OhioRISE Program - 2022 Provider Manual OhioRISE, Specialized . - Aetna
OhioRISE Program - 2022 Provider ManualOhioRISE, specialized behavioral healthcare fromAetna Better Health of tna Better Health of Ohio
Chapter 1 - Introduction . 7Welcome . 7About Aetna Better Health . 7Experience and Innovation . 7OhioRISE . 7About this Provider Manual . 9Disclaimer . 9Aetna Better Health of Ohio Policies and Procedures .10Model of Care . Error! Bookmark not defined.Chapter 2 – Contact Information.10Contact Information .10Chapter 3 – Provider Experience Department . 15Provider Experience Department Overview . 15Provider Toll-Free Help Line . 16Provider Orientation . 16Interested Providers . 17Medicaid Addendum . 17Chapter 4 – Provider Responsibilities and Important Information . 17Provider Responsibilities Overview . 17Unique Identifier/National Provider Identifier . 18Appointment Availability Standards . 18Telehealth . 19Telephone Accessibility Standards . 20CPSE. 21Covering Providers . 21Verifying Member Eligibility . 21Secure Web Portal . 22Member Care Web Portal . 23Educating Members on their own Health Care . 26Provider Requested Member Transfer . 26Electronic Health Records (EHR) . 27Medical Records Review . 28Medical Record Audits . Error! Bookmark not defined.Documenting Referrals . 30Health Insurance Portability and Accountability Act of 1997 (HIPAA) . 30Breach of PHI11 . 32Member Privacy Rights . 33Member Privacy Requests . 33Advance Directives . 34Cultural Competency. 34ODM and Cultural Competency Information . Error! Bookmark not defined.Interpretation and Translation Requirements . 35Health Literacy – Limited English Proficiency (LEP) or Reading Skills . 35Alternative Formats. Error! Bookmark not defined.Americans with Disabilities Act (ADA). 36Clinical Guidelines . 382
Office Administration Changes and Training . 38Provider Maintenance . 39ODM Provider Call Center . 39General provider information/enrollment information . 39Termination, Suspension, or Denial of ODM Provider . 40Loss of Licensure . 40Enrollment and Reinstatement After Termination or Denial . 40Continuity of Care . 40Credentialing/Re-Credentialing . 40Licensure and Accreditation . 42Financial Liability for Payment for Services . 42Out of Network Providers – Transition of Care . 42Risk Arrangements . Error! Bookmark not defined.Helpful Information . 42Chapter 5 – Covered Services. 43Covered Services . Error! Bookmark not defined.Transitional Services and Supports . Error! Bookmark not defined.Outside Service Area . Error! Bookmark not defined.Non-Covered Benefits . 46Post-Stabilization Services . 46Emergency Services . 46Out of Area Benefits . Error! Bookmark not defined.Interpretation Services . Error! Bookmark not defined.Telehealth . 46Workforce Development . Error! Bookmark not defined.Chapter 6 – Eligibility and Enrollment . 47Eligibility . 47Welcome Packet . Error! Bookmark not defined.ID Card . 48Verifying Eligibility . 48Chapter 7 – Quality Management . 48Overview . 48Aetna’s Provider Relations Approach to Engagement . 49Aetna Forums/Roundtables . 50Regular Joint Operating Committee (JOC) Meetings . 50Provider Association Meetings . 51Aetna Provider Advisory Council (PAC) . 51Identifying Opportunities for Improvement . 52Potential Quality of Care (PQoC) Concerns . 54Performance Improvement Projects (PIPs) . 54Peer Review . 55Performance Measures . 55Satisfaction Surveys . 55External Quality Review (EQR) . 56Provider Profiles. 56Clinical Practice Guidelines . 583
Chapter 8 – Medical Management . 57Identifying Members Needs . 57Child and Family Team (CFT) . 58Documenting & Communicating Meetings . 59Chapter 9 – Utilization Management . 60Emergency Services . 60Exceptions to Prior Authorizations: . 60How to request Prior Authorizations. 60Timeliness of Decisions and Notifications . 61Out-of-Network Providers . 61Referrals . 62Concurrent Review Overview . 62Discharge Planning Coordination . 62Peer-to-peer consultations . 62External Medial Review . 62Chapter 10 – Behavioral Health . 63Mental Health/Substance Abuse Services . 63Medical Records Standards . 64Specific Screening Tools . Error! Bookmark not defined.Chapter 11 – Pharmacy Management . 64Single Pharmacy Benefit Manager (SPBM) . 64Next Generation Managed Care Program . Error! Bookmark not defined.Chapter 12 – Advance Directives (The Patient Self- Determination Act) . 65Patient Self-Determination Act (PSDA) . 65Do Not Resuscitate (DNR) . 66Medical Records. 66Chapter 13– Encounters, Billing and Claims . 67Provider Network Management (PNM) System Overview . 67Aetna Better Health and PNM . 67Overview. 68Billing Encounters and Claims Overview . 68When to File a Claim . 68Clean Claims . 68Timely Filing of Claim Submissions . 69Non-Participating Providers New Claim Submissions . 69Injuries Due to an Accident . 69How to File a Claim. 69Important Points to Remember . 69Correct Coding Initiative . 69Correct Coding . 70Incorrect Coding . 70Modifiers. 70Checking Status of Claims . 71Payment in Full Information . 714
