PROVIDER MANUAL 2020 - Vibra Health Plan
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
PROVIDER MANUAL
2020
PROVIDER SUPPORT
ProviderSupport@VibraHealthPlan.com
P: 844-440-4629
This Provider manual does not include treatment protocols or
required practice guidelines. Diagnosis, treatment recommendations,
and the provision of medical care services for Health Plan Members
are the responsibility of Providers and practitioners. Please encourage
the patient to review his/her Evidence of Coverage and Summary of
Benefits for details concerning benefits, procedures, and exclusions
prior to receiving treatment, as this handbook does not supersede the
Evidence of Coverage and Summary of Benefits. The information in
this handbook may change from time to time.
Table of Contents
WELCOME TO VIBRA HEALTH PLAN ...................................................... 5
General Contact Information ................................................................................................ 5
Introduction .......................................................................................................................... 6
Service Area Map ................................................................................................................ 7
VHP’s Mission and Vision .................................................................................................... 7
VHP’s Medicare Advantage Plan ......................................................................................... 8
VHP’s Provider Network ...................................................................................................... 8
VHP Vendors ...................................................................................................................... 8
PROVIDER CREDENTIALING PROGRAM................................................ 9
Introduction .......................................................................................................................... 9
Provider Credentialing Rights ............................................................................................ 13
Facility and Ancillary Credentialing .................................................................................... 13
Reporting Mergers, Acquisitions, and Changes ................................................................. 15
PROVIDER RESPONSIBILITIES ............................................................. 16
General .............................................................................................................................. 16
Access to Care .................................................................................................................. 18
Primary Care Physicians (PCPs) ....................................................................................... 18
Specialists ......................................................................................................................... 19
Advocate for and Communicate with Members .................................................................. 19
Educate Members on Appropriate Emergency Room Use ................................................ 19
Covered Services/Member Benefits ................................................................................... 20
Coverage Determination Language ................................................................................... 20
Coordination of Benefits ..................................................................................................... 21
Advance Directives ............................................................................................................ 23
PROVIDER CODE OF CONDUCT ........................................................... 26
Compliance with Law and Non-Discrimination ................................................................... 26
Patient-Provider Relationships ........................................................................................... 26
Shared Decision-Making and Consent ............................................................................... 27
Privacy and Confidentiality ................................................................................................. 27
End of Life Care ................................................................................................................. 28
Research .......................................................................................................................... 28
Community Health ............................................................................................................. 28
Self-Regulation .................................................................................................................. 28
Inter-Professional Relationships......................................................................................... 29
Financing and Delivery of Healthcare ................................................................................ 29
References ........................................................................................................................ 30
2
ADMINISTRATIVE GUIDELINES ............................................................. 31
Rendering Services............................................................................................................ 31
VHP Plan Member Eligibility .............................................................................................. 31
Preventive Services ........................................................................................................... 32
Copayments ...................................................................................................................... 32
Member Effective/Termination Date Coincides with a Hospital Stay .................................. 33
Member Rights & Responsibilities...................................................................................... 33
Cultural Competency ......................................................................................................... 33
Hospice Election ................................................................................................................ 34
Member Advocacy ............................................................................................................. 34
Provider Portal ................................................................................................................... 35
Participation Procedures for Providers ............................................................................... 35
Reporting Changes in Practice – VHP Change Forms ....................................................... 37
Provider Anti-Discrimination Rules ..................................................................................... 38
Interference with Providers’ Advice .................................................................................... 38
Compliance with Laws, Audits, and Record Retention Requirements ................................ 39
Fraud, Waste, and Abuse .................................................................................................. 40
Offshore Outsourcing of Personal Information in Medicare ................................................ 41
CLAIMS AND BILLING ............................................................................. 42
Submission of Claims ........................................................................................................ 42
Electronic Claims Services................................................................................................. 44
InstaMed Claims Overview ................................................................................................ 45
InstaMed Remittance Overview ......................................................................................... 50
Paid Claims Quick Search and Paid Claims Reports ......................................................... 52
Readmittance Re-Association ............................................................................................ 53
Paper Claim Submissions .................................................................................................. 54
Claims and Encounter Data ............................................................................................... 54
Encounter Data for Risk Adjustment Purposes .................................................................. 55
Risk Adjusted Data Validation Audits ................................................................................. 55
