Provider Orientation

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About Us  Health Services for Children with Special Needs (HSCSN) is a unique health plan that provides innovative care management services and benefits to pediatric and young adults (ages 0-26) receiving Medicaid and Supplemental Security Income (SSI) in Washington, DC.

Each enrollee is assigned a care manager - a nurse, social worker or other qualified professional - throughout their entire enrollment. The HSCSN Care Manager provides coordination of care, ongoing support and collaboration with the primary care medical home and other specialty providers in order to successfully meet the physical, mental, behavioral and developmental service needs of each enrollee. HSCSN is a subsidiary of The HSC Foundation, along with The HSC Pediatric Center, and HSC Home Care.  

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Department of Health Care Finance (DHCF)

The mission of the Department of Health Care Finance is to improve health outcomes by providing access to comprehensive, cost-effective and quality healthcare services for residents of the District of Columbia.

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DHCF – Summary of Services

DHCF, an agency created in FY 2009, that provides health care services to low-income children, adults, the elderly and persons with disabilities.

Over 200,000 District of Columbia residents (nearly one third of all residents) receive health care services through DHCF’s Medicaid Managed Care contracts and Alliance and Fee-for-service programs.

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  Verifying Enrollee Eligibility

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Providers should verify an enrollee’s plan membership and eligibility prior to providing any service except a service in response to an Emergency Medical Condition. Providers are responsible for providing immediate services for an enrollee’s Emergency Medical condition in accordance with the provider’s license and scope of practice. Verification of an enrollee’s health plan membership is not required for requests for emergency medical assistance.

If you need assistance with verifying an enrollee’s eligibility please contact the Customer Care Department at 202-467-2737 or 866-WER-4Kiz or 1-866-937-4549.

Access Standards• Enrollees with appointments who arrive by their scheduled appointment time shall not

routinely be made to wait more than forty-five (45) minutes from their scheduled appointment time to see a PCP.

• PCPs shall offer new Enrollees an initial appointment within forty-five (45) days of their date of enrollment with the PCP or within thirty (30) days of request, whichever is sooner

• PCP’s must accommodate the need for evening and weekend appointments

• Providers place of business must comply with the regulations outlined in the American Disabilities Act (ADA)

• Providers office must be culturally competent and not discriminate against any enrollee based on cultural or religious background

• Enrollees shall have access to services for the assessment and stabilization of psychiatric crises on a twenty-four (24) hour basis, seven (7) days a week, including weekends and holidays.

• Enrollees shall have access to twenty-four (24) hour access to Urgent Care and Emergency Care seven (7) days a week, including weekends and holidays. Urgent Care will be provided directly by enrollee’s PCP or HSCSN would provide other arrangements.

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Access Standards• Health Check/ initial EPSDT screens shall be offered to new Enrollees within sixty

(60) days of the Enrollee’s enrollment date with HSCSN or at an earlier time if an earlier exam is needed to comply with the periodicity schedule

• Health Check / initial screen shall be completed within three (3) months (90 days) of the Enrollee’s enrollment date, unless provider determines that the new Enrollee is up-to-date with the EPSDT periodicity schedule.

• All Health Check / EPSDT screens, laboratory tests, and immunizations shall take place within twenty (20) days of their scheduled due dates for children under the age of two (2) and within thirty (30) days of their due dates for children over the age of two (2). Periodic EPSDT screening examinations shall take place within thirty (30) days of a request.

• IDEA multidisciplinary assessments for infants and toddlers at risk of disability shall be completed within thirty (30) days of request, and any needed treatment shall begin within fifteen (15) days of the completed assessment

• Enrollees have the right to second opinions if he/she refuses or disagrees with a recommended Plan of Treatment (POT).

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Cultural CompetencyUnderstanding Cultural Competency Healthcare providers are expected to obtain cultural background information on a patient, to help them better understand the patient’s needs and apply the knowledge in the course of their care to that patient. HSCSN providers are required and expected to intimately acquaint themselves with the cultural essence of a child with special needs; so as to assist in the management and care of the child.