Online Status through our Secure Web Portal . 71Calling the Claims Inquiry Claims Research (CICR) Department . 72Payment of Claims . 72Claim Resubmission . 72Claim Reconsiderations . 73Instruction for Specific Claims Types . 73Provider Remittance Advice . 73Encounter Data Management (EDM) System . 74Claims Processing . 74Encounter Staging Area . 75Encounter Data Management (EDM) System Scrub Edits . 75Encounter Tracking Reports . 75Data Correction . 75Chapter 14 – Grievance System . 76Member Grievance System Overview. 76Grievances . 77Grievance Extension . 77Expedited Grievance Resolution . 77Quality Improvement Organization - Quality of Care Grievances . 78Regulatory Complaints . 78Appeals . 78Continuation of Benefits . 79Appeal Process. 80Expedited Appeal Resolution . 80Appeal Extension. 81Failure to Make a Timely Decision . 81The Ohio Department of Medicaid (ODM) State Hearing . 80Administrative Law Judge (ALJ) . Error! Bookmark not defined.Participating Provider Claim Disputes . Error! Bookmark not defined.Non-Participating Provider Claim Appeals. Error! Bookmark not defined.Corrected Claims (Participating and Non-Participating Providers)Error! Bookmark not defined.Provider Grievances . 81Provider Appeals . 83Management of the Process . 83Chapter 15 – Fraud, Waste and Abuse . 83Fraud and Abuse. 83Special Investigations Unit (SIU) . 84Reporting Suspected Fraud and Abuse . 89Chapter 16 – Abuse, Neglect, Exploitation and Misappropriation of Member Property—CriticalIncidents . 89Mandated Reporters . 89Incident Reporting to Aetna Better Health . 90Provider Preventable Conditions (PPCs) / Hospital acquired Conditions (HACs) . 90Examples, Behaviors and Signs . 90Chapter 17 - Forms . 94Par Provider Dispute Form. 945
Non-Par Provider Appeals Form . 94ODM Forms . 94ODM Medicaid Addendum . 946
CHAPTER 1- INTRODUCTIONWelcomeWelcome to Aetna Better Health of Ohio Inc., an Ohio corporation, d/b/a Aetna Better Health ofOhio, the OhioRISE plan. Our ability to provide excellent service to our members is dependent onthe quality of our provider network. By joining our network, you are helping us serve thoseOhioans who need us most.About Aetna Better HealthAetna Better Health is Aetna’s Medicaid managed care plan. Backed by over 30 years ofexperience managing the care of those with a broad array of healthcare needs, our Medicaidplans have demonstrated that getting the right help when members need it is essential to betterhealth. That’s why Aetna Medicaid plans include the guidance and support needed to connectour members with the right coverage, resources, and care.Experience and InnovationWe are dedicated to enhancing member and provider satisfaction, using tools such as predictivemodeling, care management, and state‐of‐the art technology to achieve cost savings and helpmembers attain the best possible health, through a variety of service models.We work closely and cooperatively with physicians and hospitals to achieve durableimprovements in service delivery. We are committed to building on the dramatic improvementsin preventive care by facing the challenges of health literacy and personal barriers to healthyliving.Today, Aetna owns and administers Medicaid managed health care plans for more than threemillion members. In addition, Aetna provides care management services to hundreds ofthousands of high‐costs, high‐need Medicaid members. Aetna utilizes a variety of deliverysystems, including fully capitated health plans, complex care management, and administrativeservice organizations.OhioRISEOhio Resilience through Integrated Systems and Excellence (OhioRISE) program is a specializedmanaged care program for youth with complex behavioral health and multisystem needs.OhioRISE aims to expand access to in-home and community-based services.Aetna Better Health of Ohio care coordinators and care coordinators with our regional contractedcare management entities will ensure OhioRISE members and families have the resources theyneed to navigate their interactions with multiple systems such as juvenile justice, child protection,developmental disabilities, mental health and addiction, education, and others. An individual whois enrolled in the OhioRISE program will keep their managed care organization (MCO) or fee-forservice (FFS) enrollment for their physical health benefit. A member’s MCO also will be includedin their care management.7
The Ohio Department of Medicaid (ODM), state agencies, the Child and Adolescent BehavioralHealth Center of Excellence (CABHCOE), providers, families, Aetna, and other stakeholders fromlocal and state child-serving systems are engaging through an advisory council and workgroupsto develop and implement major components of OhioRISE and the new and enhanced services.OhioRISE will also feature a new 1915(c) Waiver. The waiver aims to reduce risks and preventnegative health and life outcomes for children and youth with serious emotional disturbances andfunctional impairments.OhioRISE eligibilityChildren and youth who may be eligible for OhioRISE are: Enrolled in Ohio Medicaid – either managed care or fee for service, Under the age of 21, Not enrolled in a MyCare plan, and Meet a functional needs threshold for behavioral healthcare, as identified by the Child andAdolescent Needs and Strengths (CANS) assessment tool, or an inpatient admission for abehavioral health