ICD-10 CM Codes ............................................................................................................. 55
Medical Record Documentation Requirements .................................................................. 56
Medical Record Audit Criteria ............................................................................................ 56
Federal Funds.................................................................................................................... 57
Clean Claims and Prompt Payment ................................................................................... 57
Submission Guidelines for Hospice Claims ........................................................................ 58
Balance Billing ................................................................................................................... 58
Delegated Activities ........................................................................................................... 60
Present on Admission ........................................................................................................ 60
Federally Qualified Health Center (FQHC) ......................................................................... 61
Opioid Treatment Program................................................................................................. 62
Claim Adjustments ............................................................................................................. 63
3
QUALITY IMPROVEMENT AND MANAGEMENT PROGRAM ................ 66
Goals and Objectives ......................................................................................................... 66
Performance Data Use ...................................................................................................... 67
Quality Improvement Information Available on our Website ............................................... 67
Committees ....................................................................................................................... 68
Conflict of Interest Provisions ............................................................................................. 69
Clinical Practice Guidelines................................................................................................ 69
Safety Monitoring ............................................................................................................... 69
Performance Measurement and Customer Satisfaction ..................................................... 70
Healthcare Effectiveness Data and Information Set (HEDIS®) ........................................... 70
Consumer Assessment of Healthcare Providers & Systems (CAHPS®) ............................. 70
CMS STARS Program ....................................................................................................... 71
Healthcare Navigation and Management ........................................................................... 71
Transition of Care Navigation ............................................................................................. 72
Readmission Review ......................................................................................................... 72
Landmark In-Home Program.............................................................................................. 73
Pharmacy Management ..................................................................................................... 73
UTILIZATION MANAGEMENT ................................................................. 77
Application of Clinical Criteria Guidelines ........................................................................... 77
Access to Care and Services ............................................................................................. 78
Direct Access to Preventive/Routine Gynecological and Mammography Services ............. 79
Influenza and Pneumococcal Immunizations with No Cost Sharing ................................... 79
Preauthorization................................................................................................................. 79
Special Rules for Emergency & Urgently Needed Services, Post-Stabilization Care,
Ambulance Services, Renal Dialysis .................................................................................. 85
Over/Under Utilization ........................................................................................................ 86
Inpatient Continued Care Denials ...................................................................................... 87
MEDICARE ADVANTAGE APPEALS ...................................................... 90
Medicare Advantage: Definition of an Appeal..................................................................... 90
How to File an Appeal ........................................................................................................ 91
Medicare Advantage: Appeal Processing ........................................................................... 92
Medicare Advantage: Expedited Appeal Process – Independent Review Entity (IRE)........ 93
Medicare Advantage: Expedited Review of Termination of Inpatient Care ..................... 93
Medicare Advantage: Expedited Review of Termination of Home Health,
Skilled Nursing Facility (SNF), or Outpatient Rehab ........................................................... 94
Medicare Advantage: Rules of Participation Changes........................................................ 94
Timely Submission of Medical Records.............................................................................. 94
COMPLIANCE TRAINING FOR MEDICARE PROGRAMS ...................... 96
Important Reminders ......................................................................................................... 96
4
Welcome to Vibra Health Plan
General Contact Information
Provider Portal
VibraHealthPlan.com
The Vibra Health Plan (VHP) portal offers Provider resources, eligibility, claims status, authorizations,
and more, and is the primary source for the most up-to-date information. VHP requires all participating
Providers to enroll in electronic programs sponsored and utilized by VHP now and in the future
including our Provider portal.
Provider Support
Toll Free: 844.440.4629
Email: ProviderSupport@VibraHealthPlan.com
Navigating Our Provider Service Line at 1-844-440-4629
Electronic Billing
InstaMed Provider Relations
Toll Free: 866.467.8263
or 215.789.3680, select option 1
Member Services
Toll Free: 844.388.8268 (TTY User Dial 711)
Fax: 844.774.5585
5
Pharmacy
Prime Technical Help Desk (for Providers): 855.457.1209
Prime Member Services: 855.457.1352
Pharmacy prior-authorization:
MyPrime.com/en/forms/coverage-determination/prior-authorization.html
Member Advocate Team
Toll Free: 844.575.4386
Utilization Management Team
Toll Free: 844.575.4387
Fax: 844.303.0324
E-Fax Queue: um_fax@VibraHealthPlan.com
Mailing Addresses:
For contracts & Provider change forms: For Part C Appeals:
Vibra Health Plan Vibra Health Plan
Attn: Provider Relations Attn: Appeals & Grievances
PO Box 60250 PO Box 60250
Harrisburg, PA 17106-0250 Harrisburg, PA 17106-0250
Introduction
VHP’s Provider Manual is available as a reference guide for professional, facility, and ancillary
Providers and their staff. Requirements and procedures set forth in this Provider Manual are binding
upon Participating Providers and, pursuant to the agreements between Providers and VHP,
incorporated into those agreements. The Provider Manual provides Providers and their staff with the
requirements, policies, and procedures used to administer services to our Members. To qualify to be
one of our Members, a person must: qualify for Medicare Parts A and B, enroll in a VHP health plan,
and pay the appropriate required premium.
This Provider Manual describes VHP’s general policies and procedures. If there is an inconsistency
between the policies and procedures described here and a specific provision of a Provider or facility
agreement, then the terms and conditions of the agreement will control. The descriptions of policies and
procedures in this Provider Manual should cover most situations that you and your office/facility staff
encounter in providing services, assisting Members, and receiving payments. This Provider Manual
does not include benefit coverage information for any specific Member.
NOTE: Although VHP has tried to make this Provider Manual complete, it may not include every
administrative policy or procedure nor does it replace the Member’s benefit documents.
