coventry Health Care will not be responsible for payment of services that

may otherwise be covered services but that in Coventry Health Care’s discretion are the

direct result of the member’s initial refusal to follow the recommended treatment.

Cooperating with practitioners and providers of health care services by understanding their

health problems and participating in the development of a mutually agreed-upon treatment

goal to the degree possible.

Members’ Responsibilities to Know How and When to Seek Care

Coventry Health Care members have the responsibility of knowing their health

benefits, as well as any procedures required for seeking care, such as:

Knowing whether they are seeking care from a participating or nonparticipating provider.

In most cases, benefits will vary according to the participation status of the provider

delivering covered services.

Verifying the current participation status of any provider for their specific benefit plan prior

to receiving services.

Always obtaining any required preauthorization as described in the member’s Evidence of

Coverage, Certificate of Insurance or Plan Document. If they need to seek services from a

non-participating specialist, they will need to ensure that Coventry Health Care has

approved the services before receiving covered services.

Understanding the terms and limitations of preauthorization for covered services and for

POS and PPO members, whether preauthorization are approved at the in-network or out-of-

network benefit level.

Obtaining preauthorization from Coventry Health Care prior to continuation of care if they

or a covered family member are receiving health care from a non-participating provider

when they enroll. For POS and PPO members, this applies only if they want the services to

be eligible for payment at the in-network benefit level. They should consult with their PCPs

or treating physicians who will call Coventry Health Care to obtain preauthorization.

Knowing the Preauthorization requirements that apply to the member’s benefits and

understanding the terms of preauthorization.

Understanding the role of their primary care provider in the coordination of their overall

health care.

Notifying Coventry Health Care of a change in their primary care provider prior to seeking

care from that physician as described in their Evidence of Coverage, Certificate of

Insurance or Plan Document.

Accessing behavioral health and substance abuse services as described in their Evidence of

Coverage, Certificate of Insurance or Plan Document.

Promptly notifying Coventry Health Care of any address or telephone number changes. If

correspondence is not received because a member has failed to notify Coventry Health Care

of an address change, the member’s or covered dependent’s coverage could be terminated

or not renewed in accordance with the terms and conditions of the member’s Evidence of

Coverage, Certificate of Insurance or Plan Document. The member will be responsible for

expenses he/she incurs as a direct result of not notifying Coventry Health Care of any

address or telephone number change.

Checking with their employers regarding dependent eligibility and notifying Coventry

Health Care within thirty-one (31) days of any changes.

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Making sure all family members are aware of the correct procedures for obtaining benefits

through Coventry Health Care.

Failure of the member to meet the responsibilities listed in this section may cause the member to be

financially responsible for services provided.

8.7 - Preventive Care Guidelines

The Coventry Health Care website provides information on healthy living including preventive

health guidelines. Information can be obtained at the following Internet address: www.chcwv.com.

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9 Participation Appeal Process

9.1 - Guidelines Grievance/Hearing

Procedures relating to denial of participation status for failure to meet Coventry Health

Care’s requirements

A provider may be denied participation status with Coventry Health Care for failure to meet certain

requirements, including but not limited to the following:

Lack of malpractice insurance coverage.

Insufficient malpractice insurance coverage (must be $1 million/$1 million).

No staff privileges at an affiliated hospital (or failure to obtain

satisfactory inpatient arrangements).

No current State license(s).

Board certification or eligibility.

Failure to supply correct information regarding past licensure actions, malpractice history,

Medicare/Medicaid sanctions, etc.

As these items are required of each provider, the provider will be allowed the opportunity to correct

the deficiency; however, failure to meet one or more of these requirements may result in the

provider being denied participation status.

If an applicant is denied participation or a provider’s reappointment application is denied based

upon the above criteria, the provider shall be notified in writing of the decision and the reasons for

it within sixty (60) days of the Credentialing Committee meeting at which the decision was made.

Procedures relating to denial of participation status for quality concerns

If Coventry Health Care’s Medical Director has quality of care concerns regarding a participating

provider who is engaged in behavior or practicing in a manner that appears to pose a significant

risk to the health, welfare, or safety of members, the Medical Director has the right to immediately

suspend, pending an expedited investigation, the provider’s participation status.

Examples of such quality concerns include but are not limited to:

Evidence of substandard treatment rendered to patients.

Malpractice judgments/settlements.

Any instance where corrective action will be required to be reported to the National

Practitioner Data Bank.

Any instance where a provider’s contract with Coventry Health Care is terminated for cause

under the terms of the contract.

Prior to taking any informal or formal final action to deny participation status to a provider for

quality concerns, the provider will be presented to the Credentialing Committee by the Medical

Director. The provider will be entitled to pursue the appeal process outlined below.

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If the Credentialing Committee has made a final determination to deny an applicant participation

status or not renew a provider’s reappointment for reasons based on the clinical competence or

professional conduct of the provider, the provider shall be notified in writing by the Medical

Director of the decision and the reasons for it. The provider may request a First Level informal

appeals hearing, within thirty (30) days of receipt of the decision letter. The provider must make

this request to the Medical Director in writing.

First Level Informal Appeals Hearing Rules and Procedures

The informal hearing will be held before a panel of at least three (3) qualified individuals, one of

which must be a participating provider not otherwise involved in Coventry Health Care’s

management and who is a clinical peer. At this first level appeal hearing the provider will be given

the opportunity to present additional information relevant to the issue.

A neutral Hearing Facilitator shall preside at the hearing and shall:

Present information relative to the case to the Hearing Panel

Insure that all participants in the hearing have a reasonable opportunity to be heard and to

present oral and documentary evidence subject to reasonable limits;

Maintain decorum throughout the hearing;

Determine the order of procedure throughout the hearing;

Have the authority and discretion, in accordance with these rules and procedures, to make

rulings on all questions which pertain to matters of procedure and to the admissibility of

evidence; and

Act in such a manner that all reasonably relevant information is considered by the Hearing

Panel.

Each party shall have the following rights:

To present verbal arguments regarding the relevant issues;

To present documentary evidence; and

Ask questions of either party.

The hearing will be closed to the public. All documents and testimony shall be maintained in strict

confidence by all participants, consistent with the State peer review protection statute.

Upon conclusion of the presentation of oral and documentary evidence by each party, the hearing

shall end. The Hearing Facilitator shall ask the Hearing Panel members to review and discuss the

findings of fact. The Hearing Panel shall render the findings of fact and make a recommendation to

the Medical Director within fifteen (15) days following the end of the hearing. The Medical

Director shall notify the provider, who requested the informal hearing, of the Hearing Panel’s

decision within fifteen (15) days of receiving the Hearing Panel’s decision. This notice will be sent

via certified mail, return receipt requested.

If the decision of the first level appeals hearing is to uphold the recommendation of the

Recredentialing Committee to deny the provider participation, the provider will be granted the right

to appeal this recommendation before a second level formal appeals committee and a copy of the

Provider Hearing Policy will be included with the denial letter.

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Second Level Formal Appeals Hearing Rules and Procedures

In order for a provider to request a second level formal appeals hearing, the provider must request a

hearing on the proposed action within thirty (30) days of his or her receipt of the notice. This

request must be made to the Medical Director in writing.

If the provider does request a hearing, the hearing shall be held within thirty

(30) days of receipt of the provider’s request unless Coventry Health Care and the provider agree to

an extension.

If the provider does not request an appeals hearing within thirty (30) days of his or her receipt of

the aforementioned notice, he or she will have waived the right to appeal the decision to an

appropriate hearing body.

If the provider requests an appeal, the procedure will satisfy general elements of fair procedures

established by judicial decisions. It also contains the elements of adequate procedure set forth in the

Health Care Quality Improvement Act of 1986. The hearing will proceed as follows.

The Appeals Committee shall be chaired by an impartial Hearing Officer, appointed by Coventry

Health Care, and consist of the Medical Director and at least two other providers who have

comparable or higher levels of education and training when compared to the provider making the

appeal. One member of the Appeals Committee must be a participating provider not otherwise

involved in plan management. A representative of the provider’s specialty should be a member of

the Appeals Committee, if possible. The providers chosen may not be in direct economic

competition with the provider who has requested the hearing and may not have been involved in the

first level informal appeals hearing.

The Hearing Officer shall preside at the hearing and shall:

Insure that all participants in the hearing have a reasonable opportunity to be heard and to

present oral and documentary evidence subject to reasonable limits on the number of

witnesses and duration of direct and cross-examination, applicable to both sides, as may be

necessary to avoid cumulative or irrelevant testimony or to prevent abuse of the hearing

process.

Maintain decorum throughout the hearing

Determine the order of procedure throughout the hearing

Act in such a way that all reasonably relevant information is considered by Coventry Health

Care.

At the hearing, the following procedures will apply:

The provider and Coventry Health Care may be represented by legal counsel;

A representative of Coventry Health Care shall appear at the hearing to explain the reasons

for the recommendation;

The provider or provider’s representative may ask questions of that individual;

The provider may address the Hearing Panel and/or present documentary evidence and

witnesses in his or her own behalf;

Additional witnesses may be called by the Hearing Panel at its discretion;

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If requested at least seven (7) days prior to the hearing date, a record may be made of the

proceedings, copies of which may be obtained by the provider upon payment of any

reasonable charges associated with the preparation thereof;

Members of the Hearing Panel may ask questions of the provider and the Coventry Health

Care representative; and

The provider may submit a written statement at the close of the hearing.

At the conclusion of the proceeding, the Hearing Panel shall present a written recommendation in

the matter with a statement of reasons supporting it to Coventry Health Care within fifteen (15)

business days of the hearing date.

The decision of the Hearing Panel shall be final and binding on both the provider and Coventry

Health Care. If that decision is to terminate the provider’s contract, the contract shall be terminated

at the time specified by Coventry Health Care in its initial notice of termination. If the decision is to

not renew a contract, the contract shall expire at the end of its then current term.

The Medical Director or other applicable officer of Coventry Health Care shall send the affected

provider notice of its recommendation and the basis for the recommendation no later than thirty

(30) business days after the decision is made.

All notices required or permitted to be given by Coventry Health Care pursuant to this Policy shall

be delivered via certified mail, return receipt requested, to the individual who is receiving this

notice or his or her authorized representative.

9.2 - Reporting to the National Practitioner Data Bank

Whenever Coventry Health Care has determined to deny participation status, terminate or not

renew a provider’s contract for stated reasons based on the clinical competence or professional

conduct of the provider, the Coventry Credentials Verification Center (CVC), on behalf of

Coventry Health Care, will report the action taken to the appropriate Federal and State authorities

as required by law (e.g. State Boards of Medical Examiners, National Practitioner Data Bank, etc.),

pursuant to the requirements of the Health Care Quality Improvement Act of 1986, and regulations

promulgated, thereunder, each as amended.

9.3 - General Comments

If the provider is currently a participating provider, their status as a participating provider will

remain in effect during the appeals process, unless the termination is based on any of the reasons

outlined in Section 9.1 under Procedures relating to denial of participation status for quality

concerns.

The provider’s participation may be immediately terminated if the participating provider’s conduct

presents an imminent risk of harm to an enrollee(s); or, if there has occurred unacceptable quality

of care, fraud, patient abuse, loss of clinical privileges, or licensure, or loss of professional liability

coverage, incompetence, or loss of authority to practice in the provider’s field; or, if a

governmental activity has impaired the provider’s ability to practice or participate in Medicare or

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Medicaid. A participating provider who does not meet the terms and conditions of their provider

contract can be terminated without the right to an appeal.

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10 Provider Appeal Procedures

Coventry Health Care has appeal procedures for both its members and its providers. The provider

appeal procedures are discussed in this section. Providers may appeal when a claim has been denied

or paid at a reduced level of benefits, or if preauthorization was not granted for a requested service.

Appeals are classified as either administrative or utilization management.

Issues concerning the Coventry Health Care Payment Policy Program are not appealable and

are handled as discussed in Section 4 of this Provider Manual.

Providers who have questions regarding the following Appeal Procedures or who want assistance

in filing an appeal, should contact the respective Customer Service Department.

For questions concerning Coventry Health Care Commercial Appeal Procedures, call 800-348-

2922 between 8:00 a.m. and 6:00 p.m. Monday – Friday.

For questions concerning Coventry Health Care Medicaid Appeal Procedures, call 800-348-2922,

Option 1 between 8:30 a.m. to 5:00 p.m. Monday – Friday.

10.1 -Definitions

Inquiry: Any question from a provider regarding issues such as benefits

information, claim status, or eligibility.

Complaint: Any expression of dissatisfaction expressed by a provider regarding an issue in the

Health Plan.

Appeal: An appeal is a request by the provider when the resolution of a complaint or a post service

claim review is not resolved to the provider’s satisfaction and the provider appeals the Health

Plan’s decision within the prescribed time frames.

Adverse Administrative Decision: An adverse benefit determination that is based on the

member’s benefit plan and in accordance with the member’s plan documents and NOT based on

medical judgment o Medical Criteria. Examples:

• Services that require preauthorization, but the preauthorization is not called in.

• Not covered services: i.e., hearing aids, exercise equipment, splints, work-related

injuries.

Adverse Benefit Determination:

Means (i) a determination by the health plan, or its designated utilization review entity that, based

on the information provided, a request for services under the health plan’s benefit plan upon

utilization review does not meet the health plan’s requirements for medical necessity,

appropriateness, health care setting, level of care or effectiveness or is determined to be

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experimental or investigational and the requested service is therefore denied, reduced or terminated

or payment is not provided or made, in whole or in part, for the requested service; (ii) the denial,

reduction, termination or failure to provide or make payment, in whole or in part, for a service

based on the member’s eligibility to participate in the health plan’s benefit plan as determined by

the health plan; (iii) any review determination that denies, reduces or terminates or fails to provide

or make payment, in whole or in part, for a service; (iv) a rescission of coverage determination; or

(v) that for individual policies only, any decision to deny individual coverage in an initial eligibility

determination.

Adverse Decision: Means a determination by the health plan, or its designated review entity, that

based upon information provided, a request for a service does not meet the health plan’s

requirements for medical necessity, appropriateness, health care setting, level of care or

effectiveness or is determined to be experimental or investigational and the requested service is

therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for

the requested service. When the policy includes coverage for prescription drugs and the service

rendered or proposed to be rendered is a prescription for the alleviation of cancer pain, any adverse

determination shall be made within 24 hours of the request for coverage.

Clinical Peer Reviewer: Means a practicing health care professional who holds a nonrestricted

license in a state, district or territory of the United States and in the same or similar specialty as

typically manages the medical condition, procedure or treatment that is under appeal.

Peer-to-Peer Review: A verbal review of a pre-service or concurrent review adverse decision

regarding the denial of preauthorization that is conducted between a Coventry Health Care Medical

Director and the treating provider, at the provider’s request. To be considered a Peer-to-Peer

review, the review must take place within 30 calendar days from the date of the initial notification

of the adverse decision.

Physician Advisor: A physician advisor is a physician licensed to practice medicine in West

Virginia or under a comparable licensing law of a state of the United States and who provides

advice regarding the medical necessity of a service to the Health Plan as part of its utilization

review activities.

Post-Service Claim Review: Any inquiry or complaint from a provider regarding an already

provided service wherein the provider believes an error has been made in payment or the manner in

which a claim has been processed.

UM Appeal: A UM Appeal is an appeal of an adverse decision.

10.2 - Peer-to-Peer Reviews

If a provider receives an adverse decision to a pre-service or concurrent review authorization

request based on medical necessity criteria, including denials due to the services being found to be

experimental/investigational or cosmetic, the provider may request a Peer-to-Peer Review with a

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Coventry Health Care Medical Director within 30 calendar days from the date of the initial

notification of the adverse decision.

If no additional or new information is submitted by the treating provider to a Coventry Health Care

Medical Director for consideration, and the Peer-to-Peer request is beyond 30 calendar days from

the date of the initial notification of the adverse decision, but within 90 calendar days from the date

of the initial notification of the adverse decision, the provider must then initiate the provider

appeal process as described below in Section 10.4.

The provider can contact a Coventry Health Care Medical Director directly for the Peer-to-Peer

review. Contact information for the Coventry Health Care Medical Director will be provided to the

provider’s office at the time of the verbal notification of the denial and will be included in the

written denial notification as well. The provider may also contact Health Services at 888

348-2966 to obtain the Coventry Health Care Medical Director’s contact information.

If, after the Peer-to-Peer review, the Coventry Health Care Medical Director overturns the initial

adverse decision, an approval letter will be sent to the member. The provider will be notified

verbally of the approval. If the Coventry Health Care Medical Director does not reverse the initial

adverse decision after the Peer-to-Peer review, the provider will be notified verbally and will be

reminded of their appeal rights. The member receives written notification of the adverse decision

ONLY with the initial denial.

10.3 - Submission of Additional Clinical Information after a Pre-Service Denial

If a provider receives an adverse decision to a pre-service request, they may submit additional or

new information by calling or faxing to the Coventry Health Care Health Services Department at:

Phone #: 888.348.2966

Fax #: 866.373.0274

If additional or new information is submitted within 30 calendar days from the date on the initial

notification of the adverse decision, it will be treated as a Peer-to Peer Review.

If the additional or new information is submitted after 30 calendar days from the date of the initial

notification of the adverse decision, it will be treated as a new request and the preauthorization

process will start over again.

A Health Services review nurse will review any additional or new information that the provider has

submitted beyond 30 calendar days from the date of the initial notification of the adverse decision.

If the additional or new information meets criteria, the request is approved and the provider is

notified verbally of the approval. The member receives written notification of the approval.

If the additional information does not meet criteria, the case, including the recently submitted

documentation, is sent to a Coventry Health Care Medical Director for review. If the Coventry

Health Care Medical Director overturns the adverse decision based on the additional information

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submitted, an approval letter will be sent to the provider and the member. If the Medical Director

does not reverse the adverse decision, the provider will be notified verbally and will be reminded of

their appeal rights. The member is sent written notification of the adverse decision and a

description of their appeal rights.

10.4 - Post-Service Claim Reviews and Provider Appeal Processes

Post-Service Claim Reviews

Post-service claim reviews are classified in one of the following categories:

• Timely filing denial

• Services not authorized denial

The request must be received by Coventry Health Care within 90 calendar days of the date on the

remittance advice reflecting the claim denial and/or the partial payment of a claim.

The provider can submit a post-service claim review request by writing to or calling:


Customer Service Department

PO Box 7373

London, KY 40742-7373 800-348-2922

Within 10 working days of Coventry Health Care’s receipt of the post-service claim review request,

a customer service representative will review the claim and any additional information that has

been provided. The provider will be notified of the outcome of the post-service claim review via

his/her next scheduled remittance advice.

Post Service Claim Reviews are optional. A provider may appeal a claim denial without utilizing

the Post Service Claim Review process by following the Provider Appeal Process.

Provider Appeal Process

If a provider is dissatisfied with the Health Plan’s adverse payment decision, the provider can

request an appeal. The appeal request must be received by Coventry Health Care within 90 calendar

days from the date of the initial notification of the adverse decision. The appeal should include the

following information:

Member name

Provider name

Date(s) of service

Provider mailing address

Clear indication of the remedy or corrective action being sought and an explanation of why

the health plan should “reverse” the adverse decision

Copy of documentation to support the reversal of the decision

The provider may also include written comments, documents, records and other information

relevant to the appeal

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This information should be mailed or faxed to:

Appeal Coordinator


PO Box 67103

Harrisburg, PA 17106-7103

Fax #: 888.388.1752

For administrative appeal requests, the case will be reviewed by one to three health plan

departmental managers or their designee who were not involved in any previous reviews.

For appeals based in whole or in part on a medical judgment, the case will be reviewed by a

Medical Director or a peer of the treating physician who (a) has appropriate training and experience

in the field of medicine involved in the medical judgment (b) is board certified by a specialty

approved by the American Board of Medical Specialties or by the Advisory Board of Osteopathic

Specialists from the major areas of clinical services; and who was not involved in the initial adverse

payment decision.

A decision is made and the provider is notified in writing of the decision within 30 calendar days of

receipt of the appeal request.

Urgent Care Appeals (also referred to as Expedited Appeals)

A pre-service appeal that must be reviewed under the urgent care appeal process because the

application of non-urgent appeal timeframes could seriously jeopardize: (a) the life or health of the

member or the member’s unborn child or (b) the member’s ability to regain maximum function.

Appeals shall also be considered urgent when: (a) the treating physician says that the care requested

is urgent in nature; or (b) the treating physician determines that a delay in the care would subject

the member to severe pain that could not be adequately managed without the care or treatment that

is being requested. The appeal committee’s decision must be communicated as soon as possible,

but not later than 72 hours after receipt of the urgent appeal request.

Member Appeals

The Member Complaint and Appeal procedures are explained in the individual member plan

documents. However, a participating provider may always act on behalf of the member during the

appeal process. Requests for a status on an appeal involving a Coventry Health Care commercial

member should be directed to Coventry Health Care’s Commercial Customer Service Department

at 800.348.2922. Commercial Customer Service business hours are Monday through Friday from

8:00 a.m. to 6:00 p.m.

Requests for a status on an appeal involving a Coventry Health Care Medicaid member should be

directed to Coventry Health Care’s Medicaid Customer Service Department at 800.348.2922,

Option 1. Coventry Health Care Medicaid Customer Service business hours are Monday through

Friday from 8:30 a.m. to 5:00 p.m. Customer Service can be reached during normal business hours

by calling 800-348-2922.

