ENVD 2020 Ambetter Manual FINAL 20191212 - Envolve Health
ENVD 2020 Ambetter Manual FINAL 20191212 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL1
ContentsQuick Reference Guide . 4Provider Web Portal . 4Key Contacts . 5Summary. 8Welcome.10Provider Contracting and Credentialing . 11Contracting . 11Credentialing . 11Re-credentialing. 12Electronic Funds Transfer (EFT) . 13Provider Rights & Responsibilities . 14Provider Rights . 14Provider Responsibilities . 14Member Rights & Responsibilities.16Member Rights . 16Member Responsibilities . 16Eligibility & Member Services .18Member Identification Card . 18Eligibility Verification . 19Provider Options for Treating Members in Suspended Status . 21Checking Dental Spending Status. 21Transportation Assistance . 21Member Translation/Interpreter and Hearing Impaired Services . 22Appointment Availability Standards . 23After-Hours Care . 23Referrals to Specialists . 23Missed Appointments . 24Balance Billing and Payment for Non-Covered Services . 24Cultural Competency . 25Americans with Disabilities Act (ADA) . 26Member Information and HIPAA . 29The Health Insurance Portability and Accountability Act . 29 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL2
Utilization Management & Review .31Utilization Management and Review . 31Envolve Dental Affirmative Statement . 31Utilization Review . 31Medical Necessity. 32Prior Authorization . 32Fraud, Waste and Abuse . 33General Billing Guidelines . 34Encounters vs Claims . 34Clean Claims . 34Non-Clean Claims . 35Claims Submission Information . 35Electronic Claims Submission via Provider Web Portal or Electronic Clearinghouse . 35Paper Claims . 37Claims Imaging Requirements . 37Provider Corrected Claims . 38Claims Adjudication, Editing, and Payments . 38Member Co-pays and Co-insurance . 39Billing for Services in Emergency Situations . 39Billing for Services Rendered Out-of-Office . 40Billing Limitations . 40Coordination of Benefits (COB) . 41Claim Denials . 41Complaint and Grievance Process . 46Provider Complaint and Appeal Procedures . 47Member Grievance and Appeal Procedures . 49Benefit Summary .51Benefit Descriptions . 51Clinical Definitions. 51Appendix A: Ambetter Covered Dental Benefits . 52Ambetter Dental Benefits . 52 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL3
WelcomeQuick Reference GuideProvider Web PortalEverything You NeedWhen You Need It24/7/365Our user-friendly Provider Web Portal features a full complement of resources.Real-time eligibilityClaims – submit & view statusClinical guidelinesReferral directoriesElectronic remittance adviceElectronic Funds TransferUp-to-date Provider ManualAccess the Provider Web Portal by clicking this link:https://pwp.envolvedental.com 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL4
WelcomeKey ContactsThe following chart includes several important telephone and fax numbers available to youroffice. When calling Envolve Dental, please have the following information available: NPI (National Provider Identifier) number Tax ID Number (TIN) numberREFERENCEProvider Web Customer ana844-621-4579Kansas855-434-9245 2020 Envolve Dental, Inc. PROPRIETARY AND Carolina833-605-6320Texas833-260-36255
tter MemberServices(includes ansas844-518-9505CredentialingFraud & io877-687-1189Pennsylvania833-510-4727South Carolina833-270-5443Texas877-687-1196Please call Customer Service for your health plan800-345-1642 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL6
WelcomeArizonaEnvolve DentalClaims: AZPO Box 20132Tampa, FL 33622-0132ArkansasEnvolve DentalClaims: ARPO Box 26632Tampa, FL 33623-6632FloridaEnvolve DentalClaims: FLPO Box 20654Tampa, FL 33622-0654Paper Claim Address,Appeals andCorrected ClaimAddressGeorgiaEnvolve DentalClaims: GAPO Box 22085Tampa, FL 33622-2085IllinoisEnvolve DentalClaims: ILPO Box 22377Tampa, FL 33622-2377IndianaEnvolve DentalClaims: INPO Box 20847Tampa FL 33622-0847KansasEnvolve DentalClaims: KSPO Box 25857Tampa, FL 33622-5857MississippiEnvolve DentalClaims: MSPO Box 25255Tampa, FL 33622-5255MissouriEnvolve DentalClaims: MOPO Box 20262Tampa, FL 33622-0262OhioEnvolve DentalClaims: OHPO Box 22687Tampa, FL 33622-2687PennsylvaniaEnvolve DentalClaims: PAPO Box 26631Tampa, FL 33623-6631South CarolinaEnvolve DentalClaims: SCPO Box 26632Tampa, FL 33623-6632TexasEnvolve DentalClaims: TXPO Box 26564Tampa FL 33622-6564 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL7
