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Provider Manual
TABLE OF CONTENTS
Section I:
Introduction
•
Welcome
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Background, History and Goals of the HealthChoices - SW Program
•
Program Overview
•
Quick Reference Guide
Section II:
Getting Started
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Provider Covered Services Grid - HIPAA Compliant
•
Referral Process
•
Verifying Member Eligibiity
Section III:
Utilization Management
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Child and Adolescent Strengths Based Evaluation (CCASBE-LD)
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Confidentiality
•
Drug and Alcohol Services
•
Grievance Process
•
Information Required for Service Authorization
(Documentation Guidelines for Inpatient, Documentation Guidelines for Continued Stay Reviews, Documentation Guidelines for Continued Stay Reviews, Documentation Guidelines for Discharge)
•
Inpatient and Alternative Levels of Care
•
Medical Necessity Criteria
•
Outpatient Services (Mental Health and D&A)
•
Peer Review Process
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Prevention, Education and Outreach
•
Priority Populations
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Purpose and Scope
•
Records Retention
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Requests for Authorizations/Retro-authorizations
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Service Authorization Procedures
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Special Procedures
(Electro-Convulsive Therapy, Psychological Testing and
Methadone Services)
•
Utilization Management Staff
Section IV:
Participating Provider Responsibilites
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Advanced Directives
•
Americans with Disabilities Act (ADA)
•
Appendix AA
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Appendix H
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Assessments / Evaluations
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BHRS Reporting Requirements
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Compliance with Quality Improvement and Utilization Management Programs
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Confidentiality
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Coordination of Care
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Cultural Competance
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Member Right to Continuing Course of Treatment
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Member's Right to File a Complaint, Grievance or DPN Fair Hearing
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Member's Rights and Responsibilities
•
National Provider Identifier (NPI)
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Notification of Change in Access to Services
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Notification of Change in Practice Status
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Notifying Members of Authorized Services
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Obligation to Report / Duty to Warn
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POMS Initial Consumer Registration
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POMS Quarterly Status Update
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Professional Standards
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Prohibition of Member Billing
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Reporting Adverse / Critical Incidents
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Site Visits
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Treatment of Record Reviews
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Treatment Record Standards
Section V:
Network Management
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Administrative Complaints
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Credentialing and Recredentialing
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Fair Hearing Process
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National Credentialing Commitee (NCC)
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Network Management Functions
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Non-renewal of Provider Agreement
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Provider Appeals Related to Credentialing, Sanctions or Termination
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Provider Contracting
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Provider Recruitment
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Provider Sanctions
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Provider Training
Section VI:
Claims Payment
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Assistance with Claims Questions
•
Claim Filing Requirements
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Claims Adjustments
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Claims Submission
•
Fraud and Abuse
•
Going Online with ValueOptions
•
Online Services Account Request Form
•
Online Services Intermediary Authorization Form
•
Prohibition of "Balance Billing"
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Summary Voucher / Electronic Remittance Advice (ERA)
•
Third Party Liability (TPL)
Section VII:
Quality Management Program
•
Confidentiality
•
Organizational Structure, Roles and Responsibilities
•
Purpose and Scope
•
Quality Management Activities
•
Quality Management Work Plan
•
Work Plan Evaluation and Update Process
Appendix A :
Glossary of Terms
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