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How do I get dental care? Can I get vision care? Are my dependents eligible? Are my survivors eligible? Manage benefits What is special open enrollment? Behavioral Health Hospital We cover admission to substance abuse units of general hospitals Based Detoxification or freestanding psychiatric and substance abuse hospitals.
Prior authorization is required. These services are covered up to the service limit guidance in the appropriate Nevada Medicaid Services Manual. Observation cannot exceed 48 hours up to the service limit. Includes: Neuropsychological testing Neurobehavioral testing Psychological testing These services are covered up to the service limit guidance in the appropriate Nevada Medicaid Services Manual.
Medicaid We re responsible for all services covered until the member is properly disenrolled from managed care. The enrollee will be disenrolled from Amerigroup effective the first day of the next administratively possible month following the RTC admission, and services will be reimbursed by FFS thereafter.
We remain responsible for reimbursement of all ancillary services e. The RTC admission and bed day rate will be covered by FFS for this population commencing on the first day of admission. Blood Products. Circumcisions Routine circumcisions are covered for male newborns up to 1 year of age without authorization.
Prior authorization is required over age 1. Services are covered only for prompt repair of an accidental injury or the improvement of a malformed body member in order to improve function.
Cosmetic surgery directed at improving appearance is not covered. Medicaid Members Age 21 and Older Adult Medicaid members receive emergency extractions and palliative care under certain guidelines and limitations. Medicaid Members under Age 21 and Nevada Check Up Members under Age 19 Surgery to correct a wide range of diseases, injuries and defects to the head, neck, face, jaws, and hard and soft tissues of the lower jaw and face region is covered.
Effective July 1, , Amerigroup no longer covers the dental benefit for members. The following DME and medical supplies are not covered: Enteral nutrition in situations of temporary impairment; for members with functioning gastrointestinal tracts. Complete medical screens include the following: Comprehensive health and developmental history, including an assessment of both physical and mental health development Comprehensive unclothed physical exam Appropriate immunizations, according to age and health history, unless medically contraindicated at the time Laboratory tests, including an appropriate blood-lead level assessment Health education Vision screening Hearing screening Dental screening Vision, hearing and dental exams may be performed at other intervals Other necessary health care or diagnostic screens or examinations A member under the age of 21 whose eligibility status is pregnancy-related is not eligible.
Use Modifier EP for routine screening. Use Modifier TS if referral or follow-up indicated. Coverage includes educational consultations for diabetes self-management. Also includes publications, presentations, classroom instruction and preventive services.
This is not a separately billable service. Emergency transportation services are covered. See DME for certain restrictions. Family planning services are covered without precertification at any qualified family planning provider, regardless of whether or not the provider is participating in our network. Members can self-refer to a qualified provider in or out of network. Sterilization forms are not required for anesthesiology providers only.
Hysterectomy consent forms are required for all provider types. We do not reimburse: Prenatal diagnosis for sex determination of the fetus without implications for genetic disease Self-testing home kits Genetic testing for cleft disorders Blood-typing for paternity testing.
Maintenance therapy is covered under Habilitative Services and includes the skilled therapy necessary for maintenance and development of a safety therapy plan.
Requirements include: A plan of care, addressing a condition for which therapy is an accepted method of treatment as defined by standards of medical practice. A plan of care for a condition that establishes a safe and effective skilled maintenance program. Topical hyperbaric oxygen therapy is not covered.
Hysterectomies are not covered for the sole purpose of sterilization. Please complete either the appropriate sterilization form s found in Appendix A of this manual or the Hewlett Packard sterilization form, which can be found here:. See section 5. Follow Amerigroup limits unless otherwise specified. Limited to one per year. See DME for further specifications.
Observation services are provided by the hospital and supervising physician to recipients held but not admitted into an acute hospital bed for observation. Consistent with federal Medicare regulations, the HCFP reimburses hospital observation status for a period up to but no more than 48 hours.
Osteopathic manipulation services are limited to the codes through These services are covered per the Nevada Medicaid Services Manual. Out-of-area or out-of-state emergency care does not require a. Generally, post-stabilization procedures do require prior approval. However, if post-stabilization services are administered to maintain the member s stabilized condition within one hour of the request for authorization, such services will still be covered.
Also, if post-stabilization care, administered to maintain, improve or resolve the member s stabilized condition, requires prior approval and we don t respond within one hour, we ll pay the provider for that stabilization care. We will not pay the provider an amount any greater than we would pay a network provider for those services. Nonemergency, out-of-state, acute, inpatient hospital care requires prior authorization. If our network is unable to provide medically needed services in the member service area or state , we ll cover these services adequately and in a timely manner for as long as the services are not available in our network.
