PROVIDER MANUAL - State Of Louisiana
PROVIDER MANUALTable of ContentsProvider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx
INTRODUCTION . 7Welcome. 7About US . 7Mission . 7How to Use This Manual. 5KEY CONTACTS. 5PRODUCT SUMMARY . 6Mandatory Populations . 6Voluntary Populations. 6Excluded Populations . 7VERIFYING ELIGIBILITY . 8Member Eligibility Verification . 8Member Identification Card . 9LOUISIANA HEALTHCARE CONNECTIONS WEBSITE . 9Louisiana Healthcare Connections Website . 9Secure Website . 10PRIMARY CARE PROVIDERS (PCP) .11Provider Types That May Serve As PCPs . 11Member Panel Capacity . 11Primary Care Provider (PCP) Responsibilities . 13Referrals. 14Self-Referrals. 15Specialist Responsibilities . 15Mainstreaming . 16Covering Providers . 17Telephone Arrangements . 1824-Hour Access . 18Hospital Responsibilities . 19Advanced Directives. 19Voluntarily Leaving the Network . 20CULTURAL COMPETENCY .21BENEFIT EXPLANATION AND LIMITATIONS .22Louisiana Healthcare Connections Health Plan Benefits . 22Benefits and Services Requiring Plan Authorization . 22Non-Emergent Medical Transportation . 28Network Development and Maintenance . 29With the use of GEO access tools, LHC will monitor its access to all specialists and willensure that the number of LHC members per specialist does not exceed the State ofLouisiana‘s requirements. 31LHC goal is to exceed the State‘s minimum requirements (listed as following): . 31Tertiary Care . 31MEDICAL MANAGEMENT .32Overview . 32Utilization Management . 32Second Opinion . 33Assistant Surgeon . 33Review Criteria . 35New Technology . 36Prior Authorization and Notifications . 36Authorization Determination Timelines . 37Provider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx
Notification of Pregnancy . 37Concurrent Review and Discharge Planning . 37Retrospective Review . 37SPEECH THERAPY AND REHABILITATION SERVICES .38HI TECH RADIOLOGY SERVICES .38EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT .39EMERGENCY CARE SERVICES .40Women‘s Health Care.41VALUE ADDED SERVICES .41CLINICAL PRACTICE GUIDELINES .42CASE MANAGEMENT PROGRAM .42PROVIDER RELATIONS DEPARTMENT .46Top 10 Reasons to Contact a Provider Relations Representative . 46BILLING AND CLAIMS SUBMISSION .47General Guidelines . 47Clean Claim Definition . 47Non-Clean Claim Definition . 48Timely Filing . 50Electronic Claims Submission. 51Paper Claims Submission. 51Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) . 52Claim Payment . 52Third Party Liability . 52ENCOUNTERS .53What is an Encounter Versus a Claim? . 53Procedures for Filing a Claim/Encounter Data . 53CREDENTIALING and RECREDENTIALING .54RIGHTS AND RESPONSIBILITIES .56Provider Rights. 58Provider Responsibilities . 58GRIEVANCES AND APPEALS PROCESS .60Member Grievances and Provider Complaints . 60Acknowledgement . 61Grievance Resolution Time Frame . 61Notice of Resolution . 61Appeals . 61Expedited Appeals . 62State Fair Hearing Process . 62Reversed Appeal Resolution . 63WASTE, FRAUD AND ABUSE.63Waste Abuse and Fraud (WAF) System . 63Authority and Responsibility . 64QUALITY IMPROVEMENT .65Program Structure . 65Practitioner Involvement . 66Quality Assessment and Performance Improvement Program Scope and Goals . 66Patient Safety and Quality of Care . 67Performance Improvement Process . 67Healthcare Effectiveness Data and Information Set (HEDIS) . 68Provider Satisfaction Survey. 69Consumer Assessment of Healthcare Provider Systems (CAHPS) Survey . 69Provider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx
Provider Profiling and Incentive Programs . 69MEDICAL RECORDS REVIEW .71Medical Records . 71Required Information. 71Medical Records Release . 72Medical Records Transfer for New Members . 72Medical Records Audits . 