ADMINISTRATIVE MANUAL - NETWORK PROVIDER - MEDIGOLD
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2022 Network Provider
Administrative Manual
1
Table of Contents
SECTION 1: i. Risk Adjustment Process
Welcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 6 System and Encounter
a. Welcome Data Processing System . . . . . . . . . . . . . Pg 17
b. Introduction ii. Improper Payment Measures. . . . . . . . . . . Pg18
c. Important News & Updates h. Informing Members of
d. Provider Communications Advance Directives. . . . . . . . . . . . . . . . . . . Pg 18
i. Referrals/Prior
SECTION 2: Authorization Requests. . . . . . . . . . . . . . . . Pg 18
How to Contact MediGold . . . . . . . . . . . . . . Pg 7-8 j. MediGold Member Rights
a. Case Management and Responsibilities . . . . . . . . . . . . . . . . . . Pg 19
b. Compliance
c. Contracting & Provider Relations SECTION 5:
d. Member Grievance and Appeals Quality Management . . . . . . . . . . . . . . . . . . . Pg 20
e. Member Services a. Regulatory Requirements. . . . . . . . . . . . . . Pg 20
f. Pharmacy Benefit Manager b. Healthcare Effectiveness Data
g. Provider Service Center and Information Set (HEDIS®). . . . . . . . . . . Pg 20
h. Quality Management c. What are Medicare Star Ratings?. . . . . . . . Pg 21
i. Risk Adjustment d. Program Goals . . . . . . . . . . . . . . . . . . . . . . Pg 21
j. Special Investigations Unit (SIU) e. Program Activities. . . . . . . . . . . . . . . . . . . . Pg 22
k. Utilization Management f. Risk Management/Quality
l. Stars and HEDIS Concern Reporting . . . . . . . . . . . . . . . . . . . Pg 22
g. Outcomes, Evaluations and
SECTION 3: Member-Based Studies . . . . . . . . . . . . . . . Pg 22
Eligibility and Enrollment . . . . . . . . . . . . . . . . . Pg 9 h. Access and Availability. . . . . . . . . . . . . . . . Pg 23
a. Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pg 9 i. Member and Provider Satisfaction. . . . . . . Pg 23
b. Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 9
c. The Member’s Primary Care Provider. . . . . Pg 10 SECTION 6:
d. Membership Identification Card . . . . . . . . . Pg 10 Utilization Management . . . . . . . . . . . . . . . . . Pg 24
a. Utilization Management. . . . . . . . . . . . . . . . Pg 24
SECTION 4: i. Overview. . . . . . . . . . . . . . . . . . . . . . . . Pg 24
Provider Policies and Protocols. . . . . . . . . . . Pg 12 ii. Medical Necessity. . . . . . . . . . . . . . . . . Pg 25
a. Compliance with Policy/Protocol . . . . . . . . Pg 12 iii. Prior Authorization. . . . . . . . . . . . . . . . . Pg 25
b. Provide Timely Notice of iv. Prior Authorization Process. . . . . . . . . . Pg 26
Demographic Changes. . . . . . . . . . . . . . . . Pg 12 v. Prior Authorization Decision-
c. Prohibited Billing Practices. . . . . . . . . . . . . Pg 13 making Process. . . . . . . . . . . . . . . . . . . Pg 26
i. Balance Billing. . . . . . . . . . . . . . . . . . . . . . . Pg 13 vi. Referral Policies. . . . . . . . . . . . . . . . . . . Pg 26
d. After Hours Care. . . . . . . . . . . . . . . . . . . . . Pg 14 vii. Hospital Notifications . . . . . . . . . . . . . . Pg 27
e. Delay in Service. . . . . . . . . . . . . . . . . . . . . . Pg 14 vii. Concurrent Review . . . . . . . . . . . . . . . . Pg 27
f. Medical Record Requirements . . . . . . . . . . Pg 14 ix. Readmission Reimbursement. . . . . . . . Pg 28
i. Follow Medical Record Standards . . . . . . . Pg 14 x. Urgent Care and Emergency Services. . Pg 29
ii. General Documentation Guidelines. . . . . . . Pg 15 xi. Notifications to Members . . . . . . . . . . . Pg 29
iii. Demographic Information. . . . . . . . . . . . . . Pg 16 xii. When to Deliver the NOMNC. . . . . . . . . Pg 30
iv. Member Encounters . . . . . . . . . . . . . . . . . . Pg 16 xiii. Notice Delivery to Representatives. . . . Pg 30
v. Clinical Decision and Safety Support . . . . . Pg 16 xiv. Exceptions. . . . . . . . . . . . . . . . . . . . . . . Pg 31
g. Risk Adjustment Information. . . . . . . . . . . . Pg 16 xv. Alterations to the NOMNC. . . . . . . . . . . Pg 31
xvi. When to Deliver the DENC . . . . . . . . . . Pg 31
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 3
Table of Contents
xvii. Hospital Discharge Notices. . . . . . . . . . . . Pg 31 iii. Part B Benefit versus
1. An Important Message From Part D benefit (B/D). . . . . . . . . . . . . . . . Pg 41
Medicare About Your Rights (IM).. . . . . Pg 31 i. Diabetic Glucose Monitors,
2. Detailed Notice of Discharge. . . . . . . . . Pg 32 Test Strips, and Supplies. . . . . . . . . . . . . . Pg 41
xviii. Availability of Utilization j. Self-Administered Drugs
Management Staff. . . . . . . . . . . . . . . . . . . Pg 32 in an Outpatient Setting. . . . . . . . . . . . . . . Pg 42
b. Skilled Nursing Facilities (SNF) . . . . . . . . . Pg 32 k. Non-Covered Part D Utilization
i. Prior Authorization. . . . . . . . . . . . . . . . . Pg 32 Management Requirements. . . . . . . . . . . . Pg 42
ii. Concurrent Review . . . . . . . . . . . . . . . . Pg 33
iii. MediGold Tier SECTION 9:
Reimbursement Model . . . . . . . . . . . . . Pg 34 Claims Processing
iv. Benefit Period . . . . . . . . . . . . . . . . . . . . Pg 34 Procedures and Guidelines . . . . . . . . . . . . . . Pg 43
a. Copayment and Coinsurance . . . . . . . . . . Pg 43
SECTION 7: b. Submission of Charges
Case Management . . . . . . . . . . . . . . . . . . . . . Pg 35 (Claims and Encounters) . . . . . . . . . . . . . . Pg 44
a. Case Management. . . . . . . . . . . . . . . . . . . Pg 35 i. Essential Documentation. . . . . . . . . . . . Pg 44
