Provider And Billing Manual - Ambetter Texas
Provider and Billing -C-00054 2016 Celtic Insurance Company. All rights reserved.
Table of ----------------------------------------------- 5HOW TO USE THIS PROVIDER MANUAL ---------------------------------------- 5KEY CONTACTS AND IMPORTANT PHONE NUMBERS -------------------- 5SECURE PROVIDER PORTAL ----- 6Functionality -------------- 7PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDER ---------- 7Credentialing and -------------------------------------------------- 7Provider Types that May Serve as Primary Care Providers -------------------------------------------------- 10Appointment Availability and Wait Times ------------------------ 12Hospital Responsibilities ---------------------------------------------- 15AMBETTER BENEFITS ------------- 16Overview ------------------- 16Additional Benefit Information --------------------------------------- 17VERIFYING MEMBER BENEFITS, ELIGIBILITY AND COST SHARES- 18Member Identification ------------------------------------------------ 18Preferred Method to Verify Benefits, Eligibility and Cost Shares ------------------------------------------- 19Other Methods to Verify Benefits, Eligibility and Cost Shares ---------------------------------------------- 19Importance of Verifying Benefits, Eligibility and Cost Shares ----------------------------------------------- 19MEDICAL MANAGEMENT --------- 20Utilization Management ------------------------------------------------- 20Procedure for Requesting Pre-authorizations ------------------ 23Behavioral Health Services -------------------------------------------- 24Pharmacy ------------------ 24Second Opinion --------- 25Women’s Health Care - 25Retrospective Review - 26Emergency Care -------- 26October 27, 20161
Utilization Review Criteria --------------------------------------------- 26CARE MANAGEMENT AND CONCURRENT REVIEW ---------------------- 27Care Management Process -------------------------------------------- 28Health Management ---- 28Ambetter’s Member Welcome Survey ----------------------------- 29Ambetter’s My Health Pays Member Incentive ------------ 29CLAIMS ---------------------------------- 29Clean Claims ------------- 30Clean Claim Definition -------------------------------------------------- 31Non-Clean Claim Definition ------------------------------------------- 31Upfront Rejections vs. Denials --------------------------------------- 31Timely Filing -------------- 32Who Can File Claims? - 32Electronic Claims Submission --------------------------------------- 33Online Claim Submission ---------------------------------------------- 36Paper Claim Submission ----------------------------------------------- 36Corrected Claims, Requests for Reconsideration or Claim Disputes/Appeals ------------------------- 37Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) ------------------------- 39Risk Adjustment and Correct Coding ------------------------------ 40Clinical Lab Improvement Act (CLIA) Billing Instructions -- 41Taxonomy Code Billing Requirement ------------------------------ 42CODE ------------------------------- 44CPT and HCPCS Coding Structure --------------------------------- 44International Classification of Diseases (ICD-10) -------------- 45Revenue --------------- 45Edit Sources -------------- 45Code Editing Principles ------------------------------------------------ 47Administrative and Consistency Rules ---------------------------- 50Prepayment Clinical Validation -------------------------------------- 51Inpatient Facility Claim ---------------------------------------------- 52Payment and Clinical Policy Edits ---------------------------------- 52Claim Reconsiderations Related To Code Editing And Editing --------------------------------------------- 53Viewing Claims Coding Edits ----------------------------------------- 53THIRD PARTY LIABILITY ---------- 53October 27, 20162
BILLING THE MEMBER ------------ 54Covered Services ------- 54Non-Covered Services -------------------------------------------------- 54Premium Grace Period for Members Receiving Advanced Premium Tax Credits (APTCs) -------- 54Premium Grace Period for Members Not Receiving Advanced Premium Tax Credits (APTCs) -- 55Failure to Obtain Authorization -------------------------------------- 55No Balance Billing ------ 55MEMBER RIGHTS AND RESPONSIBILITIES ---------------------------------- 55Member Rights ---------- 55Member Responsibilities ----------------------------------------------- 57PROVIDER RIGHTS AND RESPONSIBILITIES ------------------------------- 58Provider Rights ---------- 58Provider Responsibilities ---------------------------------------------- 58CULTURAL COMPETENCY ------- 60COMPLAINT PROCESS ------------ 61Provider Claim Appeal Process -------------------------------------- 61Member Complaint and Appeal Process -------------------------- 62QUALITY IMPROVEMENT PLAN -------------------------------------------------- 65Overview ------------------- 65QAPI Program Structure ----------------------------------------------- 65Quality Assessment and Performance Improvement Program Scope and Goals --------------------- 66Quality Rating System -------------------------------------------------- 69REGULATORY MATTERS --------- 71Medical Records -------- 71Federal And State Laws Governing the Release of Information -------------------------------------------- 73National --------------- 74WASTE, ABUSE AND FRAUD ---- 75False Claims Act -------- 76Physician Incentive ------------------------------------------------ 76APPENDIX ------------------------------ 77Appendix I: Common Causes for Upfront Rejections -------- 77Appendix II: Common Cause of Claims Processing Delays and Denials ------------------------------- 78October 27, 20163