72INTRODUCTIONWelcomeWelcome to Louisiana Healthcare Connections (‖LHC‖). We thank you for being part ofLHC network of participating physicians, hospitals, and other healthcare professionals. Ournumber one priority is the promotion of healthy lifestyles through preventive healthcare.LHC works to accomplish this goal by partnering with the providers who oversee thehealthcare of LHCs‘ members.About USLHC is a Coordinated Care Network (CCN) contracted with the Louisiana Department ofHealth and Hospitals (DHH) to serve Louisiana members through the Medicaid program.LHC has the expertise to work with Louisiana members to improve their health status andquality of life. LHC‘s management company, Centene Corporation (―Centene‖), has beenproviding comprehensive managed care services to individuals receiving benefits underMedicaid and other government-sponsored healthcare programs for more than twenty-five(25) years. Centene operates local health plans and offers a wide range of health insurancesolutions to individuals and to the rising number of uninsured Americans. It also contractswith other healthcare and commercial organizations to provide specialty services. LHC is aphysician-driven organization that is committed to building collaborative partnerships withproviders. LHC will serve our Louisiana members consistent with our core philosophy thatquality healthcare is best delivered locally.MissionLHC strives to provide improved health status, successful outcomes, and member andprovider satisfaction in a coordinated care environment. LHC has been designed to achievethe following goals:Ensure access to primary and preventive care servicesEnsure care is delivered in the best setting to achieve an optimal outcomeImprove access to all necessary healthcare servicesEncourage quality, continuity, and appropriateness of medical careProvide medical coverage in a cost-effective mannerAll of our programs, policies and procedures are designed with these goals in mind. Wehope that you will assist LHC in reaching these goals and look forward to your activeparticipation.Provider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx
How to Use This ManualLHC is committed to working with our provider community and members to provide a highlevel of satisfaction in delivering quality healthcare benefits. We are committed to providecomprehensive information through this Provider Manual as it relates to LHC operations,benefits, and policies and procedures to providers. Updates to this Provider Manual will beposted in LHC‘s web site and providers will be notified via Bulletins and notices posted inits provider secure web site and in its weekly Explanation of Payment notices. For hardcopies or CD copies of this Provider Reference Manual please contact the ProviderServices department (“Provider Services”) at 1-866-595-8133 or if you need furtherexplanation on any topics discussed in the manual.KEY CONTACTSThe following chart includes several important telephone and fax numbers available to youroffice. When calling LHC, please have the following information available:NPI (National Provider Identifier) numberTax ID Number (―TIN‖) numberMember‘s ID number or Medicaid ID numberHealth Plan InformationLouisiana Healthcare ConnectionsOffice AddressCity, State ne NumberFax NumberProvider Services1-866-595-81331-xxx-xxx-xxxxMember -xxx-xxxx1-xxx-xxx-xxxxAuthorization RequestConcurrent ReviewCase ManagementNurseWise(24/7 Availability)Louisiana Department ofHealth and HospitalsMedical ClaimsLouisiana HealthcareConnectionsAttn: ClaimsPO Box 4040Farmington, MO XXX-XXXXReimbursement Rate DisputeMedical Necessity AppealLouisiana Healthcare ConnectionsAttn: Claim DisputesPO Box 3000Farmington, MO 63640-3800Louisiana HealthcareConnectionsAttn: Medical NecessityOffice addressCity State and ZipElectronic Claims SubmissionLouisiana Healthcare Connectionsc/o Centene EDI Department1-800-225-2573, ext 25525or by e-mail to: EDIBA@centene.comProvider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx5
PRODUCT SUMMARYThe population of Louisiana‘s Coordinated Care Network is comprised of beneficiarieswhom are in a category of eligibility listed below:Mandatory PopulationsChildren under 19 years of age including those eligible under Section 1931poverty-level related groups and optional groups of older children in thefollowing categorieso LIFC Program (Low Income Families with Children)o FITAP Program (Families in Temporary Need of Assistance)o CHAMP-Child Programo Deemed Eligible Child Programo Youth Aging Out of Foster Careo Continued Medicaid Programo Regular Medically Need ProgramLaCHIP ProgramParents eligible under Section 1931 and optional caretaker relative groupsincluding:o LIFC Programo FITAP Programo Continued Medicaid Programo Regular Medically Needy ProgramPregnant Womeno LaMOMS (CHAMP-Pregnant Women)o LaCHIP Phase IV ProgramBreast and Cervical Cancer (BCC) ProgramAged, Blind & Disabled Adults (ABD)o Supplemental Security Income (SSI) Programo Extended Medicaid ProgramsDisabled Adult ChildrenDisabled Widows/WidowersEarly Widows/WidowersPickle (ABD persons who become ineligible for SSI or MSS)Disabled Widows/Widowers and Disabled Surviving Divorced Spouses UnableTo Perform Any Substantial Gainful ActivityBlood Product Litigation ProgramMedicaid Purchase Plan ProgramDisability Medicaid ProgramVoluntary PopulationsNative Americans who are members of federally recognized tribes except whenthe MCO iso The Indian Health Service orProvider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx6
