2012 Provider Manual MASTER FINAL v7 -...

Provider Manual

2012

Provider Manual

Updated 3/20/2012

Provider Manual

COMBW2011 UPDATED 3-01-12 Page 2

TABLE OF CONTENTS

1-1 KEY CONTACTS ................................................................................................................................... 4

GENERAL .......................................................................................................................................................... 4 REGIONAL CARE CENTERS (RCCS) ..................................................................................................................... 5 RCC KEY PHONE NUMBERS: AUTHORIZATION, RE-AUTHORIZATION, AUTH CORRECTIONS ............................................. 6 NETWORK MANAGEMENT KEY CONTACTS ...................................................................................................... 7

1-2 WELCOME.......................................................................................................................................... 8

ABOUT THIS PROVIDER MANUAL ............................................................................................................................ 8

1-3 ABOUT CARECENTRIX ......................................................................................................................... 8

ABOUT CARECENTRIX ............................................................................................................................................ 8

1-4 CORPORATE COMPLIANCE PROGRAM ................................................................................................. 9

COMPANY OBJECTIVES AND PURPOSE OF THE COMPLIANCE PROGRAM ........................................................................... 9 REPORTING SYSTEM ............................................................................................................................................ 11 RESPONSE AND CORRECTIVE ACTION TO PROMOTE PROGRAM EFFECTIVENESS ............................................................... 12

2-1 PERFORMANCE STANDARDS ............................................................................................................. 12

3-1 PROVIDER ORIENTATION .................................................................................................................. 13

PROVIDER MANUAL ............................................................................................................................................ 13 THE CONFERENCE CALL ....................................................................................................................................... 14 THE CARECENTRIX PROVIDER PORTAL .................................................................................................................... 14 SPECIAL REPORTS ............................................................................................................................................... 15

3-2 NATIONAL CREDENTIALING COMMITTEE ........................................................................................... 15

PURPOSE: ......................................................................................................................................................... 15 COMMITTEE ATTENDANCE ................................................................................................................................... 15 COMMITTEE MEETING SCHEDULE: ......................................................................................................................... 15

3-3 PROVIDER QUALIFICATION AND QUALITY MANAGEMENT .................................................................. 16

CREDENTIALING ................................................................................................................................................. 16 RE-CREDENTIALING ............................................................................................................................................ 16 PROVIDER PROFILING .......................................................................................................................................... 17 CREDENTIALING REQUIREMENTS FOR A NEW LOCATION ............................................................................................. 17 CREDENTIALING REQUIREMENTS FOR ADDING A SERVICE CATEGORY ............................................................................ 18 QUALITY MEASUREMENT ..................................................................................................................................... 18 SATISFACTION MEASUREMENT REPORT TO PROVIDERS.............................................................................................. 19

4-1 CHANGES IN YOUR ORGANIZATION .................................................................................................. 19

5-1 HEALTHCARE DELIVERY PROCESS INTRODUCTION ............................................................................. 20

5-2 COORDINATION OF AUTHORIZATION AND SERVICE ........................................................................... 20

PROVIDER RECEIVES REFERRAL FROM PRIMARY REFERRAL SOURCE .............................................................................. 20 CARECENTRIX RECEIVES REFERRAL FROM PRIMARY REFERRAL SOURCE ......................................................................... 23 REAUTHORIZATION RESPONSIBILITIES ..................................................................................................................... 27

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RETROACTIVE REAUTHORIZATION REQUESTS ........................................................................................................... 28 AUTHORIZATION INQUIRIES .................................................................................................................................. 28

5-3 UTILIZATION MANAGEMENT ............................................................................................................ 29

THE CARECENTRIX UTILIZATION MANAGEMENT PROCESS .......................................................................................... 29 UTILIZATION MANAGEMENT RESPONSIBILITIES ......................................................................................................... 30 QUESTIONS REGARDING AUTHORIZATION DECISIONS ................................................................................................ 31 APPEALING A DENIED REQUEST ............................................................................................................................. 32

6-1 SERVICE DELIVERY ............................................................................................................................. 32

THE PROVIDER’S RESPONSIBILITY ........................................................................................................................... 32 THE PROVIDER’S DISCHARGE RESPONSIBILITIES ........................................................................................................ 34

6-2 GUIDELINES SPECIFIC TO PROVIDER SPECIALTY ................................................................................... 34

TRADITIONAL HOME HEALTH (THH) ...................................................................................................................... 34 HOME INFUSION THERAPY (HIT) ........................................................................................................................... 37 HOME MEDICAL EQUIPMENT (HME) .................................................................................................................... 39 SPECIALTY PROGRAMS ......................................................................................................................................... 42 DOCUMENTATION .............................................................................................................................................. 42

6-3 GENERAL CLAIMS AND REIMBURSEMENT INFORMATION .................................................................. 43

CLAIMS ADJUDICATION PROCESS ........................................................................................................................... 43 CHECKING REIMBURSEMENT STATUS...................................................................................................................... 44 PROMPT PAYMENT LAWS .................................................................................................................................... 44 EXPLANATION OF PAYMENT .................................................................................................................................. 44

6-4 GENERAL BILLING REQUIREMENTS .................................................................................................... 45

CARECENTRIX NATIONAL CLAIMS CENTER ............................................................................................................... 45 CLAIM FORM AND FORMAT .................................................................................................................................. 45 TIMELY FILING ................................................................................................................................................... 48 BILLING WHEN ANOTHER PAYOR IS PRIMARY ........................................................................................................... 48 AUTHORIZATION ................................................................................................................................................ 48 RECOUPMENT AND ADJUSTMENTS ......................................................................................................................... 49

6-5 COMPLAINTS, CLAIMS PAYMENT RECONSIDERATIONS, AND APPEALS ................................................ 50

INTRODUCTION TO COMPLAINT, CLAIMS PAYMENT RECONSIDERATION, AND APPEALS PROCESS ........................................ 50 COMPLAINTS ..................................................................................................................................................... 50 CREDENTIALING ................................................................................................................................................. 50 UTILIZATION MANAGEMENT ISSUES ....................................................................................................................... 50

6-6 CLAIMS PAYMENT ISSUES .................................................................................................................. 50

RECONSIDERATION ............................................................................................................................................. 50 APPEALS ........................................................................................................................................................... 52 DISPUTE RESOLUTION ......................................................................................................................................... 52 BINDING ARBITRATION ........................................................................................................................................ 52

7-1 CUSTOMER ACKNOWLEDGEMENT AND RESOLUTION MANAGEMENT ................................................ 54

Provider Manual


1-1 KEY CONTACTS

GENERAL

Register for the Provider Portal

Register for EDI (electronic claims submission)

Portal Support [email protected]

EDI Support [email protected]

Initial Authorization Requests

Authorization Status

Re-authorization Requests

Add-on Services

Authorization Contact Numbers See Below

Claim Questions

Claim Status

Appeal Status

Provider Resolution Team

See Below www.carecentrixportal.com

Patient Services Team 800-808-1902

Contract/Network Management

Patient Financial Responsibility

877-725-6525

Register for Portal & EDI

Support

Authorizations

Claims

www.carecentrixportal.com



Provider Manual


REGIONAL CARE CENTERS (RCCs)

Hartford, CT Tampa, FL Overland Park, KS

Phoenix, AZ

Albuquerque, NM

Regional Care Center (RCC)

711 East Missouri Avenue

Suite 300

Phoenix, AZ 85014

● Obtain IniGal AuthorizaGon

● Obtain ReauthorizaGon

Network Management

● ContracGng

● Demographic Changes

● Provider EducaGonRegional Care Center (RCC)

6121 Indian School Road NE

Suite 122

Albuquerque, NM 87100




7725 Woodland Center Boulevard

Suite 100

Tampa, FL 33614



National Billing Center (NBC)

3903 Northdale Boulevard

Suite 100E

Tampa, FL 33624


6130 Sprint Parkway

Suite 200

Overland Park, KS 66211




323 Pitkin Street

111 Founders Plaza

Suite 1600

East Hartford, CT 06108


● Wound Care

● Specialty Programs

National Claims Center (NCC)

323 Pitkin Street

111 Founders Plaza

Suite 801


● Claims Submission

● Appeals Submission

Provider Resolution Team (PRT)

323 Pitkin Street

111 Founders Plaza

Suite 801


877-725-6525

● Claims ReconsideraGon Submission

● Request Duplicate EOP

● Demographic Changes

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RCC KEY PHONE NUMBERS: Authorization, Re-authorization, Auth corrections

Plan Phone Number

Aetna FL 888-999-9641

Assurant 877-466-0164

BCBSFL 877-561-9910

BCBSTN Med Adv 866-776-1123

Beech Street 877-466-0164

Centene FL (Sunshine State) 800-835-5916

Centene MA (CeltiCare) 888-839-5122

Centene MS (Magnolia) 888-571-6019

Centene SC (Absolute Total Care) 866-522-8555

CIGNA 877-466-0164

Cofinity 877-466-0164

Coventry National Network/ First Health 877-466-0164

Great West 877-466-0164

Health Net 877-466-0164

LoveLace 866-721-6021

VSHP 888-571-6022

Wellcare 877-466-0164

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NETWORK MANAGEMENT KEY CONTACTS States Network Manager Network Coordinator

MD, DE, DC, NJ, PA, NY Lisa Subrize

(860) 528-4038 x 112115

[email protected]

