Provider Manual Template - Meridian Illinois Managed Care Plans

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PROVIDER MANUALRevised April 2022IllinoisProvider Manual300 S. Riverside Plaza, Suite 500Chicago, IL n Medicaid Provider Manual 2022 – Illinois (Revised 4/2022)1

Dear Medicaid Provider,Meridian offers three managed care plans in Illinois, Meridian Medicaid Plan (Medicaid), MeridianMedicare-Medicaid Plan (MMP), and Meridian Managed Long Term Services & Supports (MMLTS).We welcome you to the Meridian network of providers. Our Provider Manual is a reference tool foryou and your staff, designed to assist you in understanding plan policies, procedures, and otherprotocols.The Provider Manual is a dynamic tool which evolves with Meridian. Minor updates and revisions arecommunicated to you via Provider Notices and Newsletters, and replace related information in thisProvider Manual. Major updates and revisions are communicated to you via an updated edition of theProvider Manual. Furthermore, any material modifications to the Provider Manual shall becommunicated to you with a 60-day written notice.The current Provider Manual is available on our website at ilmeridian.com.Please contact your local Network Provider Relations representative or our member and providerservices department at 866-606-3700 with any questions or concerns.Thank you for your valued participation and helping our members live healthier lives.Meridian

Table of ContentsSection 1: General Information . 8Our Mission, Vision, and Philosophy. 8About Meridian Medicaid Plan . 8Contact Information. 9Section 2: Member-Related Information . 10Member Services Department . 10Member Rights and Responsibilities. 10Interpretive Services and Alternative Formats . 11Eligibility Requirements . 11Medicaid. 12Member Identification . 12Eligibility Information . 13Medicaid. 13PCP Identification and Verification . 13PCP Changes . 14Non-Emergent Transportation: Medicaid . 14Transportation Procedure. 14Member Enrollment and Disenrollment . 15Notice of Privacy Practices . 15Member Satisfaction . 15Grievances and Appeals . 15Member Grievances . 15Member Appeals . 16Member Expedited Appeal . 17Medicaid External Independent Review of Appeals (Home and Community Based Services excluded). 17Medicaid Expedited External Independent Review of Appeals (Home and Community Based Services. 18excluded) . 18State Fair Hearing. 18Provider Directory . 19Section 3: Member Benefit Information . 19Member Benefits . 19Services Covered under MLTSS . 20Medicaid Benefits Not Covered by Meridian . 21Non-Covered Services . 21ilmeridian.comMeridian Medicaid Provider Manual 2022 – Illinois (Revised 4/2022)3

Non-Covered For Medicaid Only. 21Member Self Referrals – Medicaid . 22Family Planning . 22Women’s Health . 22Children’s Health . 22Clinical Laboratory Improvement Amendment (CLIA) . 22Therapy . 23Section 4: Pharmacy Benefit Management . 23Prescription Drug Plan Coverage . 24Medicaid-Specific Benefits . 24Obtaining a Formulary Exception. 24Obtaining a Drug Prior Authorization . 24Federally Qualified Health Centers and Rural Health Centers . 25Advance Directives . 25Section 5: Utilization Management, Care Coordination and Disease Management . 27Utilization Management . 27Behavioral Health Utilization Review. 28Concurrent Review, Discharge Planning, and Transition of Care: . 29Requesting Prior Authorization/Precertification . 29Services Requiring Authorization . 30Classifying Your Prior Authorization Request . 31Turnaround Times for Processing Service Requests . 31Notification of Determination. 32Peer to Peer Discussion. 32Specialized Services:. 32Reconsideration of an Adverse Determination . 32Pre-Service Appeal . 34Post-Service Appeal . 34Care Coordination Program . 35Home and Community Based Services (HCBS) Program. 37Home and Community Based Services include the following: . 38HCBS Provider Responsibility . 38Smoking Cessation Program . 39Section 6: Billing and Payment . 39Claims Billing Requirements. 39Coordination of Benefits (COB) . 42Claims Guidelines for Dual-Eligible Members . 42Explanation of Benefits (EOB) . 42