i. Transitions of Care Program. . . . . . . . . Pg 35 ii. Tips for Submitting Paper Claims. . . . . . Pg 44
ii. Disease Management Program. . . . . . . Pg 36 c. Remittance Advice. . . . . . . . . . . . . . . . . . . Pg 45
iii. Behavioral Health Program. . . . . . . . . . Pg. 36 d. Corrected Claims Submission. . . . . . . . . . Pg 45
iv. Chronic Care Improvement e. Request for Claims Review Form. . . . . . . . Pg 45
Program – Chronic Obstructive f. Claims Timely Filing Limitations. . . . . . . . . Pg 46
Pulmonary Disease. . . . . . . . . . . . . . . . Pg 36 g. Provider Portal. . . . . . . . . . . . . . . . . . . . . . Pg 46
v. Complex Case Management Program. . Pg 37 h. Transfer of Claims from Medicare
Nurse Advice Line Part B Carrier/MAC to MediGold. . . . . . . . Pg 47
i. Coordination of Benefits . . . . . . . . . . . . . . Pg 47
SECTION 8: j. Secondary Payor. . . . . . . . . . . . . . . . . . . . Pg 48
Medicare-Covered Drugs. . . . . . . . . . . . . . . . Pg 38 k. Medicaid as a Secondary Payor . . . . . . . . Pg 48
a. Medicare Part B Drugs:. . . . . . . . . . . . . . . Pg 38 l. Subrogation and
i. Definition Workers’ Compensation. . . . . . . . . . . . . . . Pg 48
ii. Benefit
b. Medicare Part D Drugs:. . . . . . . . . . . . . . . Pg 39 SECTION 10:
i. Definition Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 49
ii. Benefit a. Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 49
c. The Formulary . . . . . . . . . . . . . . . . . . . . . . Pg 39 b Monitoring and Auditing First Tier,
d. Tiered Drug Benefit . . . . . . . . . . . . . . . . . . Pg 39 Downstream and Related Entities (FDR) . . Pg 49
e. Medicare Part D Benefit Stages c. Annual Compliance Attestation
and Total Out-of-Pocket Costs . . . . . . . . . Pg 40 by FDRs. . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 49
f. Vaccines Covered Under d. Compliance Reporting. . . . . . . . . . . . . . . . Pg 49
Medicare Part D. . . . . . . . . . . . . . . . . . . . . Pg 40
g. Provision of and Billing
for Zostavax© and SHINGRIX© . . . . . . . . . Pg 40
h. Part D Utilization
Management Requirements. . . . . . . . . . . . Pg 40
i. Prior Authorization. . . . . . . . . . . . . . . . . Pg 40
ii. Quantity Limits. . . . . . . . . . . . . . . . . . . . Pg 41
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 4
Table of Contents
SECTION 11: SECTION 13:
Special Investigations Unit. . . . . . . . . . . . . . . Pg 49 Member Grievance and Appeal Process. . . . Pg 61
a. Fraud, Waste and Abuse. . . . . . . . . . . . . . Pg 49 a. General Information on
i. What is Medicare FWA? . . . . . . . . . . . . Pg 49 Medicare Appeals Procedures. . . . . . . . . . Pg 61
ii. Examples of Provider, Pharmacy, b. Who May File an Appeal . . . . . . . . . . . . . . Pg 62
or Vendor FWA . . . . . . . . . . . . . . . . . . . Pg 50 c. Support for the Appeal . . . . . . . . . . . . . . . Pg 62
iii. Disclosure of Ownership, Exclusion d. Assistance with Appeals . . . . . . . . . . . . . . Pg 62
and Criminal Conviction . . . . . . . . . . . . Pg 50 e. Medicare Standard Organization
iv. How to Report FWA. . . . . . . . . . . . . . . . Pg 50 Determination and Appeals Procedures . . Pg 62
f. Medicare Expedited/72-Hour
SECTION 12: Determination and Appeal Procedure. . . . Pg 65
Network Participation Responsibilities. . . . . Pg 51 g. Types of Decisions Subject to
a. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . Pg 51 Expedited/72-Hour Review . . . . . . . . . . . . Pg 65
b. How to Become a Participating h. How to Request an
Provider with MediGold. . . . . . . . . . . . . . . Pg 51 Expedited/72-Hour Review . . . . . . . . . . . . Pg 65
c. MediGold’s Code of Conduct . . . . . . . . . . Pg 51 i. How an Expedited/72-Hour
d. Credentialing Process . . . . . . . . . . . . . . . . Pg 51 Determination/Review Request
i. Physician Credentialing. . . . . . . . . . . . . Pg 51 will be Processed. . . . . . . . . . . . . . . . . . . . Pg 66
ii. Initial Credentialing . . . . . . . . . . . . . . . . Pg 52 j. MediGold Grievance Procedures. . . . . . . . Pg 67
iii. Recredentialing. . . . . . . . . . . . . . . . . . . Pg 52 k. Quality Improvement Organization
iv. Facility Credentialing Immediate Review of Hospital
and Recredentialing. . . . . . . . . . . . . . . . Pg 52 Discharges. . . . . . . . . . . . . . . . . . . . . . . . . Pg 68
v. Summary Suspension. . . . . . . . . . . . . . Pg 52 l. Quality Improvement Organization
e. Provide Official Notice. . . . . . . . . . . . . . . . Pg 54 Quality of Care Complaint Process. . . . . . Pg 69
f. Transition of Member Care Following
Termination of Your Participation. . . . . . . . Pg 55
g. Performance Assessment. . . . . . . . . . . . . Pg 55
h. Provisions of Access to Your Facility. . . . . Pg 55
i. Physician Incentive Plan
Regulation Compliance. . . . . . . . . . . . . . . Pg 55
j. Remediation Policy . . . . . . . . . . . . . . . . . . Pg 55
k. Medicare Advantage
Participation Provisions. . . . . . . . . . . . . . . Pg 56
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 5
SECTION 1:
Welcome
We are committed to partnering with our providers
to build strong relationships and make working
with us easier. We developed this manual to guide
you through MediGold policies, procedures and
processes. Great effort has been made to ensure
the information in these pages is accurate. If
there is any conflict between the contents of this
manual and your provider agreement, the provider
agreement will prevail. Please contact provider
services if you have any questions.