WelcomeSummaryQuick Reference GuideMember EligibilityProviders may access primary eligibility through one of the following. You must provide your NPInumber to access member details. Provider Web Portal: https://pwp.envolvedental.com Call Customer Service for the automated member eligibility IVR system to reach ourautomated member eligibility-verification system 24 hours a day.Claims SubmissionThe timely filing requirement for Ambetter is 180 calendar days from the date of service.Turnaround time is 30 calendar days from the date of the original submission. Submit claims in oneof the following formats: Envolve Dental Provider Web Portal at https://pwp.envolvedental.com Electronic claim submission through selected clearinghouses: Payer ID 46278Alternate pre-arranged HIPAA-compliant electronic submissions Paper claims must be submitted on a 2012 ADA claim forms and mailed to themarket-specific address.Corrected Claim SubmissionProviders who receive a claim denial and need to submit a corrected claim must send a paper claimon a 2012 ADA form including ALL codes originally submitted, plus the corrected code withsupporting documentation, within 180 calendar days from the date of notification or denial to themarket-specific appeals and corrected claim address.Provider Claim DisputesClaim payment disputes must be filed within 180 calendar days from the date of notification ofpayment or denial. Disputes will be resolved within 30 calendar days via a remittance statement. Ifunsatisfied with result, providers can submit an appeal to Envolve Dental.To request a reconsideration of a claims denial, a provider may: Call Customer Service for information Write to the market-specific appeals address.Provider Inquiries and GrievancesTo make an inquiry or grievance, email your concern to providerrelations@envolvehealth.com orcall Customer Service. 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL8
WelcomeQuick Reference GuideMember AppealsMembers must submit appeals within 180 calendar days of receiving an adverse Notice of Actionby calling 877-687-1189Pennsylvania:833-510-4727South Carolina: 833-270-5443Texas:877-687-1196Members who are not satisfied with the Ambetter appeal decision may request an External Review inaccordance with their state Department of Insurance requirements. State Fair Hearing requests arenot available to Ambetter members. 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL9
WelcomeWelcomeWelcome to the Envolve Dental provider network! We are pleased you joined our providernetwork, composed of the best providers in the state to deliver quality dental healthcare.Envolve Dental, Inc. is a wholly-owned subsidiary of Envolve Benefit Options, Inc. and CenteneCorporation, Inc., a Fortune 100 company with more than 30 years’ experience in Medicaidmanaged care programs. With the advent of the Health Insurance Marketplace, Centene developedmarketplace products to meet the needs of additional people who previously were uninsured.Envolve Dental has partnered with Ambetter health plans in Arizona, Arkansas, Florida, Georgia,Illinois, Indiana, Kansas, Mississippi, Missouri, Ohio, Pennsylvania, South Carolina and Texas toadminister the dental benefit for eligible members in 2020.This Envolve Dental provider manual supplies useful information about working with us. We striveto make information clear and user-friendly. If you have questions about specific portions of themanual or if you have suggestions for improvements, we welcome your input. Please contactCustomer Service at providerrelations@envolvehealth.com or call us at your state-specificCustomer Service number.Envolve Dental retains the right to modify items in this provider manual. Contracted providersmust acknowledge this provider manual and any other written materials provided by EnvolveDental as proprietary and confidential. 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL10
Provider Participation, Contracting and CredentialingProvider Contracting and CredentialingContractingDentists must sign a Provider Agreement and apply for network participation by submitting allcredentialing documentation. Envolve Dental Provider Agreements are available from the followingsources: Email Envolve Dental at dentalnetwork@envolvehealth.com with your specific requests. Call the state-specific number below for a contracting packet.Customer exas833-260-3625To the extent that a provider executes a contract with any other person or entity that in any wayrelates to a provider’s obligations under the Participating Provider Agreement or an Addendum,including any downstream entity, subcontractor or related entity, the provider shall require thatsuch other person or entity assume the same obligations that the provider assumes under theParticipating Provider Agreement and all Addendums.If you have any questions about the contents of the Provider Agreement or how to apply, callProvider Customer Service.CredentialingThe purpose of the credentialing and re-credentialing process is to help make certain that EnvolveDental maintains a high-quality healthcare delivery system. The credentialing and re-credentialingprocess helps achieve this aim by validating the professional competency and conduct of ourproviders. This includes the verification of licensure, board certification and education, anddisclosure of ownership or control interests, as well as identification of adverse actions, including 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL11