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11 Health Management Programs

11.1 - Preventive Health Guidelines

Our preventive health guidelines are reviewed annually through the Clinical Advisory Committee

and are based on nationally recognized guidelines from organizations such as the United States

Preventive Services Task Force and the American College of Obstetrics and Gynecology. The

guidelines are made available to all members annually and are distributed to providers in the

Provider Manual (See Sections 8.7 and 13.0 Preventive Care Guidelines and Preventive Services

Standards).

They also are available on our website at www. chcwv.com under Maintaining a Healthy

Lifestyle in the Provider section.

We have developed interventions in common areas of preventive care through

the following efforts:

Mailed reminders to parents about keeping their children’s immunizations up to date.

Mailed lists to PCPs about members needing immunizations.

Mailed information annually to women about routine preventive care. Mailed reminders to

women who have not had Pap smears or mammograms within the recommended time

frame.

Mailed reminders regarding the importance of vaccines to members over 65. For those

members 64 and under with chronic health conditions, they will also receive mailed

reminders about getting vaccines.

Members can elect to sign up for email reminders by utilizing their personalized, password

protected My Online Services at our website.

11.2 - Disease Management Programs

Coventry Health Care provides disease/health management for conditions that can be improved

through active management. Our aim is to proactively reach out to members and engage them in

managing their health, by emphasizing prevention through education, supporting the physician-

patient relationship and reinforcing compliance with their physician’s care plan. The member is

identified by various methods including, but not limited to, claims, pharmacy, laboratory,

physician, caregiver and self-referral. The member has the option to opt in by self-referral by

calling the Customer Service Department or if they chose not to participate, they may opt out by

calling the Customer Service Department or speaking with a disease management staff member.

The Clinical Practice Guidelines that support each of our disease management programs is found

on our website at www.chcwv.com » Providers » Document Library.

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11.3 - Diabetes Disease Management Programs

The Diabetes Disease Management Program is based on Clinical Practice Recommendations from

the American Diabetes Association (available at www.diabetes.org in the “For Professionals”

section). The Diabetes Disease Management Program includes:

Patient education materials for newly diagnosed diabetics and members with diabetes who

are new to Coventry Health Care.

A list of members with diabetes is available to each identified PCP.

Flu vaccination reminders which are sent to all members with diabetes each year.

An annual mailing which is sent to all members with diabetes reminding them to get dilated

retinal eye exams, A1c tests, lipid profiles or tests for kidney function.

Targeted reminders to members with diabetes whose claims do not support they have

received dilated retinal eye exams, foot exams, A1c tests, lipid profiles or tests for kidney

function. Telephone call reminders may also be made to these members.

A list of these members is available to their identified PCP.

Telephone calls to review self-care recommendations to members in case management who

have had a recent diabetes-related ER visit and/ or recent diabetes related inpatient

admission.

Individual case management is offered to members with diabetes as appropriate.

11.4 - Asthma Disease Management Program

Coventry Health Care’s Asthma Disease Management Program is based on A Practical Guide for

the Diagnosis and Management of Asthma from the National Heart, Lung and Blood Institute. A

copy is available at www.nhlbi. nih.gov in the Clinical Guidelines section. Our Asthma Disease

Management Program includes:

Patient education materials for newly diagnosed asthmatics and members with asthma who

are new to Coventry Health Care.

A list of members with asthma is made available to each identified PCP

Flu vaccination reminders which are sent to all members with asthma each year.

Targeted reminders to members fitting criteria who are not filling prescriptions per the

NHLBI-recommended controller medication guidelines. Telephone call reminders may also

be made to these members. A list of these members is made available to each identified

PCP.


have had a recent asthma-related ER visit and/or recent asthma related inpatient admission.

Individual case management is offered to members with asthma as appropriate.

11.5 - Cardiac Disease Management Program

Coventry Health Care’s Cardiac Disease management program is based upon clinical practice

recommendations from the American Heart Association (available at www.americanheart.org). The

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Cardiac Disease management Program includes: Please check the website on a regular basis for

new information: www. chcwv.com.

Patient education materials for newly diagnosed cardiac member and members with cardiac

disease who are new to Coventry Health Care.

Flu vaccination reminders which are sent to members with cardiac disease each year.


have had a recent cardiac disease related ER visit and/or recent cardiac disease related

inpatient admission.

Individual case management is offered to members with cardiac disease as appropriate.

11.6 - Maternity Management Program

Coventry Health Care’s Maternity program is based on the 2011 Coventry Health Care Health Care

Clinical Preventative Services for all pregnant women. Links to these guidelines are located on the

Coventry Health Care website. Coventry Health Care also follows the American College of

Obstetricians and Gynecologists (ACOG) guidelines for all high risk pregnancies. Coventry Health

Care utilizes the National Guideline Clearinghouse website as a source of reference for guidelines

from ACOG. Our Maternity Program includes:

Patient education materials for newly identified pregnant members.

Telephonic postpartum depression screening.

Individual case management is offered to the high risk pregnant member as appropriate

At the first prenatal visit, it is recommended the physician complete and fax a Coventry Health

Care Maternity Notification Form (Attachment B). This form assists us in the identification of high

risk factors early in the pregnancy.

11.7 - Chronic Obstructive Pulmonary Disease (COPD) Disease Management Program

Coventry Health Care’s COPD program is based on clinical guidelines developed by the Global

Initiative for Chronic Obstructive Lung Disease, World Health Organization, National Heart, Lung

and Blood Institute and the American Lung Association. Our COPD Program includes:

Mailings reminding members to have pulmonary function testing annually.

Flu vaccination reminders which are sent to members with the education materials.

Pneumococcal vaccination reminders per the established guidelines.

Smoking cessation mailings.

Individual case management is offered to members with COPD as appropriate.

11.8 - Case Management Programs

Coventry Health Care’s Case Management Programs are designed to help members effectively

manage their health problems and live a better quality of life. Entrance to case management may be

initiated because of a new diagnosis of a chronic medical condition, psychosocial problems

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influencing health, catastrophic injury or illness, chronic and/or complex medical condition, or

noncompliance with the medical plan of care. Case management is a systematic proactive model

which utilizes an organized approach to provide early intervention along with a continuum of care,

and which includes active patient self-care participation in the maintenance of their optimum state

of health. Case management utilizes a multidisciplinary team where care is provided across the

spectrum of services along a continuum of seamless care. Patient and family education are high

priority components of this approach.

Coordinated health care through case management can reduce health care costs, sick time at work,

stress associated with the health care risk, and encourages members to take a more active role with

their disease. Case management by specially trained Registered Nurses or Social Worker is an

added benefit to the member who has been identified as having a specific health care risk. The

goals are to provide effective and cost efficient treatment through multi-level education, protocol

development, compliance monitoring, and expert care.

These programs depend on a three-party relationship: the member, his or her physician, and

Coventry Health Care’s case manager. The member is identified by various methods including, but

not limited to, claims or encounter data, hospital admission or discharge data, laboratory data,

pharmacy data, Episode Risk Groups predictive modeling and employer group, physician, caregiver

and self referral. The member has the option to opt in by self-referral by calling the Customer

Service Department or if they choose not to participate they may opt out by calling the Customer

Service Department or speaking with a case manager. If you have questions about the case

management programs or would like to speak with a case manager, please call customer service.

The case management model includes (but is not limited to) the following activities:

Develop an individualized pathway of care based on input from the medical care team and

their treatment plans for the member.

Serve as contact and resource at Coventry Health Care for the member and the member’s

family.

Aid the member in the management of unique health care risks by coordinating home-based

care and access to community support systems.

Provide support and guidance on sociological and psychological issues affecting the high-

risk individual and assists in coordinating behavioral health, social services or health

department interventions.

Also available is support by phone, to aid with benefit concerns or coordination of discharge needs.

If you have any questions about any of our health management programs, please contact the Case

Management Division at 888.388.1744.The nurses in our programs practice in accordance with

applicable laws regarding patient confidentiality and release of information. Ethical principles

guide their practice with respect for the autonomy, dignity, cultural diversity, privacy and rights of

the members.

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12 Quality Improvement

12.1 - Introduction

We strive to improve the quality of care and services provided by our Participating Providers

through a Quality Improvement Program developed in accordance with the corporate mission and

vision, as well as federal and state regulatory requirements. The program supports continuous

quality improvement in the areas of clinical, behavioral health care, customer service, patient

safety, and access to care services that are provided to our members.

The Quality Improvement Program Description defines an organized framework for carrying out

objective and systematic review of activities to improve the quality of our provider network and

services for its members. The program provides a mechanism for addressing potential or actual

quality of care and quality of service issues that directly and indirectly affect the members and

promotes consistency in the application of quality improvement functions throughout the services

provided by our employees and practitioners.

The Quality Improvement Program focuses on the reduction of medical/health care errors. This

requires an integrated and coordinated approach. Effective reduction of medical/health care errors

and other factors that contribute to unintended adverse patient outcomes in a health care

organization requires an environment in which patients, their families, and organizational staff and

leaders can identify and manage actual and potential risks to patient safety. This environment

encourages recognition and acknowledgement of risks to patient safety and medical/health care

errors; the initiation of actions to reduce these risks; the internal reports identifying issues and the

actions taken; a focus on processes and systems; and minimization of individual blame or

retribution for involvement in a medical/health care error. It encourages organizational education

about medical/health care errors and supports the sharing of knowledge that may affect changes

leading to improved patient safety.

While our Quality Improvement Program attempts to identify and assist providers in improving the

quality of care of members, it is the treating provider’s responsibility to ensure the members are

receiving the care that is appropriate for their condition(s).

12.2 - Purpose

The Quality Improvement Program is designed to optimize the quality of the health care system

delivered to our members by providing direction to management for the coordination of both

quality improvement and quality management activities across all departments and matrix partners

and management/service relationships, including Utilization, and Medical Management, Provider

Relations/Network Management, Customer Service, Behavioral Health, Sales, and Marketing and

Finance. This is accomplished by using Continuous Quality Improvement (CQI) principles, which

is a problem-solving approach utilized when an opportunity for improvement is identified

through monitoring performance indicators or from other sources. The steps of the CQI process

include:

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Collection of data

Analysis of data to identify opportunities for improvement

Identification of possible root causes or barriers

Selection of opportunities to pursue

Planning of interventions

Implementation of interventions

Re-measurement and analysis to determine effectiveness of interventions

12.3 - Goals and Objectives

The Program outlines quality-monitoring requirements and provides guidance in initiating process

improvement initiatives when deficiencies are identified. Quality measurement studies are designed

and documented to objectively and systematically monitor and evaluate the quality and

appropriateness of care and services provided to members. The program requires the following

measurement activities:

The development of effective methods for measuring the health care and behavioral health

care outcomes, member and provider satisfaction, and services provided to our members,

and to apply interventions that result in continuous measurable improvements.

Achieve an effective level of administrative, clinical and behavioral health commitment and

support for the CQI process.

Ensure a consistent focus on high priority quality issues to include patient safety regarding

delivery of care and service.

To assure that clinical health care and behavioral health care services are generally

available, accessible, and appropriate for the population.

To assure that member medical records are maintained in a confidential manner and with

sufficient documentation to facilitate continuity and coordination of care.

To provide oversight of delegated activities, including, but not limited to, behavioral health

benefits management and credentialing.

To ensure effective coordination of quality improvement activities with all appropriate

functional areas, including, but not limited to, utilization management, member complaints

and appeals, provider network services, contracting, sales and marketing, and credentialing

as required by the state, federal regulations and accrediting and auditing bodies (i.e.,

Medicaid, NCQA, BOI, etc.).

To ensure the evaluation of member and provider satisfaction information. This review

includes member/provider survey data, member complaint and appeal analysis and member

satisfaction with

Access to regular and routine care, urgent and emergency care and after hours care.

To maintain mechanisms to adequately serve the cultural, ethnic and linguistic needs of

members through membership analyses, education of staff and maintenance of a provider

network to adequately meet member needs.

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12.4 -Confidentiality

All practitioners and staff involved in the Quality Improvement Program shall maintain the

confidentiality of all information that they review. This includes, but is not limited to, medical

records, practitioner/provider files and member information, as well as the results of any reviews,

deficiencies, or corrective actions taken. All practitioner/provider and member information will be

presented for review in a confidential manner. The procedures and minutes of the Executive

Quality Management Committee and any other subcommittees will be open to review by state and

federal regulating agencies, accrediting bodies, and where required by law. All physician

committee members and employees of Coventry Health Care sign a confidentiality and conflict of

interest statement upon entry into their commitment and as required. Access to member-specific,

practitioner-specific, and/or provider-specific peer review quality improvement information is

restricted to those staff and/or committee members charged with responsibility for peer review

activities. A Regional President, Vice President, Medical Affairs, or Manager of Regulatory

Compliance must authorize the use of quality management information for other than described

quality improvement purposes. In no event, is member-specific, practitioner-specific, or provider-

specific information released to any person or organization outside of the Health Plans unless

required by law. Release of information is in accordance with State and Federal laws.

12.7 - Quality Management Program Activities

The Quality Improvement Program is designed to evaluate and improve the quality and safety of

clinical care and service provided to our members and to those we are contracted to provide health

plan services Monitoring is designed to identify and pursue opportunities for improvement.

Monitoring activities include care and service that are delivered by contracting primary care

practitioners (PCPs) and specialty practitioners. Monitoring extends to both delegated and non-

delegated functions. All departments within the health plan are involved in the Quality

Improvement process.

Quality Improvement activities are coordinated with other performance monitoring activities and

management functions, including but not limited to, Utilization Management, Case Management,

Disease Management, Medical Management, Network Management, Credentialing, Complaints

and Appeals, Claims, and Customer Service and Delegation Oversight. Upon request, we will make

available to its members and practitioners, providers and partners relevant information about its

Quality Improvement Program, including a description of the Quality Improvement Program and a

report on our progress in meeting its goals. Information is shared with members and providers

through our website, newsletters, member handbooks, explanation of benefits and provider

manuals, as examples.

12.8 - HEDIS®

One of our largest QI projects is our participation in the annual NCQA HEDIS® (Healthcare

Effectiveness Data Information Set) monitoring. In the 1990s NCQA developed a broad spectrum

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of clinical and service performance measures with specific technical specifications that allow fair

health plan comparisons regarding clinical outcomes and service performance. Much of HEDIS®

data sampling is obtained from claims data, however a number of the clinical and access measures

require medical record reviews.

Your Provider Agreement states that we have the right to review medical records to monitor the

quality and appropriateness of treatment of members by our participating providers. The written

consent signed by all members at the time of initial enrollment permits disclosure of their medical

information to the health plan.

Your cooperation helps us identify ways we can improve the effectiveness of our healthcare

systems and focus activities to positively influence member health. HEDIS® results ratings are also

an integral part of the health plan accreditation scoring which in part impacts health plan

performance rankings nationally and in future planning, can impact provider profiling and

contracting.

12.9 - Patient Safety

We identify potential quality, safety, and access issues through, but not limited to:

Adverse and Never events identified by Health Services staff

Issues and problems identified by case managers

Complaints from members, providers, or vendors

Medical record reviews and data abstraction done as part of the quality improvement

activities

Adverse Events (AE) and Never Events (as defined by CMS) are investigated through claims

review, research on health plan transactional system and review of medical records (if necessary).

Per your provider contract, you are responsible for providing medical records upon request. The

Quality Improvement Coordinator will review each potential quality or safety of care issue. The

Quality Improvement Coordinator will make a determination as to whether a potential quality or

safety of care issue exists. If the Quality Improvement Coordinator determines there is no quality or

safety of care issue identified, the case will be closed and logged in the database for tracking and

trending. If the Quality Improvement Coordinator determines a quality or safety of care issue may

exist, the issue will be forwarded to the Vice President, Medical Affairs, or designee, for a review

decision and a provider site visit may be warranted. The Vice President, Medical Affairs, or

designee, may determine that a quality or safety of care issue is not apparent and no further

investigation of the case is required. If the Vice President, Medical Affairs, or designee, finds

that a quality or safety of care issue may be present, the record will be referred to a Peer Reviewer

in a related specialty or subspecialty. If the Peer Reviewer feels that a quality or safety of care issue

still exists, the case will be presented in summary form to the Credentialing Committee due to the

nature of peer review activities.

All confirmed potential quality or safety of care issues are reviewed at the time of reappointment.

Quarterly trend analysis summaries are prepared by the Quality Improvement Coordinator and

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submitted to the Clinical Advisory Committee and issues of concern may be forwarded to the

Credentialing Committee. An annual summary of activities resulting from the identification

and review of Adverse Events will be presented to the Vice President, Medical Affairs, or designee,

for review.

Member Complaints are reviewed to:

Monitor, evaluate, and effectively resolve member issues in a timely manner (within 30

days of receipt by the health plan).

Identify opportunities for improvement in the quality of provider care and services rendered

to health plan members.

Member complaints that reference a potential quality or safety of care issue or a quality of service

issue are referred to the Quality Improvement Department for investigation, resolution and to

provide a mechanism of trending complaints against individual providers for use in the

recredentialing process

The Quality Improvement Coordinator will review each potential quality or safety of care issue.

After the complaint is evaluated, the Quality Improvement Coordinator will send the involved

practitioner/provider a letter summarizing the member’s complaint and requesting a response to the

member’s allegations.

The provider is given fourteen (14) calendar days (which is documented on the letter) to respond.

Per your provider contract, you are responsible for providing medical records upon request.

If through the review and investigation, the Quality Improvement Coordinator determines there is

no quality or safety of care issue identified, the case will be closed and logged in the database for

tracking and trending. If the Quality Improvement Coordinator determines a quality or safety of

care issue may exist, the issue will be forwarded to the Medical Director for a review decision. The

Medical Director may determine that a quality or safety of care issue is not apparent and no further

investigation of the case is required. If the Medical Director finds that a quality or safety of care

issue may be present, the record will be referred to a Peer Reviewer in a related specialty or

subspecialty. If the Peer Reviewer feels that a quality or safety of care issue still exists, the case

may be presented in summary form to the Clinical Advisory Committee for further review. The

case also will be presented in summary form to the Credentialing Committee due to the nature of

peer review activities.

If three or more member quality of service complaints are received by the Quality Improvement

Department within a rolling twelve month period, a site visit will be required related to the

following criteria:

Physical accessibility

Physical appearance

Adequacy of waiting and/or exam space

Attitude

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If the member complaint is considered of a critical nature (e.g. serious health risk danger to self or

others) a site visit can be initiated at that time.

The Quality Improvement Coordinator or the Provider Relations Representative will schedule the

site visit with the practitioner office within thirty days of receipt of the member complaint. Action

plans will be instituted with offices that do not meet goals. Follow-up evaluations will occur at least

every six months until deficiencies are corrected. All site visit evaluations conducted triggered by

these member complaint criteria will be reported to the Medical Director and the Credentialing

Committee.

Complaint data are collected, reviewed, and analyzed in aggregate for trends and opportunities for

improvement. Analysis of Quality of Care and Quality of Service data is presented to the Clinical

Advisory Committee for review and recommendations. Trends identified associated with providers

is forwarded to the Credentialing Committee for further review.

12.10 - Demographics, Epidemiology & Health Disparities

Annually, the Health Plans perform at least an annual analysis of membership demographics and

epidemiology. The review of this information allows for planning for network cultural/ethnic, age,

sex and linguistic adequacy and to develop and maintain relevant programs that address the needs

of the membership. Educational resources are made available to assist staff with specific member

needs. Translation services are available Coventry-wide to adequately support member needs.

12.11 - Medical Continuity and Coordination of Care

To facilitate continuous and appropriate care for members, and to strengthen continuity and

coordination of care among medical practitioners and providers, we monitors the coordination and

continuity of care across health care network settings and transitions in those settings.

Examples of information that is monitored are as follows:

Medical Record Reviews/HEDIS Medical Record Reviews

Member Complaints

Notification and movement of members from a terminated practitioner

Presence of medical consultant reports

Home Health continuing care plans

Presence of behavioral health consultant reports following primary care referral to

behavioral health

Discharge summaries post-hospitalization for behavioral health admission

12.12 - Behavioral and Medical Continuity and Coordination of Care

To facilitate continuous and appropriate care for members, and to strengthen industry continuity

and coordination of care among behavioral and medical practitioners and providers, the designated

Health Plan, in collaboration with the contracted Behavioral Health vendor, monitors the continuity

and coordination of behavioral care through assessment of the following:

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Appropriate provider diagnosis, treatment and referral of behavioral health disorders

commonly seen in primary care

Provider evaluation of the appropriate uses of psychopharmacological medications

Management of treatment of access and follow-up for members with coexisting medical and

behavioral health disorders

Provider implementation of a primary or secondary behavioral health preventive program

Encouraging members to allow behavioral health practitioner to share information with the

PCP

12.13 - Medical Record Documentation and Monitoring Compliance

Well-documented medical records facilitate communication, coordination and continuity of care,

and promotes the efficiency and effectiveness of treatment.

We require that practitioners have organized medical record keeping systems and standards for

availability of medical records. We establish medical record documentation standards and

distributes its medical record keeping and documentation standards to their practitioners through

the provider newsletter and on our website.

Provider Relations/Network Management monitors adherence to the medical record keeping and

documentation standards on all primary care practitioners and obstetrician/gynecologists at the time

of initial credentialing and when a practitioner relocates or opens a new site and in coordination

with the QI department additional monitoring when corrective action is necessary.