6
VHP understands our commitment to provide great service to our Members begins with our ability to
provide great service to you, our participating healthcare Provider partners. VHP continues working to
ensure your interactions with us are as simple and seamless as possible, providing open lines of
communication with you to disseminate plan and program requirements and ensure effective resolution
of Provider issues. The Provider Manual serves to inform you of the information necessary to provide
our Members with the healthcare services that are included in our portfolio of coverage options.
Service Area Map
VHP’s Mission and Vision
VHP will provide a superior Member experience through relentless Member support and
improvements in healthcare coordination, quality, and affordability. VHP will drive value for its
Members ensuring that they get the best possible care through:
Extensive Member support services and advocacy for our Members.
Caring, knowledgeable, and empowered staff who provide excellent, compassionate service.
Collaboration with our Provider partners.
Promoting and using innovative technologies.
Eliminating barriers and hassles for our Members and partners.
7
VHP’s Medicare Advantage Plan
VHP is a local Medicare Advantage Prescription Drug (MAPD) PPO plan in which Medicare
beneficiaries pay less out-of-pocket costs when they utilize Providers who are part of the VHP network.
Local PPOs are available in select counties within a state. Centers for Medicare & Medicaid Services
(CMS) allows the MAPD plan to select the counties within which they want to participate. VHP
Members are not required to select a primary care physician or obtain a referral for specialty care.
However, Members are encouraged to have a primary care physician (PCP) and note the practice of
record as well as coordinate their care through a PCP. Members can utilize Providers both in and out of
the network. VHP’s focus is on quality, access, and patient experience. Preauthorization is required for
some services as defined on the authorization list.
VHP’s Provider Network
VHP’s network includes over 13,000 Providers and over 50 hospitals. For a current list of Providers,
please visit VibraHealthPlan.com and, under “Resources” dropdown menu, select “Doctors and
Pharmacies.”
VHP Vendors
Dental – Dominion National
Toll Free Provider Relations: 888.471.3631
Website: DominionNational.com
Hearing – Nations Hearing
Toll Free: 877-228-0943 (TTY:711)
Website: NationsHearing.com/Vibra
Pharmacy – Prime
Prime Technical Help Desk (for Providers): 855.457.1209, Prime Member Services: 855.457.1352
Prior-authorization: MyPrime.com/en/forms/coverage-determination/prior-authorization.html
Vision – National Vision Administrators, LLC
Toll Free: 800.672.7723
Website: e-nva.com
In-Home Health – Landmark Health
Toll Free: 877.257.2192, 717.686.9842
Website: LandmarkHealth.org
8
Provider Credentialing Program
Introduction
Our Provider credentialing program is an objective and systematic process for reviewing the credentials
of all Providers who apply to participate in our networks and support our Medicare Advantage products.
VHP utilizes procedures that comply with the National Committee for Quality Assurance (NCQA); the
Centers for Medicare & Medicaid Services (CMS); and the Commonwealth of Pennsylvania Department
of Health (DOH) regulations. Our uniform credentialing program is applicable to all Providers
participating in VHP’s Medicare Advantage network.
CAQH ProView, the standardized national online credentialing system developed by the Counsel for
Affordable Quality Healthcare, Inc. (CAQH), is used as our exclusive Provider credentialing system. All
Providers must use the CAQH ProView system for credentialing and recredentialing. Healthcare
Providers must self-register with CAQH ProView before VHP will initiate the application process.
Access CAQH ProView at caqh.org
For CAQH assistance or questions, please call: 1.888.599.1771.
In the case of a group practice that wishes to join our network, all participating Providers within the
group must be credentialed prior to the group’s participation in such networks.
Initial Credentialing
VHP follows an established process to credential Providers. In addition, VHP has delegated
credentialing arrangements with a limited number of institutions.
The initial credentialing process includes, but is not limited to:
Completion of a CAQH online application.
Signed attestation verifying all information on the application and stating any reasons for inability to
perform essential duties, lack of illegal drug use, loss of license /privileges, felony, and disciplinary
action.
Primary source verification to include:
o State licensure.
o DEA or CDS certificate, if applicable.
o Board certification, if the Provider states on the application that he or she is board certified.
o Completion of appropriate education and training.
o Hospital privileges with a participating hospital, if applicable.
o Professional liability claims history.
o Sanctions or limitations on licensure or privileges.
o Medicare or Medicaid sanctions.
9
o Medicare opt-out listing.
o Criminal convictions.
o Malpractice insurance.
Work history is reviewed to confirm no significant or unexplained gaps greater than six months.
Other verification as needed.
To be considered a participating Provider, all Providers must complete the CAQH credentialing
application, be approved by the VHP Credentialing Committee, and then sign an Agreement. The
Provider’s participation and ability to treat Members does not begin until the signed Agreement is
executed
Credentialing Timeframe
Credentialing information, including but not limited to, application, attestation, and all primary source
verification for all Providers cannot be older than 180 days at the time of the Credentialing Committee
decision. If approval cannot be obtained within the 180 day timeframe, the Provider will be required to
update their application and attestation form on the CAQH ProView website. Any primary source
verifications that exceed the 180 day timeframe will be reverified. VHP will notify participating Providers
of decisions on credentialing matters within 60 days from a decision by the credentialing committee.