Lori Castillo

(860) 528-4038 x 112117

[email protected]

CT, RI, MA,VT,NH, ME Lisa Subrize

(860) 528-4038 x 112115

[email protected]

John Hayden

(860) 528-4038 x 112118

[email protected]

AR, KS, LA, MO, ND, NE, OK, SD,TX, IA, MN Stacia Nowinski-Castro

602-604-9241 x 168243

[email protected]

Cecilia Carroll

888-375-6436 x 162120

[email protected]

TN

Counties (Eastern): Anderson, Bledsoe, Blount,

Bradley, Campbell, Carter, Claiborne, Cocke,

Cumberland, Grainger, Greene, Hamblen,

Hamilton, Hancock, Hawkins, Jefferson, Johnson,

Knox, Loudon, Marion, McMinn, Meigs, Monroe,

Morgan, Polke, Rhea, Roane, Scott, Sequatchie,

Sevier, Sullivan, Unicoi, Union, Washington

Jan Carrese

860-528-4038 x 113223

[email protected]

Karen King

860-528-4038 x 113008

[email protected]

TN

Counties (Central): Bedford, Cannon, Clay, Coffee,

Davidson, DeKalb, Fentress, Franklin, Giles,

Grundy, Jackson, Lawrence, Lewis, Lincoln, Macon,

Marshall, Maury, Moore, Overton, Pickett, Putnam,

Rutherford, Smith, Sumner, Trousdale, Van Buren,

Warren, White, Williamson, Wilson

Jan Carrese

860-528-4038 x 113223

[email protected]

Erin Mahoney

860-438-5028 x 112199

[email protected]

TN

Counties (Western): Benton, Carroll, Cheatham,

Chester, Crockett, Dekatur, Dickson, Dyer, Fayette,

Gibson, HardErin Mahoneyan, Hardin, Haywood,

Henderson, Henry, Hickman, Houston, Humphreys,

Lake, Lauderdale, Madison, McNairy, Montgomery,

Obion, Perry, Robertson, Shelby, Stewart, Tipton,

Wayne, Weakley

Jan Carrese

860-528-4038 x 113223

[email protected]

Christine Gerdin

860-528-4038 x 112198

[email protected]

IL, IN, KY, MI, OH, VA, WI, WV Jan Carrese

860-528-4038 x 113223

[email protected]

Karen Messerschmidt

860 528 4038 x 112119

[email protected]

AZ, CA, NV Andrea Serfling

913-749-5599

[email protected]

Alphonso Villela

888-375-6436 x 166126

[email protected]

CO, ID, OR, MT, UT, WA, WY Andrea Serfling

913-749-5599

[email protected]

Sherese Wilson

913-749-5620

[email protected]

FL

Counties: Hillsborough, Pasco, Pinellas, Hernando,

Sumter, Lake, Citrus, Marion, Gilchrist, Levy,

Bradford, Alachua, Putnam, Dixie, Union, Columbia,

Lafayette, Suwannee, Hamilton, Taylor, Madison,

Jefferson, Wakulla, Leon, Franklin, Gulf, Liberty,

Gadsden, Bay, Calhoun, Jackson, Washington,

Walton, Holmes, Okaloosa, Santa Rosa and Escambia

Athena Paula

888-375-6435 x 132136

[email protected]

Jennifer Roman

888-375-6435 X 132116

[email protected]

FL

Counties: Osceola, Orange, Brevard, Seminole,

Volusia, Flagler, St. Johns, Clay, Baker, Duval, Nassau,

Polk

Athena Paula

888-375-6435 x 132136

[email protected]

Gina Oliva

888-375-6435 X132252

[email protected]

FL

Counties: Miami,-Dade, Monroe, Broward, Palm

Beach, Indian River, Okeechobee, Martin, St. Lucie,

Charlotte, Highlands, Glades, Lee, Hendry, Collier,

Manatee, Hardee, Sarasota, Desoto

Athena Paula

888-375-6435 x 132136

[email protected]

Open

AL, GA, MS, NC, SC Christine Lee

888-375-6435 x132160

[email protected]

Open

AK, HI, NM Karen Harkness

888-375-6436 x 162537

[email protected]

Javier Carrizales

888-375-6436 x 162172

[email protected]

National THH Providers Karen Harkness

888-375-6436 x 162537

Javier Carrizales

888-375-6436 x 162172

[email protected]

National DME Providers Wayde Tharp

813.901.2150 x 132596

[email protected]

Aly Pena

888-375-6435 x132255

[email protected]

National HIT Providers Vanessa Cullom

631-501-7013 x 177013

[email protected]

Cheryl Herrmann

631-501-7008 x 127008

[email protected]

Provider Manual


1-2 WELCOME

Welcome to the CareCentrix Provider Network. We are proud to work with you and with our

other network providers as we strive to meet high quality standards and provide and manage

cost-effective health care solutions for the customers and patients served by our integrated

healthcare network.

As a credentialed Provider within our network, we value your services and are committed to

making your experience with us as easy as possible. To demonstrate this commitment, we have

dedicated resources to support your participation in our network, and those resources are

discussed further in sections on Provider orientation, training, communication and quality

management mechanisms.

About This Provider Manual

This manual is intended to assist you in implementing and performing your role as a

CareCentrix Network Provider. It is designed to serve as the basis for your orientation to our

philosophy, structure and operations. It also contains instructional content requisite to optimal

Provider performance and is an adjunct to our provider agreement with you.

Please read this manual carefully. It explains your rights and responsibilities as a CareCentrix

Network Provider. As indicated in your provider contract, you are obligated to comply with the

terms of this manual. Since this manual is updated regularly, we encourage you to visit our

provider portal frequently at www.carecentrixportal.com to find the most recent information.

1-3 ABOUT CARECENTRIX

About CareCentrix

CareCentrix is a healthcare delivery system available in all 50 states that provides ancillary care

management services to payors through utilization and network management, credentialing

Provider Manual


and payment processing. Our client base includes national and/or regional managed care

organizations, insurance carriers, worker’s compensation carriers, and third-party

administrators.

For more information, visit the CareCentrix web site, http://www.carecentrix.com.

1-4 CORPORATE COMPLIANCE PROGRAM

Company Objectives and Purpose of the Compliance Program

CareCentrix is committed to complying with all applicable legal requirements in the course of

conducting its operations and expects each of its associates and network providers to do the

same. CareCentrix’ Corporate Compliance Program was developed with that commitment in

mind.

One purpose of the CareCentrix Corporate Compliance Program (the “Program”) is to help

prevent and detect criminal, fraudulent and other unethical and improper conduct and to take

appropriate corrective actions upon detection of any such conduct.

One activity that the Program is intended to help prevent and detect is the submission of

improper, false or fraudulent claims for payment to the United States government or other

health care payors as prohibited by such payors and/or as prohibited under applicable state and

federal law, including applicable fraud, waste and abuse laws such as False Claims Act(s), Anti-

Kickback Act(s), and the Civil Monetary Penalties law. Violation of such laws can expose a

provider to significant civil and/or criminal penalties. Whistleblower protections under some

of these laws provide protections for individuals reporting fraud and abuse in good faith and, in

some cases, the reporter is entitled to a percentage of the proceeds of the case. Refer to the

section below entitled Reporting System for information on how to report suspected fraud and

abuse.

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Examples of improper conduct include but are not limited to:

• Billing for excessive services (not medically necessary or appropriate);

• Billing for services not rendered, not rendered as billed, and/or not used by the

patient/family (e.g. supplies);

• Failing to comply with government and other payor requirements (including billing for

home health agency visits to patients who are not homebound or do not require a

qualifying service, submission of cost reports claiming expenses unrelated to patient care or

failing to identify related parties with whom business is conducted, failure to obtain

required prior authorizations or to comply with claim submissions requirements, or using

staff who do not meet the payor requirements (e.g. using physical therapist assistants when

the payor does not permit physical therapist assistants);

• "Upcoding" diagnoses or otherwise entering false or misleading information on

assessments, orders, clinical notes, authorization requests, claims or other documents for

the intent and purpose of obtaining excessive or improper payments;

• The use of unlicensed or untrained staff;

• Falsified physician orders or plans of care;

• Forged signatures;

• Falsification of licensure/certification or other falsification of clinical records, cost reports,

OASIS assessment information, or other documents for the purpose of obtaining payment,

including but not limited to, documentation of services not provided, backdating or

falsifying dates of services, and falsifying the condition and status of a patient;

• "Split billing" among payors to circumvent payor coverage restrictions;

• Billing two or more payors for the same services resulting in a duplicate payment ("double

dipping"); and

• Kickbacks and improper relationships with referral sources.

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Reporting System

CareCentrix is committed to credentialing a network of Providers that render services adhering

to high ethical standards. To achieve these goals, it is essential that every employee and

contractor employed or contracted by your organization be committed to these goals and assist

your company in assuring compliance. In addition, early reporting of potentially improper

activities can avert more serious harm to your company’s reputation and business that would

occur if such activity were to continue.

Accordingly, it is our policy that participating providers must report potentially criminal,

fraudulent or other illegal activity immediately. To help make it more convenient and less

expensive for our network providers to fulfill their obligations under the Program, CareCentrix

has established a Corporate Compliance toll-free phone number for reporting:

• 1-888-9-NOTIFY

Individuals who make a good faith report of known or suspected violations of law or the

Program are protected from retaliation. CareCentrix will take reasonable steps to protect the

anonymity of any such reporter and to ensure no adverse actions are taken against such

reporters. This policy is not intended to protect any individual giving a report which

CareCentrix reasonably believes is fabricated, distorted, or exaggerated to either injure

someone else or to protect the reporting individual or others.