o An Indian health program or Urban Indian program operated by a tribeor tribal organization under a contract, grant, cooperative agreement orcompact with the Indian Health ServiceChildren under 19 years of age who are:o Eligible for SSI under title XVIo Eligible under section 1902(e)(3) of the Acto In foster care or other out-of-home placemento Receiving foster care or adoption assistanceo Receiving services through a family-centered, community-based,coordinated care system that receives grant funds under section501(a)(1)(D) of title V, and is defined by the DHH in terms of eitherprogram participation or special health care needs oro Enrolled in the Family Opportunity Act Medicaid Buy-In ProgramExcluded PopulationsIndividual receiving hospice servicesIndividuals residing in Nursing Facilities (NF) or Intermediate Care Facility for theDevelopmentally Disabled (ICF/DD)Individuals with Medicare dual eligibleIndividuals who have been diagnosed with tuberculosis or suspected of havingtuberculosis, and receiving tuberculosis-related services through the TuberculosisInfected Individual ProgramIndividuals receiving services through any 1915(c) Home and Community-BasedWaiver program including but not limited to:o Adult Day Health Care (ADHC)o New Opportunities Waiver (NOW)o Elderly and Disabled Adult (EDA)o Children‘s Choice (CC)o Residential Options Waiver (ROW)o Supports Waivero Other HCBS waivers as may be approved by CMSIndividuals under the age of 21 otherwise eligible for Medicaid who are listed on theOffice for Citizens with Developmental Disabilities‘ Request for Services Registry,also knows as Chisholm Class MembersIndividuals enrolled in the Program of All-Inclusive Care for the Elderly (PACE) acommunity based alternative to placement in a nursing facility that includes acomplete ―managed care‖ type of benefit combining medical, social and long-termcare servicesIndividual with a limited eligibility period includingo Spend-down Medically Needy Program – an individual or family who hasincome in excess of the prescribed income standardo Emergency Services Only – emergency services for aliens who do not meetMedicaid citizenshipo Continued Medicaid Program – short-term coverage for families who loseLIFC or TANF eligibility because of child support collections, an increase inearnings or an increase in the hours of employmentProvider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx7
Individuals enrolled in the LaCHIP Affordable Plan Program (LaCHIP Phase V)that provides benchmark coverage with a premium to uninsured low-incomechildren under age 19 who do not otherwise qualify for Medicaid or other LaCHIPprogramsIndividuals enrolled in and receiving Family Planning services only in the TakeCharge Program which provides family planning services to uninsured women 19-44who are not otherwise eligible for any other Medicaid program.Individuals enrolled in the Louisiana Health Insurance Premium Payment (LaHIPP)Program (Section 1906)VERIFYING ELIGIBILITYMember Eligibility VerificationTo verify member eligibility, please use one of the following methods:1. Log on to the secure provider portal at www.LouisianaHealthConnect.com. Usingour secure provider website, you can check member eligibility. You can search bydate of service and either of the following: member name and date of birth, ormember Medicaid ID and date of birth.2. Call our automated member eligibility IVR system. Call 1-866-595-8133 from anytouch tone phone and follow the appropriate menu options to reach our automatedmember eligibility-verification system twenty-four (24) hours a day. The automatedsystem will prompt you to enter the member Medicaid ID and the month of