12.14 - Delegated Activities

We delegate specific activities based on contractual agreements. Those activities include Utilization

Management, Credentialing/Recredentialing, Member Services, Medical Record Review, and

Quality Improvement activities. There is an on-site visit by the Representative(s) from the affected

designated areas pre-contractually and annually to evaluate compliance with Coventry Health Care

of West Virginia, applicable state regulations and NCQA standards. The delegated party is

responsible for furnishing quarterly to semiannual reports of all activities with identified trends and

action taken to the Director, Network Operations. These reports are trended by the Quality

Improvement Department and reported to the Executive Quality Management Committee and

Credentialing Committee. When necessary, clinical and utilization issues are forwarded to the

appropriate committees for approval and recommendation. A copy of the delegated party’s Quality

Improvement Program description and annual evaluation is received annually. They are reviewed

and kept on file in the Quality Improvement Department.

12.15 - Health Plan Accreditation Compliance & Annual Ranking

Accreditation compliance challenges the health plan to assure its’ operations and support to

membership meet nationally recognized standards of service and facilitation of member quality

health care. Accreditation is a state bureau of insurance requirement. Participation requires full

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HEDIS monitoring of effectiveness of care and access to services, CAHPS member satisfaction

surveys and operational performance standards on an ongoing basis.

12.16 - Medicaid Program Compliance

As a Medicaid participating managed care organization, the Health Plans are responsible for

complying with CMS and state based regulatory standards requiring oversight through an external

quality review organization. This oversight involves annual auditing, record review and required

performance improvement projects. Compliance is defined through HEDIS, CAHPS and other

required monitoring.

12.17 - Annual Quality Improvement Program Evaluation, Review and Approval

The annual evaluation of the Quality Improvement Program is conducted to assess the overall

effectiveness of the Health Plans’ quality management processes. The evaluation reviews all

aspects of the Program with emphasis on determining whether the Program has demonstrated

improvements in the quality of provider care and services that are provided through the Health

Plan. The annual evaluation includes:

An assessment of whether the year’s goals and objectives were met;

A review of whether human and technological resources are adequate;

A summary of quality improvement activities and whether improvement were realized;

The impact the quality improvement process had on improving health care and services to

members;

Potential and actual barriers to achieving goals; and

Recommendations for quality improvement program revisions and modifications for the

coming year.

The annual evaluation is reviewed and approved by the Executive Quality Management Committee

and the Governing Body. The results of the annual quality program evaluation are used to develop

and prioritize the annual quality work plan for the upcoming year.

You may request a copy of our annual program evaluation to view our clinical and service

outcomes.

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13 Clinical Standards of Care

13.1 - Preventive Health Guideline Development Policy

Purpose

To identify the preventive health services that Coventry Health Care, Inc. promotes to its members

and providers, which serve as recommendations for individuals at “normal risk.” Individuals in

certain higher risk categories may require earlier or more frequent screening exams and this should

be decided through physician/patient collaboration.

Policy

Coventry Health Care, Inc. develops prevention/early detection guidelines using evidence-based

recommendations on preventive services. Guidelines address these categories of members:

Children/adolescents

Adults

Elderly members

Members who require prenatal/perinatal care

Coventry Health Care, Inc. preventive health guidelines do not reflect reimbursement or payment.

Process: Development & Updates

Coventry Health Care, Inc. developed Preventive Health Guidelines using the U.S.

Preventive Services Task Force Guide to Clinical Preventive Services, 2nd & 3rd Edition’s

(USPSTF: 1996, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 and 2010 releases).

Guidelines are developed through Corporate Medical Management Department and receive

final approval by the Vice President Medical Officer.

Coventry Health Care, Inc. Preventive Health Guidelines are reviewed at least on an annual

basis, or whenever new scientific evidence and/or regulatory changes necessitate revisions.

The Vice President Medical Officer has final review and approval of all updates made to the

Preventive Health Guidelines.

The corporate medical team of Coventry Health Care, Inc. annually adopts the CDC’s

immunization schedules recommended by the Advisory Committee on Immunization

Practices, the American Academy of Pediatrics and the American Academy of Family

Physicians and whenever any new scientific evidence and/or regulatory change necessitate

revisions.

Updates to the Preventive Health Guidelines and the CDC Immunization Schedules are

communicated from the corporate Medical Management Unit to the Health Plans QI

Departments.

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Our local health plan Clinical Advisory Committee which includes external practicing

physicians who review the guidelines as well.

Distribution

The preventive guidelines and immunization schedules are then posted to our website for public

access and to the provider portal at www.directprovider.com. These can be found on our website at

www.chcwv.com » Providers » Document Library » Preventive Health Guidelines.

The following pages outline the Preventive Service Standards.

13.2 - Clinical Practice Guidelines

Purpose

Coventry Health Care is accountable for adopting and disseminating clinical practice guidelines

that are relevant to its members for the provision of nonpreventive acute and chronic medical

services and nonpreventive behavioral health services. Coventry Health Care uses the

nonpreventive clinical practice guidelines to assist practitioners and members make decisions about

appropriate health care for specific clinical circumstances.

Policy:

Our adopted clinical practice guidelines are reviewed nationally recognized guidelines based on

current evidenced-based clinical literature and professional medical organizations. Coventry Health

Care conducts an annual review and at any time there are significant changes formally addressed.

Our review and program initiatives are based on the prevalence and severity of impact on member

health. Annual review is conducted by Coventry Corporate and locally by our Clinical Advisory

Committee which is composed of clinical staff and external practicing physicians from different

practice specialties.

The following specific clinical practice guidelines are currently adopted and available for the

following conditions:

Medical Conditions:

Asthma

COPD

Diabetes

Hypertension

Coronary Artery Disease

Heart Failure

Prenatal and Postpartum Care

Pregnancy Complications

Postpartum Depression

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Behavioral Health Conditions:

Treatment of Depression in the Primary Care Setting

Major Depression Bipolar Disorder

Pediatric Bipolar Disorder

Schizophrenia

Alcohol Abuse

Substance Abuse

Opiate Detoxification

Distribution:

Providers can access the clinical practice guidelines for these specific medical and behavioral

health conditions on our health plan website at www. chcwv.com » Providers » Document Library

» Clinical Practice Guidelines.

These Guidelines can also be accessed on the provider portal at www. directprovider.com.

A paper copy of any of our clinical standards of care can be obtained by contacting your

Coventry Health Care Provider Relations Representative.

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PREVENTIVE HEALTH GUIDELINES

The 2012 Coventry Preventive Health Guidelines review includes a review of the 2011/2012

updates to the U.S. Preventive Services Task Force (USPSTF) Guide to Clinical Preventive

Services, in addition to other recognized guidelines/recommendations compared to Coventry’s

2011 Preventive Health Guidelines. The 2012 review is inclusive of recommendations of the

Affordable Care Act of 2010, comprising previous USPSTF updates with an “A” or “B”

recommendation, in addition to guidelines supported by the U.S. Department of Health Resources

and Services Administration (HRSA) developed by the American Academy of Pediatrics.

The review is performed annually during the first quarter of the year. Section A includes a

summary of the updates to the Coventry guidelines. Full details on the recommendations can be

found in Appendix A (USPSTF), Appendix B (Alternate Sources) and Appendix C (HRSA).

A. Updates to Coventry’s Preventive Health Guidelines

Bacteriuria screening- Pregnant women- recommendation to screen for asymptomatic

bacteriuria

with urine culture for pregnant women at 12-16 weeks of gestation or at the first prenatal

visit, if later.

Source: USPSTF 2008

Removed the word strongly from:

o PregnantWoman Guideline

Dental Health - Limit sugar foods and drinks. Avoid carbonated Beverages and juice

drinks.

Source ADA and AAP 2008

Added to the following Guideline:

o 11-24 Guideline

Dyslipidemia Screening - Risk Assessment to be performed and action to follow if positive

at age 24mo, 4 yrs., 6yr, 8 yr., 10yr, Then yearly ages 11 through 17 and once ages 18

through 21. If screening conducted as part of the action, and results are normal repeat every

3-5 years.

Source: AAP 2008

Updated Guidelines include:

o 0-10 Guideline

o 11-24 Guideline

Gonorrhea screening: women - Screen all sexually active women, including those who are

pregnant, for gonorrhea infection if they are at increased risk for infection.

Source USPSTF 2005

Updated Guideline include:

o PregnantWomen Guideline

o 11-24 Guideline

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o 25-64 Guideline

HCT/HGB Screening - Screen for iron deficiency anemia at 12 months. Risk assessment to

be performed and action to follow if positive at 4, 18, 24 months and yearly ages 3 through

21.

Source: HRSA/ AAP 2008


o 11-24 guideline

Hearing Loss Screening - Screen for hearing loss in all newborn infants. Risk Assessment

to be performed and action to follow if positive at well baby visits through 3 years and

annually ages 11 through 21. Rescreen at 4 yrs., 5 yrs., 6yrs, 8 yrs., 10yrs, Then yearly ages

11 through 17 and once ages 18 through 21.

Source: HRSA /AAP 2008


o 11-24 Guideline

Updated Guidelines include:

o 0-10 Guideline

HIV Screening – Strongly recommends screening all adolescents and adults at increased

risk for human immunodeficiency virus (HIV).

Source: USPSTF 2005

Added the word Strongly to:

o 11-24 Guideline

o 25-64 Guideline

Offer SerumAlpha-Fetoprotein (16-18 weeks)- Remove from Guidelines as screening for

neural tube defects during pregnancy is currently considered part of standard of care.

Source USPSTF 2012

Tuberculin Test- Risk Assessment to be performed and action to follow if positive at age

1,6,12, 18 and 24 months then yearly.

Source HRSA/ AAP 2008


o 0-10 Guideline

o 11-24 Guideline

o 25-64 Guideline

o 65+ Guideline

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Appendix A:

All USPSTF Recommendations reviewed for consideration:

Bacteriuria screening:

The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for

pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.

Grade: A Recommendation.

The USPSTF recommends against screening for asymptomatic bacteriuria in men and

nonpregnant women.

Grade: D Recommendation.

Cervical cancer screening [Listed on Guideline as Papanicolaou (Pap) Test (Women)]:

The USPSTF recommends screening for cervical cancer in women ages 21-65 years with

cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen

the screening interval, screening with a combination of cytology and human papillomavirus

(HPV) testing every 5 years.*


The USPSTF recommends against screening for cervical cancer in women younger than age

21 years.


The USPSTF recommends against screening for cervical cancer in women older than age 65

years who have had adequate prior screening and are not otherwise at high risk for cervical

cancer.


The USPSTF recommends screening for cervical cancer in women who have had a

hysterectomy with removal of the cervix and who do not have a history of a high-grade

precancerous lesion or cervical cancer.


The USPSTF recommends against screening for cervical cancer with HPV testing, along or

in combination with cytology, in women younger than age 30 years.


* Note that this recommendation will not be followed at this time. Coventry will continue to

follow the USPSTF 2003 recommendation as it is more stringent.

Gonorrhea screening: women:

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all

sexually active women, including those who are pregnant, for gonorrhea infection if they

are at increased risk for infection (that is, if they are young or have other individual or

population risk factors).

Grade: B Recommendation.

The USPSTF found insufficient evidence to recommend for or against routine screening for

gonorrhea infection in men at increased risk for infection.

Rating: I Statement.

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The USPSTF recommends against routine screening for gonorrhea infection in men and

women who are at low risk for infection (see Clinical Considerations for discussion of risk

factors.)

Rating: D Recommendation.

The USPSTF found insufficient evidence to recommend for or against routine screening for

gonorrhea infection in pregnant women who are not at increased risk for infection.

Rating: I Statement.

HIV Screening:

The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians

screen

for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for

HIV infection .


The USPSTF makes no recommendation for or against routinely screening for HIV

adolescents

and adults who are not at increased risk for HIV infection .

Grade: C Recommendation..

Offer SerumAlpha-Fetoprotein (16-18 weeks):

There is one recommendation :

Screening for neural tube defects during pregnancy is currently considered part of standard

prenatal care. The USPSTF knows of no reason at the present time to update its 1996

recommendation.

Appendix B:

Alternate Sources

Dental Health (ADA and AAP 2008):

Limit sugary foods and drinks to mealtimes.

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Appendix C:

HRSA Recommendations (Affordable Care Act)

Dyslipidemia Screening

Recommendation:

Perform risk assessment and action to follow if positive at age 24 months, 4 years, 6 years,

8 years, 10 years. Then yearly ages 11 through 17 and once ages 18 through 21. The AAP

recommends the following : This screening should occur in the context of well-child and

health maintenance visits. If values are within the reference range on initial screening, the

patient should be retested in 3 to 5 years.

Hearing Loss Screening

Recommendation remains:

Screen for hearing loss in all newborn infants. Risk Assessment to be performed and action

to follow if positive at well baby visits through 3 years and annually ages 11 through 21.

Rescreen at 4 yrs., 5 yrs., 6yrs, 8 yrs., 10yrs, Then yearly ages 11 through 17 and once ages

18 through 21.

HCT/HGB Screening

Recommendation:

Screen for iron deficiency anemia at 12 months. Risk assessment to be performed and

action to follow if positive at 4, 18, 24 months and yearly ages 3 through 21.

Tuberculin Test

There is one recommendation:

Risk Assessment to be performed and action to follow if positive at age 1,6,12, 18 and 24 months

then yearly.

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14 CoventryCares Medicaid

The rules applicable to the CoventryCares (formerly Carelink Medicaid) are essentially the same rules applicable

to the commercial HMO products throughout this Manual. Areas where the rules or processes may be different for

the CoventryCares product are listed below.

14.1 - Member Numbers, ID Cards and PCP Panel

CoventryCares member numbers are 10-digit numbers that begin with 005 and are assigned by the

CoventryCares member enrollment system. The entire number must be used for billing and inquiries. Each family

member receives a card listing his/her name, member number, Medicaid number, date of birth, PCP’s name and

telephone number, and customer service phone

number. Services that are considered “carve outs” and are paid fee for service by Medicaid are also printed on the

card. These services include prescriptions, nursing facilities, children’s dental and mental health / behavioral

medicine.

Additional facts and directions are printed on the back of the card including the 24-hour Nurseline phone number

which is available to members.

PCPs may have an open or closed panel for Medicaid members. Please contact your provider relations

representative for assistance.

14.2 - Management of After-Hours Access To Service

We provide access to care 24 hours a day, seven days a week. This benefit helps ensure overall quality and

continuity of care and prevents inappropriate and inefficient use of emergency room facilities for routine, non-

emergent care.

The PCP is responsible for directing a member’s after-hours, holiday, and weekend care. The PCP may direct a

patient to seek care at an emergency facility or give recommendations, prescribe treatments or medications until

the member can visit the PCP office.

A CoventryCares member will access care after normal working hours by contacting his or her PCP. Members

and contracted providers are advised that the PCP is to return a call for authorization of services or direct a

member’s care within 30 minutes. In the event that the 30 minutes has elapsed, the facility or member can call our

24 Hour Nurseline for assistance. 24 Hour Nurseline, staffed by registered nurses, is available to members 24

hours a day / 7 days a week including holidays at 1.888.348.1008. 24 Hour Nurseline will provide advice

regarding services such as seeking emergency care, specific health concerns, and other services needed after

regular business hours.

Emergencies should be treated immediately. An emergent medical condition is where the presenting symptoms

are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect

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the absence of immediate medical attention to result in placing the individual’s health or the health of an unborn

child in immediate jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or

part.

CoventryCares members are informed that the PCP and Coventry Health Care of West Virginia, Inc., must be

notified of any emergency by the next business day to ensure payment. True emergency care does not require any

advance notification to us prior to the delivery of services.

Every provider participating in the CoventryCares network must understand the mutual responsibility which

Coventry Health Care of West Virginia and the individual provider have for providing emergency services.

Please note the following:

After-hours care must be authorized by the next business day to ensure appropriate payment.

Members should be instructed to contact the PCP’s office for any follow-up care after an ER visit (e.g.,

suture removal, dressing change, etc.).

14.3 - Copayment Collection

CoventryCares members do not have copayments.

14.4 - Coinsurance and Deductibles

CoventryCares members do not have coinsurance or deductibles.

14.5 - Preauthorized Care

We must preauthorize certain services and supplies for CoventryCares members. The process to obtain

preauthorization is the same for commercial or CoventryCares members. Please refer to Attachment E for a list of

procedures.

Additional information concerning preauthorizations: The preauthorization list is updated by us from time to time.

If you are not sure about a certain service or injectable, or if you would like a copy of the most current listing, call

CoventryCares Customer Service at 888.348.2922.

14.6 - Patient Self-Determination Act

All providers are required to comply with the Patient Self-Determination Act (COBRA ‘90, Sections 4206 and

4751) as described below:

Maintain written policies and procedures with respect to all adult individuals receiving medical care by or

through the provider about patient rights under state law to make decisions concerning medical care,

including the right to accept or refuse medical or surgical treatment and the right to formulate advance

directives.

Provide written information to all adult individuals on patient policies concerning implementation of such

rights.

Document any moral or religious objections that would stop a member from making advance directives.

Assure this documentation is part of the member’s medical record.

Document in the patient’s medical record whether or not the individual has executed an advance directive.

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Not condition the provision of care or otherwise discriminate against a patient based on whether or not

he/she has executed an advance directive.

Ensure compliance with requirements of state law (whether statutory or recognized by the courts)

concerning advance directives.

Provide (individually or with others) education for staff and the community on issues concerning advance

directives.

14.7 - Customer Service/Member Eligibility/Claims Status

We have a voice response system available to providers 24 hours a day, 7 days a week to check member eligibility

and the status of a claim. Providers may access this system by calling 800.348.2922. Providers also have access to

our provider website www.directprovider.com

Providers may also contact Molina at 888.483.0793 or at the Molina website www.wvmmis.com/ welcome.screen

14.8 - Members’ Rights and Responsibilities

We are committed to treating members in a manner that respects their rights as members. CoventryCares members

have the right:

To be treated with respect and dignity.

To privacy and confidentiality.

To private health care visits and to have their health records kept confidential.

To tell us about any problems they have with u or our providers. We will look into the problem and

address it.

To get details about our services, CoventryCares benefits and CoventryCares providers

To get information about their rights and responsibilities.

To be a part of decisions the member and doctor make about their health care. The CoventryCares doctor

is required to discuss treatment alternatives and all appropriate treatment options available to the member.

To enroll with other HMOs that contract with BMS.

To choose and change their PCP.

To request and receive a copy of their medical records.

To see and correct all personal information collected by us.

To tell the doctor that they do not want treatment.

Not to be held or kept away from others as a way to force, punish or pay back or just for our convenience.

To be able to exercise these rights without being treated badly by Coventry Health Care of West Virginia

or its CoventryCares providers.

To get information from us in a way that meets their needs based on their condition and/or in a way they

can understand.

To make suggestions for what should be included as member rights and responsibilities.

To ask for a description of all types of payment arrangements that we use to pay providers for health care

services for CoventryCares members. These payment arrangements may include withholds, bonus

payments, capitation, and fee-for-service discounts. We must respond to the member request in 10

working days.

To be told at least 30 days before there are any program or site changes that affect the member.

Our members have the responsibility for cooperating with providers of health care services:

To carry their CoventryCares ID card at all times and show it to all health care providers.

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To let providers know when their CoventryCares coverage ends.

To give information needed by health care providers so the providers can treat them.

To make and keep doctor visits and to call ahead to cancel when they cannot make it.

To get medical care from providers in the CoventryCares network. This does not apply to care for family

planning or care for emergencies.

To follow instructions given by their doctor on how to stay healthy, get the needed immunizations for

themselves and their children, and know what care they should get for any medical conditions they may

have.

To call CoventryCares Customer Service at 888.348.2922; TDD 866.784.7472 if they lose their ID card.

To call CoventryCares Customer Service if they do not get their card in the mail.

To let CoventryCares Customer Service and their local Department of Health and Human Resources

(DHHR) know if they change their name, address or phone number or have a change in personal

information like birth, marriage, death or other health insurance. This allows CoventryCares Customer

Service to reach the member to send information.

To ask their doctor to get preauthorization for care when required.

To learn how to tell the difference between emergencies and when they need urgent care. Know where and

how to get care for each.

To use the emergency room only for emergencies.

To follow the advice of their PCP.

To learn about prescribed drugs. Know the reasons for taking them. Know how to take them

To transfer their health records to their PCP.

To call CoventryCares Customer Service at 800.348.2922; TDD 866-784-7472 to change their PCP

before they get care from a new PCP.

14.9 - Loss of Eligibility for Medicaid

CoventryCares members may lose eligibility therefore it is important to verify eligibility every time a Medicaid

member sees you for care. The following events may indicate that a patient is no longer enrolled in

CoventryCares:

Loss of eligibility for Medicaid or for participation in Medicaid managed care.

The beneficiary’s permanent residence changes to a location outside the MCO’s Medicaid service area.

Continuous placement in a nursing facility, State institution or intermediate care facility for the

intellectually challenged for more than 30 calendar days.

Error in enrollment.

Upon the beneficiary’s death.

14.10 - Communication Standards

We want to ensure that documents for its CoventryCares members, such as the enrollee handbook, are

comprehensive, yet written easily enough for everyone to understand. Before publication, all documents achieve a

Flesch total readability of 6th grade or lower.