Note: Throughout this manual we refer to “the
Plan” and “MediGold” interchangeably
Important News and Updates to
this Manual
Welcome
In accordance with your agreement, providers must
Welcome and thank you for participating in
abide by all provisions contained in this manual,
the MediGold Provider Network. We appreciate
as applicable. Revisions to this manual constitute
your partnership in delivering high-quality care
revisions to MediGold’s policies and procedures.
and better outcomes for our members-your
Such revisions and other updates
patients. Communication is key to any successful
to policies and procedures may be
relationship, so we hope you find the contents in
communicated to network providers via the
this manual helpful and let us know if we can do
monthly MediGold Provider Update, but may
anything to make working with us easier.
also be communicated multiple methods that may
include mail, internet, email, telephone,
Introduction and in person.
MediGold is a Medicare Advantage plan founded
in 1997. We are a provider-sponsored organization Provider Communications
dedicated to providing exceptional coverage,
We want to be a great partner and develop
customer service and access to high quality and
mutually beneficial partnerships with our providers.
cost-effective care.
Communication is essential to successful
We are a not-for-profit organization that is a part relationships and sharing information with you
of the Trinity Network and are contracted with the is very important to MediGold. We distribute a
Centers for Medicare & Medicaid Services (CMS) monthly “MediGold Provider Update” to all our
to participate in the Medicare Advantage program participating providers. It shares key information to
offering HMO and PPO products with, and without, stay current on matters that may affect your work
Part D drug coverage to Medicare beneficiaries. with MediGold and our members.
If you are not currently receiving this
You can find details on our products at:
communication, please go to
MediGold.com.
MediGold.com/For-Providers to sign up.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 6
SECTION 2:
How To Contact MediGold
Address:
6150 East Broad St., EE320, Columbus, OH 43213
Website:
MediGold.com
Provider Portal:
MediGold.com/For-Providers/Provider-Portal
Current Provider Administrative Manual:
MediGold.com/For-Providers/Tools-and-Resources/
Current Member Evidence of Coverage:
MediGold.com/Members/Member-Materials
Department Phone Numbers
Case Management Member Services
1-800-240-3870, option 4 Toll Free: 1-800-240-3851 (TTY 711)
8 – 4:30 p.m. Monday – Friday Toll Free Fax: 1-833-900-0606
Toll Free Fax: 1-833-263-4870
Email: CaseManagement@MediGold.com Pharmacy Benefit Manager
CVS Caremark Part D Services, LLC
Compliance P.O. Box 52066
Toll Free: 1-833-263-4862 Phoenix, AZ 85072-2000
Toll Free Fax: 1-833-976-0037 Phone: 1-866-785-5714
Email: MediGoldCompliance@mchs.com
Provider Service Center
Contracting & Provider Relations Toll Free: 1-800-991-9907 (TTY 711)
Toll Free: 1-800-991-9907 (TTY 711)
Toll Free Fax: 1-833-900-0606
Toll Free Fax: 1-833-900-0608
Email: MediGoldContracting@mchs.com
Quality Management
Member Grievance and Appeals Email: Quality@mchs.com
Toll Free: 1-888-898-6129 (TTY 711)
Toll Free Fax: 1-833-802-2495 Risk Adjustment
Email: MediGoldAppeals@mchs.com Email: riskadjustment@mchs.com
Toll Free Fax: 1-833-978-1756
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 7
SECTION 2:
How To Contact MediGold
Department Phone Numbers Continued
Special Investigations Unit (SIU) For Fraud, Waste, and Abuse Concerns
Voicemail: 1-833-263-4863.......................We are committed to partnering with you! If you suspect
someone of committing fraud, please report any suspicious
Email: SIU.MediGold@mchs.com fraudulent activity in one of these ways.
Toll Free Fax: 1-833-900-0606
Anonymous: MediGold.com/SIU
Utilization Management
Toll Free: 1-800-240-3870.........................To obtain prior authorization or notify us of the procedures
Toll Free Fax: 1-833-263-4869 or listed on the Prior Authorization List, services concurrent
review, or to make a referral.
Stars and HEDIS
Local: 1-888-898-6129
Toll Free Fax: 1-833-263-4823
Email: StarsAndHEDIS@mchs.com
TruHearing
Toll Free: 855-286-0550............................Contact for audiology and hearing aid services.
MediGold Vision
1-866-253-8963.........................................8 a.m. - 8 p.m., 7 days a week.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 8
SECTION 3:
Eligibity and Enrollment
Eligibility Enrollment
Generally, a Medicare beneficiary is eligible to enroll There are limits to when and how often Medicare
in MediGold if the following two conditions are beneficiaries can change the way they receive
satisfied: their Medicare benefits:
He or she is entitled to Medicare Part A and is Between Oct. 15 and Dec. 7 each year,
enrolled in Medicare Part B as of the effective anyone can make any type of change, including
date of enrollment in MediGold. adding or dropping Medicare prescription drug
He or she lives in the service area covered coverage.
by MediGold. From January 1 through March 31, anyone
There are some exceptions to the general rule, and enrolled in a Medicare Advantage Plan (except
some other eligibility rules. Please contact Member those with an MSA plan) has an opportunity to
Services for additional information. change plans or return to Original Medicare.
At each office visit your office staff should: Anyone who disenrolls from a Medicare
Ask for the member’s ID card. Advantage plan during this time can join
Copy both sides of the ID card and keep the copy a stand-alone Medicare Prescription
with the patient’s file. Drug Plan during the same period.
Determine if the member is covered by another
health plan to record information for coordination Generally, you may not make changes at other times
of benefits purposes. unless you meet certain special exceptions; such as
Refer to the member’s ID card for the telephone if you move out of the plan’s service area, want to
number to verify eligibility, deductible, coinsurance, join a plan in your area with a 5-Star Rating or qualify
copayments and other benefit information. To for extra help with your prescription drug costs.
view a member’s specific plan benefits, use
the Plan number located on the ID card to find In general, Medicare beneficiaries are only able to
the Evidence of Coverage on our website at change the way they receive Medicare benefits two
MediGold.com/Members/Member-Materials. times a year (as noted above).