Provider Participation, Contracting and Credentialingmalpractice or negligence claims, through the applicable state and federal agencies and the NationalPractitioner Data Base.If a practitioner/provider already participates with Envolve Dental in the Medicaid product, thepractitioner/provider will NOT be separately credentialed for the Ambetter product.For more information on credentialing, please email lingTo comply with accreditation standards, Envolve Dental confirms provider re-credentialing at leastevery 36 months from the date of the initial credentialing. The purpose of this process is to identifyany changes in the practitioner’s licensure, sanctions, certification, competence, or health statusthat may affect the ability to perform services the provider is under contract to provide. Thisprocess includes all providers, primary care providers, specialists and ancillary providers/facilitiespreviously credentialed to practice within the Envolve Dental network.In between credentialing cycles, Envolve Dental conducts ongoing monitoring activities on allnetwork providers. This includes ongoing monitoring of the appropriate state licensing agencies toidentify newly disciplined providers and providers with a negative change in their current licensurestatus. This monthly inquiry helps make certain that providers are maintaining a current, active,unrestricted license to practice in between credentialing cycles. Additionally, Envolve Dentalreviews monthly reports released by the Office of Inspector General and other sources to identifynetwork providers who have been newly sanctioned or excluded from participation in federal andstate programs.A provider’s agreement may be terminated at any time if Envolve Dental’s Credentialing Committeedetermines that the provider no longer meets the credentialing requirements. 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL12
Provider Contracting and CredentialingElectronic Funds Transfer (EFT)Envolve Dental makes Electronic Funds Transfer (EFT) available to providers for claims paymentsthat are faster than paper checks sent via US Mail. If you are currently enrolled in EFT with EnvolveDental, you do not need a new form to receive EFT payments for Ambetter claims.To begin receiving electronic payments, complete an EFT form (found on the Provider Web Portal)and submit it via email, with a voided check, to providerrelations@EnvolveHealth.com. The EFTform can also be mailed physically with your credentialing documents. Forms are processed withinone week; however, activation begins after four to five check runs, based on confirmation from yourbank that the set-up is complete. Remittance statements explaining the payment will be availableon the Provider Web Portal in the “Documents” tab for all providers active with EFT. 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL13
Provider Rights & ResponsibilitiesProvider Rights & ResponsibilitiesConsistent with Ambetter policies, Envolve Dental applies the following rights and responsibilitiesto all network providers. 1Provider RightsProviders have the right to: Be treated by Ambetter members, Envolve Dental staff, and other healthcare workers withdignity and respect.Receive accurate and complete information and medical histories for members’ care.Have their patients, who are Ambetter members, act in a way that supports the care given toother patients and that helps keep the provider’s office, hospital, or other offices runningsmoothly.Expect other network providers to act as partners in members’ treatment plans.Expect members to follow their health care instructions and directions, such as taking theright amount of medication at the right times.Make a complaint or file an appeal against Ambetter, Envolve Dental, and/or a member.File a grievance on behalf of a member, with the member’s consent.Have access to information about Ambetter and Envolve Dental quality improvementprograms, including program goals, processes, and outcomes that relate to member careand