Centurion Of FL Provider Manual - Home Centurion Health
the next generation in correctional healthcareCenturion of Florida, LLCProvider ManualVersion 1.1February 2016
Provider Manualthe next generation in correctional healthcareTable of ContentsCENTURION OF FL Overview . 5CENTURION OF FL Guiding Principles . 5CENTURION OF FL Approach. 5CENTURION OF FL Summary . 6Working with CENTURION OF FL . 6CENTURION OF FL Regional Office Key Utilization Management Staff . 6FDOC Facility Names and Contact Numbers . 7CENTURION OF FL On-Site Services . 8On-Site Practitioners . 8On-Site Practitioner Availability . 924-Hour Access . 9Monitoring Healthcare Services. 9Specialty Care, Emergency Department and Hospitalization Accessibility/Coordination . 10Specialty Care Prior Authorization . 10Emergency Department Services . 11Hospitalization . 11Specialty Provider Responsibilities . 11Working with the Inmates . 12Continuity of Care . 12Specialist Appointment Access Standards . 12Hospital Responsibilities . 13Provider Assistance with Public Health Services . 13Version 1.1Page 2 of 26
Provider Manualthe next generation in correctional healthcareCredentialing Requirements . 14Recredentialing . 14Provider/Facility Site Review . 14Eligibility . 14Billing and Claims . 15General Billing Guidelines . 15Billing the Inmate . 16Clean Claim Definition. 16Non-Clean Claim Definition. 16Timely Filing . 16Electronic Claims Submission. 17Paper Claims Submission . 17Provider Portal .18Unsatisfactory or Claim Payment Concerns. 18Provider Relations Assistance . 18Provider Updates . 18Provider Complaints. 19CENTURION OF FL Pharmacy Program . 19Pharmacy and Therapeutics (P&T) Committee . 19Medical Records. 20Overview . 20Release of Medical Records . 20Medical Records Audits . 20CENTURION OF FL Medical Management Department . 20Version 1.1Page 3 of 26
Provider Manualthe next generation in correctional healthcareOverview and Medical Necessity . 20Prior Authorization Overview . 21On-Site Practitioner Referral for Specialty Service . 22Specialist Referral to Specialist for Treatment or Second Opinion. 22Process to Request Follow-Up Specialty Services . 22Self-Directed Care . 23Prior Authorization Response TImeline 23Medical Necessity . 23Review Criteria . 24Requirements for Providers to Notify CENTURION OF FL Medical Management Department . 24Emergency Services . 24Notification of Observation Stays . 24Concurrent Review. 25Discharge Planning . 26Retrospective Review. 26Summary . 26Version 1.1Page 4 of 26
Provider Manualthe next generation in correctional healthcareCENTURION OF FL OverviewWelcome to the CENTURION OF FLORIDA, LLC (Centurion of FL) Provider Manual.CENTURION OF FL is a company established by two of the oldest and most respected names incorrectional healthcare and managed Medicaid services: MHM Services, Inc. and Centene Corporation.This innovative partnership brings a combination of recruiting, program management and proven careprinciples to both the on-site and off-site correctional healthcare operations.CENTURION OF FL has entered into an agreement with the Florida Department of Corrections (FDOC) toprovide comprehensive healthcare services to inmates throughout the state’s correctional system.CENTURION OF FL is committed to building collaborative partnerships with Providers.CENTURION OF FL serves the FDOC consistent with our core philosophy that quality correctionalhealthcare requires coordination of care provided within the correctional facility and the servicesprovided “outside the walls.” Headquartered in Tallahassee, all Centurion of FL employees that workwithin FDOC and Providers are based in Florida.CENTURION OF FL Guiding PrinciplesIn your dealings with CENTURION OF FL you will find that we apply the following guidelines to all ourinteractions. We Provide access to high quality, accessible, cost-effective healthcarePerform our functions with integrity, operating at the highest ethical standardsBuild mutual respect and trust in our working relationshipsCreate communication that is open, consistent and two-wayEmbrace diversity of people, cultures, and ideasEncourage innovation to challenge the status quoStress teamwork and meeting our commitments to one anotherAlso, please note that CENTURION OF FL welcomes open Provider communication regarding appropriatetreatment alternatives. CENTURION OF FL does not penalize Providers for discussing medicallynecessary, appropriate care or treatment options with our on-site primary care physicians.CENTURION OF FL ApproachRecognizing that a strong healthcare program is predicated on building mutually satisfactoryassociations with Providers, CENTURION OF FL is committed to: Working as partners with participating ProvidersPerforming our administrative and clinical responsibilities in a superior fashionAs much as possible, CENTURION OF FL programs, policies and procedures are designed to minimize theVersion 1.1Page 5 of 26