serviceto check eligibility.3. Call LHC Provider Services. If you cannot confirm a member‘s eligibility using themethods above, call our toll-free number at 1-866-595-8133. Follow the menuprompts to speak to a Provider Services Representative to verify eligibility beforerendering services. Provider Services will need the member name or memberMedicaid ID to verify eligibility.Through LHC‘s secure provider web portal, PCPs are able to access a list of eligiblemembers who have selected their services or were assigned to them. The Patient list isreflective of all changes made within the last 24 hours. The list also provides other importantinformation including date of birth and indicators for patients whose claims data show a gapin care, such as a missed Early Periodic Screening, Diagnosis and Treatment (EPSDT) exam.In order to view this list, log on to www.LouisianaHealthConnect.com. Since eligibilitychanges can occur throughout the month and the member list does not proveeligibility for benefits or guarantee coverage, please use one of the above methods toverify member eligibility on date of service.All new LHC members receive a LHC member ID card. Members will keep their stateissued ID card to receive services not covered by the plan (such as dental, hospice andpharmacy services). A new card is issued only when the information on the card changes, ifa member loses a card, or if a member requests an additional card. Since member ID cardsProvider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx8
are not a guarantee of eligibility, providers must verify members’ eligibility on eachdate of service.Member Identification CardMembers must present a member ID card each time services are rendered by a provider. Ifyou are not familiar with the person seeking care as a member of our health plan, please askto see photo identification. If you suspect fraud, please contact Provider Services at 1-866595-8133 immediately. Members must keep the state-issued Medicaid ID card in order toreceive benefits not covered by Louisiana Healthcare Connections, such as Pharmacy andDental services.LOUISIANA HEALTHCARE CONNECTIONS WEBSITELouisiana Healthcare Connections WebsiteThe LHC website can significantly reduce the number of telephone calls providers need tomake to the health plan. Utilizing the website allows immediate access to current providerand member information 24 hours, seven days a week. Please contact your ProviderProvider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx9
Relations Representative or our Provider Services department at 1-866-595-8133 with anyquestions or concerns regarding the website.LHC website is located at www.LouisianaHealthConnect.com. Physicians can find thefollowing information on the website:Provider ManualProvider Billing ManualPrior Authorization ListFormsLHC Plan NewsClinical GuidelinesProvider newslettersSecure WebsiteLHC web portal services allows providers to check member eligibility and benefits, submitand check status of claims, request authorizations and send messages to communicate withLHC staff. LHC contracted providers and their office staff have the opportunity to registerfor our secure provider website in just 4-easy steps. Here, we offer tools which makeobtaining and sharing information easy! It‘s simple and secure! Go towww.LouisianaHealthConnect.com to register. On the home page, select the Login link onthe top right to start the registration process.Through the secure site you can:Check member eligibilityView Members‘ health recordView the PCP panel (patient list)Provider Services Department 1-866-595-8133 TDD/TTY 1-xxx-xxxx10
View and submit claims and adjustmentsView payment historyView and submit authorizationsView member health recordView member gaps in careView quality scorecardContact us securely and confidentiallyWe are continually updating our website with the latest news and information, so save toyour Internet ―Favorites‖ list and check our site often. Please contact a Provider RelationsRepresentative for a tutorial on the secure site.PRIMARY CARE PROVIDERS (PCP)The primary care provider (PCP) is the cornerstone of LHC service delivery model. ThePCP serves as the ―medical home‖ for the member. The ―medical home‖ concept assists inestablishing a member-provider relationship, supports continuity of care, patient