The CareCentrix Chief Compliance Officer is responsible for investigating the report.

Information obtained in the course of any such investigation will be considered confidential but

may be disclosed to third parties at the sole discretion of CareCentrix. Any Participating

Provider knowingly failing to report unlawful conduct will be subject to disciplinary action up to

and including network termination.

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Response and Corrective Action to Promote Program Effectiveness

After any offense is detected, CareCentrix will take reasonable steps to respond appropriately

to the offense and to prevent any further similar offenses, including any necessary

modifications to its Program to prevent and detect violations of law. Depending on the

individual circumstances, appropriate responses may include, but shall not be limited to,

recoupment of inappropriately billed amounts, placement on a corrective action plan, network

termination, additional training and/or reinforcement communications to appropriate

associates, and disclosure to our customers, governmental agencies, and/or law enforcement.

2-1 PERFORMANCE STANDARDS

As a participant in the CareCentrix network of providers, you will:

• Submit timely written notice to CareCentrix of changes in your organization as required in

your provider contract and this Provider Manual.

• Maintain 24 hour on-call coverage 7 days per week and respond to patient and/or

CareCentrix contacts within 30 minutes of call, including weekends, evenings and holidays,

unless otherwise specified by contract.

• Notify appropriate CareCentrix utilization management staff immediately if not able to

service a referred case.

• Submit billing for authorized services and/or products to CareCentrix at least monthly at the

designated address for claims and submit no billing to the primary health plan for

services/products unless directed to do so by CareCentrix in writing.

• Direct all written requests for claims payment reconsideration and other written requests

pertaining to your relationship with CareCentrix to the address designated by CareCentrix

for such requests.

• Not bill the patient/member for covered services or for services where payment is denied

because you did not comply with your provider agreement or this Provider Manual.

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• Not, under any circumstance, tell the patient/member that they are not responsible for any

co-pays, coinsurance or deductibles. Payments to the provider for authorized covered

services are made in accordance with the contract rates and are not reduced by the

applicable co-pay, coinsurance or deductible. CareCentrix assumes the provider’s burden of

collecting these amounts. Although the patient is not responsible to pay co-pays,

coinsurance or deductibles to the provider since the provider has been paid in full, the

patient is responsible for remitting the patient responsibility to CareCentrix.

• For services where payment is denied because the services are not medically necessary or

are not otherwise covered under the member’s plan, not charge the member for such

services unless, in advance of the provision of the services, the member agrees in writing to

accept the financial responsibility for the services.

• Submit medical records, quality assessment, quality improvement, clinical outcomes,

program evaluation, and other reports upon request of CareCentrix personnel and at no

charge.

• Participate in CareCentrix quality initiatives as requested.

• Adhere to all other principles, practices and procedures found in the provider contract,

CareCentrix Provider Manual, and contractual relationships between CareCentrix and its

health plan customers.

3-1 PROVIDER ORIENTATION

In keeping with our commitment to CareCentrix Network Provider support, we have a variety of

Provider orientation and training communications and opportunities.

Provider Manual

Our Provider Manual is intended to allow you and others in your organization to learn the

“basics” of CareCentrix participation, as well as your roles and responsibilities as a CareCentrix

Network Provider. It also serves as an ongoing reference that is updated periodically.

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Providers have a responsibility to ensure they are following the most up to date policies and

procedures. Providers must check the CareCentrix provider portal

(www.carecentrixportal.com) frequently for any information updates, including updates to this

manual. Changes may include:

• A change in policy, process and/or procedure that impacts the Provider and/or Provider

operations.

• A change in the expectations or conditions of contract(s) with CareCentrix customers.

• New carrier contracts which the Provider may service.

The Conference Call

A continuing resource for CareCentrix Network Providers is our Provider orientation conference

call which furnishes important information on Provider responsibilities and CareCentrix

operational procedures as outlined in this manual. The Network Management Department

may contact you to set up an orientation call at a date and time convenient for maximum

participation. Network Providers may also request an orientation call at any time to give a

refresher of this manual’s contents.

The conference call is intended to give CareCentrix Network Providers a clear understanding of

how CareCentrix operates, and responsibilities for a credentialed Provider. Although this

conference call is loosely scripted, Providers are encouraged to ask questions at any time during

the presentation. The duration of the call is approximately 45 minutes to one hour. Providers

should have reviewed this manual prior to the call to obtain the most benefit from their

participation.

The CareCentrix Provider Portal

The CareCentrix Provider Portal (www.carecentrixportal.com) is simply the best place to find the

most up to date information about how to work with CareCentrix. In addition to providing key

tools to work with us (request an authorization, re-authorization, add-on service, claim and

Provider Manual


authorization status lookup), the portal also contains the most updated provider education and

information tools. Not yet using the portal? Simply go to www.carecentrixportal.com and

follow the sign-up link.

Special Reports

CareCentrix staff may issue special reports from time to time. These reports may summarize

data or information pertinent to improving Provider and/or CareCentrix quality. They may

include aggregate data on overall measurement of Provider and/or CareCentrix performance

and quality improvement initiatives.

3-2 NATIONAL CREDENTIALING COMMITTEE

Purpose:

The purpose of the Credentialing Committee is to establish a credentialing plan and process for

primary source verification and review of qualifications when a provider seeks membership in

the CareCentrix network and to review the standards and qualifications for all participating

health care providers.

Committee Attendance

The Credentialing Committee represents varied specialties from the home health care industry

and is comprised of 5 voting and 4 non-voting members. The CareCentrix Medical Director

reviews and approves clean credentialing files for acceptance and admission into the CareCentrix

Network. The Credentialing Committee does not review such files. “Clean” credentialing files are those

files that meet all of the criteria for inclusion into the Provider Network and do not require additional

review by the Committee.

Committee Meeting Schedule:

The Credentialing Committee generally meets 3 three times per year. An ad hoc conference

call is scheduled when there is an issue of quality or malpractice to address.

Provider Manual


3-3 PROVIDER QUALIFICATION AND QUALITY MANAGEMENT

Credentialing

Required items are outlined below:

• All Providers must complete the CareCentrix Credentialing Application. The application

must contain a current signature of the CEO, Administrator or other appropriate designated

representative, attesting that all information provided in conjunction with the application is

true, correct, and complete.

• CareCentrix requires copies of current licensure in accordance with state statutes.

• Proof of professional and general liability insurance. Required limits are generally one

million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in

aggregate and a copy of a current fidelity bond for fifty thousand dollars ($50,000).

• Provide a five year malpractice history.

• Copies of current accreditation or certification.

• For non-accredited, non-certified Providers, CareCentrix will perform a site visit.

• QA/QI program

Re-Credentialing

CareCentrix Network Providers are re-credentialed every 2-3 years (as determined by state law

or plan requirements). However, a Provider’s credentialing status may be evaluated by the

Credentialing Committee at any time during the 2-3 year credentialing period. This is typically

done if a Provider is adding a new service category, or malpractice or quality of care/service

issues are brought to the Committee’s attention.

When a quality of care or service issue is brought to the Committee’s attention, the Committee

reviews the issue and, based on the findings, takes appropriate action, which may include the

implementation of a corrective action plan or termination of the provider’s participation.

Provider Manual


The re-credentialing process begins approximately 6 months before the credentialing

anniversary. For re-credentialing, the following items are required:

• Copies of current licensure.

• Inclusion or exclusion on the sanction listing by CMS or OIG is grounds for termination from

the CareCentrix Network.

• Proof of professional and general liability insurance. Required limits are generally one

million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in

aggregate; a copy of current fidelity bond for fifty thousand dollars ($50,000).

• Provide a three year malpractice history. Copies of current accreditation or certification.

• For non-accredited, non-certified Providers, CareCentrix will perform a site visit.

• QA/QI program and program evaluation.

Provider Profiling

In addition to the information listed in the previous section, the re-credentialing process

includes a review of the Provider’s performance during their participation with CareCentrix.

This may include but is not limited to:

• Satisfaction surveys.

• All incidents and follow-up correspondence.

• All complaints and follow-up correspondence.

• Any correspondence received complimenting the Provider’s service.

• Compliance with CareCentrix credentialing and other policies.

Credentialing Requirements for a New Location

Adding a location (not expanding a service area) requires credentialing of the new location. The

CareCentrix Provider must contact their Network Manager to request the addition of new site

locations. Follow the initial credentialing process outlined above. CareCentrix reserves the

right to refuse addition of additional sites. Decisions are based on the network’s needs at the

time of the request.

Provider Manual


Credentialing Requirements for Adding a Service Category

For each site that will be adding a new service category (i.e. staffing, HME, Infusion), a written

notification to the Network Manager must be submitted and must include the required

material for adding a new location. Follow the initial credentialing process to add a service

category. The license required is that which indicates licensure to provide the new service

category. The information will be presented to the Credentialing Committee for determination

based on the Provider’s qualifications to provide that service. CareCentrix reserves the right to

refuse the addition of additional service categories. Decisions are based on the network’s

needs at the time of the request.

Quality Measurement

We assess the quality of our Provider networks in a variety of ways including assessing quality

against industry, regulatory, and accreditation body standards.