Provider Manualthe next generation in correctional healthcareadministrative responsibilities in the management of care, enabling the Provider to focus on thehealthcare needs of their patients.CENTURION OF FL SummaryCENTURION OF FL’s philosophy is to provide access to high quality healthcare services by combiningthe expertise of on-site primary care practitioners and specialty providers/specialty services with ahighly successful, experienced managed care administrator. CENTURION OF FL believes that successfulpatient outcomes are the result of providing care that is medically necessary, rendered in theappropriate setting and at the appropriate interval.It is the policy of CENTURION OF FL to conduct its business affairs in accordance with the standardsand rules of ethical business conduct and to abide by all applicable federal and Florida laws.CENTURION OF FL takes the privacy and confidentiality of health information seriously. We haveprocesses, policies and procedures to comply with the Health Insurance Portability andAccountability Act of 1996 (HIPAA) and Florida Privacy Law requirements.Working with CENTURION OF FLFor your convenience, we have included a quick reference guide to provide an overview of your role inproviding care and recommendations for care as part of your CENTURION OF FL contract. Theinformation below and throughout this manual will include information that should assist you and yourday-to-day operations staff. The information includes: Contact information for CENTURION OF FL Medical Management Department (UtilizationManagement staff)Name and contact number for Department of Correction sitesClaims submission and contact informationRole of the CENTURION OF FL on-site practitionerThe referral process and your roleInformation required by CENTURION OF FL on-site healthcare team for continuity and provisionof careCENTURION OF FL Regional Office Key Utilization Management StaffCENTURION OF FL Medical ManagementDepartment(Utilization Management Staff)CENTURION OF FL Statewide Medical DirectorCENTURION OF FL Chief Nursing OfficerVersion 1.11-844-243-07951-844-243-07951-844-243-0795Page 6 of 26
Provider Manualthe next generation in correctional healthcareFDOC Facility Names and Contact IIIIIIIIIIIIIIIIIIIIIIIIIIIIIISite NameApalachee East UnitApalachee West UnitCalhoun Correctional InstitutionCentury Correctional InstitutionFranklin Correctional InstitutionGadsden Re-Entry CenterGulf Correctional InstitutionHolmes Correctional InstitutionJackson Correctional InstitutionJefferson Correctional InstitutionLiberty Correctional InstitutionNorthwest Florida Reception CenterOkaloosa Correctional InstitutionSanta Rosa Correctional InstitutionTaylor Correctional InstitutionWakulla Correctional InstitutionWalton Correctional InstitutionBaker Correctional InstitutionBaker Re-entry CenterColumbia Correctional InstitutionCross City Correctional InstitutionFlorida State PrisonFlorida Women’s Reception CenterHamilton Correctional InstitutionLancaster Correctional InstitutionLawtey Correctional InstitutionLowell Correctional InstitutionMadison Correctional InstitutionMarion Correctional InstitutionMayo Correctional InstitutionPutnam Correctional InstitutionQuincy AnnexReception and Medical CenterSuwannee Correctional InstitutionTomoka Correctional InstitutionUnion Correctional InstitutionAvon Park Correctional InstitutionCentral Florida Reception CenterHernando Correctional InstitutionLake Correctional InstitutionVersion yCrestviewMiltonPerryCrawfordvilleDeFuniak SpringsSandersonSandersonLake CityCross laMayoEast PalatkaQuincyLake ButlerLive OakDaytona BeachRaifordAvon ParkOrlandoBrooksvilleClermontPhone #(850) 718-0688(850) 718-0577(850) 237-6500(850) 256-2600(850) 697-1394(850) 539-2440(850) 639-1000(850) 547-8600(850) 569-5260(850) 342-0500(850) 643-9400(850) 773-6100(850) 682-0931(850) 983-5800(850) 838-4000(850) 410-1895(850) 951-1300(386) 719-4500(386) 719-6300(386) 754-7600(352) 498-4741(904) 368-2500(352) 840-8000(386) 792-5151(352) 463-4100(904) 782-2000(352) 690-8900(850) 973-5300(352) 401-6400(386) 294-4500(386) 326-6800(850) 627-5400(386) 496-6000(386) 963-6530(386) 323-1070(386) 431-2000(863) 452-8801(407) 207-7777(352) 754-6715(352) 394-6146Page 7 of 26