Participating providers must admit patients to
a participating facility unless an emergency There are special exceptions, for example: if
situation exists that precludes safe access to beneficiaries move out of a plan’s service area,
a participating facility or if the admission is are institutionalized or have ‘Medicaid’ benefits.
approved for a non-participating facility.
The member will receive in-network benefits
onlywhen services are performed at a
participating MediGold provider.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 9
SECTION 3:
Eligibity and Enrollment
The Member’s Primary Care Provider Membership Identification Card
Each member of MediGold who enrolls in one of our MediGold issues an identification (ID) Card to
HMO products is required to choose his or her own each member. Members are required to present
primary care provider (PCP) from a list of network their ID cards for medical, hospital, and other
providers. Each PPO member must choose his or covered services. The MediGold ID card will identify
her own PCP from a list of our network providers or MediGold members to you and your staff and
an out-of-network provider. provides quick access to pertinent information
such as applicable copays, contact numbers to
Members have the option to change their PCP at coordinate medical care, hospitalization or other
any time upon request to MediGold. Changes in covered services, as well as claims submission
PCPs are effective on the first day of the month after information. MediGold members are instructed to
the request is processed by MediGold. MediGold put their Medicare cards away for safekeeping and
will monitor the frequency and reasons members present only their MediGold ID cards at the time of
change PCPs. When MediGold determines that service.
frequent changing of a PCP interferes with a PCP’s
Be sure to check the member’s ID card at each
ability to effectively manage a member’s care,
visit, especially the first visit of each year when the
MediGold may limit the ability of a member to
information is most likely to change.
change his or her PCP.
To request a PCP change, members must
call Member Services Department at
toll-free 1-800-240-3851 (TTY 711), or
submit a written request to:
MediGold Enrollment Department
Attention: PCP Change Request
6150 East Broad Street, EE320
Columbus, OH 43213
You may request a listing of MediGold
members assigned to you by contacting
provider services.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 10
SECTION 3:
Eligibity and Enrollment
MediGold’s member ID card was revised to include logos for MediGold and
information specific to each of MediGold’s products. For reference purposes,
a sample copy of the card follows:
P LE
M
SA
Front of card
P LE
M
SA
Back of card
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 11SECTION 4:
Provider Policies and Protocols
Compliance With Policy/Protocol
According to your provider agreement, you will numbers, additions or departures of health care
comply with and be bound by MediGold’s policies providers from your practice, ability of individual
and protocols, including those contained in this practitioners to accept MediGold members or any
manual. Failure to comply with such policies and other changes that affect availability to MediGold
protocols will be reviewed by MediGold and may members and new service locations.
result in appropriate action in accordance with your
provider agreement, such as denial of payment, If a provider is associated with a group that is
financial penalties and modifications to your delegated for credentialing, please verify that
reimbursement or other terms of your agreement credentialing is not affected by contacting the
with us, or ineligibility to participate in recognition Provider Service Center at 1-800-991-9907.
programs.
You are not permitted to bill our members for any
If a provider is associated with a group that is
amounts not paid due to your failure to comply
delegated for credentialing, please reach out to
with our policies and protocols.
your group’s point of contact for credentialing.
Demographic changes must be completed
Provide Timely Notice of by submitting a Provider Information
Demographic Changes Change Form. Provider terminations must
You must notify us within 30 days of any changes be completed by submitting a Provider
to demographic and participation information that Termination Request Form.
differs from the information reported with your
executed provider agreement. These include, but are Forms are available online at MediGold.com/
not limited to: tax ID changes (W9 required), office or For-Providers/Tools-and-Resources/Forms.
remittance address changes, phone numbers, suite
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 12SECTION 4:
Provider Policies and Protocols
Prohibited Billing Practices
Balance Billing What not to do:
he QMB program is a state Medicaid
T
1 Prohibited Billing of Qualified Medicare
Beneficiary (QMB) Individuals and
benefit that covers Medicare deductibles,
coinsurance and copayments, subject to
Medicare Assignment:
state payment limits.
Medicare-covered services, also covered by
Medicare providers may not balance
Medicaid, are paid first by Medicare because bill QMB individuals for Medicare
Medicaid is generally the payor of last resort. cost-sharing, regardless of whether
Medicaid may cover the cost of care that the state reimburses providers for the full
Medicare may not cover or may partially cover Medicare cost-sharing amounts.
(such as nursing home care, personal care, and
home- and community-based services).
Further, all Original Medicare and MA
providers—not only those that accept
Federal law prohibits all Medicare providers Medicaid—must refrain from charging
from billing QMB individuals for all Medicare QMB individuals for Medicare cost-
deductibles, coinsurance or copayments. All sharing. Providers who inappropriately
Medicare and Medicaid payments the provider balance bill QMB individuals are subject
receives for furnishing services to a QMB to sanctions. Federal law bars Medicare
individual are considered payment in full. The providers from balance billing a QMB
provider is subject to sanctions if you bill a QMB beneficiary under any circumstances.
individual for amounts above the sum total of all
Medicare and Medicaid payments, even when See: Section 1902(n)(3)(B) of the
Medicaid pays nothing. Social Security Act, as modified
In addition, all Medicare providers must accept by Section 4714 of the Balanced
assignment for Part B services furnished to Budget Act of 1997.
dual eligible beneficiaries. Assignment means
that the Medicare-allowed amount (Physician
Fee Schedule amount) constitutes payment in 2 NNecessary
on-Covered and/or Not Medically
Services, Integrated Denial
full for all Part B-covered services provided to Notice (IDN) Required
beneficiaries.
If you have any reason to believe that MediGold
will not cover a service, in whole or in part, and
wish to bill the member for such a service, you
What to do:
must contact MediGold’s Utilization
E
nsure that you are checking the eligibility
Management team prior to performing the
of your patients. Some Medicare enrollees
services. The utilization management team will
may qualify for both Medicare and Medicaid
review the request and, if the service is not
services. These members are called Dual
covered under the member’s benefit plan and/or
Benefits Members.
“medically not necessary,” issue an IDN to
Y
ou may confirm a MediGold member’s the member. The member must receive the IDN
eligibility for Medicaid through Medicaid in advance of receiving the service and must
Information Technology System (MITS). have sufficient time to decide if they want to
proceed with the non-covered and/or “medically
not necessary” service.
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Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc.SECTION 4:
Provider Policies and Protocols
Non-Covered Services, Integrated Denial Meeting the member at your office.