Recredentialing
VHP completes the recredentialing process at least once every three years. Our internal policies
require recredentialing for the protection of our Members. Additionally, VHP’s three year recredentialing
cycle is consistent with NCQA, CMS, and Pennsylvania’s Department of Health.
The recredentialing process includes most of the same components as initial credentialing with some
added components. At the time of recredentialing, a quality review may be conducted. This review
includes, when available, Member satisfaction, Member complaints related to both quality of service
and quality of care issues, malpractice history, sanction activity, and office site information. All
information will be considered for continued network participation.
Ongoing Monitoring
VHP routinely monitors the ongoing compliance of participating Providers with credentialing/
recredentialing criteria. Such monitoring includes, but not limited to:
U.S. Department of Health and Human Services, Office of Inspector General (OIG), List of
Excluded Individuals/Entities (monthly);
Licensing Board queries (monthly); and
Medicare Part B Opt Out List (monthly).
10If it is determined or suspected that a Provider no longer complies with credentialing, recredentialing, or
contracting requirements (e.g., revocation or suspension of license), the matter will be investigated and
presented to the Credentialing Committee for appropriate action. A Provider must immediately notify
VHP in writing if the Provider receives notice of (i) any restriction, suspension or revocation of license,
certification or DEA number, changes in the status of hospital privileges or any other event that would
cause Provider to be out of compliance with VHP’s policies and procedures related to credentialing,
hospital privileging, and accreditation criteria, or other professional requirements, (ii) the instituting of
any action, suit, or proceeding that involves the provision of healthcare services by Provider, including
any action brought by a Member, (iii) any sanction or disciplinary action by any professional
organization, hospital, or governmental agency, (iv) any criminal indictment of any nature, (v) any civil
judgment or criminal conviction, or (vi) exclusion from participating in Medicare, Medicaid, or any other
third party, state or federal program.
Credentialing Committee
The Credentialing Committee, which is comprised of participating Providers and our representatives, is
responsible for developing, monitoring, and revising the credentialing program. The Committee’s goal is
to provide a network of qualified, licensed Providers that meet specific quality standards when providing
services to our Members. All program standards are reviewed at least annually by the Credentialing
Committee. The Committee meets regularly to make determinations regarding network participation for
professional, facility, and ancillary Providers.
Approvals, requests for additional information, and denials are communicated to all applicants within 60
days following the Committee’s decision. The Committee reserves the right to recommend corrective
action, deny participation, or terminate any Provider in any and all programs within our networks.
Any Provider or other individual involved in credentialing activities will not be permitted to have any role
in the review of any case in which he/she has a professional, personal, or financial conflict of interest.
Delegated Activities
Policies and procedures are in place to delegate credentialing activities to a third party for Providers
meeting specific requirements. Delegated credentialing activities must be compliant with our
credentialing program and delegated credentialing agreement file requirements policy, NCQA, and Act
68. VHP retains accountability for all delegated credentialing functions and conduct oversight activities
of delegated entities on a regular basis.
Provider Exclusion Monitoring
The Medicare-Medicaid Anti-Fraud and Abuse Amendments mandated the exclusion of physicians and
other providers convicted of program-related crimes from participation in Medicare, Medicaid, and other
Federal healthcare programs. The Balanced Budget Act of 1997 authorized civil monetary penalties to
be imposed against healthcare Providers or entities that employ, pay, or enter into contracts with
excluded individuals/entities.
11In order to remain compliant with the Government’s exclusion mandates, VHP reviews the exclusion
lists maintained by the Office of Inspector General of the U.S. Department of Health and Human
Services and the General Services Administration for all Providers with whom it conducts business,
including those submitting applications for credentialing.
VHP is able to use the information found in its files to verify whether any Provider identified on the
Government’s exclusion list is the same individual found in our Provider files. If a match is identified and
a Provider is identified as Excluded, Precluded, or Opt Out, VHP will notify the Provider via letter as
well as any Members identified as patients of the Provider.
After the Provider is notified of the exclusion, we will reject all government programs claims. This
means we cannot pay a Provider or reimburse a Member for any such claims. In addition, the Provider
may not bill or otherwise seek payment from these Members for any services provided. For government
programs (Medicare Advantage, Affordable Care Act, and CHIP), future submission of claims by the
Provider may result in further government actions.
After the Provider is notified of the exclusion, for Traditional, Comprehensive, PPO, HMO, and POS
products, claim payments will be made to our Members according to their out-of-network benefit.
Unfortunately, although VHP may have additional information available to it for verification purposes,
the Government’s data is, at times, limited. In these instances, the Government has directed plans to
obtain a signed certification, whereby the Provider certifies that he/she is not the Provider whose name
appears on the Government’s files. If the Provider does not return the signed document within 10
business days, VHP will assume the Provider on this list is the Provider and submit a termination on the
Provider record.