Provider Manualthe next generation in correctional healthcareIIIIIIIIIPolk Correctional InstitutionSumter Correctional InstitutionZephyrhills Correctional InstitutionPolk CityBushnellZephyrhills(863) 984-2273(352) 569-6100(813) 782-5521CENTURION OF FL On-Site ServicesMost on-site Healthcare Services Units operate 24 hours a day, 7 days a week. The type of staff used toprovide services besides practitioner staff include registered nurses, licensed practical nurses, certifiednurse assistants, medical assistants, medical records clerks, and secretarial/administrative assistantstaff.The FDOC has a licensed 120-bed hospital, an ambulatory surgery center, and a cancer treatment centeron location at the Reception and Medical Center (RMC) in Lake Butler.The sites also provide on-site mental health and dental staff to allow a full complement of on-site carecapabilities. Sites are managed by a clinical and administrative team that may include a MedicalDirector, Director of Nursing, and/or Health Services Administrator.Medication services include provision of all practitioner ordered medications. These are managed onsite and generally provided by single dose administration. There are medical infirmaries which arestaffed with nursing staff 24 hours a day, 7 days a week to allow provision of higher level of medical caresuch as IV management, wound care, and pre/post op care.The goal of health services within a correctional services contract is to perform as much care/service onsite to minimize the need to transport inmates outside of the facility. We strive to provide appropriatelevel of care and services while minimizing the risk to public safety by transporting inmates to outsideservice providers.Healthcare services that are routinely provided by on-site services and/or mobile service providersinclude: CLIA waivered tests such as blood glucose monitoring, urine pregnancy tests, blood guaiac tests,etc. Sites also draw all routine labs. These labs are drawn, prepared, picked-up, and resultscompleted/returned by a contracted lab vendor.Radiology services include routine chest, and extremity radiographs. Some sites may also haveavailability of services provided by a mobile vendor for ultrasound, MRI, mammography, etc.Dialysis servicesOn-Site PractitionersPractitioners providing care can include a combination of physicians, nurse practitioners andphysician assistants. On-site practitioners are CENTURION OF FL employees and serve as theprimary care providers and medical home for the management of inmate patient care.Version 1.1Page 8 of 26
Provider Manualthe next generation in correctional healthcareSite practitioners are responsible for providing/performing care and management of urgent and routinemedical care. They are also responsible for care and management of inmate patients with chronicdisease. Site practitioners are also responsible for requesting and managing inmate patient specialtycare. Inmate patients are not allowed to ‘self-refer’ for a specialty provider/service as allowed in thecommunity.The on-site practitioners submit requests for specialty service based on the CENTURION OF FL priorauthorization list (PAL) for services identified as requiring medical necessity determination. CENTURIONOF FL uses InterQual and other evidence-based criteria to assess medical necessity of the request. Ourprogram uses a two level review system where trained utilization management nurses perform Level 1review. Any request not meeting criteria for Level 1 approval is deferred to our CENTURION OF FLStatewide Regional Medical Director for final determinationOn-Site Practitioner AvailabilityAvailability is defined as the extent to which CENTURION OF FL employs the appropriate type andnumber of practitioners necessary to meet the needs of the inmate patient population housed in theinstitution. As part of our contract with FDOC, CENTURION OF FL provides all the on-site practitionerstaff. Most on-site practitioner staff is provided Monday through Friday during the day; however, largersites with more complex inmate patients may include evening and/or weekend coverage. Hours ofpractitioner time on-site can range from 4 hours/week for a very small site to 80 hours /week for largersites.24-Hour AccessRegardless of the assigned staffing at the site, CENTURION OF FL provides access to on-callpractitioner(s) 24 hours a day, 7 days a week. Access to a provider can include a practitioner returningto the facility for such things as suturing.Monitoring Healthcare ServicesCENTURION OF FL monitors the quality of our healthcare services in numerous ways to include thefollowing:Version 1.1Page 9 of 26