 Assessing Cultural Competence: There are some unique indicators that have been determined for Special Needs Children. These key indicators are very important in assessing cultural competency for special need children and include:  Physical disability  Mental disability  Family background  Language  Diet and nutrition  Race and ethnicity  Cultural Beliefs

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Cultural CompetencyDomain areas in assessment of Cultural Competence by a Healthcare provider, as defined in HRSA (Health Resources and Services Administration) findings are as follows:  

Organizational Values: An organization's perspective and attitudes with respect to the worth and importance of cultural competence and its commitment to provide culturally competent care.  Governance: The goal-setting, policy-making, and other oversight vehicles an organization uses to help ensure the delivery of culturally competent care.  Planning and Monitoring/Evaluation: The mechanisms and processes used for: a) long- and short-term policy, programmatic, and operational cultural competence planning that is informed by external and internal consumers; and b) the systems and activities needed to proactively track and assess an organization's level of cultural competence.  Communication: The exchange of information between the organization/providers and the clients/population, and internally among staff, in ways that promote cultural competence.  Staff Development: An organization's efforts to ensure staff and other service providers have the requisite attitudes, knowledge and skills for delivering culturally competent services.  Organizational Infrastructure: The organizational resources required to deliver or facilitate delivery of culturally competent services.  Services/Interventions: An organization's delivery or facilitation of clinical, public-health, and health related services in a culturally competent manner.

 *Excerpt from; Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile. http://www.hrsa.gov/culturalcompetence/indicators/

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Care CoordinationCare Coordination is a series of activities provided by HSCSN Care Managers to assist

enrollees in gaining access to necessary services (medical, behavioral and others), coordinate preventative and specialty services and facilitate communication and coordination in the medical home. Care coordination is individualized, empowering, comprehensive, and outcome-focused.

What are the Care Manager’s role and responsibilities? • Develop a relationship with and support the enrollee and/or caregiver • Develop relationships with physicians and providers servicing enrollees • Communicate with enrollee, caregiver, treating physician(s) and providers • Assist the family with identifying their medical needs • Facilitate access and coordinating services for the enrollee (identify provider, schedule appointments,

coordinate transportation) • Develop and monitor the care coordination plan • Educate enrollees and families on HSCSN benefits, resources and processes • Identify and coordinate enrollee/caregiver education needs (classes, literature, referrals) • Support the relationship between the enrollee and their providers • Connect the enrollee/caregiver with resources • Make referrals to educational advocates and attend educational meetings (with permission of

enrollee/caregiver) • Assist the provider with obtaining home evaluations and/or social work assessments • Assist the provider and family to address overutilization and underutilization of services and noncompliance

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Care Coordination

Working with the Care Manager – what is the role of the Provider?

• Comply with EDSDT and adult preventive care requirements and guidelines

• Collaborate in development of the Care Coordination Plan (review, edit, sign, and return)

• Follow the HSCSN Referral Guidelines for services requiring preauthorization

• Ensure that referrals for home care, durable medical equipment and medical supplies are complete and that services are monitored as indicated

• Communicate with the HSCSN Care Manager about concerns (risks, noncompliance, overutilization, underutilization, health education needs, etc.) and progress

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General Claims HSCSN will process all claims through an automated system. Our goal is to pay providers for covered services within 30 days of receipt of each completed clean claim form. Your tax identification number is your provider ID. Please include it and the NPI on every claim to help expedite payment.

Professional providers and Home Health Agencies are required to submit for payment of covered services on the Centers for Medicare and Medicaid Services (CMS)-1500 Health Insurance Claim Form and Home Health Agencies. Hospitals are required to submit for payment of covered services on the CMS UB04. These forms are available from CMS at http://www.cms.hhs.gov/CMSForms.