We have contracts with Language Line Translation Services for members with limited English proficiency. If our

CoventryCares members contact us about their coverage benefits we will conference call Language Line to

translate for these members.

For individuals with hearing impairment, we have a dedicated TDD telephone line. CoventryCares members may

contact us at 866.784.7472.

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As a provider of services, you should be aware of members who do not speak English or who have hearing

impairments. Under Title VI of the Civil Rights Act and the Federal Rehabilitation Act, interpreter services must

be available to ensure effective communication regarding treatment, medical history, or health education. We will

arrange and pay for trained professionals when technical, medical, or treatment information needs to be discussed

with the CoventryCares member. Providers must offer the member access to interpreter services, even when the

member brings a friend, or family member to interpret. In this event, the member must still be offered interpreter

services and be informed that the services are offered at no charge; the friend or family member should not be

used to interpret unless specifically requested by the member, after having been advised of the availability of free

interpreter services through us. Please call CoventryCares Customer Service at 888.348.2922 to request either

language or signing interpreter services for CoventryCares members. If interpreter services are declined,

document this in the members’ medical record. This documentation could be important if a member decides that

the interpreter he or she has chosen has not provided him/her with full knowledge regarding his/her medical

history, treatment or health education.

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During our credentialing process, we ask you what other languages you speak so that we may refer our members

with special language needs to you. If you have not updated us on your language capabilities, please contact your

Network Management Representative at 800.348.2900 in Charleston or at 800.896.9612 in Wheeling.

14.11 - Special Needs Populations

We consider the following categories of enrollees to be special needs populations:

Children with special physical and mental health care needs

Individuals with a physical disability

Individuals with delays in development or a developmental disability

Individuals with HIV/AIDS

CoventryCares members with a disabling condition or chronic illness may have a specialist as a PCP. If you have

a member that would benefit from a specialist acting as a PCP or you are a specialist that is willing to be a PCP

for a member, please contact CoventryCares Customer Service 800.348.2922 to make the request.

14.12 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Early and periodic screening, diagnosis and treatment is a federally mandated comprehensive child health program

for Medicaid enrollees. We covers EPSDT services for CoventryCares enrollees under the age of 21. We notify

Medicaid members about EPSDT through the member handbook, newsletters, and an EPSDT reminder mailing

program.

Network providers shall be subject to our documentation requirements for EPSDT services. EPSDT services shall

also be subject to the following additional documentation requirements:

Per the state guideline, use procedure code 96110 with a modifier code EP to indicate an EPSDT care visit.

The medical record shall indicate which age-appropriate screening was provided in accordance with the

periodicity schedule.

EPSDT Screenings

Providers should use the following guidelines to provide comprehensive EPSDT services to CoventryCares

members.

Comprehensive, periodic health assessments, or screenings, from birth through age 20, at intervals which

meet reasonable standards of practice, as specified in the EPSDT medical periodicity schedule established

by the DHHR. The medical screening shall include:

a comprehensive health and developmental history, including assessments of both physical and mental

health development

a comprehensive unclothed physical examination, including: vision and hearing screening; dental

inspection; and a nutritional assessment

Appropriate immunizations according to age, health history and the schedule established by the Advisory

Committee on Immunization Practice (ACIP) for pediatric vaccines. Immunizations shall be reviewed at

each screening examination, and necessary immunizations must be administered.

Appropriate laboratory tests at participating lab facilities. The following recommended sequence of

screening laboratory examinations should be provided by CoventryCares’s participating providers;

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additional laboratory tests may be appropriate and medically indicated (e.g., for ova and parasites) and

shall be obtained as necessary.

hemoglobin/hematocrit

urinalysis

tuberculin test (for high-risk groups)

blood lead assessment using blood level determinations as part of scheduled periodic health screenings

appropriate to age and risk must be done for children according to the following schedule:

o between 12 months and 24 months of age.

o between the ages of two to six years if the child has not previously been screened for lead

poisoning.

All screening shall be done through a blood lead level determination. Results of lead screenings, both positive and

negative results, shall be reported to the local DHHR office.

Health education/anticipatory guidance

Referral for further diagnosis and treatment or follow-up of all correctable abnormalities uncovered or suspected.

EPSDT screening services shall reflect the age of the child and shall be provided periodically according to the

following schedule:

neonatal exam

under 6 weeks

2 months

4 months

6 months

9 months

12 months

15 months

18 months

30 months

2 years

annually from age 3 through 20 years

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EPSDT Vision Services

Participating providers should perform periodic vision assessments appropriate to age, health history and risk,

which includes assessments by observation (subjective) and/or standardized tests (objective), provided at a

minimum according to the DHHR EPSDT periodicity schedule. At a minimum, these services shall include

diagnosis of and treatment for defects in vision, including eyeglasses. Vision screening in an infant shall mean, at

a minimum, eye examination and observation of responses to visual stimuli. In an older child, screening for visual

acuity shall be done.

EPSDT Hearing Services

All newborn infants will be given a hearing screening before discharge from the hospital after birth. Those

children who do not pass the newborn hearing screening, those who are missed, and those who are at risk for

potential hearing loss should be scheduled for evaluation by a licensed audiologist.

Participating providers should perform periodic auditory assessments appropriate to age, health history and risk,

which includes assessments by observation (subjective) and/or standardized tests (objective), provided at a

minimum at intervals recommended in the DHHR EPSDT periodicity schedule. At a minimum, these services

shall include diagnosis of and treatment for defects in hearing, including hearing aids. Hearing screening shall

mean, at a minimum, observation of an infant’s response to auditory stimuli. Speech and hearing assessment shall

be part of each preventive visit for an older child.

EPSDT Dental Services

Dental screening in this context shall mean, at a minimum, observation of tooth eruption, occlusion pattern,

presence of caries, or oral infection. A referral to a dentist at or after one year of age is recommended. A referral

to a dentist shall be mandatory at three years of age and annually thereafter through age 20.

Other EPSDT Services

Participating providers should perform such other medically necessary health care, diagnostic services, treatment,

and other measures as needed to correct or ameliorate defects and physical and mental illnesses and conditions

discovered by the screening services.

14.13 - Transportation

Our Medicaid product covers emergency transportation for Medicaid members. For non-emergent transportation

the member is covered under WV Medicaid’s Fee-For-Service program and must contact their local DHHR office

to arrange services.

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14.14 - Maternity

The length of stay for a vaginal delivery is two nights. The length of stay for a cesarean section delivery is four

nights. For mothers or babies whose medical condition warrants additional days, preauthorization is required by

us. Shorter stays shall occur where patient and physician agree.

Benefits for inpatient care and a home visit(s) are determined in accordance with the criteria outlined in the most

current version of the “Guidelines for Perinatal Care” prepared by the AAP and ACOG or the “Standards for OB/

GYN Services” prepared by ACOG. We are allowed a six-month period to incorporate any changes in these

guidelines or standards in its procedures. If the procedure outlined below is found not to be in accordance with

these guidelines and standards, then the conflicting procedure in the guidelines and standards prevails.

Each expectant mother is mailed information during her pregnancy that includes a request to notify us of the

baby’s physician. In addition, we send mothers-to-be a Pregnancy Health packet which includes information on

the stages of pregnancy, eating smart for two, and provides a list of community classes and resources.

Newborn Enrollment

Newborn children of eligible members will be automatically enrolled with the mother’s health plan, unless

mothers choose a different health plan for their child. Newborns will be enrolled in the plan on birth month for a

minimum of 60 days starting with the day of birth.

To maintain Medicaid eligibility, newborns must have their own Medicaid numbers before the end of the birth

month, plus two month time frame. To ensure that you will continue being paid for services, you should remind

mothers to contact their local DHHR office to obtain a Medicaid number for their child.

14.15 - Abortions

CoventryCares will cover a pregnancy termination determined to be medically necessary by the attending

physician in consultation with the patient in light of physical, emotional, psychological, familial, or age factors (or

a combination there of) relevant to the well-being of the patient.. All federal and state laws regarding this benefit

must be adhered to and shall comply with the requirements of 42 CFR 441. Subpart E.

14.16 - Sterilization/Hysterectomy

CoventryCares will cover a sterilization or hysterectomy determined to be medically necessary by the attending

physician in consultation with the patient.

All federal and state laws regarding this benefit must be adhered to, ensuring the completion of the required

forms, and shall comply with the requirements of 42 CFR 441. Subpart F.

The required forms are located at http://www. svmmis.com/contentDelivery/forms.screen.

Claims including sterilization or hysterectomy procedures must include the state required consent form attached as

notes. All sterilization or hysterectomy claims submitted without the attached consent form will be denied.

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14.17 - Division of Surveillance and Disease Control Reporting

Health care providers are required to report certain diseases by state law. This is to allow for both disease

surveillance and appropriate case investigation/ public follow-up. The three primary types of diseases that must be

reported are:

Sexually Transmitted Disease Program: Per WV Statute Chapter 16

4-6 and Legislative Rules Title 64, Series 7, providers must report cases involving a sexually transmitted disease

to the Division of Surveillance and Disease Control.

Tuberculosis Program: Per WV Statute Chapter 26-5A-4 and WV Regulations 16-25-3, providers must report

individuals with diseases caused by M. tuberculosis to the WV Bureau for Public, DSDC, TB Program.

Communicable Disease Program: Per WV Legislative Rules Title 6-4, Series 7, providers must report cases of

communicable disease noted as reportable in West Virginia to the local health departments in the appropriate time

frame and method outlined in legislative rules. Per legislative rule, reports of category IV diseases, including HIV

and AIDS are to be submitted directly to the state health department, not to local jurisdictions.

14.18 - Routine Childhood Immunizations

Medicaid enrollees aged 0 through 18 are eligible for vaccines through the West Virginia Vaccines for Children

Program (VFC). Primary Care Physicians who administer childhood immunizations for Medicaid members must

enroll in the West Virginia Vaccines for Children Program. When a Medicaid member aged 0 through 18 needs

immunizations, you may obtain these immunizations free from DHHR. You should only bill us for administering

this drug. If you run out of VFC vaccinations, you may use your private stock for Medicaid members and ask the

DHHR to reimburse you.

14.19 - Claims Filing Procedures

Submit charges on an HCFA 1500 Health Insurance Claim form (or UB92 OR UB04 if applicable) directly to the

Claims Department.

Use a separate claim form for each provider.


Submit one claim for all services provided in the same day.

Submit original form to us; keep a copy for your files.


When applicable, write other insurance information on the claim form. When we are secondary, please

attach the primary carrier’s Explanation of Benefits (EOB) to the claim.

Include primary diagnosis and all pertinent secondary diagnosis information.

Include the complete National Provider Identifier (NPI), CoventryCares provider number, Medicaid

provider number, and provider tax identification number.

Include member’s name, CoventryCares number, Medicaid number, gender and date of birth.

Dates of service.

Type of service.

Charges and units.

Signature of treating provider.

Bill type

Place of Service

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Procedure Code

Billing Name, address, zip code, and phone number

Discharge status

Please note any special circumstances, and/or include office notes with claims submitted for services that require

special consideration. Remember to include:

Authorization Number for hospitalization, outpatient hospital services, and other services or procedures

requiring authorization.

Authorization Number for services performed by out-of-network providers.

CPT Procedure Codes - unlisted codes must be accompanied by description of service, test, or procedure

before payment will be considered.

ICD-9-CM Diagnosis Code, (four or more digits must be used when required by the guidelines set forth in

the most recent ICD-9-CM coding book).

Modifiers if appropriate.

The accuracy and completeness of claims is necessary to help ensure correct payment in a timely manner.

Initial Submission of Claims: Claims for CoventryCares members should be sent to:


Attn: CoventryCares Claims Department

P.O. Box 7373

London, KY 40742-7373

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14.20 - Electronic Claims

If submitting claims electronically, please use number 25140 as the Payer ID number.

The regulations promulgated pursuant to the Health Insurance Portability and Accountability Act (HIPAA)

requires that we comply with Electronic Data Interchange (EDI) standards for health care as established by the

Secretary of Health and Human Services. In support of HIPAA and its goal of Administrative Simplification, we

encourage physicians and medical providers to submit claims electronically. Electronic claims submission can

have significant, positive impact on the productivity and cash flow for your practice:

EDI reduces the paperwork and costs associated with printing and mailing paper claims.

EDI reduces the time it normally takes for us to receive a claim by eliminating mailing time.

EDI reduces the delays due to incorrect claim information by returning these errors directly to you through

the same electronic channel. These claims can be corrected and re-submitted.

Electronic claim submission improves claim accuracy by decreasing the chance for transcription errors and

missing/incorrect data.

EDI claims can be tracked and monitored through claim status reports received electronically.

Electronic claim submission to us is easy to establish. Providers can submit directly to Emdeon. Electronic claim

submissions will be routed through Emdeon who will review and validate the claims for HIPAA compliance and

forward them directly to us. Contact your Provider Relations Representative to begin the process. You can also

contact Emdeon directly and Emdeon can provide the electronic requirements and set-up instructions. Providers

should call 302.283.6570 for information on direct submission to Emdeon or problems with EDI filing.

EDI claim submitters should review our EDI Exclusion List and Electronic Claim Submission Requirements. We

use the ANSI X12N 837 v4010 and v4010A1 implementation guides that have been established as the standard

claim transactions for HIPAA. The official implementation guides for claim transactions are available

electronically from the Washington Publishing Company website: www.wpc-edi.com.

We encourage and recommend regular review of all EDI Acknowledgement and Reject Reports returned to you.

For more information on electronic claims submission, please visit our website at

www.chcwv.com » Providers » Claims Information.

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14.21 -Adjustment Requests

When filing an adjustment or a corrected claim, please use the address listed below. Adjustment requests must be

received by us within 365 days of the date of service of the claim.

Coventry Health Care, Inc. Attn: Adjustments

P.O. Box 7373

London, KY 40742-7373

Information and Adjustments

A Claim Inquiry/Adjustment Request Form should be used whenever resubmitting a claim. The form allows you

to put in writing your inquiry about a claim. Attaching this form to resubmitted claims helps us process and/or

review requests in a timely manner. Please contact the Provider Relations Department for Claim

Inquiry/Adjustment Request Forms. For your convenience, a form is enclosed as Attachment C to be used for

Adjustments.


Any service or supply that is not medically needed or is not a covered service.

Care from providers not in the CoventryCares network, except for family planning services or services

received in an emergency.

Care you get from any provider when the care was not preauthorized by us as required in this Handbook.

Administrative services such as phone calls; filling out forms; copying and/or transfer of health records;

returned checks; stop-payment on checks; and other such clerical charges.

School based services. These are therapy, skilled nursing and psychiatric/psychological services outlined

in the Individual Education Plan (IEP) and provided to children who qualify under the federal Individuals

with Disabilities Act.

Services for, or related to, eye surgery for the purpose of fixing refractive errors, such as radial keratotomy

and other refractive eye surgery are not covered

Exams needed only for insurance, employment, school, sports or camp, unless these exams are part of a

covered routine health assessment. Shots needed for travel and work unless these shots comply with

accepted medical practices

Osteopathic manipulation; biofeedback therapy; and acupuncture therapy

Care at an assisted living facility or nursing facility. Care for rest cures, respite, domiciliary, residential or

convalescent care. Private duty nursing except as (1) covered under your home health care benefit; and (2)

provided for children when medically needed.

Fertility services, including but not limited to, in-vitro fertilization, embryo transplants and fertility drugs.

The reversal of sterilization and complications that result from such procedures.

Procedures, services and supplies related to sex transformations or sexual dysfunction.

The cost of care for problems that federal, state or local laws require be treated in a public center. Care or

supplies provided or arranged by a government center when no charge would be made if you had no health

benefits insurance.

The cost of health care covered under the Medicare program or other insurance.

Care for military service connected disability and conditions that you are entitled to as long as these

centers are reasonably easy for you to get to.

Health care or remedial care services by Christian Science nurses are not covered.

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Health care services at Christian Medical, surgical or health care supplies that are experimental or investigational

are not covered.

Care or supplies are experimental or investigational if they meet any of the following:

They are in the testing stage or in early field trials on animals or humans.

It is under clinical investigation by health professionals or is undergoing clinical trial by any governmental

agency, including but not limited to, the Department of Health and Human Services or the Food and Drug

Administration.

It is a drug for the treatment of a specific type of cancer that is not FDA-approved, is not approved for one

type of cancer and the drug has not been recognized as safe and effective for treatment of the specific type

of cancer for which the drug has been prescribed in any of the Standard Reference Compendia. It is a drug

for the treatment of a specific indication that is not FDA-approved, the drug has not been approved by the

United States Food and Drug Administration for at least one indication and the drug is not recognized for

treatment of the covered indication in one of the Standard Reference Compendia or in substantially

accepted peer-reviewed medical literature.

It is a health product or service that is subject to Investigational Review Board (IRB) review or approval.

It does not have required final federal regulatory approval for commercial distribution for the specific

indications and methods of use assessed or has not been approved by the Centers for Medicare and

Medicaid Services for coverage by Medicare.

It is a health product or service that is not considered to have demonstrated value based on clinical

evidence reported by Peer-Review Medical Literature and by generally recognized academic experts.

We do not provide the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

We do not provide transportation for members to pick up WIC checks. The DHHR provides the WIC

Program. Expectant mothers will receive information on WIC in their CoventryCares Baby Matters

material. If members want to find out more about WIC, they should call their local DHHR office.

Care that is not medically necessary. We may determine this in its sole discretion. Again, a member’s

doctor has the right to request an appeal to a decision by sending a request to our Utilization Management

department or sending a request directly to DHHR. This process is described in Section 11 of this manual.

Any type of health service, supply or treatment not (1) specifically listed or (2) covered by the DHHR.

Some services are covered under Medicaid but not through CoventryCares benefits. Call CoventryCares Customer

Service at 800.348.2922; TDD 866.784.7472 for information on these services. You may also call the DHHR to

obtain a list of these services.

14.23 - Encounter Claims and Other Electronic Data Submission

We submit all claims related information to WV Medicaid on a monthly basis. We must ensure that all electronic

data submitted to the DHHR are timely, accurate and complete. An encounter is any service received by the

CoventryCares member and paid for by us. We submit encounters/claims for all services it covers, including, but

not limited to, inpatient and outpatient procedures, EPSDT screens, durable medical equipment (DME), and home

health services. Due to this requirement, we request that all providers follow our filing procedures listed above.

A process is available for reconsideration of claims denied for failure to file within the deadline. Information,

including copies of claims and documentation of previous filing(s) supporting the request, should be sent to:

Coventry Health Care, Inc.

Attn: CoventryCares Claims Department

P.O. Box 7373

London, KY 40742-7373

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In the event you are not satisfied with the outcome, you may initiate the Appeal/ Hearing Guidelines procedure

included in this manual.

14.24 - Status of Claims

You may call the Customer Service Department to check the status of claims. Customer Service Representatives

are available to answer any claim inquiries Monday through Friday between 8:00 a.m. and 5:00 p.m. The number

is 800.348.2922. This information is also available through the voice response system at the number listed above.

We recommend that claims status inquiries not be made unless it has been at least 45 days since the date of

submission.

14.25 -Coordination of Benefits

CoventryCares members may have other primary health insurance. If a CoventryCares member has other health

insurance, please contact Customer Service and provide the coverage information. This coverage from other

insurance carriers may duplicate or overlap with their Medicaid coverage.

This additional coverage may stem from a spouse’s health insurance, Workers’ Compensation, motor vehicle

insurance, Medicare, or Veteran’s Administration benefits. The primary insurance will pay first; Medicaid is

always the payer of last resort.

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14.26 - Maternal/Child Case Management

This program is dedicated to promoting healthier babies and protecting the well being of the mother. As a

member, receiving services under our CoventryCares program, all expectant mothers are eligible to receive

Pregnancy Health Guide handouts. The Pregnancy Health Guide packet provides information on healthy baby

basics, understanding health care coverage and a list of community classes and resources available to expectant

mothers in an easy to read format.

The educational information included in the Pregnancy Health packet follows an expectant mother through

prenatal care, delivery, and post-partum care.

At the member’s first prenatal visit, the physician will complete the Maternity Notification and Risk Screen

(Attachment B) and fax a copy to us at 1.866.373.0274. The physician may substitute the state mandated West

Virginia Prenatal Risk Screening Instrument in place of our form. The OB Case Manager will evaluate the risk

factors on this form. Case Management and educational interventions will be provided to the member, as

appropriate. This care is designed to serve as a health benefit and is not a substitute for or intended to interfere

with the mother’s current medical care.

Other Case Management Services:

If you have any questions on the Disease Management Programs or Case Management please contact the Case

Management Division of Health Services at 1.888.388.1744. The Case Managers practice in accordance with

applicable laws regarding patient confidentiality and the release of information. Ethical principles guide their

practice with respect for the autonomy, dignity, privacy, and rights of the members.

14.27 - Providers Excluded from Participation in Federal health Care Programs

We are prohibited from participating with or entering into any provider agreement with any individual or entity

that has been excluded from participation in federal health care programs, including Medicare, Medicaid or the

Children’s Health Insurance Program.

The federal Health and Human Services – Office of Inspector General (HHSOIG) has an online exclusions

database available at http://exclusions.oig.hhs.gov/. It is a comprehensive listing of individuals and firms that are

excluded from participation in federal health care programs. This database allows providers to screen their

practice, managing employees, contractors, etc., to determine whether any has been excluded from participating in

federal health care programs.