Encounter Billing Guidelines – ERC, FQHC, and RHC . 43Electronic Claims Submission . 43Provider Appeal and Claim Dispute Process . .44How to File an Appeal .44Appeals Process for Denied Claims . 44What Types of Issues Can Providers Appeal? . 44How to File a Post-Service Appeal . 44Time Frame for Filing a Post Service Appeal . 45Response to Post-Service Appeals . 45Medicaid-Specific Guidelines . 46Section 7: Quality Improvement (QI) . 40QI Introduction. 46QIP Goals and Objectives . 46Medicaid Performance Improvement Projects. 47Community Based Care Coordination Overview . 47Follow-Up After Hospitalization Overview . 47QIP Processes and Outcomes. 48Provider Opportunities in QIP Activities . 48Quality Improvement Committee . 49Credentialing Committee . 50Physician Advisory Committee. 50Grievance Committee . 51Contractual Arrangements. 51Non-Delegated . 51Delegated . 52Quality Improvement Program Activities . 52Monitoring Quality Performance Indicators – Clinical and Operational . 52Monitoring Quality Performance Indicators – Surveys. 52Members . 52Providers . 53Meridian Medical Policies and Clinical Practice Guidelines . 53Monthly Provider HEDIS Education. 53Peer Review. 53Management of Quality of Care Complaints . 54Patient Safety . 54Confidentiality and Conflict of Interest . 55Confidentiality . 55ilmeridian.comMeridian Medicaid Provider Manual 2022 – Illinois (Revised 4/2022)5

Conflict of Interest . 55Member Safety . 56Provider Critical Incident Reporting . 57Section 8: Provider Functions and Responsibilities . 60Provider Roles and Responsibilities . 60Primary Care Providers/Patient-Centered Medical Homes . 61Identification of Medical Homes . 61Assessment and Support of Medical Homes . 61Specialty Care Providers. 62Hospital Providers . 63Ancillary Providers . 63Medicaid-Specific Roles and Responsibilities . 63Member Access and Availability Guidelines . 64Guidelines: . 64Encounter Reporting Requirements . 65Member Access and Availability Guidelines . 65Office Visit Appointments . 66PCP Appointment Availability Standards (Excludes OB/GYNs) . 66Behavioral Health Appointment Availability Standards . 66Specialty Care Providers Appointment Availability Standards . 67After Hours Access Standards . 68Physician Intent to Discharge Member from Care. 68Site Visits . 68Confidentiality and Accuracy of Member Records . 68Obligations of Recipients of Federal Funds. 69Fraud, Waste, and Abuse . 69Non-Discrimination . 70Provider Enrollment, Credentialing, and Re-Credentialing. 70Provider Credentialing Rights and Responsibilities . 72Credentialing Criteria . 72Corporate Credentialing Committee. 73Peer Review. 74Appeals Process . 74Facility Criteria . 76Delegated Credentialing . 77Delegated Credentialing Requirements . 77Credentialing FAQs. 78Becoming Credentialed . 78

Time Frame of the Credentialing Process . 78Checking the Status of a Credentialing Application . 78CAQH . 78Section 9: Clinical Guidelines and Recommendations . 79Immunizations. 79Well-Child Visits . 81Adolescent Well-Care Visits . 82Pregnancy Care. 82Family Planning Services . 83Preventive Health Recommendations for Adults. 83Clinical Practice Guidelines . 85Attestation of Training Completion. 87ilmeridian.comMeridian Medicaid Provider Manual 2022 – Illinois (Revised 4/2022)7