Providers have the option of submitting claims electronically through EMDEON or via mail. HSCSN’s payor ID is 37290. Claims should be mailed to:

HSCSNPO Box 29055Washington, DC 20017

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General Claims Timely Processing of Claims In accordance with D.C. Code § 31-3132, HSCSN shall accept Network and non-Network Provider initial Claims for Covered Services no later than one hundred and eighty (180) days from the date of service.  Health Care Acquired Conditions  The Patient Protection and Affordable Care Act of 2010 include provisions prohibiting Federal Financial Participation (FFP) to States for payments for health care acquired conditions (HCACs) and other provider preventable conditions or Never Events.   HSCSN shall no longer reimburse providers for procedures relating to the following health care acquired conditions when any of the following conditions are not present upon admission in any inpatient setting, but subsequently acquired in that setting.

Appeals Claim payments or denials can be appealed in writing within 90 days of the denial or payment. 13

General Claims Electronic Billing Providers now have the opportunity to submit claims electronically and check your claims through a system called claims status link. HSCSN encourages you to sign up by visiting the HSCSN website and follow the link: www.Emdeon.com/PAYERLISTS/payerlists.php

HSCSN PAYOR ID 37290

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General Claims

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Coordination of Benefits

Health Services for Children with Special Needs, Inc. (HSCSN), is always the payer of last resort when the enrollee has another insurance coverage. As a provider, you must always submit your claims to the other insurance company first. Once you receive an explanation of payment from them, you should file the claim with HSCSN. You must attach a copy of the explanation of payment from the other carrier or a copy of the letter of denial. HSCSN will coordinate the payment with the other carrier’s payment. HSCSN will pay up to the amount that is contracted. The provider will not receive payment for more than the charge or contracted amount when combining the payments of both payers.

HSCSN’s Provider Manual, Pages 24-59, has further information on Claims.

Authorizations These services – DO NOT – require authorization:

•Specialty office visits (except behavioral health)

•Primary care visits

•Well woman care (including Depoprovera shots)

•Vision services (including eye glasses)

•Labs and Radiology (including X-Rays, sonograms, MRIs, CT and PET Scans) 

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Authorizations Required Authorizations for Medical/Surgical

•Early Intervention Services•Rehabilitative therapies (physical, speech, occupational)•OB Global services and services associated with pregnancy•Home health (nursing, personal care aide and rehab therapies) and hospice care•Durable Medical Equipment and Assistive Technology•Supplies and Nutritional supplements•Anesthesia for dental procedures•Elective medical admissions (including feeding programs)•Facility admissions - Sub-acute, Rehab, Transitional and Long Term Care•Elective surgery (including plastic surgery), outpatient and inpatient•Home Modification

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Authorizations  Required Authorizations for Behavioral

•Psychiatric and Neuropsychiatric evaluations•Psychological testing and evaluations•Psychotherapy, Counseling and Applied Behavioral Analysis (ABA)•Psychotropic medication management visits•Intensive Outpatient Programs and Day Rehabilitative services•Partial hospitalization programs•Sub-acute admission•Substance Abuse treatment (inpatient and outpatient) •Residential Treatment Facility•Intermediate Care Facility for Mental Retardation (ICF-MR)• 

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Authorizations Home Health Services- Medical

Home health services (Skilled Nursing) must be ordered by a physician. The ordering provider must submit a completed HSCSN Home Care Referral Form prior to service initiation. The form will improve and expedite referrals, reviews and authorizations. The completed HSCSN Home Care referral form can be faxed to 202-721-7190. The care requested must be appropriate to the home setting and to the enrollee’s needs. The request will be reviewed every 60 days within the Home Health Unit for medical necessity. The requesting provider must review and sign the plan of care from the home care agency every 60 days to ensure that services are appropriate and continue to be medically necessary.  For Personal Care Aides – HSCSN requires an in-home assessment of the enrollee’s personal care needs by an RN prior to the initial authorization of services and a minimum of every 6 months for ongoing services.

Please call HSCSN at 202-467-2737 and request to speak with the Home Health Review Nurse if you need assistance.