Provider Manualthe next generation in correctional healthcareDepartmentData AvailableDescriptionFrequency ofMonitoringEnsures that CENTURION OF FL employs theappropriate type and number of on-sitepractitioners and specialty careproviders/services necessary for appropriateSpecialty Provider and timely access to care.and SpecialtyAnalyzes a variety of reports to determine ifService Availability additional Providers may be requiredOngoingPrior Auth &ConcurrentReviewEnsures prior authorization and managementof care based on evidence based practiceguidelinesDailyOn-site QualityImprovementMonitoringComplaintsMonitors provision of on-site and off-siteaccess to care; tracks and trends inmatecomplaints and rocess andOutcome StudiesSummary information is reported for reviewand recommendation at the QIC and isincorporated into CENTURION OF FL’s annualassessment of quality improvement activitiesNetwork gs atleastQuarterlySpecialty Care, Emergency Department and HospitalizationAccessibility/CoordinationAs part of our health services contract, CENTURION OF FL has a Medical Management Department. Thedepartment includes utilization management staff performing prior authorization, concurrent review,retrospective reviews, appeals management, and other utilization review activities.Specialty Care Prior AuthorizationOn-site practitioners are responsible for requesting any services requiring prior authorization.Therefore, prior to the inmate being scheduled for an appointment, the service requested, such as‘initial evaluation and treatment recommendations’ will have been authorized. Upon return from aspecialist visit, the on-site practitioner will review the evaluation and recommendations from thespecialist. Based on the recommendations, the on-site practitioner may submit a new request foradditional services that were recommended as part of the initial specialty consultation. You, as thespecialist, are not responsible for requesting the prior authorization.Version 1.1Page 10 of 26
Provider Manualthe next generation in correctional healthcareEmergency Department ServicesEmergency department visits do not require prior authorization. If an inmate patient is sent to youremergency department for services, the on-site nursing staff will notify you that the inmate is in route toyour facility and provide a report regarding the patient’s current care/status. Inmates presenting to theemergency room will be transported by one or two correctional officers who will stay with the inmatethroughout the course of the emergency department visit.Our on-site nursing supervisor will routinely make contact with the emergency department requestingupdates for prolonged visits. If it is determined the inmate will require hospitalization, it is important tocontact the referring site’s healthcare nursing supervisor. If the inmate requires transfer to anotherinstitution, you will need to work in conjunction with the correctional officers and site healthcare staffregarding the transfer. Inmates requiring transfer to an inpatient bed or inpatient facility will befollowed by CENTURION OF FL utilization management staff.HospitalizationPre-planned hospitalizations require prior authorization. The prior authorization process is initiallymanaged by the on-site practitioner. Upon admission to the hospital, CENTURION OF FL utilizationmanagement staff should be notified. While the on-site nursing staff provides notification to theCENTURION OF FL utilization management staff, we also request that the utilization review staff at theinpatient facility provide notification regarding the inmate patient admission to the facility.Management of concurrent review of hospitalized inmate patients is coordinated by the CENTURION OFFL utilization management staff. Our staff coordinates review with hospital utilization staff and providesnecessary updates for the on-site practitioner and nursing staff. CENTURION OF FL utilizationmanagement staff also assists with coordinating discussions related to discharge planning. The goal ofdischarge planning is to discharge the inmate back to the facility as soon as medically indicated;remembering that discharge planning may include release back to one of the correctional facilities thathas infirmary capabilities.Specialty Provider ResponsibilitiesSpecialty services are obtained within the CENTURION OF FL network upon approval of the priorauthorization request initiated by the on-site practitioner. Specialists may complete diagnostic tests ifpart of the authorized service. It is important to remember that when coordinating scheduling, the onsite staff should be informed of results of testing and patient history that may be required as part of thespecialty visit. These documents, test results, radiology exams, etc. will be sent with the inmate for yourreview.If an immediate need arises during the visit to your office and you feel additional services, evaluation ortesting may be required immediately; you will be required to contact the CENTURION OF FL MedicalManagement Department to request prior authorization for those services. This would include suchVersion 1.1Page 11 of 26