Notice (IDN) Required (continued)
irecting the member to your pre-arranged,
D
Failure to obtain an IDN for a non-covered and/or network PCP on-call.
“not medically necessary” service will result in an
administrative denial, for which you may not seek any
Delay in Service
reimbursement from MediGold or the member.
Facilities that provide inpatient services must
You should know or have reason to know maintain appropriate staff, resources and equipment
that a service may not be covered if: to ensure that covered services are provided to our
The service is expressly excluded from members in a timely manner. A delay in service is
coverage in the member’s Summary of defined as a failure to execute a physician order in a
Benefits and Evidence of Coverage. timely manner that results in a longer length of stay.
A delay in service may result for any of the following
e have provided general notice either that
W
reasons:
we will not cover a particular service or that
particular services are only covered under quipment needed to execute a physician’s order
E
certain circumstances. is not available.
e have made a determination that planned
W
taff needed to execute a physician’s order
S
services are not covered and/or “not medically
is not available.
necessary” services and have communicated
that determination to you. facility resource needed to execute a
A
Member Responsibility: Nothing herein or in your physician’s order is not available. Facility does
agreement with MediGold prohibits you from not discharge the patient on the day the
collecting any coinsurance, deductible, or physician’s order is written. Payment to
copayments specifically identified in the member’s facilities may be affected for delays in service.
Evidence of Coverage, available online at:
MediGold.com/Members/Member-Materials. Medical Record Requirements
Follow Medical Record Standards
You may not bill our members for non-covered
services if you do not comply with this policy. Medical record requests may be made by MediGold
and/or its designated vendor for a variety of reasons.
Requests for medical records may be necessary in
After Hours Care any of the following circumstances:
MediGold members are instructed to contact their
PCP before any form of care is rendered. Therefore, dditional information is required before MediGold
A
the PCP may receive telephone calls outside routine can process a claim.
office hours. It is incumbent upon you to determine A complaint or allegation of possible fraud,
whether the requested care is of an emergency waste or abuse of the Medicare program
nature. Every reasonable and medically appropriate which requires investigation.
attempt should be made to give advice and arrange
for the member to be seen during regular office ny complaint alleging possible quality of care,
A
hours. As the provider, you should consider: service or access to care.
eeting the member at the emergency room or
M eview of an established or new physician or
R
directing the member to the nearest urgent care practitioner is warranted, before or after a claim
center or emergency room, where appropriate. is paid, based on analysis of data.
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Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 14SECTION 4:
Provider Policies and Protocols
Medical Record Requirements (continued) If you choose to charge the Plan for medical records,
Plan shall reimburse physician for records requested
Payment retraction.
by the Plan at the Medicare rate, plus postage when
Data collection for HEDIS. applicable. Payment shall be made by the Plan to
physician upon the Plan’s receipt of the requested
isk adjustment purposes that include, but are
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records.
not limited to: verifying the accuracy of coding,
ensuring all diagnosis codes are properly
General Documentation Guidelines
supported by relevant medical records, medical
record review to identify any conditions not We also expect you to follow these commonly
captured through claims or encounter data, and accepted guidelines for medical record information
to comply with CMS requests for records when and documentation:
conducting any Improper Payment Measure
Date all entries and identify the author.
audits.
ake entries legible. If signatures are illegible,
M
MS request for records (MediGold performs
C
you may be required to provide an attestation or
health care operations for CMS).
signature log.
dditional information is required to support
A
ite medical conditions and significant illnesses
C
delegation oversight monitoring and auditing
on a problem list.
activities to ensure compliance with CMS
guidelines. ive prominence to notes on medication allergies
G
and adverse reactions. Also note if the member
In all cases, it is extremely important that has no known allergies or adverse reactions.
requested records are provided to the proper
entity within the timeframe specified. ake it easy to identify the medical history and
M
include chronic illnesses, accidents
and operations.
It is understandable that there are concerns about
patient confidentiality, but the Health Insurance or medication records, include name of
F
Portability and Accountability Act (HIPAA) Privacy medication and dosages. Also, list over-the-
Rule permits disclosure of protected health counter drugs taken by the member.
information without a patient’s authorization when
the information is necessary to carry out treatment, Code all ICD-10 codes to the highest specificity.
payment or health care operations. Document these important items:
When Medicare Beneficiaries enroll in MediGold, All member conditions that are currently being
they are informed of MediGold’s use of their treated or monitored.
protected health information to carry out health care
Blood pressure.
operations. Providing the requested documentation
does not violate HIPAA and does not require Height/weight and body mass index (BMI).
additional beneficiary authorization.
Tobacco items, including advice to quit.
Your cooperation is a legal obligation as outlined in Alcohol use and substance abuse.
the Social Security Act, the law governing Medicare
(Section 1842), as well as a contractual requirement Immunization record.
of your participation in MediGold. CMS requires Family and social history.
MediGold, as one of its contractors, to report
suspected fraud. Failure to forward records that Preventive screenings and services.
substantiate service may force MediGold to
consider this action.
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Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 15SECTION 4:
Provider Policies and Protocols
Demographic Information Clinical Decision and Safety Support Tools
The medical record for each MediGold member in Place to Ensure Evidence-Based Care is
should include: Provided
ember name and/or ID number on
M Examples of clinical decision and safety support
every page. tools include, but are not limited to:
Gender. LT/AST laboratory test done if member taking
A
statins.
Age or date-of-birth.
Immunization tracking sheet.
Address.
Flow sheet for chronic diseases.
Marital status.
Member reminder system.
Occupational history.
Electronic medical records.
Home and/or work phone numbers.
E-prescribing.
ame and phone number of
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emergency contact. Risk Adjustment Information
Name of spouse or relative. In 1997, CMS created a new payment methodology
Insurance information. for Medicare Advantage plans. The new
methodology uses the health status of Medicare
beneficiaries to determine accurate payment rates.
Member Encounters
Physicians and other health care providers play
When you see MediGold members, document the
an important role in risk adjustment because CMS
visit by noting:
looks at provider encounter data (extracted by
Member’s complaint or reason for the visit. MediGold from claims) to determine payment rates.
Encounter data you submit to MediGold must be
Physical assessment.
accurate and complete.