Locum Tenens
VHP will allow for Reciprocal Billing Arrangements (e.g. Locum Tenens) when a patient’s regular
Provider is unable to provide services and a substitute Provider provides service for a continuous
period not to exceed longer than 60 days. The HCPCS code modifier Q6 (services furnished under a
fee-for-time compensation arrangement) should be reported on all claims during this time-period. Any
claims submitted after the continuous 60 day period are non-payable. Providers providing care to
Members after this 60-day period must undergo initial credentialing and, if applicable, re-credentialing
at least every three years.
Confidentiality and Anti-Bias Statements
All Provider information obtained during the credentialing and recredentialing process, except as
otherwise provided by law, is kept confidential.
In our selection of Providers, VHP does not discriminate against a healthcare professional’s race,
ethnic/national identity, gender, age, sexual orientation, types of persons the healthcare professional
treats, or the healthcare professional’s refusal to provide certain healthcare services (e.g., abortion) on
moral or religious grounds.
12Provider Credentialing Rights
Providers have the following rights related to our credentialing and recredentialing processes:
Providers have the right to review information obtained to support or evaluate the Provider’s
credentialing or recredentialing application. VHP is not required to make available references,
recommendations, or peer-review protected information.
Providers have the right to correct erroneous information submitted by the Provider or any outside
source (e.g., malpractice insurance carriers, state licensing boards), with the exception of
recommendations or other peer-review protected information.
Our credentialing unit will contact the Provider in writing or by telephone if information obtained
during the credentialing or recredentialing process varies substantially from the information
submitted. Our credentialing unit will give the timeframe for making corrections, the format for
submitting corrections, and where to submit the corrections. VHP is not required to reveal the
sources of information that were obtained to meet verification requirements or if the federal or state
law prohibits disclosure.
Providers may contact us at 1.844.440.4629 to request information regarding application status. VHP
will respond to Providers by telephone or in writing.
Providers have the right to appeal an adverse determination by our credentialing committee, as
provided in our applicable policies and procedures in effect at such time.
All Provider information obtained during the credentialing process is considered confidential, except
as otherwise provided by law.
Facility and Ancillary Credentialing
VHP credentials all organizational Providers (facility, ancillary) in order to ensure they are in good
standing with all regulatory and accrediting bodies. Participation and credentialing requirements are
based upon internal business decisions, as well as the standards set by the regulatory and accrediting
agencies.
VHP defines “facilities” as those Providers billing services in the UB-04/837I format to include:
Acute Care Hospital.
Psychiatric Facilities.
Substance Abuse Treatment Centers.
Skilled Nursing Facilities (SNF).
Ambulatory Surgical Centers (ASC).
Renal Dialysis Facilities.
Hospice.
Home Health.
Comprehensive Outpatient Rehabilitation Facilities (CORF).
Rehabilitation Hospitals.
Long-term Acute Care Facilities (LTAC).
13 Clinical Laboratories.
Portable Radiology Suppliers.
Residential Treatment Centers (RTC).
VHP defines “ancillary Providers” as those Providers billing services in the 1500/837P format to include:
Ambulance.
Durable Medical Equipment.
Home Infusion.
Orthotics/Prosthetics.
Urgent Care Centers.
Clinical Laboratories.
Initial Credentialing
To begin the process for credentialing and participation in our networks, facilities and ancillary
Providers must complete the Join Our Network form on the Provider page of our website. In addition, a
facility or ancillary survey may be required.
Note: Certain ancillary Provider networks, such as durable medical equipment, skilled nursing facility,
etc. may be closed to new applicants. VHP will do targeted outreach when it is determined that such
services are needed. If an application is received for a closed network, a general response will be sent
indicating our network is closed.
Initial Credentialing process includes, but may not be limited to, review of the following:
Copy of current state license, certificate, registration, permit etc.
Copy of accreditation by the Joint Commission or similar accreditation agency, approved by the
program.
DOH survey report.
Medicare verification.
Certificate of Insurance.
Recredentialing
VHP completes the recredentialing process at least once every three years for facility and ancillary
Providers. Our internal policies require recredentialing for the protection of our Members. Additionally, a
three year recredentialing cycle is consistent with NCQA, CMS, and Pennsylvania’s DOH.
The recredentialing process includes most of the same components as initial credentialing with some
added components. At the time of recredentialing, a quality review may be conducted. This review
includes, when available, Member satisfaction, Member complaints related to both quality of service
and quality of care issues, and office site information. All information will be considered for continued
network participation.
14Reporting Mergers, Acquisitions, and Changes
VHP requires advance notice of the following events: mergers, acquisitions, changes of ownership,
legal name changes, dissolution, material reduction of operations or business activities, new or
changed locations or services. Provider must provide sixty (60) days’ advance written notice of these
organizational changes.
Claims for services provided at a new facility location cannot be billed under the facility agreement until
VHP has received proper contractual notice and given its prior approval, as set forth in the applicable
facility agreement. The approval requirement applies to all new facility locations, whether the location is
brand new, the result of movement of services or combination of services, or addition of services
through a merger, acquisition, change of ownership or some other legal event of an existing healthcare
entity or practice.