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Authorizations Home Health Services- Behavioral

The goal of our behavioral health home care service is to work with enrollees, their families and community providers to treat challenging behaviors that interfere with a youth's successful functioning at home and in the community. In-home services are delivered by a trained Behavior Specialist and a supervising licensed behavioral health professional. The HSCSN Behavioral Health Home Services Referral Form must be submitted for all home-based behavioral health service requests. The form will improve and expedite referrals, reviews and authorizations. It is important that the provider supply all relevant clinical history. The completed HSCSN Behavioral Health Home Services Referral form can be faxed to 202-721-7190. The requests are reviewed by the Home Health Unit and referred to an independent licensed social worker to conduct an assessment and provide recommendations for services. Behavioral health home services are authorized based on the recommendation. The services will be reassessed every 6 months within the Home Health Unit for continued medical necessity.  Please call HSCSN at 202-467-2737 and request to speak with the Home Health Review Nurse if you need assistance.

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Authorizations Durable Medical Equipment (DME), Orthotics, Prosthetics and Assistive Technology

The documentation required for the authorization is dependent on the type of equipment requested. The following are standard requirements:  Physician Order for the ServiceCertificate of Medical Necessity (CMN) or Physician Letter A pended authorization is generated after receipt of the CMN and the physician order. Delivery confirmation receipt from the vendor is required before an authorization can be approved. Please fax receipt to the DME Review Nurse within 24 hours of delivery (or next business day if after hours) at 202-467-0978. Receipt should include the following information: Signature of person taking possession of equipment at time of delivery;Delivery date;Documentation of education conducted; andBrand name, model number, quantity, serial/identification number(s) of equipment delivered HSCSN verifies all new and replacement durable medical equipment, prosthetics, orthotics, and assistive technology delivered to the enrollees in the home. 21

Authorizations Inpatient Admissions

Non-emergent (elective) medical/surgical inpatient admissions and outpatient surgical procedures must receive prior authorization from the UM Department. The PCP or specialist should contact the UM Department at least 3 business days prior to the scheduled admission or procedure to obtain authorization.All emergent/urgent inpatient admissions must be reported to the UM Department within 24 hours of the admission. Please fax admission information to 202-635-5590. The following information is needed for the admission: Enrollee NameID NumberAdmitting PhysicianHospital Name and AddressAdmission DateDiagnosis and clinical informationName and Telephone Number of Contact Person 

If notification is not received within 24 hours of the admission, the day’s prior to notification will be denied unless there are documented extenuating circumstances.

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Medical Necessity GuidelinesA service is Medically Necessary for an individual if a physician or other treating health Provider, exercising prudent clinical judgment, would provide or order the service for a patient for the purpose of evaluating, diagnosing or treating illness, injury, disease, physical or mental health conditions, or their symptoms, and that is: In accordance with the generally accepted standards of medical practice

Clinically appropriate, in terms of type, frequency, extent, site and duration

considered effective for the patient’s illness, injury, disease, or physical or mental health condition

Not primarily for the convenience of the individual, Care giver, treating physician, or other treating healthcare provider

More cost effective than an alternative service or sequence of services, and at least as likely to produce equivalent therapeutic or diagnostic results with respect to the diagnosis or treatment of that individual’s illness, injury, disease or physical or mental health condition.

Refer to HSCSN’s Provider Manual for more detail regarding medical necessity criteria. Pages 83-86.

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Appealing a Clinical DecisionProvider Rights to Appeal a Clinical Denial Decision  Providers have the right to:  Discuss denial decisions with the licensed clinical reviewer  Speak with the physician reviewer who issued the denial (or designee)  Obtain an explanation of appeals process, including timeframes for appeal decision  Appeal decision by submitting written comments, documents or any relevant information  To File an Appeal There are two ways to file an Appeal: Telephone the Utilization Review Line at 202 721-7162 Mon. – Friday 8:30am – 5:00pm Health Services for Children with Special Needs, Inc. 1101 Vermont Avenue, NW - Suite 1200 Washington, DC 20005 Attn: Utilization Management Department - Appeals

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Outpatient Mental Health Services

Authorizations for medication management and therapy services (individual, group, family) are provided by the enrollee’s Care Manager in accordance with the table below.

 The behavioral health treatment plan or outpatient treatment report must be received by the Care Manager within 30 days of initiating services and every six (6) to twelve (12) months for continued authorization, depending on the authorized service (see table). HSCSN does not accept psychotherapy notes.