Providers are encouraged to check their information in the exclusions database on a monthly basis. Providers must

immediately report to us any exclusion information discovered.

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15 CoventryOne

As discussed in Section 7 of the Provider Manual, CoventryOne is a PPO product offered to individuals and

families through a Non-Employer Group Trust, underwritten by Coventry Health and Life Insurance Company.

This PPO policy offers coverage for:

Preventive Care

Routine Wellness Exams

Immunizations

Hospital Care

Outpatient Care

Urgent and Emergency Care

Prescription Drugs (including a mail order program)

Behavioral Health care

Here are some ways CoventryOne is different from our traditional employer group sponsored plans.

Pre-existing Conditions

For Members age 19 and older, coverage will be excluded for pre-existing conditions. Any such exclusion applies

to conditions which the member received or were recommended to receive medical advice, diagnosis, care, or

treatment from a physician or other licensed health care provider in the six months prior to the member’s effective

date of coverage. The services related to the pre-existing condition will not be covered for a period of time no

greater than the first 12 months of the member’s coverage under a CoventryOne benefit plan. However, if the

member had Creditable Coverage and had not experienced a lapse in such coverage of more than 63 days, we will

shorten the 12-month pre-existing condition exclusion period by the aggregate amount of time in which the

member had Creditable Coverage.

Maternity/Obstetrical Care

Coverage for maternity/obstetrical care is available with the purchase of a maternity rider. This is not standard

coverage for all CoventryOne members.

Customer Service

Customer Service can be reached by calling 866.364.5663 for questions regarding a CoventryOne member’s

benefits.

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Submission of Claims

CoventryOne claims should be sent to:

CoventryOne

Attn: Claims Department

P.O. Box 7704

London, KY 40742

Adjustment Requests

When filing an adjustment or a corrected claim, please use the address listed below. Adjustment requests must be

received by Coventry Health Care within the time frame set out in your provider agreement for timely filing.

CoventryOne

Attn: Adjustments

P.O. Box 7704

London, KY 40742

Administrative and UM Appeals Address

All CoventryOne administrative or UM appeal requests should be mailed or faxed to:

Appeals Coordinator

CoventryOne

P.O. Box 1711

Charleston, WV 25326

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16 Coventry Health Care, Inc.

For questions pertaining to members with Coventry National, First Health and Mail Handlers, please visit our

website at www.coventryhealthcare.com. There you will find up to date information related to claims payment,

billing information, and member eligibility. Should you have any additional questions, please contact your

Provider Relations representative.

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17 Pharmacy Services-Coventry Cares of WV

We will expand our drug formulary to include new products approved by the Food and Drug Administration

(COMAR 10.09.67.04D(3)) in addition to following the State of West Virginia’s Preferred Drug List (PDL) AND

maintaining drug formularies that are at least equivalent to the standard benefits of the West Virginia Medicaid

program. This requirement pertains to new drugs or equivalent drug therapies, routine childhood immunizations,

vaccines prescribed for high risk and special needs populations and vaccines prescribed to protect individuals

against vaccine-preventable diseases. If a generic equivalent drug is not available, new brand name drug rated as P

(priority) by the FDA will be added to the formulary. Coverage may be subject to preauthorization to ensure

medical necessity for specific therapies. For formulary drugs requiring preauthorization, a decision will be

provided in a timely manner so as not to adversely affect the enrollee’s health and within two business days of

receipt of necessary clinical information but not later than 14 calendar days from the date of the initial request. If

the service is denied, CoventryCares of West Virginia will notify the prescriber and the enrollee in writing of

the denial (COMAR 10.09.71.04).

When a prescriber believes that a non-formulary drug is medically indicated, we have procedures in place for non-

formulary requests (COMAR 10.09.67.04F(2)(a)). The state expects a non-formulary drug to be approved if

documentation is provided indicating that the formulary alternative is not medically appropriate. Requests for

non-formulary drugs will not be automatically denied or delayed with repeated requests for additional

information.

Pharmaceutical services and counseling ordered by an in-plan provider, by a provider to whom the enrollee has

legitimately self-referred (if provided on-site), or by an emergency medical provider are covered, including:

Legend (prescription) drugs;

Insulin;

Contraceptives;

Hypodermic needles and syringes;

Select OTC products when accompanied by an prescription would be covered;

Enteric coated aspirin prescribed for treatment of arthritic conditions;

Nonlegend ferrous sulfate oral preparations;

Some nonlegend multi-vitamin with iron combinations are covered on the formulary;

Lifescan® lancets, test strips, and syringes . (Lifescan® products only);

Medical supplies for compounding prescriptions for home intravenous therapy;

Most Mental health drugs are on BMS PDL;

Most HIV/AIDS drugs are covered

CoventryCares of West Virginia drug utilization review program is subject to review and approval by WV

Bureau of Medical Services and is coordinated with the drug utilization review program of the Specialty Mental

Health Service delivery system.

Limitations: neither the State nor the MCO cover the following:

Prescriptions or injections for central nervous system stimulants and anorectic agents when used for

controlling weight; or

Non-legend drugs other than select OTC products, insulin and enteric aspirin ordered for treatment of an

arthritic condition.

Medications to treat erectile dysfunction

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The State of WV mandated PDL and Prior Authorization Criteria is on the web.

CoventryCares of WV formulary is also available on the web.

http://www.dhhr.wv.gov/bms/Pharmacy/dur/Documents/Preferred%20Drug%20List/WV_PDL01302013v2013_2d.pdf

http://chcmedicaid-westvirginia.coventryhealthcare.com/for-members/benefits-and-services/prescription-formulary/index.htm

http://chcmedicaid-westvirginia.coventryhealthcare.com/for-members/benefits-and-services/prescription-formulary/index.htm

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18 Medicare

18.1 What is Medicare? Medicare is a federal health insurance program established in 1965 as an amendment to the Social Security Act. It provides

hospital (Part A) and supplemental medical (Part B) coverage for people 65 years of age and older, certain disabled people,

and those of any age with End Stage Renal Disease (ESRD).

The Medicare Program is administered by The Center for Medicare and Medicaid Services (CMS), of the U.S. Department

of Health and Human Services (DHHS).

18.1.1 What is Advantra HMO?

Advantra HMO is a Medicare Advantage (MA) HMO Program that includes all the benefits of original Medicare coverage

plus many extra benefits offered to HMO Members. These benefits may include preventive care, vision exams and

pharmacy coverage, depending on the Member's plan.

Advantra Members may pay monthly premiums for their HMO coverage. However, the Advantra Member is required to

continue paying their Medicare Part B premium.

Coventry Health Care of WV (CHCWV) has entered into a Medicare Advantage (MA) HMO Contract with CMS. This

contract authorizes CHCWV under the Advantra product name to provide comprehensive health services to people who are

eligible to receive Medicare benefits and who choose to enroll with Advantra. Advantra assumes full financial risk for the

continuing health care of the Medicare Member in return for a prepaid monthly payment from CMS. Because these

payments are federal funds, Advantra and its contracted entities are obligated to comply with certain laws applicable to the

Medicare Program.

HOW DOES THE PROGRAM WORK?

Advantra HMO Members must choose a Primary Care Physician (PCP) from the Advantra contracted network. The

Member’s choice of PCP usually determines which delivery system, hospital and specialists he/she will use. A Member

may change PCPs monthly and benefit plans once a year during the annual election period.

Advantra HMO Members do not need to have a referral from the PCP to seek specialty care. However, select services may

require prior authorization. Members are advised to coordinate all of their health care needs through their PCP to monitor

their health care progress.

The Primary Care Physician or Specialist will include the Member in the planning and implementation of their care and will

have input in their proposed treatment plan.

Advantra will not pay for services that have not been authorized (if authorization is required) or that have not been provided

by an “in-network” provider.

18.1.2 What is Advantra PPO?

Advantra PPO is a Medicare Advantage (MA) Preferred Provider Organization (PPO) Program that includes all the benefits

of Original Medicare coverage, plus many extra benefits offered to PPO Members, such as preventive care and prescription

drug coverage.

Coventry Health and Life Insurance Company D/B/A Coventry Health Care of WV (CHCWV) has entered into a

Medicare Advantage (MA) PPO contract with CMS. This contract authorizes CHCWV under the Advantra

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product name to provide comprehensive health services to people who are eligible for Medicare benefits and who

choose to enroll in Advantra’s PPO program. The PPO Program assumes full financial risk for the continuing

health care of the Medicare Members in return for a prepaid monthly payment from CMS. Because these

payments are federal funds, Advantra and its contracted entities are obligated to comply with certain laws

applicable to the Medicare Program.

HOW DOES THE PROGRAM WORK?

The Advantra PPO offers more flexibility and choice than the Advantra HMO product. Members are not required

to select a Primary Care Physician. They can choose to visit any doctor, any specialist or any hospital at any time.

Members can use network physicians and specialists who have agreed to accept our payment to them as payment

in full. Members are responsible for copayments for a doctor or specialist visit. If Members choose Providers

outside the network, they are still eligible for benefits, but their cost share will be higher.

Advantra Members may pay monthly premiums for their coverage, must be eligible for Medicare Part A and are required to

continue paying their Medicare Part B premium.

18.2 Medicare Advantage’s Member Rights & Responsibilities

Medicare Advantage HMO and PPO Members have the right to:

Timely, Quality Care

Choose a Primary Care Provider (PCP). (Note: Contact Customer Service to learn which doctors are accepting new

patients.) (HMO only.)

Go to a women's health specialist without a referral.

Candid discussion of appropriate or Medically Necessary treatment options for their condition, regardless of cost or benefit

coverage. This discussion may also include being told about programs offered to help members manage their medications

and use drugs safely.

Know their treatment options and participate in decisions about their health care including: to know about all their choices,

to know about the risks, to have the right to say “no” to recommended treatment, and to receive an explanation if they are

denied coverage for care.

Timely access to Plan Providers and referrals to specialists when Medically Necessary.

Get appointments and covered services from the Plan’s network of providers within a reasonable amount of time. This

includes the right to get timely services from specialists when they need that type of care.

Access to Emergency Services without prior authorization when they, as a prudent layperson, acting reasonably, believe

that an emergency medical condition existed. Payment would not be withheld in cases where they sought emergency

services.

Receive urgently needed services when traveling outside the Plan’s service area or in the Plan’s service area when unusual

or extenuating circumstances prevent them from obtaining care from their Participating Provider.

Treatment with Fairness and Respect

Be treated with respect and fairness at all times, and to have their right to privacy of their medical records and personal

health information recognized.

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Exercise their rights regardless of their race, physical or mental disability, ethnicity, gender, sexual orientation, creed, age,

religion or national origin, cultural or educational background, economic or health status, English proficiency, reading

skills, or source of payment for care. Expect their rights to be upheld by both the Plan and participating Providers.

Confidential treatment of all communications and records pertaining to Member’s care. Members have the right to access

their medical records and personal health information. Access to their records and any information that pertains to the

Member must be provided in a timely manner.

Except as authorized by state or federal law or government agencies, written permission must be obtained from the

Member or their authorized representative before medical records can be made available to any person not directly

concerned with their care or responsible for making payments for the cost of such care.

Have the right to know how their health information has been given out and used for non-routine purposes.

Extend their rights to any person who may have legal responsibility to make decisions on their behalf regarding their

medical care.

Refuse treatment or leave a medical facility, even against the advice of physicians (providing the Member accepts the

responsibility and consequences of the decision).

Stop taking their medication.

Be involved in decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment.

Complete an Advance Directive, Living Will, or a Power of Attorney of Health Care and provide a copy(ies) to their

Participating Providers.

Medicare Advantage HMO and PPO Information

Be informed of Medicare Advantage policies and procedures regarding services, benefits, Providers, and Member Rights

& Responsibilities and to be notified of any significant changes.

Receive information about Medicare Advantage and Covered Services written in a manner that truthfully and accurately

provides information in a format easy to read and understand.

Know the names and participation status of physicians and health care professionals involved in their medical treatment.

Receive information about an illness, and all of the treatment options that are recommended for their condition, regardless

of the cost or whether the services are covered by our Plan.

Receive information regarding how medical treatment decisions are made by the Participating Provider, including payment

structure.

Receive information about their medications – what they are, how to take them and possible side effects, as well as how to

manage their medications and how to use them safely.

Receive “Notice of Privacy Practice” which tells about the Member’s privacy rights and explains how Participating

Providers and their Plan protect the privacy of their health information.

To ask Plan to make corrections or additions to their medical records.

Receive as much information about any proposed treatment or procedure as they may need in order to give an informed

consent or to refuse a course of treatment. Except in cases of Emergency Services, this information shall include a

description of the procedure or treatment description, the medically significant risks involved, any alternate course of

treatment or non-treatment and the risks involved in each.

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Reasonable continuity of care and to know in advance the time and location of an appointment, as well as the physician

providing care.

Get appointments and Covered Services from the Plan’s network of providers within a reasonable amount of time. This

includes the right to get timely services from specialists when that care is needed.

Be advised if any proposed medical care or treatment is part of a research experiment. Member has the right to participate,

or refuse to participate, in such research projects or experimental treatment.

Be informed of continuing health care requirements following discharge from inpatient or outpatient facilities.

Examine and receive an explanation of any bill for Non-Covered Services, regardless of payment source.

General coverage and Plan comparison information.

Plan utilization control procedures.

Receive summary of statistical data on grievances and appeals that Members have filed against the Medicare Advantage

Program and how it compares to other Medicare Advantage health plans.

Know the financial condition of Coventry Health Care of WV.

Timely Problem Resolution

Make complaints and appeals without discrimination and expect problems to be fairly examined and appropriately

addressed.

Responsiveness to reasonable requests made for services.

Receive a detailed explanation from Coventry Health Care of WV if Member believes that a Plan Provider has denied care

that Member believes he/she is entitled to receive. To receive this explanation, Member will need to ask Plan for a

coverage decision.

Members of Medicare Advantage Plans have the responsibility to:

Provide their physicians or other care providers the information needed in order to care for them.

Do their part to improve their own health condition by following treatment plans, instructions and care that they have

agreed upon with their physician(s).

Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree

possible.

Behave in a manner that supports the care provided to other patients and the general functioning of the office or facility.

Accept the financial responsibility for any copayment, deductibles or coinsurance associated with covered services

received while under the care of a physician or while a patient at a facility.

Accept the financial responsibility for any premiums associated with membership in Medicare Advantage Plans.

Review information regarding Covered Services, policies and procedures as stated in their Evidence of Coverage or

Member Handbook.

Ask questions of their Plan Provider or Medicare Advantage. If they have a suggestion, concern, or a payment issue, we

recommend they call the Medicare Advantage Member Services Department.

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Pay the full cost of any medical services or medications that are not covered by Plan or by any other insurance Member

may have.

18.3 Member Identification

Advantra gives every Advantra Member an identification card shortly after joining the Plan. The identification card

contains the following information:

Member Name

Member ID Number

Primary Care Physician's Name and Phone Number (if HMO)

Primary Care & Specialist Office Visit Copayments

Group number

Information specific to Part D (RxBin #, RxPCN, RxGrp)

Medical Claim Mailing Address

Customer Service Phone Numbers

18.4 Unique Services Advantra offers a more comprehensive benefit package for its Members compared to Fee-For-Service Medicare or Medicare

Supplement Plans. Examples of these service enhancements are described below. Please note that Advantra services have

coverage limitations that are different from the commercial product. In most cases, the coverage limitations follow

traditional Medicare Fee-for-Service coverage guidelines.

Note: Members are responsible for the copayment indicated on their identification card for certain services.

18.4.1 Emergent/Urgent Care/Renal Dialysis Services/Clinical Trials

Emergency Care

Emergency services for both inpatient and outpatient services are covered. Emergency care requires no prior authorization.

Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity

(including severe pain) such that a prudent layperson with an average knowledge of health and medicine could reasonably

expect the absence of immediate attention to result in (1) serious jeopardy to the health of the individual (or an unborn

child); (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part.

Medically necessary emergency services are covered no matter where Members are, even if they are provided by a doctor or

facility that is not contracted with Advantra.

Post-Stabilization Care is medically necessary, non-emergency services needed to ensure that the enrollee remains stabilized

from the time that the treating hospital requests authorization from Advantra until (1) the Member is discharged, (2) a

contracted physician arrives and assumes responsibility for the enrollee’s care, or (3) the treating physician and Advantra

agree to another arrangement.

Members receiving emergency services are requested to notify their Primary Care Physician for follow-up care by calling

the phone number listed on their card within 48 hours, or as soon as possible.

Coverage for Renal Dialysis Services

Renal dialysis services are covered from qualified dialysis providers when the Member is temporarily absent from the Plan’s

service area. The PCP should coordinate these services; however, no authorization is required for in network services.

Authorization is required for out of network services.

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Urgent Care

If possible, Members are instructed to call their Primary Care Physician before seeking care. However, if this is not an

option, Members may seek care from an urgent care facility or hospital emergency room and should inform their Primary

Care Physician of urgent services they have received within 48 hours, or as soon as possible.

Clinical Trials

Call 1-888-781-9422 if an Advantra Member is participating in an approved clinical trial.

18.5 Referrals/Prior Authorization

Advantra HMO

Advantra Members may self-refer to participating providers. When a Primary Care Physician is coordinating

care for an Advantra Member, he/she must refer to an Advantra participating provider. A listing of Providers can

be found in the Provider Directory at www.chcwv.cvty.com. No authorization numbers are required for specialists.

Physician should always consider member input in the proposed treatment plan. For prior authorization call the

Utilization Management Department at: 1-800-669-2202 - Fax: 1-800-247-4791.

Advantra PPO

Certain Advantra PPO services require prior authorization. Participating Providers are required to obtain the prior

authorization before performing the service. If non participating providers are being used for services, the member is

responsible for the prior authorization.

Covered services that need prior authorization, either by the Participating Provider or by the Member who is using non-

participating providers, may call the Advantra Authorization Department at 1-800-669-2202. Monday – Friday 8:30 a.m. to

5:00 p.m. Notification for the outcome of the medical necessity review will be either by telephone or fax to the provider.

Denial notices are sent if the services are not authorized.

18.5.1 Mental Health/Substance Abuse Services Prior Authorizations

MHNet Behavioral Health (MHNet) manages the mental health/substance abuse.

MHNet is available 24 hours a day, seven (7) days a week for emergencies by calling 1-866-369-8362 or during normal

business hours, Monday through Friday, 8:00 AM to 5:00 PM EST, for routine referrals to a Provider.

The Member or physician must contact MHNet prior to initiating behavioral health services to discuss prior

authorization, provider selection and benefit information.

Physicians may contact MHNet with treatment or referral recommendations.

The Mental Health Provider (MHP) is responsible for obtaining a release of information from the Member if required by

law or regulation, after which the physician will be kept apprised of the Member’s status and progress during treatment.

MHNet will assist the physician in obtaining consultation regarding behavioral health issues.

MHNet Mailing Address MHNet Mailing Address

For Clinical Operations: For Claims Submissions:

MHNet - HAPA MHNet

1211 State Road 436, Suite 355 P.O. Box 209010

Casselberry, FL 32707 Austin, TX 78720

Phone: 1-866-369-8362 Phone: 1-866-992-5246

http://www.chcwv.cvty.com/

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18.6 Member Input in Treatment Plan

Physician should always consider Member input in the proposed treatment plan. It is the right of Members to be

represented by parents, guardians, family members or other conservators for those who are unable to fully

participate in their treatment decisions. Physician is expected to educate Members regarding their health needs,

share findings of history and physician examination, discuss potential options (without regard to plan coverage),

side effects of treatment and management of symptoms; and recognize the Member has the final course of action

among clinically accepted choices.

18.7 Advance Directives

An Advance Directive is a written set of instructions expressing a Member’s wishes for medical treatment.

In Pennsylvania, an Advance Directive can take the form of a “Durable Power of Attorney for Health Care,” where a

Member names a person to make treatment decisions for him/her, or a “Living Will,” where a Member gives specific

directions to his/her health care provider.

In West Virginia, an Advance Directive can take the form of a “Medical Power of Attorney,” where the Member names a

person to make treatment decisions for him/her, or a “Living Will,” where the Member gives specific directions to his/her

health care provider.

In Ohio, an Advance Directive can take the form of a “Durable Power of Attorney for Health Care,” where the Member

names someone to make health care decisions for him/her when he/she cannot speak for himself/herself, or a “Living Will,”

where the Member gives specific directions to his/her health care provider.

When an Advantra Member visits your office, we ask that you discuss Advance Directives and document in the

medical records whether or not the Member has executed an Advance Directive.

All Advantra Members receive an Advance Directive document as part of their membership materials and then again

annually via letter. Extra copies can be obtained through your Provider Relations Representative or under the attachments

section of the manual.

18.8 AUTHORIZED REPRESENTATIVES FOR AN ADVANTRA MEMBER

A Member may appoint a representative to become their authorized representative in the event the Member is

incapacitated or incompetent. The Authorized Representative should have the appropriate documentation such as

Durable Power of Attorney, a health care proxy; appointment of guardianship required by applicable law and

regulation or another legally recognized form of appointment to act in this capacity. The Authorized

Representative documentation allows a Member’s representative to facilitate care or treatment decisions when the

Member is unable to do so because of physical or mental limitations.