If a facility bills for services at the new location prior to notification and approval by VHP, this may result
in the following occurrences:
Denial of payment.
Denial of authorization.
Decreased payment.
Increased audit activity.
As indicated in the facility agreement and/or related agreements and documents, this may be
considered a breach of contract.
15Provider Responsibilities
General
General responsibilities in the following categories apply to all Providers:
Standards of Care
o Evaluating each Member’s healthcare needs.
o Providing medical care and services in accordance with accepted medical practice.
o Performing duties consistent with the proper practice of medicine and in accordance with the
customary rules of ethics and conduct of the applicable state and professional licensure boards
and agencies.
o Facilitating quality care delivery in a timely and appropriate manner.
o Providing Members the same access and quality of services that all other patients enjoy.
o Providing services to Members regardless of race, sex, sexual orientation, age, religion, place of
residence, health status, membership in a program, national origin, physical or mental disability,
medical condition, ethnicity, claims experience, medical history, evidence of insurability
(including conditions arising out of acts of domestic violence), genetic information, or source of
payment.
o Providing care to the Member within the timeframes set forth in VHP access to care standards.
o Providing culturally competent communication about care and treatment options, including the
option of no treatment.
o Healthcare professionals must assure that Members with disabilities have effective
communications with participants throughout the healthcare system in making decisions
regarding treatment options.
o Being aware of and appropriately using the medical resources in the community.
o Advising or advocating on behalf of the Member regarding:
The Member’s health status, medical care, or treatment options (including any alternative
treatments that may be self-administered), including the provision of sufficient information to
the Member or the Member's representative to provide an opportunity to decide among all
relevant treatment options.
The risks, benefits, and consequences of treatment or non-treatment.
The opportunity for the Member to refuse treatment and to express preference about future
treatment decisions.
Program Requirements
Providers are responsible for:
o Meeting all credentialing and re-credentialing criteria, including maintaining admitting privileges,
as appropriate. For facility and ancillary Providers, meeting all assessment and reassessment
requirements.
16o Cooperating with administrative policies and clinical program activities including, but not limited
to, cooperating with VHP’s Utilization Management (UM) and Quality Improvement (QI)
programs.
o Cooperating with and participating in peer review discussions.
Confidentiality
Providers are responsible for:
o Maintaining the confidentiality of information contained in the medical records of enrollees, as
well as other enrollee information, per standards set forth by state or federal law, accreditation
entities, VHP’s policies, or other pertinent requirements standard in the industry.
Administrative Procedures
Providers are responsible for:
o Verifying Member eligibility at the time service.
o Referring Members to participating Providers and to participating facilities.
o Obtaining authorization for services (e.g., Benefit Exceptions, Pre-authorizations, including
submission of documentation that supports medical necessity) as necessary.
o Verbally notifying Members of the pre-authorization determination.
Medical Records
Providers are responsible for:
o Maintaining a single current and comprehensive medical record that conforms to standard
medical practice and the Provider agreement. As further detailed in the Provider agreement and
this Provider Manual, as a condition for payment for covered services, the medical record must
sufficiently document the Member’s condition and contain comprehensive, legible information
related to the medical necessity of the healthcare services provided for the Member.
o Making available, at no charge, the medical record to VHP, the Commonwealth of
Pennsylvania, Centers for Medicare & Medicaid Services (CMS), or any other agency with
accreditation, regulatory, or enforcement jurisdiction over VHP.
o Retaining the confidential medical record for each Member for whom the Provider has provided
healthcare services. For Medicare Advantage Members, the Centers for Medicare & Medicaid
Services (CMS) requires that medical records be retained at least 10 years for adult Members,
and for minor Members, one year after such minor has reached the age of 18, but no less than
10 years.
o Transferring copies of the Member’s medical records, x-rays, or other data when requested to
do so in writing by VHP or the Member at no charge to VHP or the Member.
17 Coverage and After-Hours Arrangements
Providers are responsible for:
o Providing appropriate coverage arrangements (24 hours a day, seven days a week) with
another Provider who is a participating Provider and/or with a Provider VHP has otherwise
approved during the credentialing process.
o Providing after-hours messaging information, including a telephone number, to allow the
Member to contact the Provider or covering Provider, and instructing the Member to call 911 or
go to an emergency room if this is an emergency.
Disputes
Providers are responsible for:
o Informing the Member of their right to appeal, when VHP denies a service or referral.
o Adhering to Medicare’s appeals/expedited appeals procedures for our Members, including
gathering/forwarding information on appeals to VHP as necessary.
Access to Care
As a participating Provider, you agree to provide Members with timely access to services. Participating
Providers and covering Providers agree to be available to treat Members or schedule appointments in
accordance with the timeframes shown in the following sections.
Primary Care Physicians (PCP)
In addition to the responsibilities of all Providers, PCPs have the following responsibilities:
Providing or arranging for most covered healthcare services for Members, 24 hours a day, seven
days a week.