If prior authorization is required for a specific outpatient or inpatient service in the member service area or state , then prior authorization will be required for a specific outpatient or inpatient service outside the member service area or state.
Please see the Nevada Medicaid Services Manual for details. Medical necessity review may be required for prior authorization. These services are covered under certain circumstances as outlined in the Medicaid Service Manual MSM including but not limited to: Assistance with bathing, grooming and dressing one service Assistance with toileting needs Assistance with transferring and positioning nonambulatory recipients Assistance with ambulation Assistance with eating Assistance with medications Prior authorization is required.
All symptomatic and general preventive health visits to physicians or physician extenders within the scope of their licenses are covered benefits. Physician services covered include services received while admitted in the hospital, outpatient hospital department, in a clinic setting or in a physician s office.
Amerigroup covers medically-needed preventive foot care for Medicaid members under age 21, and will cover Nevada Check Up members through their 19th birthdays who are referred to a podiatrist as part of a Healthy Kids checkup. Services for Adult Diabetics Amerigroup will allow reimbursement for podiatry services for our diabetic members over 21 years of age. Preventive Health Services We don t cover preventive care including the cleaning and soaking of feet, application of creams to ensure skin tone and routine foot care including trimming of nails and cutting or removal of corns or calluses in the absence of infection or inflammation.
These services are covered under certain circumstances as outlined in the Medicaid Service Manuals: Private duty nursing services may be approved for chronically ill recipients who require extensive skilled nursing care to remain at home. This is covered. See page 28 for Habilitative Services information. SBCHS recipients have a limit for no more than two individualized education plans in a calendar year.
The following services are not covered: Services provided to students over the age of 21 or under the age of 3 Services classified as educational or recreational Services to non-medicaid eligible individuals Information furnished by a provider to recipient over the telephone Dental or related services Treatment of obesity Any immunizations or biological products and other products available free of charge from the state health division Transportation of school-aged children to and from school, including specialized transportation for Medicaideligible children on days when they receive Medicaid covered services at school These services are covered.
Covered services include all nursing facilities, swing-bed admissions, and all other medically necessary services through the first 45 days of admission. On the 46th day, these services are covered by FFS. Our holistic program administered through National Jewish Health includes coaching, written and online education and Nicotine Replacement Therapy NRT delivered to the member s home.
Members can self-refer to the program by contacting. All FDA-approved tobacco cessation medications, both prescription and over-the-counter, are covered for a minimum of 90 days. Prior authorization is not required. Combination therapy: The use of a combination of medications, including but not limited to the following combinations, is allowed: Long-term over 14 weeks nicotine patch and other nicotine replacement therapy gum or nasal spray Nicotine patch and inhaler Nicotine patch and bupropion SR There are no stepped-therapy requirements.
Members are also referred to local health education classes that include topics to cover smoking cessation. One of our case managers educates the member at risk on the effects of smoking and engages in a discussion around smoking cessation strategies and programs. Ameritips, educational tools that address tobacco use, are sent to members who are enrolled in the disease management, CM or OB case management programs and who have been identified as using tobacco products.
Members may also be referred to a behavioral health provider for evaluation and treatment of substance abuse, including tobacco use. Autologous stem cell transplantation is not covered as treatment for acute leukemia not in remission, chronic granulocytic leukemia, solid tumors other than neuroblastoma and tandem transplantation for recipients with multiple myeloma.
Heart, lung, pancreas and intestinal transplants and their associated costs are NOT covered for adults. Medicaid Members under 21 We cover any medically necessary transplant that is not experimental. No prior authorization is needed for members under age Prior authorization is required for members age 21 and over if the month limitation is exceeded. Frames Existing frames must be used whenever possible. If new frames are needed, they may be metal or plastic. Contacts Not covered unless: Medically needed to meet minimum criteria required to avoid legal blindness.
Exams under this condition do not require a prior authorization. Glasses may be provided at any interval without prior authorization of EPSDT recipients as long as there is a change in refractive status from the most recent exam. Not Covered Sunglasses and cosmetic lenses Replacement lenses unless there is a significant change in refractive status Transitional lenses Faceted lenses Additional cost of extended repair or replacement warranty Frames with ornamentation OkFrames which attach to or act as a holder for hearing aid s Well-baby and Well-child Care Routine well-baby and well-child care services are covered for enrollees ages and include routine office visits with health assessments and physical exams, routine lab work, and age-appropriate immunizations.