18.9 IMPORTANT INFORMATION

If a Provider is informing a Member that a service is not authorized or telling a Member that the service is not

covered, the Provider must give the health plan a copy of the Member Request Form located in the attachment

section, and also must inform the Member of the right to appeal as per “Member Grievance or Medicare Appeals

Process.” Please direct any Members with questions regarding the Medicare Appeals Process or the Plan’s

Internal Grievance Process to Advantra Customer Service Organization.

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18.10 Provider Appeals Process

Advantra is authorized to make benefit determinations in accordance with Medicare guidelines for Medicare-covered

services. Advantra is obligated to ensure that services are provided in a culturally competent manner and consistent with

professionally recognized standards of health care.

These benefit determinations are never intended to limit, restrict, or interfere with the physician’s judgment or to

discriminate against the Member based on health status. In all cases, decisions regarding treatment continuation or

termination, treatment alternatives, or the provision of medical services are between the physician and the patient.

However, Advantra is not obligated to pay for unauthorized care (except in cases of emergency). If the Provider does not

agree with a medical management determination, and the matter cannot be resolved informally, Advantra maintains a

Physician Appeal Process through which all providers (physicians, facility or ancillary) may appeal a medical management

issue or benefit determination.

This process also includes provisions for Expedited Provider Appeals. Where there is a clinical necessity for a prompt

decision, the Provider can expect a determination within 24 hours of initiating the request.

18.11 Member Grievance OR Medicare Appeals Process for Medical Coverage

Advantra has a separate Customer Service Organization with service representatives for Advantra Members.

If a Member has a concern or complaint, Advantra has steps to resolve them.

There are two types of procedures for resolving enrollee complaints:

the Medicare (CMS) Appeals Process

the Advantra Internal Complaint/Grievance Process

Members have the right to make a complaint if they have concerns or problems related to their coverage or care.

“Appeals” and “grievances” are the two different types of complaints Advantra Members can make.

An “appeal” is a type of complaint made when a Member wants Advantra to reconsider and change a decision

Advantra has made about what services are covered or what Advantra will pay for a service. For example, if

Advantra refuses to cover or pay for services the Member thinks should be covered, the Member can file an

appeal. If Advantra or one of the Plan Providers refuses to give Member a service they think should be covered,

the Member can file an appeal. If Advantra or one of the Plan Providers reduces or cuts back on services the

Member has been receiving, the Member can file an appeal. If the Member thinks coverage is stopping too soon,

the Member can file an appeal.

A “grievance” is a type of complaint a Member makes if they have any other type of problem with Advantra or one of our

Plan Providers. For example, the Member would file a grievance if they have a problem with circumstances such as the

quality of care, waiting times for appointments or in the waiting room, the way the doctors or others behave, being able to

reach someone by phone to get the information they need, or the cleanliness or condition of the doctor’s office.

Grievance Procedure

Members have the right to file a grievance with Advantra if they are in any way dissatisfied with Advantra or its

Participating Providers. The following is a list of examples where the Advantra Grievance Procedure could be used:

Service complaints including waiting times, provider behavior and any complaint that does not include a liability for

payment decision.

Complaints about the quality of the services received.

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A Member is encouraged to resolve the complaint informally by working with their Member Service Representative. A

Customer Service Organization representative will review, research and resolve Member complaints in a timely and

equitable manner. Members will be informed of the resolution in writing within 30 days. Advantra may extend the time

frame by up to 14 days if the Member asks for the extension, or if Advantra justifies a need for additional information and

the delay is in the Member’s best interest.

An exception to the 30-day resolution process is the expedited grievance process. If a Member’s grievance is about a

decision not to conduct an expedited organizational or coverage determination, reconsideration, or redetermination, the

expedited grievance process will be followed. Advantra will respond to a Member’s complaint within 24 hours of his/her

contacting Advantra.

If a complaint cannot be informally resolved, Members have the option to file a written complaint for review by

Advantra’s Grievance Committee.

Advantra Providers are responsible for forwarding any medical records or necessary information when requested

by Advantra Quality Assurance.

Medicare Appeals Procedure

Every Advantra Member has the right to appeal any decision made by Advantra or a Provider about medical bills

or health care services. Specifically, a Member can use the Medicare Appeals Process whenever he/she thinks

Advantra or the Provider:

has not paid a bill; for example, bills for urgently needed care outside the service area or a denied claim from a

non-plan provider that should have been provided, arranged or paid for by Advantra; has not paid a bill in full;

will not approve or deliver care that the Member believes is covered;

has reduced or terminated services that the Member believes are medically necessary and are Covered Services.

In addition, a Member may appeal any decision to discharge him/her from the hospital too early. In this case, the Member is

given an important message from Medicare that gives him/her the information on how to appeal to a Medical Review

(Quality Improvement) Organization. The Member can remain in the hospital while the Quality Improvement Organization

reviews the decision.

The Medicare Appeal Procedure has two distinct processes:

the 72-hour appeal process

the 30-day appeal process

Expedited 72-Hour or Fast Appeal Process:

This is the process a Member may use if he/she believes that his/her health, life or ability to regain maximum function may

be jeopardized by using the standard 30-day Appeal Process. Members may not use this process to appeal claim payment

denials.

Any provider may provide oral or written support for a Member’s request for an Expedited Appeal. Unless the physician

makes a request for an Expedited Appeal on behalf of a Member, Advantra makes the determination as to whether the

request for a 72-Hour Appeal will be sent through that process or the standard 30-Day Appeal Process.

30-Day Appeal Procedure:

This is the standard process that a Member should use when he/she requests that the Plan change any decisions made related

to:

Health services, provided by a non-Advantra contracted Provider, which the Member believes should have been

provided, arranged or reimbursed by Advantra.

Services not yet rendered, but which the Member believes are covered by

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Advantra and should be provided.

Claims for services for which no written notice has been issued within 60 days after submission.

This process should be used when the Member believes that the issue he/she is appealing is not time sensitive.

Appeal Process:

The Member may file the appeal directly or may appoint a representative to file the appeal on his/her behalf. Please note the

Member may appoint any provider, whether contracted or non-contracted with Advantra, as his/her representative. In such

cases, the appointment must be submitted to Advantra Customer Service Organization in writing and it must contain:

the Member’s name and Medicare number

a short statement appointing the representative

the Member’s signature and date

the representative’s signature and date

The Member can also submit an appeal to the Social Security Administration or the Railroad Retirement Board within 60

days of the date of the notice of the initial decision by Advantra.

If Advantra upholds its decision to deny either in whole or in part, the entire file is forwarded to the CMS Appeals contractor

for their review.

18.11.1 Notice of Discharge and Medicare Appeal Rights

Hospital Inpatient Discharges

When Members think they are being discharged from the hospital too soon

When a Member is hospitalized, he/she has the right to get all the hospital care covered by Advantra necessary to diagnose

and treat his/her illness or injury. The day the Member leaves the hospital (“discharge date”) is based on when the stay in the

hospital is no longer medically necessary.

Information Members should receive during their hospital stay

When Advantra Members are admitted to the hospital, someone at the hospital should give him/her a notice called Important

Message from Medicare. This notice explains the Member’s rights:

to get all medically necessary hospital services covered;

to know about any decisions that the hospital, the doctor, or anyone else makes about the hospital stay and who will

pay for it;

that their doctor or the hospital may arrange for services the Member will need after he/she leaves the hospital;

to appeal a discharge decision.

Quality Improvement Organizations review of Advantra Members’ hospital discharge

When Advantra Members are being discharged from the hospital, someone at the hospital should give him/her a notice

called Important Message from Medicare. This notice will tell the Member:

The reason he/she is being discharged.

The date that Advantra will stop covering the hospital stay (i.e. stop paying its share of the hospital costs).

What the Member can do if he/she thinks he/she is being discharged too soon.

Who to contact for help.

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The Member (or someone he/she authorizes) may be asked to sign and date this document, to show that the Member

received the notice. Signing the notice does not mean the Member agrees that he/she is ready to leave the hospital – it only

means the Member received the notice.

Members have the right by law to ask for a review of their discharge date. As explained in the Notice of Discharge &

Medicare Appeal Rights, if the Member acts quickly, he/she can ask an outside agency called the Quality Improvement

Organization to review whether the discharge is medically necessary.

Skilled Nursing, Home Health, or Comprehensive Outpatient Rehabilitation Facility Discharges

Advantra Members have the right to appeal if they think their coverage for skilled nursing, home health or comprehensive

outpatient rehabilitation facility services is ending too soon.

When a patient is in a Skilled Nursing Facility (SNF), home health agency (HHA), or comprehensive outpatient

rehabilitation facility (CORF), Members have the right to get all the SNF, HHA or CORF care covered by Advantra

medically necessary to diagnose and treat their illness or injury. The day the Provider decides to end their SNF, HHA or

CORF coverage is based on when their stay is no longer medically necessary.

Information Members should receive during their SNF, HHA or CORF Stay

If the Provider decides to end the Member’s coverage for SNF, HHA, or CORF services, the Member will get a written

notice from the Provider at least 2 calendar days before his/her service ends. The Member (or someone he/she authorizes)

will be asked to sign and date this document, to show that he/she received the notice. Signing the notice does not mean that

the Member agrees coverage should end – it only means the Member received the notice.

How Members can appeal their coverage to the Quality Improvement Organization

Members have the right by law to ask for an appeal of termination of their coverage. As explained in the notice, Members

can ask the Quality Improvement Organization (the “QIO”) to perform an independent review to determine whether

terminating the coverage is medically necessary.

If Members want to have the termination of the coverage appealed, they must act quickly to contact the QIO. The written

notice the Member receives from the provider gives the name and telephone number of the QIO and tells the Member what

he/she must do.

If Members get the notice 2 days before the coverage ends, the Member must be sure to make his/her request no

later than noon of the day after he/she gets the notice from the Provider.

If Members get the notice and have more than 2 days before the coverage ends, then the Member must make his/her

request no later than noon the day before the date that the Medicare coverage ends.

What will happen during the review?

If the QIO reviews the case, the QIO will ask for the Member’s opinion about why he/she believes the services should

continue. Members do not have to prepare anything in writing, but may do so if they wish. The QIO will also look at the

Member’s medical information, talk to the doctor, and review other information given to the QIO.

After reviewing all the information, the QIO will give an opinion about whether it is medically necessary for the Member’s

coverage to be terminated on the date originally set for him/her. The QIO will make this decision within one full day after it

receives the information it needs to make a decision.

What happens if the QIO decides in the Member’s favor?

If the QIO agrees with the Member, then coverage will continue for the SNF, HHA or CORF services for as long as

medically necessary.

What happens if the QIO denies the Member’s request?

If the QIO decides that the decision to terminate coverage was medically necessary, the Member will be

responsible for paying the SNF, HHA or CORF charges after the termination date on the original advance notice

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given to the Member. Neither traditional Medicare nor Advantra will pay for these services. If the Member stops

receiving services on or before the date given on the notice, he/she can avoid any financial liability.

18.12 Quality Improvement Organization Review

The Quality Improvement Organization (QIO), an independent agency, has contracted with the Secretary of the

Department of Health and Human Services (DHHS) to review records of medical care provided to Advantra

Members when they register complaints concerning the quality of or access to care.

Members also have the right to an Immediate Review by the QIO if the Member believes that he/she is being discharged

from the hospital too soon. When Advantra issues a Member a notice of discharge, the notice is subject to QIO Review.

Advantra will contact a Provider’s office to obtain medical records upon the Quality Improvement Organization’s request.

All re-reviews will be performed by a board-certified physician of like specialty who was not involved in the original

determination and has no relationship to Advantra.

Please direct any questions regarding the Quality Improvement Organization and the Review Process to your

Provider Relations Representative.

Pennsylvania: Ohio:

Quality Insights of Pennsylvania KePro Inc.

2601 Market Place Street Rock Run Center, Suite 100

Harrisburg, PA 17110 5700 Lombardo Center Dr.

Beneficiary Hotline 1-877-346-6180 Seven Hills, OH 44131

1-800-589-7337 216-447-9604

Fax: 216-447-7925

West Virginia: West Virginia Medical Institute (WVMI)

3001 Chesterfield Place

Charleston WV 25304

1-800-642-8686 ext. 2266

304-346-9864

Fax: 216-447-7925

18.13 Claims and Encounter Submission

It is recommended that CMS 1500 Form or UB 04 Form be submitted within 60 days from the date of service for all claims.

Advantra has adopted standard billing guidelines so that completion of the CMS 1500 Form or UB 04 Form is consistent

with Medicare Guidelines.

The NPI number must be included on each CMS 1500 Form submitted.

The mailing address for Advantra claims is:

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Advantra Claims Department

P.O. Box 7087

London, KY 40742-7087

Submission of all Encounter information is required for all physician, inpatient, outpatient hospital, skilled

nursing facility and home health services.

18.14 Mediare Advantage (MA) Risk Adjustment

The Balanced Budget Act of 1997 specifically required implementation of a Risk Adjustment Method Payment

Methodology to Medicare Advantage Organizations. Risk Adjustment Payment Methodology improves the capitated

payments made by Centers for Medicare and Medicaid Services (CMS) to MA Organizations by adjusting monthly payment

amounts based on the health status of each enrolled Medicare beneficiary in the Advantra Program.

All hospitals and physicians must use current valid International Classification of Diseases - 9th

Edition - Clinical

Modification (ICD-9-CM or most current version) Codes, report all relevant diagnoses related to services performed

(supported by medical record documentation), and must follow official coding guidelines using the most specific code.

All Providers who participate in the Advantra program are required to submit complete and accurate claims data and

maintain clean, concise and complete medical record documentation practices.

The following paragraphs outline steps that will assist Providers in the compliance of regulatory requirements when

submitting encounter information and in the maintenance of medical record documentation.

1. Use the appropriate ICD-9-CM code set for reporting diagnoses, and code to the highest level of specificity

known for all conditions present or being managed at the time of a visit.

NOTE: There is an exception to this rule: History codes (V10 through V19) may be used as secondary codes if

the historical condition or family has an impact on current care or possibly influences treatment.

Providers are responsible for ensuring that coding adheres to the ethical standards as outlined by the American

Health Information Management Association (AHIMA). All diagnoses that impact the patient's care should be

documented in the medical record and coded according to official coding guidelines.

2. Submit all diagnoses that impacts the patient evaluation, care and treatment:

Main reason for visit or admission;

Co-existing acute condition;

Chronic condition;

Permanent past conditions.

3. Periodically review claim/encounter data submission to ensure that it is accurate, complete and truthful and is

supported by the patient medical record or other relevant documentation.

4. Maintain appropriate medical record documentation. This process includes the recording of conditions and

diseases; updating a problem list, if used; and the recording of the patient's name on each page of the medical

record. Documentation should be concise, clean, consistent, complete and legible.

Physician should sign and date each entry in the medical record.

It is important for physicians and their office staff to be aware of risk adjustment data validation activities because they may

be requested to provide medical record documentation to Advantra.

The medical record documentation must show that the diagnosis was assigned within the data collection period, may include

the entire medical record or only parts of the record and diagnostic data must comply with ICD-9-CM (or most current

version) coding guidelines.

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Advantra will monitor the data being submitted from a Provider’s office for accuracy, thus ensuring correct payment from

CMS to Advantra. If an error or missing data is identified, Advantra may request from a Provider coding specificity to

correct erroneous data and/or the reporting of missing data.

Providers who submit risk adjustment diagnostic data to Advantra for CMS payment purposes do not violate Health

Insurance Portability and Accountability (HIPAA) privacy regulations. Therefore, a patient's authorized information release

is not required to comply with risk adjustment data submission or to respond to a medical record request from CMS for data

validation.

Importance of Medical Record Documentation

Accurate risk adjusted payment relies on complete medical record documentation and diagnostic coding.

CMS annually conducts risk adjustment data validation by Medical Record Review.

The medical record chronologically documents the care of the patient and is an important element contributing to high

quality care.

Educational Quick Facts

ICD-9-CM Overview

ICD-9-CM Coding Process - Physician and Hospital Outpatient

Medical Record Documentation Tips

Tips for Documentation: The Problem Oriented Medical Record (POMR) Problem List

Medical Record Progress Notes - SOAP Notes

Resources Section

CMS Official Coding Guidelines Link: http://www.cms.hhs.gov/providers/pufdownload/

Web Links:

ICD-9-CM Public Use Files

http://cms.hhs.gov/paymentsystems/icd9/default.asp

ICD-9-Coding Guidelines

http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm

QUICK FACTS

ICD-9-CM

(International Classification of Diseases 9th Revision-Clinical Modification)

OVERVIEW

This ICD-9-CM (International Classification of Diseases-9th Revision-Clinical Modification) QUICK FACTS serves as an

easy reference to explain ICD-9-CM coding guidelines. Since diagnostic information is critical for risk adjusted payment,

ICD-9-CM codes must be reported accurately.

http://www.cms.hhs.gov/providers/pufdownload/

http://cms.hhs.gov/paymentsystems/icd9/default.asp

http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm

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USE CURRENT VERSION OF ICD-9-CM

All hospitals/physicians must use current valid International Classification of Disease- 9th Edition-Clinical Modification

(ICD-9-CM) codes.

ICD-9-CM codes are updated annually on October 1.

If hospitals/physicians use the Diagnostic Statistical Manual of Mental disorders, 4th edition (DSM IV) for coding, they

will need to convert the information to the official ICD-9-CM codes.

RELATE DIAGNOSIS TO SERVICE PERFORMED & DOCUMENT

The medical record must support the diagnosis.

The diagnosis reported must match the coding submitted by the hospital/physician as documented in the medical record.

Report all secondary diagnoses that impact clinical evaluation, management and/or treatment.

Report all relevant V-codes and E-codes pertinent to the care provided.

The medical record must be retrievable to validate the diagnosis reported.

CODE TO THE HIGHEST LEVEL OF SPECIFICITY

Basic Coding guidelines prescribe the use of the most specific code (the highest level of specificity). ICD-9-CM is

composed of codes with 3, 4, or 5 digits. Codes with 3 digits are included in ICD-9-CM as the heading of a category of

codes that may be further subdivided by the use of 4th and/or 5th digits, which provides greater specificity.

Assign three-digit codes only if there are no four-digit codes within that code category.

Assign four-digit codes only if there is no fifth-digit sub-classification for that subcategory.

Assign the fifth-digit sub-classification code for those subcategories where it exists.

Coding guidelines recommend that an unspecified code should not be used if the medical record provides adequate

documentation for assignment of a more specific code.

Resources: Go to www.hcfa.gov/medlearn/cbt_icd9.htm for a computer-based training course on the ICD-9-CM.

Additional resources for ICD-9-CM coding are located on www.cms.hhs.gov

(do a site search for ICD-9-CM) and the CSSC web site at www.mcoservice.com.

QUICK FACTS

ICD-9-CM Coding Process-Physician and Hospital Outpatient

(International Classification of Diseases 9th Revision-Clinical Modification)

Review the medical record to identify the reason for the visit.

Review the medical record for other conditions and confirmed diagnoses that are related to the reason for the visit.

Do not code conditions described as “rule out,” “possible,” or “suspected.”

Look up the main terms of these conditions in the ICD-9-CM index.

o Main terms may be followed by other descriptors in parentheses. These terms are called “non-essential

modifiers”. The presence or absence of these terms does not affect the coding of the main terms.

o Search the indented terms under each main term to find the closest description of the condition documented.

o The index may refer to another main term.

o More than one main term may be required to fully describe the condition.

Look up the codes selected in the Tabular Index.

http://www.hcfa.gov/medlearn/cbt_icd9.htm

http://www.cms.hhs.gov/

http://www.mcoservice.com/

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Read all definitions and follow all cross reference notes, inclusion notes and exclusion notes found at the beginning

of each code category in the Tabular Index.

Code to the highest specificity possible. If there is a fourth and fifth digit to select, use the most appropriate one.

o If the index refers to a code with the fourth digit of .8 (NEC-not elsewhere classified) or .9 (NOS-not

otherwise specified) refer back to the medical record to see if other more specific listings in the code

category may apply.

Determine if any of the conditions can be combined or are symptoms of another condition and, therefore, not to be

coded.

First, list the diagnosis code chiefly responsible for the service(s) provided. Then, list codes for all other conditions

documented.

Code only those conditions supported by clinical medical record documentation on the corresponding date(s) of

service.

QUICK FACTS

Medical Record Documentation Tips

Medical records should be organized in a systematic format for communication and retrievability.

Notes on scraps of paper, sticky notes, index cards, etc. are not acceptable.

Only persons authorized to do so may document the medical record, and each person

must be identified.

Entries must be made at the time of treatment and dated.

Avoid non-clinical remarks within the body of the record that mention any financial

issues or unprofessional remarks about patients or other healthcare team Members.

Use only standard abbreviations and keep them to a minimum.

Each page of the medical record should identify the patient.

The medical record must contain sufficient information to identify the patient, justify the treatment (and level of care),

support the diagnosis, document the patient’s progress and the results of treatment, and promote continuity of care

among healthcare providers.

Medical Records Must Include Documentation of:

Admission diagnosis/initial impression.

Reason for admission, visit, treatment, and/or consultation requests. Many of these

reasons will be part of a list of final diagnoses.

All operative and non-operative procedures, test results and consultations including the

rationale for the procedure/treatment/test and evidence that the results or

consultation was noted by the physician.

Patient’s response to care including any complications or conditions (diagnoses) that

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impact or extend the inpatient length of stay.

Medications ordered, dispensed and any adverse reactions.