Provider Manualthe next generation in correctional healthcarerequests as, referral to another specialist or admission to the hospital. Prior authorization is notrequired in a true emergency situation. However, all non-emergency inpatient admissions require priorauthorization from CENTURION OF FL.Please call the Utilization Management team at 1-844-243-0795 for prior authorization beforeperforming any tests or procedures that are not part of the original authorization for this visit.Working with the InmatesThe inmate patient will be accompanied by one or two correctional officers whenever he/she comes foran appointment. The officers transporting will work closely with you and your office staff to provideprivacy for your other patients. CENTURION OF FL and FDOC will work with you to minimize anydisruption to your other patients.The transporting correctional officer will provide you and your staff with a sealed envelope that includesthe inmate patient’s confidential medical record. The packet may also include a document on which youcan briefly document the synopsis of the encounter/visit. If a document is not included, simplydocument the note on a standard progress note from your office and include a copy with the returningrecords. All medical record information should be placed back in the envelope, re-sealed and providedto the transporting correctional officers prior to leaving your office.When working with the inmate patient, it is important that you do not share any information withhim/her specific to follow-up recommendations and particularly follow-up appointment dates, if alreadyand/or previously scheduled. If at any point you realize that you have informed the inmate patient of anupcoming appointment date and/or time, it is important that you notify the healthcare unit immediatelyto permit the appointment to be rescheduled.Continuity of CareSince CENTURION OF FL on-site practitioners are responsible for continuity of care, it is extremelyimportant that they obtain timely and thorough documentation from you, as the specialist, related toyour evaluation and treatment recommendations for the inmate patient. Therefore, importantresponsibilities of you as the specialist include: Coordinate the inmate patient’s care with the on-site practitionerComplete written evaluation/report and return as part of the inmate patient’s visitProvide the on-site practitioner with complete consult report and other appropriate recordswithin 5 business days of seeing the inmate patientSpecialist Appointment Access StandardsTimely access to appointments for inmate patients requiring evaluation and/or follow-up care isimportant to providing acceptable access to services as well as to maintaining positive outcomes.Version 1.1Page 12 of 26
Provider Manualthe next generation in correctional healthcareCENTURION OF FL staff responsible for coordinating scheduling will work with your office scheduler ordesignee to identify a routine process for scheduling, including routine times/days of the weeks thatmay be coordinated or set aside for easier access to appointments.Our contracts routinely require that specialty appointments be completed within a designatedtimeframe from the time of their prior approval by our utilization management staff. Our UtilizationManagement staff will work closely with you to access services within our specified time frames.CENTURION OF FL will monitor appointment timeliness and access to specialty services as part of ourongoing Quality Improvement Program. Issues specific to access and timeliness will be discussed withindividual providers and/or services if required.Hospital ResponsibilitiesCENTURION OF FL utilizes a network of hospitals to provide services to inmates. Hospitals providingservices as part of the
I Gulf Correctional Institution Wewahitchka (850) 639-1000 I Holmes Correctional Institution Bonifay (850) 547-8600 I Jackson Correctional Institution Malone (850) 569-5260 . II Quincy Annex Quincy (850) 627-5400 II Reception and Medical Center Lake Butler (386) 496-6000 II Suwannee Correctional Institution Live Oak (386) 963-6530 II Tomoka .
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