services.Contact Customer Service with any questions, comments, or problems.Collaborate with other health care professionals who are involved in the care of members.Not be excluded, penalized, or terminated from participating with Ambetter or EnvolveDental for having developed or accumulated a substantial number of patients in Ambetterwith high cost medical conditions.Collect member copays, coinsurance, and deductibles at the time of the service.Provider ResponsibilitiesProviders are responsible for: 1Making covered services available on a timely basis, based on medical appropriateness.Treating members with respect, fairness, and dignity, including HIPAA-compliant privacystandards.Not discriminating against members on the basis of race, color, national origin, age, gender,pre-existing mental or physical disability/condition, religion, limited language proficiency,marital status, arrest record, conviction record, or military involvement.Maintaining the confidentiality of members’ personal health information, including medicalrecords and histories, and adhere to state and federal laws and regulations regardingconfidentiality.Giving to members a notice that clearly explains their privacy rights and responsibilities asthey relate to the provider’s practice and scope of service.Ambetter 2018 Provider Handbook 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL14
Provider Rights & Responsibilities Providing members with an accounting of the use and disclosure of their personal healthinformation in accordance with HIPAA.Allowing members to request restriction on the use and disclosure of their personal healthinformation.Providing members, upon request, access to inspect and receive a copy of their personalhealth information, including medical records.Providing clear and complete information to members - in a language they can understand about their health condition and treatment, regardless of cost or benefit coverage, and allowmember participation in the decision-making process.Telling a member if the proposed medical care or treatment is part of a research experimentand give the member the right to refuse experimental treatment.Allowing a member who refuses or requests to stop treatment the right to do so, as long asthe member understands that by refusing or stopping treatment the condition may worsenor be fatal.Respecting members’ advance directives and include these documents in their medicalrecord.Allowing members to appoint a parent/guardian, family member, or other representative ifthey can’t fully participate in their treatment decisions.Allowing members to obtain a second opinion, and answer members’ questions about howto access health care services appropriately.Following all state and federal laws and regulations related to patient care and rights.Participating in Ambetter and Envolve Dental data collection initiatives, such as HEDIS andother contractual or regulatory programs.Reviewing clinical practice guidelines distributed by Ambetter.Complying with the Envolve Dental Ambetter Medical Management program as outlinedherein.Disclosing overpayments or improper payments to Envolve Dental.Providing members, upon request, with information regarding the provider’s professionalqualifications, such as specialty, education, residency, and board certification status.Obtaining and reporting to Envolve Dental information regarding other insurance coveragethe member has or may have.Giving Envolve Dental timely, written notice if provider is leaving/closing a practice.Contacting Envolve Dental to verify member eligibility and benefits, if appropriate.Inviting member participation in understanding any medical or behavioral health problemsthat the member may have and to develop mutually agreed upon treatment goals, to theextent possible.Providing members with information regarding office location, hours of operation,accessibility, and translation services.Objecting to providing relevant or medically necessary services on the basis of theprovider’s moral or religious beliefs or other similar grounds.Providing hours of operation to Ambetter members which are no less than those offered toother commercial members. 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL15