Conclusions, instructions for follow-up and a summary of care including outcome, disposition, and final diagnoses.

QUICK FACTS

SOAP Notes

One common method of documenting medical record progress notes (for all provider types) that contain all the necessary

elements is called the Problem Oriented Medical Record (POMR). POMR includes a problem list and SOAP notes. Each

letter in SOAP stands for a section of the progress notes as follows:

SUBJECT

How the patient describes what brings them to the facility/office for care, what medications they have

taken, and any other relevant observations by the patient about their condition. This includes chief complaints and

associated symptoms.

OBJECTIVE

Data obtained by the current problem focused exam, lab results, vital signs, and other observations made

directly by the physician. A full history and physical is a separate document typically generated during the initial

patient visit.

ASSESSMENT

Listing and description of a patient's current diagnosis or symptom and status of all chronic conditions.

This includes how the objective data relates to each of the patient's problems. Conditions are listed by problem

number, referring back to the problem list.

PLAN

The plan includes four elements:

Diagnostic plan: further diagnostic test or consultation/referrals

Therapeutic plan: medications and treatments such as physical therapy

Patient education: instructions for care at home, expected outcomes, potential complications, side effects of

medication, etc.

Follow-up: next scheduled appointment or conditions for return visit or phone call.

QUICK FACTS

Tips for Documentation:

The Problem Oriented Medical Record (POMR) Problem List

The problem list is a numbered index of the patient’s problems from identification to resolution.

The list should be kept in the front of the physician office record, clinic record, or hospital progress note section.

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The problems should include acute or chronic diagnoses, symptoms not related to an established diagnosis, social

issues, or any other condition that may impact the patient’s care and treatment.

The problems are numbered and dated so they can be identified in ongoing SOAP notes (see above). The date the

problem is resolved can be entered in a separate column.

Example Problem List

Patient Identification Allergies: None known

Problem #1 10/4/02 Asthma, COPD

Problem #2 10/4/02 History of smoking, quit 2 years ago

Problem #3 12/30/02 Wife expired, no one to render care at home

Problem #4 1/7/03 Broken toe resolved 3/3/03

Problem #5 3/3/03 Depression, continued grief reaction

Three of the most commonly used formats of the POMR SOAP notes include:

1) “Pure” POMR notes address each numbered problem with separate SOAP breakdown.

Problem #1 Problem #4

S S

O O

A A

P P

2) “Hybrid” POMR notes list SOAP one time and identify the applicable numbered problems under each note.

S

Problem #1

Problem #4

O

Problem #1

Problem #4

A

Problem #1

Problem #4

P

Problem #1

Problem #4

3) Untitled SOAP notes do not use a numbered problem list but document the current

pertinent symptoms and diagnoses in the SOAP format.

Date of visit: 1/7/03

S Patient tripped at home and has pain and swelling of left great toe.

O X-ray - Fractured left toe, COPD and asthma- stable with home oxygen as

needed.

A Fractured toe, COPD

P Splint toe, instructions to elevate foot, OTC pain reliever per label

instructions. Phone numbers given for meals on wheels, follow up in office in 2 weeks. Call

office if pain or swelling increases or 911 if experiencing trouble breathing.

18.15 Special Status Medicare Members

CMS reimburses contractors at different rates for each Member based on age, sex, county of residence, and also on the

classification into one of five special Status Categories.

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The Special Status Categories include:

Institutional Status

End Stage Renal Disease

Medicare/Medicaid Dual Eligible

Hospice

Working Aged

It is important that a Provider understand the different Special Status Categories and take the actions defined below

when a Member is identified as meeting the Special Status definition.

End Stage Renal Disease (ESRD) is defined by CMS as the state of renal impairment that appears to be irreversible and

permanent, and requires a regular course of dialysis or kidney transplantation to maintain life.

If 36 months or more has elapsed since a kidney transplant, the person is no longer considered to have ESRD status.

It is very important that a Provider inform its Advantra Medical Management contact of any enrolled Members who meet the

ESRD definition. Advantra receives a higher reimbursement from CMS for Members who are ESRD. ESRD status is

reported to CMS through the ESRD Network Organization located in 18 geographic areas in the United States. The

Provider, usually a contracted nephrologist or renal dialysis facility, needs to submit a completed CMS 2728-U4, “Medical

Evidence Report Form,” to the applicable ESRD Network Organization.

The ESRD Network Organization reviews the form and transmits the data to CMS electronically. CMS will notify Advantra

of Members who are ESRD and will pay Advantra at a higher rate. (NOTE: Advantra may be secondary payer for

individuals who have both Medicare coverage and Employer Group Health Plan coverage.)

Medicare/Medicaid Dual Eligible is an individual who is covered under both the Medicare and Medicaid programs.

For a qualified Medicare beneficiary (QMB), the state Medicaid program pays for the annual Medicare Part A deductible,

Medicare Part A coinsurance, monthly Medicare Part B premium, annual Part B deductible and Medicare Part B

coinsurance.

Hospice is a Member who has selected Medicare certified Hospice coverage. Prospective Members are entitled to enroll in

Advantra if they are receiving Hospice coverage.

An Advantra Member becomes Medicare certified Hospice when he/she completes a Hospice Election Form. This form is

usually provided by a Medicare certified Home Health or Hospice Provider. The Provider then submits the form along with

the provider bills to the fiscal intermediary. The fiscal intermediary pays the Hospice claims, not Advantra. Advantra

receives a lower reimbursement rate from CMS for Members that are Medicare certified Hospice since the fiscal

intermediary is paying the claims.

Working Aged is defined as the CMS Medicare Advantage risk payment category for an individual who is defined as

eligible for Medicare and (1) is either working for an employer with more than 20 employees or (2) has a spouse with

coverage under an Employer Group Health Plan which covers the Advantra Member.

Advantra receives a lower payment rate from CMS for these Members. If a Provider identifies a Member with Employer

Group Health Plan coverage in addition to their Advantra coverage, Advantra Member Services needs to be informed. If a

Member is Working Aged, a Provider should bill the Employer Group Health Plan as primary and Advantra as the

secondary payer.

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18.16 Privacy of Medical Records

Providers should safeguard the privacy of the Member’s medical record. Original medical records should be released only

in accordance with Federal or State laws, court orders or subpoenas.

All records should be kept confidential and maintained for 10 years. All Member information should be available to be

transferred upon request by the Member, or authorized representative, to any organization with which the Member may

subsequently enroll, or to a provider to ensure continuity of care.

Providers need to ensure timely access by a Member to pertinent records, and information, upon request. Members can be

charged a reasonable fee for copies of records.

The Provider must abide by all Federal and State laws regarding confidentiality, documentation on whether or not a Member

has executed an Advance Directive and disclosure for mental health records and medical records.

18.17 CMS Requirements

Please be advised that all communication to Advantra Members require prior approval by the CMS.

Advantra has various CMS-approved materials that can be made available to Providers to announce participation with the

Advantra program. Please contact the Advantra Marketing Department if there is an interest in pursuing any communication

to Advantra Members regarding the Advantra program.

Advantra Personal Health Profiles

All new Advantra Members are sent an Advantra Personal Health Questionnaire within the first 90 days of enrollment. The

questionnaire is to be completed by the Member and is then sent back to Advantra.

The form asks the Member a number of questions specific to the Member’s medical history, as well as questions about

lifestyle. The form is also used to educate Members about the use of Advantra contracted Providers and to transition

Members into receiving services from contracted Providers.

Advantra requests the Member discuss his/her Personal Health Questionnaire with his/her PCP. The information from the

Personal Health Questionnaire will assist the PCP or Specialist in providing direction regarding the Member's health needs

and potential treatment options. This exchange will allow the Member to participate in the development of their treatment

plan. Advantra will also assist in the coordination of care for complex or serious disease cases with the PCP or Specialist,

will inform Members of any follow-up care, and provide training in self-care through the Case Management or Disease

Management Program.

Laws and Regulations

All Advantra Providers must comply with applicable Medicare laws and regulations, including but not limited to, Title VI of

the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, the Rehabilitation

Act of 1973, and other laws applicable to recipients of Federal funds.

Providers should provide services to Advantra Members without regard to the race, color, religion, sex, ethnic origin, age or

disability of such person, or any other classification prohibited by Law.

140

Advantra’s policy, as well as Federal Law, states that no form of discrimination prohibited by Law will be permitted on the

basis of sex, race, color, disability, age, religion or ethnic origin, and that all Members will have access to their medical

services at all contracted provider facilities.

Member Access to Care and Information from Advantra Providers

Advantra Members have the right to get timely access to Advantra Providers and to all services covered by Advantra.

“Timely access” means that Members get appointments and services within a reasonable period of time. Members have the

right to get full information from their doctors when they get medical care. Members have the right to participate fully in

decisions about their health care, which includes the right to refuse care.

If HMO/POS Members need to talk with their PCP or get medical care when their PCP’s office is closed, and it is not a

medical emergency, the Member should call the PCP number listed on their HMO/POS Advantra Membership card. There

will always be a doctor on call 24 hours a day, 7 days a week, to help them.

Disclosure of Information

At the request of Advantra or CMS, the Provider shall disclose all information necessary to (1) administer and evaluate the

program, to include quality performance indicators and information regarding Members’ satisfaction and health outcomes;

and (2) establish and facilitate a process for current and prospective beneficiaries to exercise their right to choose Medicare

services.

Continuation of Benefits

Provider shall continue to provide covered services to Advantra Members who are hospitalized on the date the CMS contract

terminates or expires, of if Coventry Health Care of WV becomes insolvent, through the date of each Advantra Member’s

discharge or for the remainder of the period for which the Member’s Medicare premium has been paid.

External Review

Provider agrees to cooperate with all independent quality review and improvement organization activities required by CMS

and/or Advantra pertaining to the provision of services for Advantra Members.

Plan Provider Termination Notices

The MA Organization must make a good faith effort to notify Members of the termination of a Provider’s contract 30 days

before the termination is effective. Providers must follow the termination provision as defined in their contracts to ensure

timely notification.

Advantra will notify Providers in writing of the reason(s) for any denial, suspension or termination of the Provider’s

participation in the provider network.

When contracted Providers choose to opt out of Medicare or sanctions are taken against that Provider, Advantra will take

immediate steps to terminate that Provider’s contract with Advantra.

Compliance with Medical Management

Providers must agree to comply with the Advantra’s Medical policies, QI and Medical Management Programs, and adhere to

appeals/grievance procedures.

What Drugs are Covered by Medicare Drug Plans?

Advantra drug plans must make sure the people in their plan can get medically-necessary drugs to treat their conditions.

Advantra prescription drug coverage uses an approved drug list also know as our Formulary. This formulary covers both

141

generic and brand name prescription drugs that must be approved by the FDA (Food and Drug Administration) as safe and

effective.

The Formulary includes a range of drugs in the prescribed categories and classes. This range makes sure that people with

different medical conditions get the treatment they need. To have lower costs, Advantra plans place drugs into different

“tiers,” which cost different amounts.

Prior Authorization (PA)*

Advantra requires Providers to get prior authorization for certain drugs listed on our Formulary. This means a Provider will

need to get approval from Advantra before prescriptions can be filled for Advantra Members. If an approval is not obtained,

the drug may not be covered.

Quantity Limits

For certain drugs, Advantra limits the drug units covered per prescription or for a defined period of time. For example,

Advantra will provide up to 4 units per prescription for FOSAMAX per 30 days. If the medication is listed on the Quantity

Level Limitations (QLL) Lists, then no action is needed. Medications on the QLL are identified as once daily.

Step Therapy (ST)*

In some cases, Advantra requires Members to first try certain drugs to treat medical conditions before it will cover another

drug for that condition. For example, if Drug A and Drug B both treat a certain medical condition, Advantra may require the

Provider to prescribe Drug A first. If Drug A does not work for the patient, Advantra will then cover Drug B. Additional

requirements or limits on certain drugs can be found on the Advantra Formulary, which can be obtained from your Provider

Services Representative.

*For those medications listed on the Prior Authorization (PA) and Stepped Therapy (ST) Lists, the pharmacy system

will automatically allow a “first fill” without action needed by the Provider. An automatic temporary “first fill” of

30 days will be dispensed so the Member will be stabilized during the transition and will allow the Member time to

contact the prescribing Provider (prescriber) to request approval if treatment is necessary beyond the “first fill”

supply. After the 30-day first fill, the Member and the Provider will be required to follow the normal process for

requesting prior authorizations and medical necessity review, step therapy, or exception processing. Decisions on

transitions will appropriately address situations involving the Member’s need to be stabilized on drugs not on

Advantra’s formulary and that have known risks associated with any changes in the prescribed regimen.

To request Prior Authorization or to place a Member in Step Therapy, the prescribing Provider should:

1. Call 1-800-290-0190 between 7 a.m. – 6 p.m., Monday – Friday, and provide the following Information:

Member’s full name

Member’s Advantra Member ID number

Requested Drug

Reason for the request

2. After hours, the prescribing Provider should call Medco, Advantra’s pharmacy benefits manager (PBM) at 1-866-

823-5178. Depending on the situation, Medco will either grant a 72 hours fill or contact the on-call pharmacist.

Exception – Medicare Prescription Drug Coverage Determination

Under the Medicare Advantage Part D (MA-PD) prescription drug benefit program for both Advantra RX and First Health

RX Part D, a Member or Provider can ask Advantra to make an exception to restrictions or limits. There are several types of

exceptions:

Cover a drug even if it is not on the Formulary

Waive coverage restrictions or limits on drugs

Provide a higher level of coverage for the drug

Please contact Advantra to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception.

Providers should submit a statement supporting this request. Generally, Advantra must make their decision within 72 hours

of getting the prescribing Provider’s supporting statement. An expedited exception is an option if the patient or the Provider

believes the patient’s health can be seriously harmed by waiting up to 72 hours for a decision. If a request for an expedited

142

review is granted, Advantra must provide a decision no later than 24 hours after getting the prescribing Provider’s

supporting statement.

A Provider Request Form can be found on the www.chcadvantra.com website & choose the “Provider” tab.

A request for a standard coverage determination must be made in writing & mailed to:

Advantra

Pharmacy Department

3721 TecPort Drive


Or may be faxed to: 1-866-738-9682

To request an exception, the prescribing Provider may either call 1-877-215-4100 or fax the request to 1-717-541-

5909. Advantra’s hours of operation are 7:00 a.m. to 6:00 p.m. (EST), Monday through Friday.

After hours, Provider may call Medco, Advantra’s pharmacy benefits manager, (PBM) at 1-866-290-6660. The Medco

agent will notify the Provider that if the situation is an emergency, the pharmacy provider may enter an override code which

will cover a 72 hour supply for the Member. The prescribing Provider may then call the clinical call center once it re-opens

to request a long term exception.

If the prescribing Provider requires an immediate response, Medco will contact the Advantra on-call pharmacist, who will

respond to the prescriber as quickly as possible.

To request an exception, the prescribing Provider needs to provide the following information:

Member’s full name

Member’s Advantra Member ID number

Requested drug

Reason for the exception

Once an exception request is approved, it is valid for the remainder of the plan year or the length of the therapy authorized,

so long as the Provider continues to prescribe the drug, and it continues to be safe and effective for treating the Member’s

condition.

Please contact your Provider Services Representative for a copy of the Advantra Formulary or if you need additional

information on any of the topics discussed above. Or you can visit our website at www.chcadvantra.com and choose the

“Provider” tab.

Part D Appeals Rights

Standard (7 days) – Members can request a standard appeal for a case that involves coverage or payment. The independent

reviewer must give the Member a decision no later than 7 days after receiving the appeal.

Expedited (72 hours) – Members can request an expedited appeal for cases that involve coverage; if the Member, or the

Provider, believes that the Member’s health could be seriously harmed by waiting up to 7 days for a decision. If the

Member’s request to expedite is granted, the independent reviewer must make a decision no later than 72 hours after

receiving the Member’s appeal.

If the Provider who prescribed the drug(s) asks for an expedited appeal for the Member, or supports the Member in

asking for one, and the Provider indicates that waiting for 7 days could seriously harm the Member’s health, the

independent reviewer will automatically expedite the appeal.

If the Member asks for an expedited appeal without support from a Provider, the independent reviewer will decide if

the Member’s health requires an expedited appeal. If the Member does not get an expedited appeal, the appeal will

be decided within 7 days.

http://www.chcadvantra.com/

http://www.chcadvantra.com/

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How do Members request an Appeal?

For an Expedited Appeal: The Member or their appointed representative should contact us by telephone or fax:

Phone: 1-800-290-0190 (TDD 1-800-207-1262)

Fax: 717-526-2789

For a Standard Appeal: The Member or their appointed representative should mail the written appeal to the address

below:

Medicare Appeals

Advantra

Attn: Appeals & Grievance Coordinator

3721 TecPort Drive


What do Members include with their Appeal?

The Member’s name, address, Advantra Member ID number, the reasons for appealing and any evidence they wish to attach.

If the appeal relates to a decision not to cover a drug not on the Advantra formulary, the prescribing Provider must indicate

that all of the drugs on any tier of the formulary would not be as effective to treat the Member’s condition as the requested

off-formulary drug, or that the formulary drugs could be harmful to the Member’s health.

What Happens Next?

When the Member appeals, the independent reviewer will review Advantra’s initial decision. If any of the prescription

drugs the Member or Provider requested are still denied, the Member or appointed representative can appeal to an

administrative law judge (ALJ) if the value of the Member’s appeal meets a minimum dollar amount. If the appointed

representative or the Member disagrees with the ALJ decision, the Member has the right to further appeal.

18.19 Medicare Provider Training and Education

Coventry Health Care, Inc. (“Coventry”) is pleased to have the opportunity to work with you as a

provider or provider organization in delivering high value services to our members. Our

association, particularly in relation to our Medicare product lines, relies on a contracted

relationship that establishes your entity as a first tier1 or related entity

2. As a first tier or related

entity, there are several requirements imposed upon you, some by federal law, some by federal

regulations as promulgated by the Centers for Medicare & Medicaid Services (“CMS”), and other requirements in light of

your contracted relationship with Coventry. As a result, you, your entity, any downstream entities3 and/or related entities

under your direction, and in several cases your individual employees who are assigned to work on Coventry’s Medicare

business, must complete a number of requirements.

The requirements are summarized below and are applicable to your organization, as well as any

of your downstream and/or related entity arrangements.

1. General Compliance and Fraud, Waste and Abuse (“FWA”) Training

You and/or your organization must complete general compliance training. In addition,

you must complete the FWA portion of the training unless you are deemed to have met

the FWA certification requirements through enrollment into Parts A or B of the Medicare

program or through accreditation as a supplier of DMEPOS.

You must provide general compliance training to all of your employees, downstream,

and related entity arrangements who are assigned to work on Coventry Medicare business initially upon hire and

annually thereafter. You must also provide FWA training, initially upon hire and annually thereafter, to all your

employees, downstream, and related entity arrangements who are assigned to work on Coventry Medicare business

unless these individuals are deemed to have met FWA certification requirements as described above. In addition,

your organization must provide either Coventry’s Code of Conduct (“COC”) or your own equivalent COC to all of

your employees, downstream, and related entities who are assigned to work on Coventry Medicare business initially

upon hire or contract commencement and annually thereafter.

144

2. Reporting Mechanisms

You and/or your organization must report compliance concerns and suspected or actual

misconduct to Coventry.

3. Exclusion/Debarment

You and/or your organization must ensure that none of its employees or downstream

and/or related entities that service Coventry Medicare business are on any of the

following excluded persons, sanction and debarment lists: HHS Office of Inspector

General (OIG); General Services Administration (GSA).

4. Downstream and Related Entity Oversight

You and/or your organization must ensure that compliance is maintained by you and/or

your organization as well as any of your contracted downstream and/or related entities

that service Coventry Medicare business.

5. Offshore Operations

You and/or your organization must ensure that you do not engage in offshore operations

for Coventry-related Medicare business without the express consent of an authorized

Coventry representative. Offshore operations are usually contractually prohibited by

Coventry. Any Coventry-approved offshore arrangements are subject to reporting

requirements to alert CMS of these activities and therefore must be reported to Coventry

before utilization.

You must access the training and compliance materials mentioned above, along with additional

information concerning these requirements, available for you on the Coventry Medicare FDR

Training and Education Portal under Provider and Provider Group FDRs. This portal can be

accessed through the following URL link: www.CoventryMedicareFDRs.com.

Further, if you and/or your organization utilizes downstream and/or related entities to perform

Coventry Medicare work or serve Coventry Medicare members, that entity is also responsible for satisfaction of all of the

above requirements. Due to the unique nature of the relationship

between you and your downstream and/or related entities, Coventry expects that you ensure that they receive these

requirements.

You and/or your organization are responsible to ensure that evidence of the effectuation for all of the requirements is

developed and maintained. This evidence may be in the form of attestations, training logs, or other means determined by you

to best represent fulfillment of your obligations. Please be reminded that Coventry and CMS require records to be retained

for a period of ten (10) years, and that your records must be available to Coventry and/or CMS upon request.

Coventry takes these responsibilities very seriously. If you have any questions or concerns

regarding this requirement or if you have difficulty accessing the Coventry Medicare FDR

Training and Education Portal, please contact Coventry’s FDR Governance personnel at

[email protected].

1 A first tier entity is defined as any party that enters into a written arrangement acceptable to CMS with a Sponsor (i.e.,

Coventry) to provide administrative or health care services for a Medicare eligible individual under Part C or Part D.