Unresolved problems from the previous visit(s).
isk adjustment is based on ICD-10 diagnosis
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iagnosis and treatment plans consistent with
D codes, not CPT codes. Therefore, it is critical
your findings. for your office to refer to an ICD-10-CM coding
Member education, counseling or coordination of manual and code accurately, specifically and
care with other providers. completely when submitting claims to MediGold.
Date of return visit or other follow-up care. iagnosis codes must be supported by the
D
medical record. If it is not documented in the
Review by the primary physician (initialed) on medical record, MediGold has the right to not
consultation, lab, imaging, special studies submit the diagnosis code to CMS through
andancillary, outpatient and inpatient records. EDPS or submit a delete through EDPS.
Consultation and abnormal studies are initialed Medical records must be clear and complete.
and include follow-up plans. ever use a diagnosis code for a ‘probable’ or
N
‘questionable’ diagnosis. Instead code only to
the highest degree of certainty.
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Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 16SECTION 4:
Provider Policies and Protocols
Risk Adjustment Information (continued) the visit but not fully supported within the medial
record to CMS through EDPS.
e sure to distinguish between acute vs. chronic
B
conditions in the medical record and in coding.
Improper Payment Measure (IPM)
Only choose diagnosis code(s) that fully describe
the member’s condition and pertinent history at In accordance with risk adjustment requirements,
the time of the visit. CMS performs risk adjustment data validation
e sure that the diagnosis code is appropriate for
B (IPM) audits to validate the MediGold members’
the member’s gender. diagnosis data that was submitted by MediGold
drawn from provider claims submissions. These
lways carry the diagnosis code all the way
A audits are typically performed annually. If MediGold
through to the correct digit for specificity. A code is selected by CMS for a IPM audit or to validate
is invalid if it has not been coded to the full submitted diagnosis information, you are required,
number of characters required for that code, as a participating provider to comply and timely
including the 7th character where applicable. submit requested medical records to substantiate
(Where place holders exist, ‘X’ must be used for the diagnosis data submitted.
the code to be valid).
ode all documented conditions that coexist at
C Encounter Data Processing System (EDPS)
the time of the encounter/visit, and require or
MediGold is required to submit accurate diagnosis
affect patient care treatment or management. Do
not code conditions that were previously treated information on all of its members to CMS through
and no longer exist. the Encounter Data Processing System (EDPS).
ensure complete and accurate diagnosis codes
To For EDPS submissions, CMS will filter claims data
are submitted to CMS, MediGold will conduct according to their risk adjustment guidelines. This
internal data validation audits by reviewing a
filtering logic may prevent some claims that have
sample of provider medical records to ensure
coding accuracy. You may be contacted by traditionally been paid by MediGold from being
MediGold requesting medical records for data accepted by CMS for risk adjustment purposes.
validation. In order for a chart to be valid the Because of this, there may be instances where
following criteria must be met:
MediGold will need to reach out to a provider to
Complete patient demographic information
obtain missing or incomplete data that would be
Date of Service needed for Risk Adjustment submissions. Below are
Valid Signature the CMS websites that provide technical information
Illegible provider signature will require a on EDPS guidance.
signature attestation per CMS guidelines
Documentation must indicate the diagnoses are Medicare Encounter Data System—
being monitored, evaluated, assessed/addressed, Institutional Companion Guide
or treated (MEAT).
Medicare Encounter Data System—
MediGold will add any diagnosis codes document Professional Companion Guide
within the record but they were not coded or
coded to the highest specificity at the time of Medicare Encounter Data System—
the visit. In addition, MediGold will delete any DME Companion Guide
diagnosis codes that were coded at the time of
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 17SECTION 4:
Provider Policies and Protocols
Informing Members of Advance Directives
iving Wills: The living will is a document through
L
The federal Patient Self-Determination Act (PSDA)
which a member may inform his/her physician
gives individuals the legal right to make choices
that, if the member has a terminal condition (no
about their medical care in advance of incapacitating
chance of recovery) and death will occur in a
illness or injury through advance directive.
relatively short period of time, the member only
wants a desired level of care provided. This
Under this federal act, physicians and other
document goes into effect only when a member is
professional providers, including hospitals, skilled
permanently unconscious or terminally ill and can
nursing facilities, hospices, home health agencies
no longer speak for him/herself.
and others must provide written information to
members on state laws about advance treatment ights of the Terminally Ill Act: Members have
R
directives, about members’ rights to accept or the right to control decisions relating to their
refuse treatment and about your own policies medical care when they are terminally ill. This
regarding advance directives. includes the decision not to undergo procedures
that extend life in case of a terminal illness. To
To comply with this requirement, we also inform do this, the member must make a written notice
members of laws on advance directives through our advising his/her physician to withhold or withdraw
Member Agreement and other communications. We procedures that continue life in the event of a
encourage these discussions with your patients. terminal condition. The member is encouraged
to give this form to his/her physician and closest
As long as the member can speak for him/herself, relative and it should be kept on file should the
you must honor his/her wishes. If the member event ever occur.
becomes so sick that he/she cannot speak for him/ You must document in a prominent part of the
herself, then this directive will guide you in treating member’s medical record whether or not the
the member and will save the member’s family, member has executed an advance directive.
friends and other providers from any guesswork
as to what course of treatment, if any, the member Referrals/Prior Authorization Requests
would have wanted.
All referrals and prior authorization requests for
MediGold members for out-of-network services
There may be several types of advance directives to
must be made by a network provider. Prior
choose from, depending on state law. Most states
authorization is not required for referrals for in-
recognize:
network services however, all referrals and prior
Durable Power of Attorney for Health Care authorization requests for out-of-network services
(DPAHC): DPAHC form allows the member to should be made by a network provider.
appoint an agent (family, friend or other person)
whom he/she trusts to make treatment decisions
for him/her should there come a time the member
is unable to make them for him/herself.
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Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 18SECTION 4:
Provider Policies and Protocols
Referrals/Prior Authorization Requests
(continued)
You are responsible for the care of your members
whether you provide the care directly or indirectly.
Medical care, including diagnostic testing, sought
out-of-network (excluding emergent or urgent care)
at your direction but not prior authorized, will be
subject to MediGold’s Remediation Policy. Prior
authorization requests received after the date of
service will not be processed.
See the Utilization Management Section in
this manual for more details.
MediGold Member Rights and Responsibilities
We tell our members that they have the following
rights and responsibilities, all of which are intended
to help uphold the quality of care and services they
receive from you.