Appendix III: Common EOP Denial Codes and ----------- 78Appendix IV: Instructions for Supplemental Information --- 79Appendix V: Common Business EDI Rejection Codes ------- 81Appendix VI: Claim Form Instructions ----------------------------- 83Appendix VII: Billing Tips and Reminders ---------------------- 103Appendix VIII: Reimbursement Policies ------------------------- 105Appendix IX: EDI Companion Guide ----------------------------- 108October 27, 20164
WELCOMEWelcome to Ambetter from Superior HealthPlan (“Ambetter”). Thank you for participating in our network ofparticipating physicians, hospitals and other healthcare professionals.Ambetter is a Qualified Health Plan (QHP) as defined in the Affordable Care Act (ACA). Ambetter will beoffered to consumers through the Health Insurance Marketplace, also known in Texas as the Health Care“Exchange.” Celtic Insurance Company (Celtic) is the Texas licensed Exclusive Provider Organization(EPO) contracted with the Center for Medicare and Medicaid Services (CMS) offering the Ambetterprogram in Texas. Celtic is contracted with Superior HealthPlan, Inc., in order to offer the SuperiorHealthPlan, Inc. network of contracted providers for the Ambetter program.The goals of the Affordable Care Act are: to help more Americans get health insurance and stay healthy; and to offer consumers a choice of coverage leading to increased health care engagement andempowerment.HOW TO USE THIS PROVIDER MANUALAmbetter is committed to assisting its provider community by supporting their efforts to deliver wellcoordinated and appropriate health care to our members. Ambetter is also committed to disseminatingcomprehensive and timely information to its providers through this Provider Manual (“Manual”) regardingAmbetter’s operations, policies and procedures. Updates to this Manual will be posted on our website atAmbetter.SuperiorHealthPlan.com. Additionally, providers may be notified via bulletins and notices postedon the website and potentially on Explanation of Payment notices. Providers may contact our ProviderServices Department at 1-877-687-1196 to request that a copy of this Manual be mailed to you. Inaccordance with the Participating Provider Agreement, providers are required to comply with the provisionsof this Manual. Ambetter routinely monitors compliance with the various requirements in this Manual andmay initiate corrective action, including denial or reduction in payment, suspension or termination, if thereis a failure to comply with any requirements of this Manual.KEY CONTACTS AND IMPORTANT PHONE NUMBERSThe following table includes several important telephone and fax numbers available to providers and theiroffice staff. When calling, it is helpful to have the following information available.1. The provider’s NPI number2. The practice Tax ID Number3. The member’s ID numberHEALTH PLAN INFORMATIONWebsiteHealth Plan address(correspondence rior HealthPlan5900 E. Ben White Blvd.Austin, TX 78741PhoneFaxRelay Texas/TTY Line1-800-735-2989Provider Services1-877-687-1196October 27, 20165Email or Web Address
HEALTH PLAN INFORMATIONDepartmentPhoneFaxEmail or Web AddressMember ServiceMedical Management ElectiveInpatient and Outpatient PriorAuthorizationEmergent Inpatient Admissions/ Concurrent ReviewAdmissions/Census Reports/Clinical 1961-866-838-7915Care Management1-800-732-7562Behavioral Health PriorAuthorization1-855-283-910124/7 Nurse Advice linePharmacy Services1-866-399-0828[BIN # 008019]Advanced Imaging (MRI, CT,PET) (NIA)1-800-424-4916www.RadMD.comCardiac Imaging (NIA)1-800-424-4916www.RadMD.comEnvolve Vision1-866-753-5779Dental Services1-888-308-4766Interpreter Services1-877-687-1196To report suspected fraud,waste and abuse1-866-685-8664EDI Claims assistance1-800-225-2573ext. E PROVIDER PORTALAmbetter offers a robust secure provider portal with functionality that is critical to serving members and toease administration for the Ambetter product for providers. Each participating provider’s dedicated AccountManager will be able to assist and provide education regarding this functionality. The portal can beaccessed at Ambetter.SuperiorHealthPlan.com. If you are already a registered user on the Secure ProviderPortal, a separate registration is not needed.October 27, 20166