2 A related entity is defined as any entity that is related to the Sponsor by common ownership or control and a) performs some of the Sponsor’s management functions under contract or delegation; b) furnishes services to Medicare

enrollees under an oral or written agreement, or c) leases real property or sells materials to the Sponsor at a cost of

more than $2500 during a contract period. 42 CFR 423.501

3 A downstream entity is defined as any party that enters into a written arrangement, acceptable to CMS, below the

level of the arrangement between the Sponsor and the first tier entity. These written arrangements continue down to the level of provider of both health and administrative services.

http://www.coventrymedicarefdrs.com/

mailto:[email protected]

145

Attachments

To access the attachments, please select the corresponding document in the Attachments navigation panel to the

left. If you have hidden the panel, you can re-open it by clicking on the paperclip icon.

Attachment A: Services Requiring Preauthorization (Commercial & Medicare/Advantra)

Attachment B: Maternity Notification and Risk Screen

Attachment C: Claim Inquiry/Adjustment Request Form

Attachment D: Provider Reimbursement — Fee Schedule

Attachment E: Services Requiring Preauthorization for CoventryCares

Attachment F: Provider Change in Information Form

Attachment G: Advance Directives

Attachment H: Quick Reference Guide

Attachment I: HEDIS Measures – Tips for Providers

Attachment J: Advantra Member Sample ID Card

Attachment K: CoventryCares of WV Sample ID Card

146

Attachment A – Commercial and Medicare Preauthorization List

Commercial and Advantra (Medicare) Services Requiring Preauthorization 2014

The following services, surgeries and procedures require preauthorization. The Plan Document describes the level of coverage available

under the plan in which you are enrolled. When seeking services from a non-participating provider, please refer to the section of the Plan

Document that describes the process for obtaining preauthorization. This list is subject to change. Please check the website or call

Customer Service for the most current list.

Automatic Internal Cardiac Defibrillator (AICD)

Behavioral Health and Substance Abuse Services: Some inpatient or outpatient Behavioral Health services or Substance Abuse

treatment or rehabilitation*

Bi-ventricular Pacemaker

Biofeedback Therapy

Cardiac Catheterizations- elective

Clinical Trials

CT Scans

Cosmetic Treatments/Surgeries

Dental Treatment for Dental Accidents

Durable Medical Equipment (DME): all rentals of DME and repairs ,purchase of DME costing over $500, (except ostomy supplies)

Early Intervention services which include Physical Therapy, Occupational Therapy, and Speech Therapy assistive technology devices.

Genetic Testing and Genetic Counseling

Hospice and Home Health Care (Nursing, Infusion, Respiratory, Physical, Occupational, and Speech Therapy etc.)

Hospital Observation Stays

Hyperbaric Oxygen - all places of service

Injectable and Self-Administered Injectable Drugs, if covered under Medical and Surgical Benefits instead of Prescription Drug

Benefits

Inpatient Admission Stays: includes Acute, Skilled Nursing Facility Care and Inpatient Hospice

Insulin Pump and Supplies

Joint Replacements- whether received inpatient or outpatient

Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiogram (MRA)/Positive Emission Tomography (PET Scan)

Molecular Diagnostic Testing

Non-emergency Ambulance Transportation

Nonimplanted Prosthetic Devices

Nuclear Radiology

Oral Surgery

Orthotics

Outpatient Polysomnograms (Sleep Apnea Studies)

Outpatient Surgery (Hospital or Freestanding Surgical Center)

Pain Management Services/Program, including Epidural Steroid Injections

Prenatal Services - Notification Only

Psychological or Neuropsychological Testing, when performed by a medical provider

Radiation Oncology Services

Rehabilitative Services: whether received inpatient or outpatient

Services Related to the Diagnosis of Infertility or the Diagnosis and Treatment of Infertility if an employer group has elected the

Infertility Rider

Stress Echocardiograms

Transplant Consultations, Evaluations and Testing/Transplant Procedures

* Please contact the contracted behavioral health/mental health and substance abuse vendor at the number listed on the member ID card

for a list of behavioral health/mental health and substance abuse services requiring preauthorization.

147

In addition, the following specific services require preauthorization regardless of the place of service.

CPT or HCPCS Code Description

J0894, J9010, J9027, J9041, J9055, J9202, J9207, J9213, J9214, J9217, J9218, J9225, J9226, J9264, J9303, J9305, J9310, J9328, J9330

Chemotherapeutic Drugs

23470, 23472, 23473, 23474, 24360,24361, 24362, 24363, 24365, 24366, 24370, 24371, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27442, 27445, 27446, 27447, 27700, 27702, 27703

Total Joint Replacements- Clinical is required for medical necessity review

50592, 50593, 32998 Radiofrequency Ablation

72285 Discography

76873, 76950, 76965, 77011, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77299, 77300, 77301, 77305, 77310, 77315, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77399, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418, 77421, 77422, 77423, 77424, 77425, 77427, 77431, 77469, 77470, 77499, 77600, 77605, 77610, 77615, 77620, 77750, 77789, 77790, 77799, 0182T, G0251, G0339, G0340 77371, 77372, 77373, 77432, 77435, G0173

Stereotactic Radio surgery and Radiation Treatment

77600 Hyperthermia Treatment

77520, 77522, 77523, 77525 Proton Treatment Delivery

41019,77761 – 77779, 77326 – 77328, 77785 – 77787, C1716 – C1719, C2616, C2634 – C2699, Q3001

Brachytherapy

91035 Esophageal Reflux Tests

91111 Gastrointestinal tract imaging, intraluminal

93228, 93229 Real Time EKG

93350, 93351 Echocardiography

95951 Electroencephalography

96000-96004 Motion Analysis Studies

93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias

93760, 93762 Thermogram; cephalic and peripheral

93784 Ambulatory Blood Pressure Monitoring

95981, 95982 Electronic analysis of neurostimulator, with or without reprogramming

96570 Photodynamic Therapy

96920 - 96922 Laser treatment for inflammatory skin disease (psoriasis)

Category Three Codes (CPT codes ending in “T”)

Temporary codes for emerging technology

A4264 Permanent implantable contraceptive device

A4575 Topical Hyperbaric Oxygen

A9277, A9278, A9279, S1031 Transmitter, Receiver, Monitoring features for Continuous Blood Glucose Monitor to include non-invasive continuous glucose monitoring

E1700, E1810 Rehabilitative, Orthopedic Devices

G0166 External Counterpulsation, per treatment session

G0251,G0339,G0340 Stereotactic Radiosurgery

G0302 – G0305 Preoperative pulmonary surgery services for the preparation for LVRS, complete course of services

148

M0075 Cellular Therapy

M0076 Prolotherapy

M0100 Intragastric hypothermia using gastric freezing

M0300 IV Chelation therapy (chemical endarterectomy)

M0301 Fabric wrapping of abdominal aneurysm

Q3031 Collagen skin test

Q4107 Graft Jacket

S0345 –S0347

Electrocardiographic monitoring utilizing a home computerized telemetry station with automatic activation and real-time notification of monitoring station, 24-hour attended monitoring, including physician review and interpretation

S2107 Adoptive immunotherapy, i.e., development of specific antitumor reactivity (e.g. tumor-infiltrating lymphocyte therapy) per course of treatment

S3650 Saliva test, hormone level; during menopause

S3652 Saliva test, hormone level; to assess preterm labor risk

S3708 Gastrointestinal fat absorption study

S3900 Surface electromyography (EMG)

S3902 Ballistocardiogram

S3904 Master’s two step

S3905

Noninvasive electrodiagnostic testing with automatic computerized hand-held device to stimulate and measure neuromuscular signals in diagnosing and evaluating systematic entrapment neuropathies

S9015 Automated EEG monitoring

S9025 Omnicardiogram/cardiointegram

S9090 Vertebral axial decompression, per session

U256 Experimental Drugs

Please Note: Not all of the above are covered benefits. Benefits vary by product type or employer groups. Confirmation of benefits and

eligibility is required at the time services are rendered, not only when they are preauthorized.

149

Attachment B - Maternity Notification and Risk Screen

150

151

Attachment C - Claim Inquiry/Adjustment Request Form

ALL INFORMATION MUST BE COMPLETED OR IT WILL BE RETURNED WITHOUT REVIEW.

Please see the attached Adjustments Guidelines for submission timeframes.

DO NOT USE FOR AN APPEAL

CLAIM DATA

Member Name: Date of Birth:

Member ID Number: Claim Number:

Date of Service:

PROVIDER DATA

Provider Name:

Contact Person:

Phone Number:

Mailing Address:

Fax Number:

E-Mail Address:

REQUEST FOR REVIEW WITH DOCUMENTATION ATTACHED

Modifier/Code Review

Medical Records (explain below)

ER Notes

Denied Duplicate in Error

Fee Dispute

Timely Filing

Itemized Bill

Corrected/Updated Claim

Primary Carrier’s EOB

Other (explain below)

Description of request:

Commercial & Medicaid Members MAIL TO:

Coventry Health Care of West Virginia / Post Office Box 7373 / London, KY 40742-7373

152

Attachment D – Provider Reimbursement Fee Schedule

153

Attachment E: Carelink Medicaid Services Requiring Preauthorization

Services Requiring Preauthorization for the Carelink Medicaid Program – 2014

CoventryCares of West Virginia must preauthorize certain services and supplies for Medicaid members.

The process is the same for commercial and Medicaid members; however, the list for the Medicaid

program is different.

Automatic Internal Cardiac Defibrillator (AICD)

Bi-ventricular Pacemaker

Biofeedback Therapy

Clinical Trials

CT Scans

Dental Treatment for Dental Accidents

Durable Medical Equipment (DME): all rentals of DME and repairs, purchase of DME costing over

$500 (except ostomy supplies)

Elective Cardiac Catheterizations

Genetic Testing

Hospice and Home Health Care (nursing, infusion, respiratory, etc.)

Hospital Observation Stays

Hyperbaric Oxygen – All Places of Service

Injectable and Self-Administered Injectable Drugs, if covered under the medical and surgical Benefit

instead of prescription drug benefit

Inpatient Hospital Care- includes inpatient hospice admissions

Insulin Pump and Supplies

Joint Replacements- whether received inpatient or outpatient

Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiogram (MRA)/Positive Emission

Tomography (PET Scan)

Molecular Diagnostic Testing

Non-Emergent Ambulance Transportation

Non-implanted Prosthetic Devices

Nuclear Radiology

Nutritional Formulas and Supplements

OB Ultrasounds (Beginning with 3rd

Ultrasound)

Oral Surgery

Orthotics

Outpatient Polysomnograms (Sleep Apnea Studies)

Outpatient Surgery (Hospital or Freestanding Surgical Center)

Pain Management Services/Programs, including Epidural Steroid Injections

Psychological or Neuropsychological Testing (Medical Services Only. Psychologists / Psychiatrists

Covered Through the State Fee-For-Service)

Radiation Oncology Services

Rehabilitative Services: Physical, Occupational, or Speech Therapy whether received Inpatient or

Outpatient

Services from a non-participating provider except emergency services and family planning

Stress Echocardiograms

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Transplant Consultations, Evaluations and Testing/Transplant Procedures

In addition, the following specific services require preauthorization regardless of the place of service: CPT or HCPCS Code Description J0894, J9010, J9027, J9041, J9055, J9202, J9207, J9213, J9214, J9217, J9218, J9225, J9226, J9264, J9303, J9305, J9310, J9328, J9330

Chemotherapeutic Drugs

23470, 23472, 23473, 23474, 24360,24361, 24362, 24363, 24365, 24366, 24370, 24371, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27442, 27445, 27446, 27447, 27700, 27702, 27703

Total Joint Replacements- Clinical is required for medical necessity review

50592, 50593, 32998 Radiofrequency Ablation 72285 Discography 76873, 76950, 76965, 77011, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77299, 77300, 77301, 77305, 77310, 77315, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77399, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418, 77421, 77422, 77423, 77424, 77425, 77427, 77431, 77469, 77470, 77499, 77600, 77605, 77610, 77615, 77620, 77750, 77789, 77790, 77799, 0182T, G0251, G0339, G0340 77371, 77372, 77373, 77432, 77435, G0173

Stereotactic Radiosurgery and Radiation Oncology Services

77600 Hyperthermia Treatment 77520, 77522, 77523, 77525

Proton Treatment Delivery

41019,77761-77779, 77326-77328, 77785-77787, C1716-C1719, C2616, C2634-C2699, Q3001

Brachytherapy

91035 Esophageal Reflux Tests 91111 Gastrointestinal tract imaging, intraluminal 93228, 93229 Real Time EKG 93350, 93351 Echocardiography 95951 Electroencephalography 96000-96004 Motion Analysis Studies 93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias 93760, 93762 Thermogram; cephalic and peripheral

95250, 95251

Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording and

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physician interpretation and report 96920 - 96922 Laser treatment for inflammatory skin disease (psoriasis)

95981, 95982 Electronic analysis of neruostimuilatorneurostimulator, with or without reprogramming

96570 Photodynamic Therapy Category Three Codes (CPT codes ending in “T”)

Temporary codes for emerging technology

A4264 Permanent implantable contraceptive device A4575 Topical Hyperbaric Oxygen A9277, A9278, A9279, S1031

Transmitter, Receiver, Monitoring features for Continuous Blood Glucose Monitor to include non-invasive continuous glucose monitoring

E1700, E1810 Rehabilitative, Orthopedic Devices G0166 External Counterpulsation, per treatment session G0237, G0238, G0239 Therapeutic procedures to improve respiratory function G0251,G0339,G0340 Stereotactic Radiosurgery

G0302 – G0305 Preoperative pulmonary surgery services for the preparation for LVRS, complete course of services

M0075 Cellular Therapy M0076 Prolotherapy M0100 Intragastric hypothermia using gastric freezing M0300 IV Chelation therapy (chemical endarterectomy) M0301 Fabric wrapping of abdominal aneurysm Q3031 Collagen skin test Q4107 Graft Jacket

S0345 –S0347

Electrocardiographic monitoring utilizing a home computerized telemetry station with automatic activation and real-time notification of monitoring station, 24-hour attended monitoring, including physician review and interpretation

S2107 Adoptive immunotherapy, i.e., development of specific antitumor reactivity (e.g. tumor-infiltrating lymphocyte therapy) per course of treatment

S3650 Saliva test, hormone level; during menopause S3652 Saliva test, hormone level; to assess preterm labor risk S3708 Gastrointestinal fat absorption study S3900 Surface electromyography (EMG) S3902 Ballistocardiogram S3904 Master’s two step

S3905

Noninvasive electrodiagnostic testing with automatic computerized hand-held device to stimulate and measure neuromuscular signals in diagnosing and evaluating systematic entrapment neuropathies

S9015 Automated EEG monitoring S9025 Omnicardiogram/ cardiointegram S9090 Vertebral axial decompression, per session U256 Experimental Drugs

Please Note: Not all of the above are covered benefits. Confirmation of benefits and eligibility is required at the

time services are rendered, not only when they are preauthorized..

156

Attachment F – Advance Directives

ADVANCE DIRECTIVE FORM

I, , being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strongly about the following forms of

treatment: (please circle your response).

Cardiopulmonary Resuscitation (CPR) The use of drugs and/or electric shock to start the heart beating and

artificial breathing I want I do not want

Mechanical Respiration Breathing by machine I want I do not want

Tube Feeding Artificial, invasive form of food given through a tube in the veins, nose or

stomach I want I do not want

Artificial Hydration Artificial, invasive form of liquids given through a tube in the veins, nose or

stomach I want I do not want

Blood or Blood Products

The use of whole blood or parts of the blood to replace blood lost I want I do not want

Surgery Use of any form of surgery to remove or repair any part of the body I want I do not want

Invasive Diagnostic Tests Tests that help reach a diagnosis by entering the body in some way, i.e., a

tube inserted to look at the stomach, etc. I want I do not want

Kidney Dialysis Machine used to cleanse the blood of toxic waste because the kidneys are

unable to do so on their own I want I do not want

Antibiotics Medicine given to treat or prevent an infection I want I do not want

Other I want I do not want

157

I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above (page 1), I may receive that form of treatment. SURROGATE OPTION (PROXY) I (do) (do not) want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Surrogate's Name: Address: Substitute Surrogate (if surrogate above is unable to serve): Name: Address: I made this declaration on the ______ day of ____________, _______. Declarant's Signature: Address: The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence. The declarant appeared lucid, rational and of sound mind. Witness' Signature: Address:

Witness' Signature: Address: __________________

158

Attachment G – Provider Change in Information Form

PROVIDER CHANGE IN INFORMATION FORM

In an effort to keep records updated and to ensure proper claims payment, please complete this form when any of the below

takes place within your practice. Your cooperation and participation are greatly appreciated. Please make copies if you

have additional information changes. If you have a change in your Tax ID number, please enclose the new W-9 form.

Notification should be provided as far in advance as possible to the Provider Relations Department prior to the change.

Date these changes became effective: ______________________________________________________

Practice Name:______________________________________________ NPI:______________________

Provider Name(s):___________________________________________ NPI:______________________

We are making changes to our: Office Info_________ Billing Info__________ Tax ID______________

Current Address:_______________________________________________________________________

Current Phone:_________________________________ Current Fax: _____________________________

New Address:__________________________________________________________________________

New Phone:___________________________________ New Fax:_______________________________

Current Tax ID Number(s):________________________ New Tax ID Number(s):___________________

Current Billing Address:__________________________________________________________________

Current Billing Phone:__________________________ Current Billing Fax:________________________

New Billing Address:____________________________________________________________________

New Billing Phone:_____________________________ New Billing Fax:__________________________

Other changes you would like for us to know about: ___________________________________________

_____________________________________________________________________________________

Office Manager/Contact: _______________________________ Phone:____________________________

Please sign and date: ____________________________________________________________________

Please return this form to your Provider Relations Representative 500 Virginia Street E, Ste 400 2001 Main Street, Ste 201

Charleston, WV 25301 Wheeling, WV 26003

(304) 348-2900 (304) 234-3481

Toll Free: 888-388-1744 Toll Free: 800-896-9612

Fax: 304-348-2064 Fax: 866-804-4810

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Attachment H – Quick Reference Guide

Network Management

Charleston Office Wheeling Office

500 Virginia Street E., Ste. 400 2001 Main St., Ste. 201

Charleston, WV 25301 Wheeling, WV 26003

Phone: 1-888-388-1744 Phone: 1-800-896-9612

Fax: 1-304-348-2064 Fax: 1-866-804-4866

Customer Service

Commercial, Medicaid, Medicare/Advantra Commercial

• Claims/Benefits Phone: 1-800-348-2922 | Fax: 1-724-778-4299

• Member Verification Medicaid

• Provider Status Phone: 1-800-348-2922 | Fax: 1-302-283-6586

• Member Appeals Medicare/Advantra

Phone: 1-800-365-6052 Fax: 1-866-759-4415

Claims/Billing Address Health Services - Preauthorization

Commercial & Medicaid Medicare/Advantra Commercial & Medicaid

ATTN: Claims ATTN: Claims Phone: 1-888-348-2966 Fax: 1-866-373-0274

PO Box 7373 PO Box 7822 Medicare/Advantra

London, KY 40742-7373 London, KY 40742-7087 Phone: 1-800-669-2202 Fax: 1-866-373-0271

Payer ID for EDI - Commercial, Medicaid, Medicare/Advantra

25133

To File a Provider Appeal* - Commercial, Medicaid, Medicare/Advantra

Coventry Health Care Phone: 1-800-348-2922

ATTN: Appeal Coordinator Fax: 1-888-388-1752

PO Box 67103

Harrisburg, PA 17106-7103 *Appeals must be received 90 days from original denial.

Electronic Services

• Check member eligibility and benefits Website

• Check claims history and payment www.directprovider.com

• Online remittance advice www.chcwv.com

• Authorization submission www.wv.chcadvantra.com

Net Support

• For directprovider.com functionality issues, please call Net Support at 1-866-629-3975.

• For problems with Coventry electronic claims transactions, please contact Front-End Operations

(FEO) by phone at 1-302-283-6570 or by e-mail: [email protected].

• For claim issues using an Emdeon product, contact the Help Desk by dialing 1-800-845-6592.

http://www.directprovider.com/

http://www.chcwv.com/

mailto:[email protected]

Attachment I – HEDIS Measures – Tips for Providers

161

162

Attachment J- Advantra Sample Member ID Card

163

164

Attachment K- CoventryCares of WV Sample Member ID Card Front-

Back-

IMPORTANT FACTS • Customer Service Phone #: 888-348-2922 • TDD #: 866-784-7472 TTY: 711 • For Providers only, Express Scripts Phone #: 800-922-1557 • Scion Dental Members: 888-983-4693 Providers: 855-844-0623 • If you experience a sudden unexpected medical problem that may endanger your life if not treated immediately, go directly to the nearest medical facility. - Examples of these problems may include: Severe Chest Pain, Loss of Consciousness, Uncontrolled Bleeding. You must call your Primary Care Physician within 48 hours to report this emergency treatment or if you are admitted to the facility. Mailing Address for Claims:

CoventryCares of WV, Attn: Claims P.O. Box 7373 London, KY 40742

• Emdeon Payer ID: 25133 • Not sure if it is an emergency? Call the Nurseline at 1-888-348-1008 • Keep this card with your State Medicaid Card. Show both cards every time you receive medical care.