Satisfaction Measurement

In compliance with our own policies and procedures, and in keeping with NCQA and URAC

standards and the contractual requirements of our customers, we or our health plan customers

may sample and report findings regarding:

• Patient satisfaction

• Physician satisfaction

• Customer (health plan) satisfaction

In addition, we are concerned with your satisfaction as a participant in the CareCentrix Provider

Network. Therefore, we may assess your satisfaction through two means:

• Provider satisfaction surveys via email, web, letter and telephone.

• Provider focus groups

Provider Manual


Satisfaction Measurement Report To Providers

We may periodically report satisfaction data results, analyses and related quality improvement

initiatives to our Network Providers for purposes of providing feedback on CareCentrix

performance and improvement efforts and to foster improved relations between and among

your patients, physicians, CareCentrix Network Providers, health plan customers and

CareCentrix associates.

4-1 CHANGES IN YOUR ORGANIZATION

You must notify us of changes in your demographic information or changes to the information

submitted with your credentialing application in writing on company letter head within 7 days

of the change. The written notice should be directed to your Regional Network Manager

located at the Regional Care Center.

Changes in the items may affect receipt of referrals and reimbursements. Please be diligent in

timely reporting changes to such information including changes to the following:

• Address(es), including the remit to address

• Telephone number(s) and/or fax number(s)

• Name of key organizational contact(s)

• Names(s) of key local operations contact(s)

• Tax Identification Number

• Days/hours of operations

• Service/product capabilities

• Service area

• Accreditation status, including revocations

• New malpractice actions

• Licensing status, including sanctions

• Liability insurance coverage

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• Change in business structure or ownership

• Closure of operations/business site

5-1 HEALTHCARE DELIVERY PROCESS INTRODUCTION

CareCentrix has contracts with many payors. The processes that CareCentrix applies to a given

patient’s referral are based upon the specifics of the contract between CareCentrix and the

payors.

5-2 COORDINATION OF AUTHORIZATION AND SERVICE

CareCentrix providers may receive referrals for new patients in one of two ways:

1. Provider has a relationship with a primary referral source (physician, hospital discharge

planner, etc.) and the primary referral source contacts the provider with the referral. In

all cases, subject to patient choice, CareCentrix reserves the right to select an

alternative provider to service the referral.

2. CareCentrix receives a request from the primary referral source, the member, or an out-

of-network provider and directs the referral to the provider.

The following describes the provider’s role in each situation.

Provider Receives Referral From Primary Referral Source

Providers submit requests for authorization to provide a service/item via the CareCentrix on-

line Provider Portal (www.CareCentrixportal.com). The Provider Portal identifies the

information necessary to complete an authorization request, so that CareCentrix has the

information it needs in order to review the Provider’s request. The required information

generally includes, but is not limited to, the following:

A. Patient first and last name

B. Patient date of birth

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C. Patient insurance company and insurance subscriber ID number

D. Patient physical address (not PO Box) including zip code

E. Patient phone number

F. Patient gender

G. Diagnosis

H. If recently discharged from hospital or other inpatient setting, facility name and full

address

I. Ordering and primary physician first and last name, full address and telephone number

J. HCPC code or complete service/item description

K. Number of requested units, start and stop date of requested authorization

L. Medical necessity justification for the service or item requested

M. Confirmation that physician orders exist for services for which authorization is being

requested

If the Provider does not submit all of the required information, the request will not be accepted

by CareCentrix, and the Provider will be required to resubmit the request. Authorization and

re-authorization requests must contain complete and accurate information because

CareCentrix relies on the information provided by the Provider when reviewing the

authorization request against medical necessity criteria.

The level of review for medical necessity varies depending on which health plan the member

belongs to. For example, an item or service may require a review for medical necessity under

one health plan but not another, and these specific requirements may change from time to

time. Therefore, receipt of an authorization from CareCentrix does not guarantee that the

service was reviewed for medical necessity. If medical necessity is later determined not to

exist Provider’s claim for service may be denied or payments made recouped.

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In many cases, requests submitted via the Portal can be processed immediately and the

provider receives an electronic notification of authorization.

Some requests require verification of administrative information or clinical review. These

requests are routed to a CareCentrix associate for processing. Reasons for routing include, but

are not limited to:

1. Other insurance

2. Medical necessity review

3. Obtaining authorization from the health plan

Once any necessary verification or routing is completed or when a request is automatically

processed and approved, an authorization is generated and a Service Authorization Form (SAF)

is faxed to the provider.

Providers should in every instance verify eligibility and benefit availability with the health plan

prior to providing any service, equipment or supply item. CareCentrix does not conduct

electronic eligibility and benefit verification transactions, but our health-plan customers do.

Please remember that eligibility and benefit verification and utilization management

authorization are not a guarantee of payment for services such as, but not limited to, items

provided when the member is not eligible or there is no available benefit.

All requests for service, whether for the initial start of care or reauthorization for continued

care, must be requested prior to the service being provided. If a Provider fails to request an

authorization prior to providing services, those services performed may not be reimbursable

and are not billable to the patient.

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CareCentrix Receives Referral From Primary Referral Source

Provider Staffing is the process of choosing a Provider to meet the needs of a specific patient. A

CareCentrix Provider Staffing Associate makes decisions based on a variety of factors, including

but not limited to:

• The location where the patient will receive service and corresponding location of the

Provider

• The services/products for which a Provider is credentialed to perform or supply

• The lines of business for which a Provider is credentialed (e.g. Medicaid, Medicare)

• The Provider’s ability to provide the service or item for the required start of care

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CareCentrix makes no representations or guarantees about the number of patients that will be

referred to a CareCentrix Network Provider as a result of the Provider’s participation in the

CareCentrix Network and reserves the right to direct and/or redirect patients to selected

CareCentrix Network Providers. In addition, CareCentrix customers reserve the right to

exclude certain CareCentrix Network Providers from the network accessed by their members.

The process for Provider Staffing is as follows:

A. CareCentrix receives a request for a service or item from the primary referral source.

B. A CareCentrix associate contacts the provider to present the referral.

C. The provider accepts the referral. Upon acceptance, the CareCentrix associate verbally

provides the referral information to the provider.

D. The CareCentrix associate enters the authorization and a Service Authorization Form

(SAF) is faxed to the provider.

E. Providers should verify eligibility and benefit availability with the health plan prior to

providing any service, equipment or supply item. Authorization is not a guarantee of

payment for services/items provided for certain reasons including when the member is

not eligible, there is no available benefit or medical necessity is deemed not to exist.

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After accepting a referral and receiving an authorization, it is the provider’s responsibility to

abide by the following:

• Notify the CareCentrix Regional Care Center immediately if the start of care/delivery must

be delayed or if unable to continue the case.

• Carefully consider your ability to accept every case and only do so when you are confident

you can meet the patient’s need. Referral turn-backs can be a serious quality of care and

service concern when turn-backs cause delays in the start of care.

• Notify patients covered under a Medicare Advantage or Medicaid plan within the

timeframe required by law that the medical necessity of the services has been authorized.

• Render no service unless ordered by the appropriate physician.

• Provide after hours (on call) home visits as appropriate and necessary in situations that

cannot be resolved by telephone consultation.

• Notify the CareCentrix utilization management staff of changes in patient/family status

within 24 hours upon occurrence and/or identification, including:

• Illness

• Hospitalization

• Death

• Any other adverse incident or change affecting continued service delivery.

• Notify CareCentrix of complaints made by the patient, family, physician or health plan upon

occurrence.

• Except as otherwise provided in this Provider Manual, submit requests for service/product

re-authorization at least 72 hours prior to expiration date of the previous authorization.

o Obtain authorization for any previously unauthorized emergency or urgent services 24

hours a day, seven days a week, 365 days per year. CareCentrix provides 24/7 on-call

access for emergency and urgent situations.

o Provide assessment reports, progress reports, organizational forms or other

organizational documents within 48 hours of request by CareCentrix.

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• Respond to grievances/complaints filed against the CareCentrix Provider within 24 hours

and pursue timely resolution as acceptable by CareCentrix staff.

• Notify CareCentrix if other insurance or additional sources of reimbursement are

identified.

Reauthorization Responsibilities

A reauthorization or concurrent review is required to continue service if either 1) the date span

of the authorization will be exceeded, regardless of any remaining units or 2) the authorized

number of visits/units will be exceeded. Obtaining a re-authorization is the responsibility of the

Provider.

Except as otherwise provided in this Provider Manual, Providers must submit requests for re-

authorization at least 72 hours prior to the expiration of the authorization and provide clinical

status and objective reasons for re-authorization. Re-authorization should not be requested

more than 7 days prior to authorization expiration. Re-authorization requests received prior to

that timeframe may be rejected, and the Provider will be required to resubmit the re-

authorization request.

Reauthorization should be requested via the Provider Portal at www.carecentrixportal.com.

The Provider Portal identifies the information required in order to complete your request for

reauthorization. That information includes, but is not limited to, the following:

i. Intake ID

ii. Patient’s Last Name

iii. HCPC Code needing reauthorization

iv. Number of requested units, start and stop date of requested authorization

v. Medical necessity for the service requested

vi. Physician orders for all services for which authorization is requested for

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If the Provider does not submit all of the required information, the request will not be

accepted by CareCentrix, and the Provider will be required to resubmit the request.