MediGold Members’ Rights
o be treated with dignity, respect and fairness at
T MediGold Members’ Responsibilities
all times by MediGold and network providers.
e familiar with your coverage and the rules
B
rivacy of your medical records and personal
P to follow to obtain care as a member.
health information.
ive your physician and other professional
G
o see network providers and get covered
T providers the information they need to care
services within a reasonable period of time and for you, and to follow the treatment plans and
within a reasonable distance from your home. instructions that you and your providers have
agreed upon.
o know your treatment choices and to participate
T
in decisions about your health care. ct in a way that supports the care given
A
to other patients and does not prevent
o use advance directives (such as a living
T
the provider or MediGold office from
will or a power of attorney).
running smoothly.
o make complaints if you experience problems
T
ay your plan premiums and any copayments/
P
or have concerns related to your coverage or your
coinsurance you may owe for covered
care.
services received.
o obtain information about your health care
T
ontact us with any questions, concerns,
C
coverage and costs.
problems or suggestions.
o obtain information about MediGold and
T
network providers.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 19SECTION 5:
Quality Management
Regulatory Requirements Healthcare Effectiveness Data and
Information Set (HEDIS)
An effective Quality Management (QM) program
must comply with the applicable federal and state HEDIS is a set of standardized performance
standards. Compliance requires the collaborative measures. The purpose of HEDIS is to provide
efforts of MediGold and all network providers. members with a means to assess the value they
MediGold must meet all regulatory requirements receive for their health care dollar and to hold health
of the MA program, including required quality plans accountable for their performance. As a
improvement projects, Stars and HEDIS, enrollee network provider, you may, at times, be required to
satisfaction surveys and surveys to assess assist in medical record data collection.
enrollees’ understanding of their health outcomes.
The requirements MediGold must comply with
regarding quality are published in the Medicare
Currently, there are 91 measures
Managed Care Manual, Chapter 5. This chapter
describes how MediGold must operate and perform across seven (7) domains of care.
quality measurement and improvement related to
These domains are:
the delivery of health care and enrollee services.
The chapter’s purpose is to assist MA organizations
in developing quality assurance and performance 1 Effectiveness of care.
improvement programs, as well as to provide CMS
with a road map for monitoring the MA Plan’s Quality 2 Accessibility/availability of care.
Management program.
The requirements in Chapter 5 include: 3 Experience of care.
ormal QM program with participation by network
F
providers. 4 Relative resource use.
Chronic Care Improvement Program (CCIP).
5 Utilization and risk-adjustment
Minimum performance levels in studies. utilization.
nnually reported standard quality-related
A
measures including Healthcare Effectiveness Data 6 Health plan descriptive information.
& Information Set (HEDIS), Consumer Assessment
of Healthcare Providers and Systems (CAHPS) and 7 Measures collected using electronic
Health Outcome Survey (HOS). clinical data systems.
aintenance of a health information system that
M
integrates all data necessary to implement the QM
program.
Identification and correction of significant systemic
problems.
ontract with the independent Quality
C
Improvement Organization (QIO)
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 20SECTION 5:
Quality Management
What are Medicare Star Ratings? Program Goals
The CMS uses a 5-Star quality rating system to The MediGold QM program is a comprehensive
measure how well providers and Medicare program designed to comply with regulatory
Advantage health plans are delivering care to requirements to monitor the quality of care and
members. Successful collaboration with our services provided by the MediGold delivery system.
providers and quality patient care for our members is This includes administrative activities of the Plan
very important to us. Ratings range from 1 to 5 stars, and its contracted providers.
with 5 being the highest and 1 being the lowest.
The program’s purpose is to pursue opportunities for
The Star measures are made up of performance improving medical care, service and the well-being
measures from HEDIS, CAHPS, HOS (measures of MediGold members. The focus is on continuous
comparison of members health plan assessment quality improvement with a constant eye on how
over 2 years), prescription drug program and CMS care and services can be provided at a higher
administrative data. level of quality. Dedicated MediGold resources are
allocated to conduct ongoing quality assessment of
performance toward goals with problem resolution,
Star Ratings include measures as necessary.
applied to the following five broad
categories: The QM program focuses on three
dimensions of health care delivery:
1 Outcomes: measures that reflect
improvements in a member’s health. 1 Delivery system structure itself.
2 Intermediate outcomes: measures that 2 Processes involved in delivering
reflect actions taken with patients that health care.
assist in improving a member’s health
status, i.e. controlling blood pressure. 3 Results of care delivery.
3 Patient experience: measures that By continuously monitoring and evaluating these
reflect the member’s perspectives three dimensions of health care delivery, MediGold
of the care they receive. constantly strives to provide the highest quality care
in the most appropriate setting in the most efficient
4 Access measures: measures that manner to attain the utmost satisfaction of MediGold
reflect processes and issues that could members.
create barriers to receiving needed
care, i.e., Plan makes timely decisions
about appeals.
5 Process measures: those that capture
the health care services provided to
members who can assist in maintaining,
monitoring or improving their health
status.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 21SECTION 5:
Quality Management
Risk Management/Quality Concern
Reporting
The goal of Risk Management, a component of the
QM program, is to control and minimize possible
risks arising in the direct provision of care, as well
as risks associated with administration of the Plan.
The Risk Management/Quality Concern Reporting
Form provides a reporting mechanism for contracted
providers to report risk management cases or
quality concerns. This reporting mechanism is used
to identify cases/incidents with potentially serious,
undesirable and/or unexpected occurrences that
may include loss of life, limb or function or has the
potential to adversely affect MediGold’s reputation. If
there is a risk management or quality concern issue
in your office regarding a MediGold member, please
contact MediGold’s QM Department at the
email listed in the Contact Us section of this manual.
Outcomes, Evaluations and
Member-Based Studies
Program Activities
The outcomes of clinical care are measured in
A variety of activities are involved in implementing the following terms: improved health, illness and
the MediGold QM program including, but not limited death reduction, whether the treatment or therapy
to, the following: improved outcome as planned, whether the medical
action positively altered the course of the disease’s
Risk management/quality concern reporting. natural history and whether clinical actions taken
onitoring of member service activities, including
M provided positive outcomes. Outcomes evaluation
complaints, appeals and grievances. identifies potentially adverse events resulting from
quality issues. Adverse outcomes identified in
HEDIS data collection/monitoring. significant number or scope are investigated and
member-based studies are conducted to improve
Member satisfaction surveys.
measurable outcomes.
ember-based performance improvement
M
projects/studies.