Serving as the Member’s healthcare manager, overseeing the Member’s total healthcare needs.
Initiating referrals for specialty care and facility services in accordance with referral requirements
where applicable.
Arranging for and monitoring specialty care for medically necessary services to Members when
appropriate. When referring a Member to a specialist, the PCP will provide the necessary
documentation pertinent to the care of the Member.
18Specialists
In addition to the responsibilities of all Providers, specialists are responsible for the following:
Actively supporting and contributing to the provision of quality, cost-effective healthcare services.
Providing specialty services in accordance with referral instructions, when applicable.
Informing the Member’s PCP of all diagnoses and treatments provided, including all appropriate
medical documentation, to assure continuity of care between Providers.
Periodically reporting to the Member’s PCP, if PCP selected, after each visit, or at least once during
every 30 days of active treatment.
Advocate for and Communicate with Members
Providers are encouraged to communicate with our Members who are their patients, including
discussing a Member’s health status, medical care, or treatment options.
VHP is committed to supporting Providers in the care and service of their patients who are our
Members and will not sanction, terminate, or fail to renew a Provider’s participation in VHP’s network
for any of the following reasons:
Advocating for medically necessary and appropriate healthcare services for a Member.
Filing a grievance or appeal on behalf of, and with the written consent of, a Member or helping a
Member to file a grievance or appeal.
Protesting a VHP decision, policy, or practice the Provider believes interferes with his or her ability
to provide medically necessary and appropriate healthcare.
Taking another action specifically permitted by the provisions of law.
In addition, VHP will not penalize or restrict Providers from discussing any of the information permitted
under applicable law or other information they reasonably believe is necessary to provide a Member
with full information concerning the healthcare of the Member.
Educate Member on Appropriate Emergency Room Use
Participating Providers are encouraged to educate Members on the appropriate use of the emergency
room. Listed below are some helpful tips to assist Providers in managing inappropriate use of the
emergency room by their patients. Providers are encouraged to use any of these concepts that they
feel are appropriate for their practice.
Make sure your patients have good access to care. Normal office hours are often inconsistent with
many lifestyles. Providers are encouraged to allot time for “open scheduling” and to offer extended
office hours.
19 Discuss appropriate and inappropriate emergency room use with your patients.
Provide written instructions on common medical problems to your patients during an office visit.
Include guidance on when a trip to the emergency room is appropriate and when it is not. Focus the
discussion on common medical problems that are most applicable to the individual patient.
Covered Services/Member Benefits
Covered services must be medically necessary and appropriate. To verify Member’s covered
services, please access VHP’s Provider Portal at VibraHealthPlan.com. Click on the “For Providers”
tab in the top right corner. First-time users will need to create a username and password to access the
secure portal.
All services covered under VHP are subject to specific Member Certificate of Coverage benefit
exclusions. Healthcare services, treatment, and supplies that are not covered services under the terms
and conditions of a Member’s Certificate of Coverage are “non-covered services.”
If VHP does not cover or approve benefits for any procedure or course of treatment, it is the Provider’s
responsibility to describe the service and inform the Member of his or her financial responsibility for the
service prior to the provision of any non-covered services.
Please see Summary of Benefits at VibraHealthPlan.com, under “Members” dropdown menu, select
“Documents and Forms”, then “Member Forms.”
Coverage Determination Language
VHP uses Local Coverage Determinations (LCDs), established by the local Medicare Administrative
Contractor. LCDs and National Coverage Determinations (NCDs), are each a resource to establish
policy on whether to cover a particular service and for processing claims for payment.
LCDs are located on the Novitas-Solutions.com/webcenter/portal/.
LCDs for Durable Medical Equipment (DME), located on: Med.NoridianMedicare.com/web/
jddme/policies/lcd/active.
NCDs are located on CMS.gov/medicare-coverage-database/overview-and-quick-
search.aspx?list_type=ncd.
20Coordination of Benefits
Coordination of Benefits (COB) rules apply whenever a Member has healthcare coverage from more
than one health plan. COB rules provide for establishing the order in which plans pay claims and permit
secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed the
total allowable expenses within the claim determination period. When a Member has coverage from
more than one health plan, Providers should use the information in the following sections to help
determine which health plan is primary.
Order of Benefit Determination
Primary insurance coverage is determined based on guidelines set forth in this section. Secondary
insurance, in many situations, considers the portion of covered service expenses not paid by the
primary insurance carrier. Primary and secondary carriers are usually determined as follows:
The primary carrier is usually the health plan that covers the individual as a result of the individual’s
status as an employee or retiree.
The secondary carrier is usually the health plan that covers the individual as a spouse.