Retroactive Reauthorization Requests

Providers must submit all requests for authorization of service/items prior to the service/item

being provided or delivered. If a Provider fails to request a reauthorization and continues to

provide services, those services performed prior to receiving authorization may not be

reimbursed and are not billable to the patient.

Authorization Inquiries

After submitting an authorization or reauthorization requests, providers may check the status

of their authorization by accessing the CareCentrix Provider Portal at

www.carecentrixportal.com.

Providers are able to view all complete authorization requests made within the last 60 days.

Information available on the Portal is as follows:

• Request type – referral or reauth

• Intake ID

• HCPC code requested/authorized

• Service code (CCX code)

• Description of HCPC code

• Date request received

• Status of request

o Approved

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o Cancelled

o Denied

o Denied by the health plan

o In process – elevated to the health plan

o In process – pending additional information

o In process – under review

• Authorization ID if authorized

• Provider name of who was supplied authorization if authorized

• Number of units for HCPC code authorized

• Unit of Measure for HCPC code authorized

• Authorization start and stop date

5-3 UTILIZATION MANAGEMENT

The CareCentrix Utilization Management Process

Utilization Management is the evaluation of the appropriateness, medical necessity and

efficiency of healthcare services according to established criteria or guidelines under the

provisions of the patient’s benefit plan. When CareCentrix is responsible for conducting a

review of the medical necessity of a proposed service, the following is the medical necessity

definition that is standardly applied:

• Appropriate and consistent with the diagnosis of the treating Provider and the omission of

which could adversely affect the eligible Member’s medical condition;

• Compatible with the standards of acceptable medical practice in the community;

• Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis

and the severity of the symptoms;

• Not provided solely for the convenience of the Member or the convenience of the Health

Care Provider or hospital; and

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• Not primarily custodial care unless custodial care is a covered service or benefit under the

Member’s evidence of coverage.

The above definition is subject to the requirements of the applicable payor and plan and

applicable law (for example, the mandated definition for medical necessity for Medicare and

Medicaid plans will apply to patients covered under such plans; a state mandated definition for

medical necessity for insured commercial plans will apply to patients covered under such

plans). Medical necessity reviews can be conducted for both initial and reauthorization requests

and can be required for traditional home health (THH), home medical equipment (HME), home

infusion therapy (HIT) and Orthotics & Prosthetics (O&P).

Utilization Management Responsibilities

Providers have the following responsibilities:

• Obtain verbal authorization prior to beginning services/products. Services/products

performed without authorization may be denied for payment, and any such denial of

payment is not billable to the patient by the Provider.

• Verify the information on the authorization sheets (service codes, HCPC, number of units,

start and stop date, provider name and location) upon receipt. While the CareCentrix

utilization management staff work to assure the accuracy of the authorization sheets,

mistakes can occur. Should you identify an error, call CareCentrix within 24 hours to correct

the service authorization form (SAF). Failure by the Provider to obtain the authorization

sheet and verify services/products authorized may result in non-payment.

• Notify CareCentrix immediately if, when the services or equipment is delivered, the

diagnosis is determined to be different than the diagnosis information obtained from

CareCentrix.

• Notify CareCentrix if the services ordered will not meet the needs of the patient. Provider

will assist in identifying alternatives and discussing with CareCentrix and the ordering

physician.

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• Notify CareCentrix of changes in patient/family status affecting continued service delivery

within 24 hours (includes illness, hospitalization, death or other change)

• Participate in case conferences

• Respond to all requests for contact from CareCentrix within 24 hours

• Respond to all requests for contact from the health plan case manager within 1 business

day. In most cases, CareCentrix will act as a liaison when a health plan case manager

requests information. Providers should not initiate contact with a health plan case manager

unless directed to do so by CareCentrix.

• If requested by CareCentrix, provide assessment reports, progress reports, organization

forms or other organization documents within 48 hours of request.

• Verify all initial physician orders with the physician and obtain physician orders for

additional services/products as necessary.

A disagreement with the service authorization should be handled by the patient through the

Health Plan utilization management appeals process. Although CareCentrix or the health plan

may make authorization approval decisions, for most of our health plan customers, the Plan

makes the denial determination, and patients should be referred to the health plan’s Member

Services department to discuss the denials. If a utilization management appeal is submitted to

CareCentrix, we will document and refer to the appropriate health plan.

Paid claims can be subject to retrospective audits, and Providers have the obligation to

maintain and make available documentation to support the medical necessity of services

rendered. CareCentrix may recover any payment for services determined not to meet medical

necessity requirements, including recovery through recoupment.

Questions Regarding Authorization Decisions

As the provider, you may request a copy of the utilization criteria that CareCentrix used in

making an authorization decision. If services/products have been authorized for less than what

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has been ordered, re-authorization should be requested prior to the end of the authorization

period. The clinical status of the patient, plan of treatment and treatment goals will be

necessary to make a re-authorization decision. It is the Provider’s responsibility to supply

updated clinical information.

Appealing a Denied Request

If services/products have been denied by the Plan in their entirety and new and/or additional

information is obtained, the Provider should contact the CareCentrix utilization management

staff to relay the new information and have the authorization request reviewed.

If services/products have been denied in their entirety and there is no new information

available, the patient or physician may submit an appeal to the health plan in accordance with

their appeals process. Unless otherwise indicated (e.g., BCBSFL), CareCentrix has not been

delegated the denial or utilization management appeals process, and appeals of denials

should be directed to the health plan.

6-1 SERVICE DELIVERY

It is important that a Provider clearly understand the responsibilities for service/product

delivery and the discharge of patients from service. Following the steps as indicated in this

section can help ensure that a Provider is in compliance with CareCentrix policy and procedure.

The Provider’s Responsibility

For service/product delivery, a Provider must:

• Verify physician’s orders and obtain physician signature within the time specified by state

regulations and licensure.

• Meet the start of care requested by CareCentrix. Any inability to meet start of care or delay

in start of care requires notification to CareCentrix by calling the Regional Care Center

• Notify CareCentrix immediately if unable to continue service delivery to the case.

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• Notify CareCentrix within 24 hours if the information obtained during CareCentrix

registration process has changed or was incorrect. The utilization management staff will

review the authorization to determine if a change to the authorization is required. For

example:

o An authorization is given for Ampicillin. When the PCP is contacted, the Provider is

notified of a drug, dosage or frequency change.

o An initial referral and authorization is given for diabetic teaching. The Provider, upon

completing the initial assessment, identifies a need for wound care visits and supplies.

o HME Provider identifies the equipment is not the correct size/type to meet the patient

need.

• Bill CareCentrix only for services/products that have been ordered by an appropriate

physician and authorized by CareCentrix.

• Provide after hours (on-call) home visits as appropriate and necessary in situations that

cannot be resolved by telephone consultation.

• Report adverse incidents to CareCentrix within 24 hours of occurrence. Do not contact the

health plan unless instructed to do so by CareCentrix.

• Report complaints to CareCentrix within 24 hours of occurrence. Do not contact the health

plan unless instructed to do so by CareCentrix.

• Comply with state and federal licensing requirements and other applicable laws.

• Conduct and document discharge planning on an on-going basis during the care and

document that discharge needs were met upon discharge.

• Contact CareCentrix (not the health plan) for problems regarding services/products or

products.

• Not auto ship supplies unless the patient has expressly requested auto-shipment.

• Not provide equipment or supplies without first confirming medical need.

• Not deliver or ship supplies unless, in advance of delivery or shipment, you have verified

with the patient or their treating physician that the patient needs additional supplies.

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The Provider’s Discharge Responsibilities

Discharge from service can be for any of the following reasons:

• The patient expires.

• The patient meets the Plan of Care.

• The patient and/or family are capable of assuming care.

• The patient no longer wishes to receive services/products. The physician should be notified

of the patient/family’s request before stopping services/picking up equipment.

• The patient/family refuses to comply or is incapable of compliance.

• The Provider cannot provide the services/products ordered and authorized because of lack

of staffing or expertise.

• The physician does not provide the needed orders.

• The patient is institutionalized.

• Home care is no longer appropriate due to risk factors.

• The patient relocates outside of the geographic service area.

• The patient refuses assignment of a Provider employee to deliver care/services/products on

a discriminatory basis.

6-2 GUIDELINES SPECIFIC TO PROVIDER SPECIALTY

This section outlines the guidelines specific to the specialty area of a Provider. Guidelines are

prescribed for traditional home health (THH), home infusion therapy (HIT) and home medical

equipment (HME). These guidelines are standard for CareCentrix and are used by the

CareCentrix referral coordinators.

Traditional Home Health (THH)

Traditional home health consists of skilled nursing (intermittent and hourly), physical therapy,

occupational therapy, speech therapy, social workers and home health aides.

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• A visit (2 hours) is defined as an episode of service (treatment or procedure) performed in a

predetermined period of time with a predictable outcome. CareCentrix must authorize any

service that will be billed in excess of one visit in advance.

• Provider subcontracting is not allowed

• Any laboratory tests collected by a CareCentrix Network Provider must be taken to the

laboratory participating in the patient’s insurance plan. Lab studies are not included in the

CareCentrix Provider Agreement.