Member Rights & ResponsibilitiesMember Rights & ResponsibilitiesConsistent with Ambetter policies, Envolve Dental applies these rights and responsibilities to allmembers. 2Member RightsMembers have the right to: View medical records.Be informed of changes within the Ambetter or Envolve Dental networks.Information about Ambetter and its health plans.A current list of Ambetter and Envolve Dental providers.Select a dental provider from within the Envolve Dental network.Talk to a provider about new uses of technology; members can also ask Ambetter forinformation on our quality plan, how members use the plan and how we review newtechnology view medical records.Receive considerate, respectful care at all times.Receive assistance in a prompt, courteous and responsible manner.Be treated with dignity when receiving care.Be free from harassment by the health plan or the plan’s providers if there are any businessdisagreements between the plan and provider.Select a health plan or switch health plans, within the Health Insurance Marketplace (HIM)guidelines, without any threats or harassment.Receive and have privacy respected.Access treatment or services that is medically necessary regardless of age, race, creed, sex,sexual preference, national origin or religion.Access medically necessary, emergency services 24 hours a day and seven (7) days a week.Seek a second medical opinion from a participating provider at no cost to the member.Receive information in a different format in compliance with the Americans withDisabilities Act if the member has a disability.Member ResponsibilitiesMembers are responsible for: Participating in their healthcare by giving accurate and complete information about presentconditions. Following the provider’s treatment plan and asking questions to fully understand it. Presenting the Ambetter ID card when obtaining services and informing the plan if the cardis lost or stolen. Going to the emergency room only when the health condition is an emergency. Making and keeping appointments and notifying the provider prior to an appointment ifunable to attend. Treating all staff, providers, and other members with respect and dignity.2Ambetter 2018 Member Handbook 2020 Envolve Dental, Inc. PROPRIETARY AND CONFIDENTIAL16
Member Rights & Responsibilities Keeping current all personal information with providers, the Ambetter plan, and the HealthInsurance Marketplace, including address, name, and telephone number.Informing healthcare providers about other insurances in effect.Reporting to
Dec 27, 2019 · Envolve Dental has partnered with Ambetter health plans in Arizona, Arkansas, Florida, Georgia, Illinois, Indiana, Kansas, Mississippi, Missouri, Ohio, Pennsylvania, South Carolina and Texas to administer the dental benefit for eligible members in 2020. This Envolve Dental provider manual sup
feel free to contact Ambetter and IlliniCare Health Provider Services at: Ambetter Health Plan Phone TTY/TDD Website Ambetter of Arkansas 1-877-617-0390 1-877-617-0392 AmbetterofArkansas.com Ambetter from Sunshine Health 1-877-687-1169 Relay FL - 1-800-955-8770 Ambetter.SunshineHealth.com
Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 1 AMBETTER fi FROM SUSHINE HEATH . area by using the Provider Directory available on our website. Remember, your PCP, also known as a personal doctor, is the main doctor you will see for most of your medical care. This
SECURE PROVIDER PORTAL . Ambetter offers a robust secure provider portal with functionality that is critical to serving members and to ease administration for the Ambetter product for providers. The Portal can be accessed at . Ambetter.IlliniCare.com. Functionality . All users of the secure provider portal must complete a registration process.
1 of 6 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period : 01/01/2021 - 12/31/2021 Ambetter from Sunshine Health: Ambetter Balanced Care 12 (2021) Coverage for: Individual/Family Plan Type: EPO SBC-21663FL0130039-06 Underwritten by Celtic Insurance Company
the “For Members” page on Ambetter.SunshineHealth.com. Complete your online Ambetter Welcome Survey. Completing the survey will help us design your plan around your specific needs. When you complete your survey, you can earn 50 on your My Health Pays prepaid Visa Card. To complete your survey, log in to your online Member Account.
Ambetter Essential Care 1 (2018) Vista (nivel de bronce) Ambetter Essential Care 1 (2018)
Ambetter Essential Care 1 (2018) (Bronze Level) Covered benefits are for In-network providers only. To find our most up to date list of in-network providers, please visit our website at. Ambetter.
and STM32F103xx advanced ARM-based 32-bit MCUs Introduction This reference manual targets application developers. It provides complete information on how to use the low-, medium- and high-density STM32F101xx, STM32F102xx and STM32F103xx microcontroller memory and peripherals. The low-, medium- and high-density STM32F101xx, STM32F102xx and STM32F103xx will be referred to as STM32F10xxx .