service.OhioRISE servicesAll OhioRISE covered services are outlined in the Ohio Administrative Code rule 5160-59-03,including existing behavior health services and the following new and improved servicesavailable through OhioRISE: Care coordination at three different levels:o Tier 1: Limited Care Coordination (LCC) is delivered by Aetna and is for children oryouth needing lower intensity care coordination.o Tier 2: Moderate Care Coordination (MCC) is delivered by contracted regional caremanagement entities (CMEs) and includes strategies informed by wraparoundprinciples.o Tier 3: Intensive Care Coordination (ICC) is delivered by contracted regional CMEsand is consistent with principles of High-Fidelity Wraparound. Tier 3 is for childrenand youth with the greatest behavioral health needs. Intensive Home-Based Treatment (IHBT) – Provides intensive, time-limited behavioralhealth services for children, youth, and families that help stabilize and improve the child oryouth’s behavioral health functioning. In-state Psychiatric Residential Treatment Facilities (PRTFs) – This service will beavailable in-state beginning in January 2023. Today it’s covered when children or youthneed this level of care from facilities located outside Ohio. Ohio’s PRTF service will keepchildren and youth with the most intensive behavioral health needs in-state and closer totheir families and support systems. Behavioral Health Respite – Provides short-term, temporary relief to the primarycaregiver(s) of an OhioRISE plan enrolled youth, to support and preserve the primarycaregiving relationship. Primary Flex Funds – Provides funding to purchase services, equipment, or supplies nototherwise provided through Medicaid that addresses a need in a child or youth’s service8
plan. Funds must be used to purchase services/items that will reduce the need for otherMedicaid services, keep kids and families safe in their homes, or help the child or youth bebetter integrated into the community. See page 45 for more information on primary flexfunds.Mobile Response and Stabilization Services (MRSS) – MRSS provides rapid in-personcare when a child or youth is experiencing significant behavioral or emotional distress. It’savailable 24 hours a day, 365 days a year, and is delivered in the home, school, or atanother location in the community. This service is available to any child or youth coveredby Ohio Medicaid.OhioRISE 1915(c) Waiver Services Out-of-Home Respite: A service provided outside of the youth’s home that will provideshort-term temporary
Welcome to Aetna Better Health of Ohio Inc., an Ohio corporation, d/b/a Aetna Better Health of Ohio, the OhioRISE plan. Our ability to provide excellent service to our members is dependent on the quality of our provider network. By joining our network, you are helping us serve those Ohioans who need us most. About Aetna Better Health Aetna .
Feb 19, 2022 · Miami-Dade County Daily Covid-19 Hospital Report Category 02/05/2022 02/06/2022 02/07/2022 02/08/2022 02/09/2022 02/10/2022 02/11/2022 02/12/2022 02/13/2022 02/14/2022 02/15/2022 02/16/2022 02/17/2022 02/18/2022 Beds Acute Care Beds Beds that may be converted to Acute Care Beds IC
National Bank of the Republic of North Macedonia Statistics Department Skopje, 31 January 2023 Press Release Significant developments in interest rates of banks and savings houses1: . 12.2021 1.2022 2.2022 3.2022 4.2022 5.2022 6.2022 7.2022 8.2022 9.2022 10.2022 11.2022 12.2022 in % on annual level
Medicine provider, but they had insufficient data (i.e., the provider group does not have enough commercial health plan claims data to be evaluated, as required by the statistical requirements of the Provider Excellence Program; the provider group did not have enough quality data; or the provider group does not have enough cost-efficiency data). 3.
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
The PNM module will replace the current MITS provider enrollment subsystem and MITS provider portal beginning Oct. 1, 2022. The PNM system and portal will allow for one front door for provider enrollment, centralized credentialing, provider self-service (demographic updates and group affiliations), and an enhanced provider directory. 2.
Provider Transition Plan (PTP) System PTP #AD-003910 Provider Information * Mandatory (required) fields below are marked with an asterisk. Legacy Provider ID * 0 New Provider ID * 0 Provider Name * Demonstration Provider Provide
Provider ID: 1457472029 Provider Gender: Male Accepting New Patients: Yes Anthony Euser, DO 2801 Purcell St Brighton, CO 80601 303-659-7600 Adams County Provider ID: 1588634810 Provider Gender: Male Accepting New Patients: Yes John Fontenot, MD 1860 E Egbert St Brighton, CO 80601 303-659-4000 Adams County Provider ID: 1033373410 Provider Gender .
From Ramsey/Sleeper Architectural Graphic Standards, 9th ed., The American Institute of Architects, 1994. 37 Overhangs Overhang variances are needed where curbs, sidewalks, and signage exist. Overhangs also come into effect where retaining walls are present. From Ramsey/Sleeper Architectural Graphic Standards, 9th ed., The American Institute of Architects, 1994. 38 Vertical Clearance Diagram .