• The reimbursement for a skilled nursing visit includes the following routine supplies:

o Dressing supplies-gauze pads, sterile/unsterile gloves, ABDs, Kerlix, tape

o Betadine wipes

o Peroxide

o Syringes for nurse administered injections (excludes specialty syringes, special order

items)

o Lab tubes and needles for drawing lab work

o KY jelly

o Cotton balls and alcohol sponges

o Gloves

o Band-aids

o Thermometers

o Vacutainers

• Excluding the list above, certain supplies may be billed to CareCentrix but require separate

authorization prior to delivery. The list of supplies, itemized cost, and the amount used

daily must be submitted via portal or phone to the utilization management staff for

authorization. If you do not obtain authorization for these supplies, you cannot be

reimbursed for them.

• Supplies for care rendered by the patient or family are to be obtained from the insurance

carrier’s supply Provider unless the nursing Provider has supplies in its contract with

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CareCentrix. Preferred supply vendors are identified on your Service Authorization Form

(SAF).

• In the event that an LVN/LPN needs to be substituted for an RN, it is the Provider’s

responsibility to ensure that 1) the care to be rendered is within the scope of practice for

the LVN/LPN as defined by the state in which the LVN/LPN is licensed and that 2) the

physician is in agreement with the substitution.

• Rehab para-professionals (COTA, PTA) used to support a physical or occupational therapy

plan of treatment must be authorized as a paraprofessional. Paraprofessionals will only be

authorized where both state licensure and the health plan contract allows for them to

deliver services/products.

Aetna No

Assurant Yes

BCBSFL Yes

BCBSTN Med Adv Yes

Beech Street No

Centene MS (Magnolia) Yes

Centene MA (Celti Care) Yes

Centene FL (Sunshine State) Yes

Centene SC (ATC) Yes

CIGNA Yes

Cofinity No

Coventry No

Great West Yes

Health Net No

Lovelace Yes

Sutter No

Wellcare Yes

Does the Plan allow substitution of PTA and OTA? (as of 2/29/2012)

Based on state regulations regarding the use of PTA's or OTA's or the member's benefits.

• The coordinating Provider is responsible for:

o Coordinating services/products such that vital services/products are received in

compliance with physician orders and meeting patient needs.

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o Ensuring assessment/services/products by other Providers are started after they have

assessed the patient but within 48 hours.

o Obtaining and providing to CareCentrix the clinical information needed for re-

authorization.

o Notifying other involved Providers of authorization decisions, eligibility issues, etc.

o Checking, at least monthly, the eligibility and benefits for patients who are considered

non-managed (or “branch managed”) and ensuring that benefits have not been

exhausted

o For managed plans, when services (i.e. RN visits) are authorized by a

CareCentrix Regional Care Center, the specific service, units (i.e. 10 visits),

pricing and the start and end date of the service are entered in the CareCentrix

computer system and an authorization is generated. For Non-Managed plans,

the start and end date of service on the SAF will be the same and the units will

be zero. CareCentrix calls this a footprint authorization, and indicates that it is

up to the Provider to manage to the patient’s benefit. This includes regularly

(at least monthly) contacting the patient’s health-plan (not CareCentrix) to

verify eligibility and benefits.

Home Infusion Therapy (HIT)

Consistent with industry standards, reimbursement for medications is based on the Thompson

Reuters Red Book Average Wholesale Price (AWP). Most infusion service authorizations consist

of three components: the drug, a per diem/dispensing fee and nursing. Exceptions to this

authorization methodology are Total Parenteral Nutrition (TPN) and hydration therapy, which

are reimbursed on a bundled per diem basis. Utilization management staff provides via the

service authorization form (SAF) the infusion therapy-specific codes for authorization and

billing. TPN and hydration therapy have only a per diem code plus nursing.

The standard per diem includes:

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• All administrative overhead including: on-call pay, overtime, travel and facility expenses.

• All pharmacy, warehouse and delivery expenses.

• All emergency kits including: anaphylactic kits, extravasation kits, narcotic antidote kits, etc.

• All clinical monitoring: vital signs, lab draws, etc. Labs should be transported to the

patient’s (health plan’s) participating laboratory.

• All infusion-related supplies including stationary, ambulatory, disposable, syringe or other

infusion devises.

• Nursing is authorized separately to the per diem and includes but is not limited to; patient

assessment, first dose administration, teaching, IV catheter insertion (including mid-lines

and PICC lines,) and maintenance, troubleshooting of products and services, lab draws,

resolving patient complaints, etc.

• Providers are responsible for managing the inventory of patient supplies. Overstocked

drugs or supplies may not be reimbursed.

• If a patient or caregiver wastes medication or supplies, the Provider must notify CareCentrix

and provide documentation to the events.

• Reimbursement for drugs will be based on the lowest possible units of measure and

maximum allowable costs (MAC) as calculated by CareCentrix. Generic drugs are

encouraged when clinically appropriate.

• Drugs and per diems will be reimbursed on the lesser of authorization period or actual dates

of patient care.

• Subcontracting is not allowed. The Provider must notify the CareCentrix utilization

management staff if any product or service is not directly provided by the employees of, or

from a facility owned by the Provider BEFORE the services take place. Provider may utilize a

contracted home health agency to perform the nursing component of an infusion case.

Provider must use best efforts to utilize a CareCentrix credentialed agency.

• Utilization management staff will make the determination of which per diem to attach to an

ordered medication. The per diem is determined by the type of medication, if there is more

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than one medication prescribed, and what services/products will actually be provided.

Example: Ampicillin q6 and Vancomycin q8. Provider would receive the following per diems:

o anti-infective (Ampicillin) q6 primary per diem and;

o anti-infective (Vancomycin) q8 multiple second (more than one (1) medication ordered)

• It is important to maintain an accurate record of patient authorizations so that claim

payment is not delayed or denied. Payment may be denied or reduced if the service billed

does not match the service authorized.

• Request for reauthorization should take place at least 72 hours before the initial

authorization expires, if continuation orders have been written at that time.

• Re-authorization should not be requested more than 7 days prior to authorization

expiration. Exceptions to this rule are specialty medications, such as Immune Globulin,

where additional clinical documentation and review is required by the Health Plan prior to

approval.

Home Medical Equipment (HME)

Home medical equipment is durable medical equipment that is appropriate for home use. It

does not include unrelated consumable supplies, orthotics or prosthetics. However, for some

health plans, it may or may not include consumable supplies, orthotics and prosthetics.

• Initial authorization for rental HME will generally be 1 billing month, unless the physician

order or actual use period will be for less time or unless the health plan approves more than

one billing cycle.

• CareCentrix will review requests for vendor or brand-specific equipment on a case-by-case

basis.

• For authorization of custom equipment, a manufacturer’s specification sheet, including

retail and CareCentrix pricing, needs to be submitted to the utilization management staff.

Note: For custom equipment, CareCentrix may instruct the Provider to complete 2 claims, if

required for the specific CareCentrix contract. If this requirement is not met, the all-

inclusive claim will be denied.

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• For non-managed plans and with full EDI/EBA Provider contracts, re-authorization is the

responsibility of the Provider. The Provider must verify with the patient that the equipment

is still in use, that there is still a valid prescription for the equipment and verify with the

physician an ongoing medical need and that the patient is receiving therapeutic benefits.

• Re-authorization can be for 90 to 180 days depending upon the equipment, diagnosis and

prognosis. For EDI Providers, auto authorization is 1 billing cycle.

• CareCentrix should be notified immediately of any rental equipment returned before the

end of the authorization period.

• Provider should only submit claims for the actual days on billing months.

• Notification of a re-authorization request for HME is to occur 3 days prior to authorization

expiration date, unless directed otherwise by special arrangements or contractual

stipulations.

• All equipment and supplies will be delivered and set up in accordance to the payer’s

guidelines and in compliance with all federal, state and local guidelines.

• Wheelchair pricing includes all patient evaluation, delivery, fitting and set-up.

• Supplies for the following services are included in the monthly rental and should not be

billed separately (for purchased equipment, supplies should be billed directly to the

patient):

o Apnea Monitors

o Pulse Oxymeter

o Oxygen

• Usual and necessary ventilator accessories including circuits, filters, batteries and

humidifiers are included in the monthly rental unless specifically noted by the payer in their

clinical guidelines and under prescribed conditions

• If a patient is prescribed an Oxygen concentrator only, excluding a prescription for an

additional oxygen device for portability or mobility usage by the patient then PROVIDER

shall provide to the patient a “Back-up” System that is selected by CARECENTRIX and

approved by the patient’s physician, the costs of such “Back-up” Equipment are included

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with the rental fee for the oxygen concentrator. If a patient is prescribed a ventilator that is

for use in excess of twelve (12) hours a day or if patient cannot breathe independently for

four (4) consecutive hours, then patient will be provided with a "back-up" system that is in

accordance with the payer clinical guidelines and selected by CARECENTRIX and approved

by patient's physician. CARECENTRIX agrees to authorize payment for the "back-up" system

per the payer guidelines if such additional payment is permitted PROVIDER in addition to

the monthly rental charge for the primary ventilator, will be paid an additional charge at

fifty percent (50%) of the charges listed above for the ‘back-up’ system.

• Supplies and accessories that are factory installed and required for proper operation of

equipment are included in the initial purchase or rental price and should not be billed

separately. Replacement supplies and accessories that are required for proper use of

equipment in the capped rental category can be authorized per physician orders and

patients need.

• One download per month for pneumograms, sleep studies and apnea monitors are included

in the rental price. CareCentrix does not reimburse for interpretations unless specifically

requested and authorized. CareCentrix does not pay for physician professional fees. These

need to be billed by the physician to the health plan.