Section 1: General InformationOur Mission, Vision, and PhilosophyOur mission is to deliver better health outcomes at lower costs guided by the philosophy that qualityhealthcare is best achieved locally to ensure our vision of transforming the health of the community,one person at a time.About MeridianMeridian is the most extensive Medicaid health plan in Illinois, providing healthcare to nearly900,000 Medicaid members in every county throughout the state. In 2008, the Illinois Department ofHealthcare and Family Services (HFS) partnered with Meridian specifically to increase qualityoutcomes for the Medicaid population. Meridian currently provides care to those beneficiariesenrolled in the AllKids, Family Care, and Moms and Babies programs.Meridian Advantage Plan of Illinois (HMO SNP) was approved in the summer of 2012 by the Centersfor Medicare and Medicaid Services (CMS) to coordinate Medicare benefits for the dual-eligibleSpecial Needs (D-SNP) population starting January 1, 2013.On July 1, 2013, Meridian began serving the Seniors and Persons with Disabilities (SPD) population inthe central and metro east regions of Illinois. On January 1, 2014, Meridian began serving theAffordable Care Act (ACA) population. Meridian began providing healthcare services to the ManagedLong-Term Services & Supports (MLTSS) population on July 1, 2016.About Meridian HealthChoice IllinoisMeridian HealthChoice Illinois (Meridian), provides government-sponsored managed care services tofamilies, children, seniors, and individuals with complex medical needs primarily through MeridianMedicaid Plan (Medicaid), Medicare Advantage (WellCare), Medicare-Medicaid Plans ((MMP),Medicare Prescription Drug Plans (WellCare), and the Health Insurance Marketplace (Ambetter ofIllinois). Meridian is a wholly owned subsidiary of Centene Corporation, a leading multi-nationalhealthcare enterprise committed to helping people live healthier lives.About Centene CorporationCentene Corporation, a Fortune 500 company, is a leading multinational healthcare enterprisecommitted to helping people live healthier lives. The Company takes a local approach – with localbrands and teams – to provide fully integrated, high quality, and cost-effective services togovernment-sponsored and commercial healthcare programs, focusing on under-insured anduninsured individuals. Centene offers affordable and high-quality products to nearly 1 in 15individuals across the nation, including Medicaid and Medicare members (including MedicarePrescription Drug Plans) and individuals and families served by the Health Insurance Marketplace, theTRICARE program, and individuals in correctional facilities. The Company also serves severalinternational markets, and contracts with other healthcare and commercial organizations to providea variety of specialty services focused on treating the whole person. Centene focuses on long-termgrowth and the development of its people, systems and capabilities so that it can better serve itsmembers, providers, local communities, and government partners.

Contact InformationContact and Service FunctionTelephone NumberBehavioral Health Inpatient Mental Health Outpatient Mental Health Substance Abuse Treatment866-796-1167Illinois Client Enrollment Broker (ICEB) Managed Care Enrollment Questions877-912-8880Illinois Relay ServicesMember Services General Information and Assistance Verify Member Eligibility Benefit Information Status Claims File Complaints/Grievances Verify/Report Newborn Information Coordination of Benefits Interpretive Language armacy (PBM) Pharmacy Questions and Concerns Formulary Information Pharmacy-Utilization Management InformationMedicaid855-580-1688Provider Services Fee Schedule Assistance Discuss Problems and Concerns Contractual Issues Primary Care Administration Initiate Affiliation, Disaffiliation and Transfers866-606-3700Quality Improvement Request Clinical Practice Guidelines Request Preventive Healthcare Guidelines Quality Initiative Information Quality Regulatory Requirements Disease Management Program Information866-606-3700Transportation Member Non-Emergent Transportation866-796-1165Utilization Management Prior Authorizations Notification of Emergent and Urgent Hospital Admissions Requests for Clinical Criteria Peer to Peer Discussions Discharge Planning Information866-606-3700ilmeridian.comMeridian Medicaid Provider Manual 2022 – Illinois (Revised 4/2022)9

Care Coordination and Long Term Services and Supports Speak to a member’s care coordinator Request Individualized Plans of Care Check waiver eligibility information866-606-3700Section 2: Member-Related InformationMember and Provider Services DepartmentMeridian’s Member and Provider Services department exists to benefit both our members andproviders. Member and Provider Services is available to respond to all questions about Meridianbenefits, policies, and procedures.Member and Provider Services Representatives are available Monday through Friday, 7 a.m. to 5:30p.m., to assist with questions and resolve issues related to the following: Member eligibility Approval of non-emergency services Primary Care Provider (PCP) and site changes Women’s healthcare provider changes Complaints/grievances Disenrollment requests Claim status Rights and responsibilitiesMember and Provider Services is available Monday through Friday, 7 a.m. to 5:30 p.m., to confirmeligibility of benefits and ensure access to Emergency Services and Post-Stabilization Services.Members and providers are encouraged to call any time they have a question or concern. Questionsoutside the purvie

ilmeridian.com Meridian Medicaid Provider Manual 2022 - Illinois (Revised 4/2022) 1 . PROVIDER MANUAL . Revised April 2022 . Illinois . Provider Manual . 300 S. Riverside Plaza, Suite 500 . Chicago, IL 60606 . 312-705-2900

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