 See HSCSN’s Provider Manual – Pages 76-79 for further information.

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Type of service requested Benefit Initial Authorization Requirement

Continued Authorization Requirement

Medication Management Plan allows 16visits/year

Submit initial treatment plan

Updated treatment plan or submitted treatment report - required every 12 months

Individual, Group and Family Therapy

Plan allows 90 visits/six months

Submit initial treatment plan

Updated treatment plan or submitted treatment report – required every 6 months

HealthCheck/EPSDT Participation

Medicaid's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program is a preventive primary health care program for eligible low-income children and teens ages birth to 21. EPSDT emphasizes preventive care, especially screening services, to promote good health and identify and treat problems early and effectively.

EPSDT is a joint federal-state partnership program administered by the Centers for Medicare & Medicaid Services (CMS). The program has two operational components:

Assuring the availability and accessibility of required health care resources Helping Medicaid recipients and their parents or guardians to effectively use these resources

CMS, state Medicaid agencies, and EPSDT providers have a shared obligation to ensure comprehensive pediatric preventive care for eligible children and teens, and to support their families in accessing the health services available through EPSDT.

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HealthCheck/EPSDT Participation

The DC Department of Health Care Finance (DHCF) in partnership with Georgetown University has developed the free, online HealthCheck Provider Education System.

Please take a minute to REGISTER at http://dchealthcheck.net to review the curriculum. Your registration ensures that your training is recorded by DHCF. This is necessary so that you get credit for fulfilling the training obligations required to be a Medicaid provider. Please note that this training will fulfill your obligations for all Medicaid Managed Care Organizations (MCOs) with which you are paneled:Chartered Health PlanHealth Services for Children with Special Needs UHC Community Health Plan (Unison)

In addition, you will receive 5 CME’s upon completion of the curriculum. 27

Blood Lead Screening All Medicaid eligible children are to receive blood lead screening by ages 12 months and 24 months of age to be in compliance with the requirements of 42 U.S.C. § 1396d (r) (1) (B) (iv) and the CMS State Medicaid Manual, section 5123.2D.

This testing is reported annually as part of the CMS Form 416 report on Health Check services.

Blood lead screenings are also required for those children greater than 24 months (2 years) of age, up to 72 months (6 Years) of age, for whom blood lead screenings cannot be documented.

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Individuals with Disabilities Education Act (IDEA)

Individuals with Disabilities Education Act (IDEA): Federal law governing the rights of infants and toddlers to receive early intervention (Part C) and the educational rights of school-age children and youth with education-related disabilities (Part B).

The early intervention system is designed to serve children from birth through three years of age (36 months) who are DC residents. In order for the child to receive services he/she must be found eligible. Children are eligible if they were born with a disability or health condition that affects their development or are functioning at half their age (greater than 50% delay) in one or more areas of performance such as:

Physical developmentCognitive developmentCommunication, language & speech developmentSocial/emotional developmentAdaptive/self-help skills

Early intervention may include speech, physical, occupational and family therapists, developmental educators, assistive technology, nursing.

Infants and Toddlers with Disabilities (ITDD) of the Department of Health and the MCO’s coordinate the needed services.

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Level of Care CriteriaThe medical and behavioral criteria approved for the use by HSCSN for clinical determinations is InterQual Level of Care Criteria. HSCSN is licensed to utilize the criteria by McKesson Health Solutions, LLC. All InterQual criteria sets are based on two major clinical components:

1) Severity of Illness 2) Intensity of Service

The sets are sub-grouped by body system, clinical findings, imaging findings, laboratory findings and daily treatment protocols.  See HSCSN’s Provider Manual, Pages 83-84, for further information.

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Clinical Guidelines HSCSN encourages the use of evidence-based Clinical Practice Guidelines to ensure that the best and most current quality of care is provided to enrollees.

HSCSN reviews all Clinical Guidelines every two years.

For a list of all clinical practice guidelines adopted and approved by HSCSN’s Quality Council can be found on the Provider Resources page on the HSCSN Website @ www.hscsn-net.org.

The Clinical Guidelines may also be found in your HSCSN Provider Manual on pages 102-103.