safety, leadsto elimination of redundant services and ultimately more cost effective care and better healthoutcomes. LHC offers a robust network of primary care providers to ensure every memberhas access to a medical home within the required travel distance standards (30 miles in therural regions and 10 miles in the urban regions). LHC requests that PCP‘s inform ourmember services department when a LHC member misses an appointment so we maymonitor that in our system and provide outreach to the member on the importance ofkeeping appointments. This will assist our providers in reducing their missed appointmentsand reduce the inappropriate use of Emergency Room services.Provider Types That May Serve As PCPsPhysicians who mayserveas ynecologists, Family and General Practitioners and Nurse Practitioners. ThePCP may practice in a solo or group setting or at a FQHC, RHC or outpatient clinic. LHCmay allow some specialists to serve as a member‘s PCP for members with multipledisabilities or with acute or chronic conditions as long as the specialists is willing to performthe responsibilities of a PCP as stipulated on page 13 of this manual.LHC will provide access to PCPs that offer extended office hours (minimum of two hoursafter 5:00 pm) at least one day a week and on Saturdays four hours or longer. As part of itsreporting responsibilities, LHC will notify the State‘s enrollment broker of any PCP that willnot accept new patients or who has reached member enrollment capacity.Member Panel CapacityAll PCPs reserve the right to state the
Louisiana Healthcare Connections Office Address City, State Zip www.LouisianaHealthConnect.com Department Telephone Number Fax Number Provider Services 1-866-595-8133 1-xxx-xxx-xxxx Member Services 1-xxx-xxx-xxxx (TDD/TTY) 1-xxx-xxx-xxxx 1-xxx-xxx-xxxx Authorization Request Concurrent Review Case Management
Baton Rouge, Louisiana Ashley N. Freeman Lake Charles, Louisiana Samuel T. French Fayette, Mississippi Samantha G. Gahn Baton Rouge, Louisiana Landon P. Gauthier Gonzales, Louisiana John C. Ginart Chalmette, Louisiana Andres Gomez Lafayette, Louisiana . Taylor Alexander . Lake Charles, Louisiana
Louisiana Purchase PowerPoint Notes Answer Key Louisiana 1. Louisiana was the large area west of the Mississippi River. 2. 1762 - Louisiana was given to Spain after the French & Indian War. 3. 1800 - France took control of Louisiana New Orleans 4. What was the largest port in Louisiana? New Orleans 5. What were the American farmers worried .
University Louisiana Lafayette: Upward Bound Math & Science (TRIO) Crystal Vallier cvallier@louisiana.edu Constance Broussard connie@louisiana.edu Shauna Landry Ahauna.landry@louisiana.edu Janice Nix Victorian jnix@louisiana.edu July 17-July18 (
Computer Science Nona Istre nona@louisiana.edu Informatics Dr. Hsiu-Yuen (Sonya) Hsu sonyahsu@louisiana.edu Environmental Science Dr. Durga Poudel ddpoudel@louisiana.edu Geology Dr. Tim Duex tduex@louisiana.edu Mathematics Dr. Ross Chiquet car4205@louisiana.edu Physics Dr. Andi Petculescu C00250270@louisiana.edu Department of Biology
Baton Rouge/Lafayette Chapter, Greater New Orleans Chapter, . Louisiana Historical Society, Louisiana Library Association (LLA) Louisiana State Archives As in the past, the State Archives provided the Archives Month poster to the Council of . FRIENDS of the Louisiana State Archives Barnes &
Louisiana State Agency P/S Federal Agency C/P/S Louisiana Economic Development P US Department of Commerce C Louisiana Workforce Commission S FEMA P Louisiana Departmentof Revenue S US Department of Agriculture P University of Louisiana‐Lafayette/NIMSAT S US Department
The Louisiana Health Insurance Survey (LHIS) is a biennial survey designed to assess health insurance coverage in Louisiana. The survey was first conducted in 2003. This report focuses on the results of the 2019 survey. The LHIS has helped state policy makers track changes in health insurance as Louisiana's economy, health care environment,
Louisiana Go Grant, and other assistance programs. TOPS PROGRAM A program of state scholarships for Louisiana residents who attend either one of the Louisiana public colleges and universities, schools that are a part of the Louisiana Community and Technical College System, Louisiana approved proprietary and cosmetology schools, or