Order of Benefits Exceptions
When a Member has coverage as a dependent by an employer group and has Medicare coverage,
there are exceptions to the rule where Medicare is primary. If you are unsure if the Member’s primary
coverage is Medicare, contact Provider Support at:
Toll-Free: 844.440.4629
E- mail: ProviderSupport@VibraHealthPlan.com
Other Party Liability (OPL) and Third Party Liability (TPL)
Other Party Liability (OPL) refers to the coordination of healthcare benefits with motor vehicle insurance
and workers’ compensation carriers. Third Party Liability (TPL) or subrogation provides the ability for us
to recover payments made on behalf of a Member who is injured or becomes ill, based on the actions
of a responsible third party.
Participating Providers must cooperate with us to facilitate payment for services provided to Members
by the proper insurer when workers’ compensation or motor vehicle insurance is involved.
Motor Vehicle or Auto Insurance
VHP is the secondary payer when duplicate healthcare coverage exists between us and motor vehicle
insurance under the Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL).
21MVFRL covers an insured individual who sustains an injury as a result of the maintenance, operation,
or other use of a motor vehicle.
Our products (group and individual) exclude coverage for services eligible under MVFRL. The first party
auto insurance benefits must be exhausted before VHP will consider charges related to a motor vehicle
accident/injury.
If one of our Member’s auto benefits have been exhausted, a claim can be submitted as normal and
should include the notation, “Auto Benefits Exhausted with the date of Exhaust,” in Remarks. This
written notation should be submitted as follows:
UB-04 paper – record in Locator 80 (Remarks).
CMS 1500 paper claims – attach a copy of the Personal Injury Protection (PIP) sheet and exhaust
letter to the hard-copy form.
ANSI 837 – record in the 2300 loop, NTE segment.
Please Note: To comply with HIPAA privacy regulations, when coordination of benefits information
is included with a claim and one insurer’s Explanation of Benefits (EOB) or payment notice is being
submitted to another insurer, any patient information that does not pertain to the patient and
services at issue must be removed prior to submission to the second insurer.
If it is determined by a Peer Review Organization (PRO) or court that a Provider has provided
unnecessary medical treatment or rehabilitative services or merchandise or that future provision of such
treatment, services, or merchandise will be unnecessary, the claims are not eligible under our
Agreement with that Provider.
Workers’ Compensation
Pennsylvania state law assigns the liability to the employer for injuries, illnesses, or conditions resulting
from on-the-job accidents or working conditions. Self-employed individuals and executive officers of a
corporation are not generally covered by the law and are ineligible for workers’ compensation. For
processing consideration, an executive officer must submit a copy of the Executive Officer Application,
Executive Officer Affidavit, and notification from the Department of Labor approving the opt out with the
effective date. Our health plans (group and individual) exclude coverage for services eligible under
workers’ compensation. VHP considers such claims only after the workers’ compensation carrier has
denied the workers’ compensation claim or has determined that services are not related to a particular
workers’ compensation diagnosis.
VHP does not provide benefits for claims related to the workers’ compensation diagnosis when the
Member has entered into a lump sum settlement with the employer or workers’ compensation carrier
that covers future medical expenses or if it is determined by a Peer Review Organization or court that a
Provider has provided unnecessary medical treatment or rehabilitative services or merchandise or that
future provision of such treatment, services, or merchandise will be unnecessary, the claims are not
eligible under our health plan.
22If a Provider wishes to submit a claim that was denied by workers’ compensation, VHP requires a copy
of the workers’ compensation denial and information on any possible appeal by the Member. Any such
claims denied by workers’ compensation will not be considered for payment by us if:
The employee did not use the Provider specified by the employer or workers’ compensation carrier.
Timely filing limits were not met (120 days for Member to notify employer, 72 hours for employer to
notify workers’ compensation carrier after receiving notification from the employee).
Third Party Liability/Subrogation
VHP has the right of subrogation on all claims paid on behalf of a Member from the party responsible
for the Member’s injury or illness. Subrogation recovery is initiated after VHP pays Covered Services in
accordance with the Member’s plan.
Advance Directives
An advance care directive, also known as a living will, personal directive, medical directive, or advance
decision, is a legal document in which a person specifies what healthcare actions to take if they are
unable to make decisions because of illness or incapacity.
It is the Member’s choice whether or not to complete an Advance Directive. Providers may not deny
care and treatment based on whether or not a Member has an Advance Directive, and they may not
provide care that directly conflicts with a Member’s Advance Directive. A Member’s Provider should be
the primary source of information about Advance Directives but there are community and national
resources available to obtain information about Living Wills, Medical Powers of Attorney, and Advance
Directives.
Under existing state law, Providers must allow a representative appointed by the Member pursuant to
an Advance Directive that complies with state law to manage care and treatment decisions when the
Member is incapacitated and unable to do so, in accordance with the terms of the Advance Directive.
Additionally, Providers must allow a duly appointed representative under an Advance Directive that
complies with state law to be involved in decisions on behalf of the Member related to withholding
resuscitative services or declining/withdrawing life-sustaining treatment in accordance with the terms of
the Advance Directive and as authorized by state law.
Notwithstanding whether or not a Member has Advance Directives, state law permits a person to be an
appointed medical power of attorney who may facilitate care or treatment decisions for a Member who
is incapable of doing so because of physical or mental limitations.
23You can also read