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Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS is a program designed and Managed by the National Committee on Quality Assurance (NCQA). The program is designed to measure a set of quality indicators and then be able to make comparisons across the nation based on plan type. HSCSN posts our results on our website and in our Provider Newsletter annually. You as a provider may also receive information throughout the year on your personal provider status with these measures as well as our overall health plan status. These are tools to help us partner to improve outcomes with the care delivery system for our enrollees.

For complete information see Pages 111-114 of the HSCSN Provider Manual.

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HEDIS®What can HSCSN’s network physicians do?

Diabetes CareEducate on the importance of eye exams, lipid control, blood

pressure control, foot exams, and serum glucose control. Tight management of diabetic enrollees to assist in meeting HEDIS goals is recommended. The goals for good Diabetic Management are:

Lipid control = LDL-C < 100mg/dLHbA1C = < 7% good control, < 8% control, > 9% poor controlBP = < 130/80 good control, < 140/90 poor controlAnnual medical attention for nephropathy

1.Refer enrollees to ophthalmologists/optometrists at least every two years.2.Encourage enrollees to have ordered labs drawn.3.Contact HSCSN Care Management when enrollees cancel appointments.4.Ensure that diabetic patients receive a comprehensive examination annually.5.Code information on your claims to document care delivery

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HEDIS®What can HSCSN’s network physicians do?

Monitoring of BMI and associated components of good health In order to target Obesity and malnutrition and begin interventions as early as possible for both of these conditions it is accepted that monitoring of BMI and tracking what percentile and enrollee falls in is the most reliable way to date of determining where an enrollee is in the growth cycle. HEDIS also looks for documented discussions surrounding nutrition and exercise between the physician and caregiver or enrollee. Coding can also be used for all of these measures to document your care

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HEDIS®What can HSCSN’s network physicians do?

Childhood ImmunizationsHEDIS looks at the Immunizations recommended by the CDC as an area of comparison for quality care. The Childhood immunization measure most specifically counts recommended immunizations that have been given PRIOR to the child’s second birthday. Immunizations that have been recommended to be given prior to 24 months of age that are given after the child’s second birthday are considered non-compliant.

Rotavirus administration is low, this may be because you must document if you are giving the two doses or three dose vaccines. If there is no documentation it is assumed the three dose vaccine was used and one dose was missed.

Rates of administration of the Influenza vaccine have been low in the last few years. This is a CDC recommendation that influenza vaccines be administered to children under two annually.

Call the HSCSN care manager to be your partner in getting enrollees in to get their immunizations in the recommended time frame. 

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HEDIS®What can HSCSN’s network physicians do?

Timeliness of Prenatal Care and of Postpartum Care 1.Schedule/provide initial prenatal care as soon as pregnancy is confirmed.2.Remind expectant enrollees to make appointments for prenatal care and postpartum care3.Educate enrollees about the importance of prenatal and postpartum care.4.Contact HSCSN Care Management when enrollees cancel/fail to show up for scheduled visits.5.Alert HSCSN Care Management to any needs for outreach6.Provide postpartum visits between 21 and 56 days after delivery7.Global billing is a tool for your office to use for ease of billing purposes but you may submit documentation of visits/care delivery by submitting the CPT II (Table 4) codes to document individual visits not captured in the global billing. Codes should be used with a zero charge as individual visit payments are already included in the global payment. 

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Fraud, Waste and Abuse Fraud - means an intentional deception or misrepresentation by a

person with the knowledge that the deception could result in some unauthorized benefit to himself or to some other person. It includes any act that constitutes fraud under applicable Federal or State law.

  Waste - means the over-utilization of services not caused by

criminally negligent actions; waste involves the misuse of resources.   Abuse - means provider practices that are inconsistent with sound

fiscal, business, or medical practices, and that result in an unnecessary cost to the Medicaid program, or in reimbursement for services medically unnecessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program

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Fraud, Waste and Abuse

What is your role concerning the FCA?  You are essential to your organization’s compliance with the FCA. The codes your office/facility attaches to diagnoses and procedures, the

documentation you keep for each patient, the bills you file –even the dates you record when procedures occur are subject to the FCA. Therefore, your work must be clear, accurate and in compliance with all rules and regulations.