Provider-based performance improvement.
Physician access and availability surveys.
Review of quality concerns for each physician at
the time of recredentialing.
equired data reporting to CMS, such as hospital
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acquired conditions and serious reportable
adverse events.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 22SECTION 5:
Quality Management
Access and Availability overed services are provided in a culturally
C
competent manner to all members including
An additional measure of quality is the access
those with limited English proficiency
to care and availability for MediGold members.
or reading skills, diverse cultural and
Access means that medically necessary care is
ethnic backgrounds and physical or
available in a timely manner and that members
mental disabilities.
are able to schedule appointments and obtain any
required referrals, as indicated, based on clinical
Members have timely access to copies
needs. Availability means that MediGold has made of pertinent information from their
arrangements for the provision of all covered medical records.
services to members by the proper types, mix and
number of network providers. The standards for Compliance with standards is evaluated by
measuring the adequacy of access and availability reviewing medical records, claims and encounter
are stipulated in the MediGold Provider agreement history, scheduling systems and records, complaints
and MediGold’s Network Practitioner’s Access and and grievances, and member satisfaction and
Availability Standards. disenrollment surveys.
The access and availability requirements which have Member and Provider Satisfaction
been approved by MediGold’s Quality Management
Committee are as follows: MediGold monitors members’ perceptions of
the quality of care and services received. Member
elephone coverage service 24 hours a day,
T satisfaction is considered an indicator of the
seven (7) days a week. success of an organization in providing quality care.
Member calls returned within 24 hours. This MediGold assesses member satisfaction using
includes attempts made to members by leaving the following sources of information: member
voice mail messages, leaving verbal messages complaints and grievances, PCP change requests,
with other relatives, etc. and random sampling by CMS through use of
standardized disenrollment surveys and member
rgent appointments scheduled with the PCP
U satisfaction surveys. MediGold may also periodically
or a network PCP acting on your behalf within conduct independent provider and member
three days of the request. Urgent appointments satisfaction surveys to assess provider access and
are identified as any convolution of persistent availability, members’ perception of access to care
symptoms which are perceived urgent by and services, wait times, referrals, explanations
a prudent layperson or that may endanger of care, members’ education and members’
members not seen within 48 hours. participation in the decision-making process to meet
Routine appointments are scheduled by the PCP their health care goals.
or a network PCP acting on your behalf within MediGold also monitors providers’ perceptions of
ninety (90) days of request. the quality of administrative services provided by
embers with a concern they view as needing
M MediGold. Network provider surveys are periodically
medical attention prior to routine appointments, conducted to evaluate provider satisfaction and
under the assistance of health plan case identify areas for improvement.
management, may be requested for access within
the 90-day timeframe.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 23SECTION 6:
Utilization Management
Utilization Management The goal of utilization management is to
assure appropriate utilization and to achieve
Overview
the following objectives for all members to:
The purpose of MediGold’s Utilization Management
Program is to ensure the delivery of medically ssure effective and efficient utilization of facilities
A
necessary, optimally achievable, quality care through and services through an ongoing monitoring
appropriate utilization of resources in a cost effective and educational program. The program is
and timely manner to all members. To ensure this designed to identify patterns of utilization, such
level is achieved and/or surpassed, programs are as overutilization, underutilization and inefficient
consistently and systematically monitored and scheduling of resources.
evaluated. ssure fair and consistent utilization management
A
Utilization management is performed to ensure an decision-making.
effective and efficient medical and behavioral health ducate medical providers and other health care
E
care delivery system. It is designed to evaluate professionals on appropriate and cost-effective
the cost and quality of medical services provided use of health care resources. MediGold works
by participating physicians, hospitals and other cooperatively with its participating providers to
ancillary providers. assure appropriate management of all aspects of
the members’ health care.
ontinually improve the quality of care and
C
resource allocation within the organization.
Evaluate advancing medical technologies
to determine the level of coverage provided
to members.
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 24SECTION 6:
Utilization Management
Medical Necessity According to Plan policy, medical necessity is
defined as those services determined by MediGold
The utilization management process will assess,
or its designated representative to be:
direct and efficiently control health care resources
in a cost-effective manner while maintaining high- reventive, diagnostic and/or therapeutic
P
quality care. This process is accomplished through in nature.
comprehensive interdisciplinary utilization and case
pecifically relates to the condition which
S
management programs.
is being treated/evaluated.
MediGold utilizes evidence-based medicine in its
endered in the least costly medically appropriate
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decision-making process. Utilization management
setting (e.g., inpatient, outpatient, office), based
review is applied in the determination of medically
on the severity of illness and intensity of service
necessary services, ensuring that the criteria are
required.
applied consistently and fairly to all members.
Criteria is reviewed and updated on an annual basis
Not solely for the member’s convenience or that
and is available to providers as requested. of his or her physician.
Resources utilized by MediGold in determining Supported by evidence-based medicine.
medically necessary services include, but are not The information needed will often include
limited to: the following:
edicare National and local coverage
M Patient name, MediGold ID#, age, gender.
determinations.
Brief medical history.
MCG Rapid Recover Guidelines.
Diagnosis, co-morbidities, complications.
National Comprehensive Cancer
MediGold policies and procedures. Signs and symptoms.
Attending practitioner exam. rogress of current treatment, including results of
P
pertinent testing.
Recommended treatment plans.
Medical records (hospital and office). Providers involved with care.
Board-certified practitioner who is a peer of the Proposed services.
attending practitioner. Referring physician’s expectations.
ember contract (benefits/criteria related to the
M
Psychosocial factors, home environment.
request).
Practitioner contacts (consultations and/or Prior Authorization
information). Prior authorization is conducted to determine if the:
Medical literature. Requested treatment is a covered service.
Service is medically necessary and appropriate.
Service is performed by an appropriate provider.
Please refer to the MediGold Prior Authorization List
through the MediGold website at:
MediGold.com/For-Providers/Tools-and-
Resources/Utilization-Management/Prior-
Authorization-MediGold
MediGold is a registered trade name of Mount Carmel Health Plan, Inc.,
Mount Carmel Health Insurance Company, and Mount Carmel Health Plan of Idaho, Inc. 25You can also read