• Provider subcontracting is not allowed under this contract, however, it is allowable for the

Provider to sub-rent equipment if they will deliver and set-up.

• Providers may provide an upgraded piece of equipment from that which is authorized if

ordered in writing by the physician and if the patient agrees (in writing, prior to delivery) to

pay the difference between the contract price and the cost of the upgrade. You may not

market to the patient. This cost difference is billable only to the patient, not CareCentrix or

the health plan.

• Equipment maintenance is to be done in compliance with the Safe Medical Device Act and

manufacturers maintenance recommendations and noted on the patient’s records chart if

done while the equipment is in use by the patient.

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• CareCentrix must authorize repairs to member-owned equipment in advance of Provider

providing the service.

• For all life support, sustaining or patient monitoring equipment a provider must verify with

the ordering physician all changes to orders up to and including discontinuation.

• Providers should supply the least costly alternative that meets the physicians order and

patient’s needs.

• All HCPC codes listed and contracted for a provider may not be applicable to all payer

contracts.

• Respiratory Therapist visits or consultations for non-routine equipment support or set up

will be authorized in accordance to the plan guidelines and charged per visit or consultation

(up to two hours). Non-routine visits are visits provided in accordance with a physician's

plan of care, or are required by State regulations. Most plans do not authorize separate

payment to DME providers for routine RT visits, fittings or consultation.

Specialty Programs

Some CareCentrix contracts with health plans include the provision of specialty programs such

as, but not limited to, Transitional Care programs (HomeSTAR), Nurse Practitioner Assessments,

sleep management, disease management, and hospital early release. For these specialty

programs, select contracted Providers are contacted and invited to participate if they satisfy

and agree to the terms and conditions of the program. Program training is mandatory for the

Provider to participate. CareCentrix reserves the right to terminate a Provider’s participation in

its sole discretion.

Documentation

As an ancillary heath care delivery system, CareCentrix does not maintain medical records. All

medical record requests are recorded, logged, and forwarded by CareCentrix to the appropriate

Provider of service. CareCentrix does not promote Provider policies that prevent or inhibit

members from viewing medical records. CareCentrix does not require members to be

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accompanied when reviewing records. Provider is required to maintain all medical records

and other documentation necessary to support services rendered in accordance with applicable

laws, rules, regulations, this Provider Manual and the Provider Agreement and to provide

CareCentrix with access to and/or copies of such records upon request and at no charge.

6-3 GENERAL CLAIMS AND REIMBURSEMENT INFORMATION

Claims Adjudication Process

For managed plans, when services (i.e. RN visits) are authorized by a CareCentrix Regional Care

Center, the specific service, units (i.e. 10 visits), pricing and the start and end date of the service

are entered in the CareCentrix computer system and an authorization is generated. For Non-

Managed plans, the start and end date of service will be the same and the units will be zero.

CareCentrix calls this a footprint authorization.

Claims received for services provided to health plan patients serviced by CareCentrix are

processed based on the authorization for managed plans or initial footprint authorization for

non-managed plans. To expedite payment of claims, the Provider should match the billable

services against the hard copy authorization or initial footprint of the CareCentrix authorization

before a claim is generated. Claims for services, date of service or units that do not exactly

match the authorization may be denied in part or in whole. Alternatively, if the Provider bills

for a higher level of service, equipment or supply than the level authorized, payment may be

made in accordance with the rate associated with the authorized service, equipment or supply,

and Provider will accept that rate as payment in full.

Claims will be paid based on the lower of the Provider’s usual billed charge or the

contracted/negotiated rate.

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Authorization of services is not a guarantee of payment, and payment of services rendered is

subject to the patient’s eligibility and coverage on the date of service.

Checking Reimbursement Status

Providers should utilize the CareCentrix provider portal to check the status of their claims.

After checking the provider portal, any further questions regarding the status of claims should

be directed to the CareCentrix Provider Resolution Team (PRT). The PRT is available Monday

through Friday between the hours of 9:00 a.m. and 6:00 p.m. Eastern Standard Time. The PRT

phone number is 1-877-725-6525; follow the prompts for claims and service category.

Prompt Payment Laws

Our goal is to adjudicate our network providers’ claims within the period of time specified in

our provider contract or the period of time required by the state prompt pay law if applicable.

Please do not make status calls or payment inquiries until 45 days after you reasonably expect

the claim to be received by CareCentrix.

Explanation of Payment

An Explanation of Payment (EOP) is issued in connection with each payment to a network

provider for services rendered. The EOP details payments and denials by line item for a given

invoice or claim.

EOPs are also used to communicate adjustments to claims that have already been processed

when it is determined that additional payment will be made on the claim. An adjustment may

be made as a result of a Claims Reconsideration Request or an appeal. The amount of the

adjustment will be detailed by claim line item.

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The Provider may also receive an EOP that includes a credit or amount due to CareCentrix. The

credit will be applied against amounts due the Provider and the net amount will appear on the

accompanying check. If a Provider has a credit balance, no EOP will be generated until that

credit balance has been relieved.

6-4 GENERAL BILLING REQUIREMENTS

In this section, we specify our billing requirements as they relate to the address, format, form,

and timeframe for claim submissions, billing when another payer is primary, authorization

requirements, adjustments, and recoupments. Compliance with our billing requirements is

required and can help ensure the timely processing and reimbursement of Provider claims.

CareCentrix National Claims Center

The CareCentrix National Claims Center (NCC) is where Provider claims are processed. Claims

should be submitted via EDI (electronic) or sent to the address at the bottom of the

authorization for services rendered to help speed claims processing. Always check the service

authorization for the claims address, as occasionally a contract with a health plan will dictate a

deviation from usual operating procedure.

Claim Form and Format

Claims must be submitted electronically or on standard claims forms (CMS 1500 or UB-04). Our

required data elements for both electronic and paper claims include the following:

• Patient name, Member ID number, address, relationship to subscriber, gender, and date of

birth

• Insurance name and group number

• Subscriber name, address, and gender

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• Place of service

• Primary diagnosis code(s) (ICD9/ICD10 codes)

• Rendering provider name, service location, and billing address

• Rendering provider National Provider Identifier (NPI) number, Federal Tax ID number,

Medicaid ID number (Medicaid network providers only), and Taxonomy Code

• Referring provider name and NPI number

• Individual line level charge for each service

• Number of invoiced units for each claim line

• HCPCS/ CPT code(s) and modifier combination

• NDC codes, NDC unit of measure, and NDC units (i.e. prescription drugs)

• Date of service (FROM and TO required; FROM date must be before the claim receipt date

and before or equal to the TO date)

• Whether the patient’s condition is related to employment, auto accident or other accident

• Other insurance information (if other insurance, include other insured’s name, date of birth,

other insurer’s name, group or policy number)

• Coordination of benefits information for secondary claims (explanation of payment from

primary carrier)

• Service authorization number

Claims missing any of the above required information cannot be processed. Paper claims

without the required information will be returned, and the Provider will be informed of the

information that is missing. Claims submitted electronically without the required information

will be rejected by the clearinghouse with corresponding reasons for the rejection. Such

incomplete claims must be resubmitted by the Provider to CareCentrix so that a complete claim

is received by CareCentrix within the original timely filing timeframe as specified below subject

to applicable law.

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CareCentrix reserves the right to update, modify, and/or clarify HCPC codes in accordance with

federal, state, or other regulatory bodies. It is the provider’s responsibility to regularly check

the CareCentrix portal for updates to HCPC codes, descriptions, and the CareCentrix billing

crosswalk. The current billing crosswalk can be found at: www.carecentrixportal.com.

CareCentrix will only accept original documents for payment consideration that are typed or

printed in indelible ink without erasures, strikeovers, whiteout or stickers. Dot matrix printers

should not be used when typing information onto paper claims forms. Also, it is important that

the name of the Provider organization and service location on the claim match the Provider

name on the related authorization form(s).

With regard to services delivered, the claim must include a description of the service provided

(i.e. “RN visit” or “CPAP rental”) as well as the relevant HCPCS, CPT or revenue code and

applicable modifier(s) found on the CareCentrix Service Authorization Form or the billing

crosswalk (located at www.carecentrixportal.com). Claims without a description of the service

provided will be returned. The address to which claims should be sent is found in the lower

portion of the authorization form. Services should be billed at the contracted rates. No billing

to the patient or health plan of the difference between the negotiated or contracted rate and

the Provider’s list price is permitted. If your billing system is unable to support billing at the

contracted rate, the difference between the contract rate and your list price must be adjusted

off your accounts receivable. Doing so will avoid repeated claims inquiries. In addition, when

billing for custom equipment, the claim should reflect the full rate, the discount as negotiated,

and the net price. You should attach to the claim the manufacturer’s specification sheet for the

equipment. For custom equipment, you may be instructed to complete 2 claims if required for

specific CareCentrix health plan contracts.

Claims submitted without all required information may be denied.

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When sales tax is applicable, the tax must be broken out separately from the charge for the

related item or identified in some manner that will alert the claims examiners as to the

existence and amount of the tax charged. Failure to properly allocate the tax charges may

result in improper payment of claims.

Timely Filing

CareCentrix adheres to state and federal laws regarding prompt payment and timely filing of

claims when applicable. Please refer to your applicable state and federal laws. Claims must be

filed at the address designated by CareCentrix within 45 days from the date of service or within

the period of time required by applicable law if longer. Claims received by CareCentrix after the

filing deadline may be denied, and Providers cannot bill the patient for such services.