Safeguard your organization by ensuring: You document orders in the patient’s medical record; Services are deemed medically necessary based on patient’s needs; Medical necessity is documented in the patient’s medical record; All billing, coding, and reimbursement rules are followed; Services not rendered, are credited to the patient’s account; Accountability for your actions and acting with integrity in all circumstances. You do not retain Medicaid funds that were improperly paid

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Reporting Requirements

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By law, providers must report all occurrences of sexually transmitted diseases, communicable diseases, vaccine preventable diseases, immunizations administered, lead levels and developmental delay in infants and children to the following organizations:

Sexually Transmitted Diseases, Communicable Diseases Department of Health (202) 727-6408

 Immunizations, Dept. of Health (Vaccine for Children) (202) 576-7130

 Lead Levels, DC Lead Registry (202) 535-1398

 Developmental Delay – DC Early Intervention (202) 727-3665 or visit www.strongstartdc.com

 

Health Insurance Portability and Accountability Act (HIPAA)

The goals of the privacy standards are to protect the confidentiality of individually identifiable information obtained, restricts how it can be used and disclosed and to protect individual rights.

Access to Enrollee Records   Permitted Uses and Disclosures:  HSCSN may request Protected Health Information (PHI) for:

a) Treatment, payment or healthcare operations,b) The healthcare operations of another covered entity or healthcare provider, if each

entity has or had a relationship with the individual who is the subject of the PHI being requested, and the disclosure is:

i. For a purpose listed in the definition of healthcare operations; orii. For the purposes of healthcare fraud and abuse detection or compliance.

c) Another covered entity that participates in an organized healthcare arrangement with The HSC System for any healthcare operation activities of the organized health care arrangement.

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Provider Manual General Services pages 7-59

Provider ServicesProvider websiteAppointment Access Credentialing and re-credentialingContractingCustomer Care

EnrollmentCultural Competency

Care ManagementFamily and Community Development (Outreach) ServicesClaims and Billing

CMS 1500UB04

http://www.hscsn-net.org/provider-services/provider-resources

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Provider Manual Enrollee Benefits and Authorizations pages 60-86

 Benefits and Pharmacy List Care Management ServicesUtilization Management

Authorization Guidelines Medical Necessity CriteriaAppeals ProcessFair Hearing ProcessOB/GYN Behavioral Health

Care Management ServicesUtilization Management

Authorization Guidelines Medical Necessity CriteriaAppeals ProcessFair Hearing ProcessOB/GYN Behavioral Health

http://www.hscsn-net.org/provider-services/provider-resources

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Provider Manual Clinical Practice Standards pages 87-104 Primary Care and specialty servicesHealthCheck (formerly EPSDT) Supplemental Security Income (SSI) programIndividuals with Disabilities Education Act (IDEA)Adult Care VaccinesDentalClinical Practice GuidelinesAdvance DirectivesMandatory Reporting Clinical conditions

http://www.hscsn-net.org/provider-services/provider-resources

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Provider Manual  Regulatory Standards pages 138-142

 Corporate Compliance

Fraud, Waste and Abuse Audit and Oversight ActivityProvider Responsibilities

Appendix A – Forms pages 143-157Behavioral Health Home Services Referral From

Disclosure of Ownership Home Health Care Referral FormMental Health Screening ToolOB Gobal Authorization and PsychoSocial Form Outpatient Treatment Report (Sample)Provider Interest Form Unusual Incident Report DC Medicaid Universal Referral Form  

Appendix B – Acronyms pages 158-159

 

http://www.hscsn-net.org/provider-services/provider-resources

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Always….Remember to always refer to your Provider Manual

Contract your Provider Service Representative with any questions or concerns

Refer to your important numbers (Page 5) of your Provider Manual

Notify us of any changes in your practice:•Provider resigned•New provider on staff •Change of address Read your voucher, post your payment and review the reason code description in a timely manner.

Visit us at www.hscsn-net.org

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Questions???

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