FunctionalityAll users of the Secure Provider Portal must complete a registration process.Once registered, providers may: Check eligibility and view member roster; View the specific benefits for a member; View members remaining yearly deductible and amounts applied to plan maximums; View the status of all claims that have been submitted regardless of how submitted; Update provider demographic information (address, office hours, etc.); View and print patient lists (for Primary Care Providers). This patient list will indicate themember’s name, member ID number, date of birth, care gaps, Disease Management enrollmentand the product in which they are enrolled; Submit authorizations and view the status of authorizations that have been submitted formembers; View, submit, copy and correct claims; Submit batch claims via an 837 file; View and download Explanations of Payment (EOP); View a member’s health record including visits (physician, outpatient hospital, therapy, etc.)medications and immunizations; View gaps in care specific to a member including preventive care or services needed for chronicconditions; Send and receive secure messages with Ambetter staff; and Perform as an account manager to manage additional portal accounts needed in your office. Youcan manage permission access for those accounts.PROVIDER ADMINISTRATION AND ROLE OF THE PROVIDERCredentialing and RecredentialingThe credentialing and recredentialing process exists to verify that participating practitioners and providersmeet the criteria established by Ambetter, as well as applicable government regulations and standards ofaccrediting agencies.If a provider already participates with Superior HealthPlan in the Medicaid or a Medicare product, theprovider will NOT be separately credentialed for the Ambetter product.Note: In order to maintain a current provider profile, providers are required to notify Ambetter ofany relevant changes to their credentialing information in a timely manner but in no event laterthan 10 days from the date of the change.Texas utilizes the Texas Standardized Credentialing Application. Whether the provider completes theapplication or has registered their credentialing information on the Council for Affordable Quality Health(CAQH) website, the following information must be on file:October 27, 20167
A valid NPI number; Signed attestation as to correctness and completeness, history of license, clinical privileges,disciplinary actions and felony convictions, lack of current illegal substance use and alcoholabuse, mental and physical competence; and ability to perform essential functions with or withoutaccommodation; Completed Ownership and Control Disclosure form; Current malpractice insurance policy face sheet which includes insured dates and the amounts ofcoverage; Current Controlled Substance registration certificate, if applicable; Current Drug Enforcement Administration (DEA) registration certificate for each state in which thepractitioner will see Ambetter members; Completed and signed W-9 form; Current Educational Commission for Foreign Medical Graduates (ECFMG) certificate, ifapplicable; Current unrestricted medical license to practice or other license in the State of Texas; Current specialty board certification certificate, if applicable; Work history for the previous five (5) years - any gap greater than six (6) months must beexplained by the practitioner and presented to the Credentials Committee for approval; Proof of highest level of education and in the case of physicians, proof of graduation from anaccredited medical school or school of osteopathy, proof of completion of an accredited residencyprogram, or proof of board certification (verification of completions of a fellowship does not meetthis requirement); Current admitting privileges in good standing with an in-network inpatient facility or writtendocumentation from a physician or group of physicians, who participate with Superior, statingthey will assume the inpatient care of all the practitioner’s plan members who require admission,and that they will do so at a participating facility; Mid-level practitioners must submit proof of supervising, collaborative agreement, protocols, orother written authorization (as required by state law or Superior requirements) with a licensedphysician who is participating with Superior, that sets forth the manner in which the mid-levelpractitioner and licensed physician cooperate, coordinate and consult with each other in theprovision of health care to patients; History of professional liability claims that resulted in settlements or judgments paid by or onbehalf of the practitioner for the past five (5) years or any cases that are pending professio
program in Texas. Celtic is contracted with Superior HealthPlan, Inc., in order to offer the Superior HealthPlan, Inc. network of contracted providers for the Ambetter program. The goals of the Affordable Care Act are: to help
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
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.
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
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
Ambetter offers a robust and secure provider Portal with functionality critical to serving members and to easing administration of the Ambetter product for providers. Each participating provider’s dedicated Provider Relations Specialist will be able to assist and provide education regarding this functionality. The Portal can be accessed at
Ambetter from Meridian 1 Campus Martius, Suite 700 Detroit, MI 48226. If you want to talk, we're available Monday through Friday, . Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. . AMB20-MI-C-00051; Front Back; Member/Provider Services: 1-833-993-2426
Ambetter from Sunshine Health: 1-877-687-1169 (Relay Florida: 1-800-955-8770) Ambetter.SunshineHealth.com 2 MEMBER HANDBOOK OVERVIEW Member Handbook Overview . in your 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
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.