Billing When another Payor is Primary

If the Provider becomes aware that the CareCentrix customer is the secondary payor, the

Provider should immediately notify CareCentrix so that services can be appropriately

authorized. Please note that, when the CareCentrix customer is the secondary payor, the claim

submitted to CareCentrix must include a copy of the related denial or explanation of

benefits/payment from the primary payor. Such claims must be submitted to CareCentrix with

the primary payor’s EOB attached within 45 days of the date of the primary payor’s EOB or

within such longer period of time required by applicable law.

Authorization

Only covered services for which prior authorization or footprint authorization (from CareCentrix

for managed plans or the health plan for non-managed plans) was obtained will be reimbursed.

Authorization, however, does not guarantee reimbursement or that the service was reviewed

for medical necessity as some services are not subject to a pre-service medical necessity

review. CareCentrix reserves the right to deny and recover reimbursement for services

Provider Manual


delivered after the patient’s health plan policy or eligibility was terminated or for services

delivered in excess of initial authorization or that are otherwise not covered. Additionally,

claims for services that fall outside the authorized date range or which exceed the number of

authorized units may be denied. See also Recoupment and Adjustments.

The Provider also should note that only the Provider indicated in the authorization receives

reimbursement for authorized covered services rendered.

Recoupment and Adjustments

There may be instances in which recoupment of payment is initiated so that the Provider can

bill the appropriate party. For example, we reserve the right to recoup or adjust payment (or

request a refund) for amounts paid for services delivered. This can occur in a number of

situations, including but not limited to:

• The patient’s health plan was terminated or there was some other change in the patient’s

eligibility, benefit or payor source.

• The CareCentrix customer is discovered to be the secondary payor.

• The Provider did not bill CareCentrix timely and CareCentrix was unable to secure

reimbursement from the CareCentrix customer

• Based upon a post service audit or review, the services did not meet medical necessity

criteria

Refund requests and recoups will appear on the CareCentrix Explanation of Payment (EOP) as a

“credit” adjustment. We will provide appropriate information so that the Provider may bill the

responsible party.

See also Service Specific Billing Requirements.

Provider Manual


6-5 COMPLAINTS, CLAIMS PAYMENT RECONSIDERATIONS, AND APPEALS

Introduction to Complaint, Claims Payment Reconsideration, and Appeals Process

Our Complaint, Claims Payment Reconsideration, and Appeals process is a continuous process

improvement mechanism that establishes a consistent guideline for responding to complaints

and credentialing, claims payment, and other issues.

Complaints

Complaints relating to possible fraudulent, illegal or unethical activities must be communicated

to our Compliance Hotline, 1-800-9-NOTIFY.

Credentialing

Credentialing issues should be directed to: Christine Kyle 631-501-7156 or

[email protected].

Utilization Management Issues

Unless otherwise indicated by CareCentrix, CareCentrix does not perform appeals of utilization

management decisions, and the member appeal process is not delegated to CareCentrix.

Appeals of utilization management decisions by or on behalf of the member should be directed

to the appropriate payor.

6-6 CLAIMS PAYMENT ISSUES

Reconsideration

If you receive a payment from CareCentrix that is different from what you expected, you should

first try to understand the difference and reconcile the discrepancy. If you cannot reconcile the

discrepancy and wish to request a reconsideration, you must notify our Provider Resolution

Team either verbally at 877-725-6525 or submit a request for reconsideration in writing using

Provider Manual


our Claim Reconsideration Form which can be found on our provider portal at

www.carecentrixportal.com. Please submit the completed Claim Reconsideration Form along

with a copy of the claim to the following address:

CareCentrix

Request for Reconsideration

111 Founders Plaza

Suite 801, 8th Floor,


Your request for reconsideration must be received by CareCentrix within 45 days after the date

of our explanation of payment, or within the period of time required by applicable law if

longer. Requests received without a copy of the claim in question will be mailed back to the

submitter.

After receipt of your completed request for reconsideration, we will research your concern and

respond to you as soon as possible. If the request for reconsideration is resolved in your favor,

the claim will be adjusted and an explanation of payment (EOP) issued. If it is not resolved in

your favor, you will be advised to submit an appeal in writing using our Appeal Form which can

be found on our provider portal at www.carecentrixportal.com. Please submit the completed

Appeal Form along with a copy of the claim to our Appeals Unit at the following address:

CareCentrix

Appeals Unit

111 Founders Plaza

Suite 801, 8th Floor


Your appeal must be received by CareCentrix within 30 days from the date we orally advised

or, for written requests for reconsideration, the date of our written notice (EOP, letter, etc.)

advising that your request for reconsideration was not resolved in your favor or within the

period of time required by law if longer. Appeal requests received without a copy of the

claim in question will be mailed back to the submitter.

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Appeals

Our Appeals Unit will endeavor to complete the review of your appeal within 30 calendar days

of the date the Appeals Unit receives all information necessary to review your appeal. We will

communicate the results of our review of your Appeal in writing which may include, when

payment is issued, a check along with an explanation of payment.

CareCentrix Network Providers may not bill a patient or that patient’s insurance company (if

the insurance company is a CareCentrix client) for a balance remaining after a decision has been

made on a CareCentrix Network Provider appeal.

Dispute Resolution

If the Provider is not satisfied with the resolution of the appeal, the Provider may request in

writing that the parties attempt in good faith to resolve the dispute promptly by negotiation

between representatives of the parties who have authority to settle the dispute within 30 days

of the date of the appeal decision letter. If the matter is not resolved within 30 days of the

Provider’s written request for such negotiation, the Provider may submit the matter for

resolution in accordance with the dispute resolution process outlined in the Provider’s contract

with CareCentrix. The right to submit the matter for dispute resolution will be waived if the

matter is not submitted for dispute resolution within 60 days of the date of the appeal decision

letter or within the time period required by applicable law if applicable law requires a time

period longer than such 60 day period. If the provider contract does not provide for a specific

dispute resolution mechanism, the following dispute resolution process shall apply to the

extent permitted by applicable law:

Binding Arbitration

If, after exhausting the CareCentrix appeal process, a CareCentrix Network Provider is not

satisfied with the resolution, the Provider has the option to pursue binding arbitration in

accordance with the rules of the American Arbitration Association as amended from time to

time. In connection with the foregoing, each party shall select an arbitrator and the two

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arbitrators selected by the parties shall select a third, mutually agreeable arbitrator.

Arbitration shall then proceed before the panel of the three arbitrators. Arbitration shall be the

exclusive remedy for the resolution of disputes arising under this Agreement, and the award or

decision of the arbitrator shall be final and binding. All costs of arbitration, not including

attorneys’ fees, shall be shared equally by the parties. Judgment upon the award rendered by

the arbitrators may be entered in any court of competent jurisdiction. The Agreement will

remain in full force and effect during any such period of arbitration unless otherwise

terminated pursuant to the termination provision(s) of the Agreement which termination

provision(s) shall not be affected or overridden by this Binding Arbitration provision. This

Binding Arbitration provision shall survive any termination of the Agreement.

6.7 Contract Termination

Both CareCentrix and the Provider may exercise their option to terminate the provider

agreement in accordance with the terms of the provider agreement. In the event of a

termination, the Provider must comply with the Provider’s post termination continuity of care

obligations as specified in the provider contract, this Provider Manual and applicable law. The

provider contract rates will apply to authorized covered services provided during the post

termination continuity of care period. Provider shall provide a list of patients currently on

service at the time of termination, with a description of the services they are receiving.

Provider will maintain a professional attitude regarding CareCentrix to patients and the

community, regardless of the reason for the contract termination. The Provider shall assist in

transitioning the care of patients whose services will continue beyond the continuity of care

period to new CareCentrix Network Providers (e.g. provide a case summary and status upon

discharge; provide prescriptions to CareCentrix or the new Provider). In the event that Provider

wishes to appeal the termination of the Provider’s contract, Provider may submit a request for

an appeal, along with supporting documentation, to their Network Manager found at the

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beginning of this manual.

Your appeal must be received by CareCentrix within 30 days from the date of CareCentrix’s

termination notice. Your appeal will be handled in accordance with any appeal processes

required by applicable law, and we will endeavor to complete our review of your appeal within

30 calendar days of the date we receive your appeal. We will communicate the results of our

review of your appeal in writing. If you are dissatisfied with the results of your appeal, you may

request that the termination be reviewed in accordance with the Dispute Resolution and

Binding Arbitration provisions set forth above.

7-1 CUSTOMER ACKNOWLEDGEMENT AND RESOLUTION MANAGEMENT

Complaint and resolution management allows for the prompt resolution of inquiries,

complaints and concerns expressed from an external source, whether that is a member,

provider or other complainant. As a network provider, you are expected to submit patient

records or to provide additional information, as requested and at no charge, so that a

complaint may be investigated and resolved. It is important that documents are submitted to

CareCentrix within the desired timeframe. If a request for records is received directly from a

Payer, please notify Network Management contact.

Provider specific complaint data is tracked, trended and analyzed and used during the

recredentialing process and to promote on-going process improvement. If an adverse provider

trend is identified, CCX initiates corrective action. This action may be in the form of verbal

counseling, written warning, a formal remediation plan or, in the most severe instances,

suspension from network participation or termination and decredentialing. Providers are

expected to comply and remedy any corrective action plan which has been brought against

them by CareCentrix.

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