Note: We do not cover the use of any experimental procedures or experimental medications. A list of participating clubs is available from Member Services. Additional member benefits are as follows: Free cellphone with free monthly minutes, data and text messages. Additional transportation assistance to provider appointments and health related services. My wellness guide so member can take control of their health and well-being set goals, track progress and get tips for healthier living.
Bedside delivery of medications to member s bedside when discharged from a hospital setting. Podiatry benefits for members with diabetes. Child care provided for mothers and fathers who need to obtain health care services.
Max hours enforced by health plan. Free holistic smoking program is a smoking cessation to support members age 18 or older and includes telephonic outreach, education, nicotine replacement therapy and coaching.
Text based peer support services program provides crisis text services to adolescents. The program allows members to engage with a qualified mental health professional and receive resource information in the manner that best meets their individual needs and preferences. We also. Visit a doctor through video chat is a telehealth service to members and essentially offers online video chat if there is a need in support for minor illnesses. Shelter bed reservations program assists members enrolled with Well Care for BH services with the need for overnight shelter.
Transportation and case management are in addition to the services provided. Taking Care of Baby and Me is part of a corporate-supported standardized Member Incentive Program MIP that enables the health plan to reward members for completing specific health activities for non-cash rewards that may assist in the prevention, wellness or management of chronic conditions.
The program is highly versatile and intended to boost clinical performance metrics and health outcomes for pregnant women and new moms. Healthy Rewards Programs for Members The Healthy Rewards Program is a corporate supported standardized Member Incentive Program MIP that enables the health plan to reward members for completing specific healthy activities for non-cash rewards that may assist in the prevention, wellness or management of chronic conditions.
The program is highly versatile and intended to boost clinical performance metrics and health outcomes. A few of the incentives are: Incentives for adolescent well-care visits Incentives for well-child visit Incentives for breast cancer screening Incentives for diabetes screening hba1c Incentives for cervical cancer screening Incentives for asthma medication fills Incentives for antidepressant medication management fill Incentives for ADHD medication fill and doctor visits Incentives for prenatal and postpartum care visit Incentives for well-baby visits 5.
It identifies pregnant women as early in their pregnancies as possible through review of state enrollment files, claims data, lab reports, hospital census reports, and provider notification of pregnancy and delivery notification forms and self-referrals. Once pregnant members are identified, we act quickly to assess obstetrical risk and ensure appropriate levels of care and case management services to mitigate risk.
Case managers collaborate with community agencies to ensure mothers have access to necessary services including transportation, WIC, home-visitor programs, breastfeeding support and counseling. When it comes to our pregnant members, we are committed to keeping both mom and baby healthy. This program provides pregnant women proactive, culturally appropriate outreach and education through Interactive Voice Response IVR , text or smart phone application.
This program does not replace the high-touch case management approach for high-risk pregnant women.
However, it does serve as a supplementary tool to extend our health education reach. The goal of the expanded outreach is to identify pregnant women who have become high-risk, to facilitate connections between them and our case managers and improve member and baby outcomes.
Eligible members receive regular calls with tailored content from a voice personality Mary Beth. Parents receive education and support to be involved in the care of their babies, visit the NICU, interact with hospital care providers and prepare for discharge. Parents are provided with an educational resource outlining successful strategies they may deploy to collaborate with the care team.
Please help us identify members who would benefit from OB case management and make referrals to the case management program by calling and asking for an OB case manager.
The program is designed to identify medical conditions and to provide medically necessary treatment to correct such conditions. Healthy Kids offers the opportunity for optimum health status for children through regular, preventive health services and the early detection and treatment of disease. Use modifier TS if referral or follow up indicated.
If modifier 25 is not billed appropriately, the sick visit will be denied. Appropriate diagnosis codes must be billed for respective visits. Well-child care services are available for Nevada Check Up members ages These services include regular or preventive diagnostic and treatment services necessary to ensure the health of babies, children and adolescents as defined by the state.
Well-child care services should be performed for newborns in the hospital and then as follows: Age Range Under days old 1 month 2 months 4 months 6 months 9 months 12 months 15 months 18 months 24 months 30 months 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 5. If you re licensed by the state to prescribe vaccines, contact the Nevada State Health Division to enroll.
The Immunization Program will review and approve your enrollment request. As a VFC-enrolled provider, you must cooperate with the Nevada State Health Division for purposes of performing orientation and monitoring activities regarding VFC program requirements.
Participate in the Nevada State Health Division s Immunization Registry by reporting to the state all immunizations of children up to 2 years of age.
We ll assist you if you don t have the capability to meet these requirements upon request. Vaccine administrations are separately reimbursable expenses from well-child exams or office visits. When the vaccine administration is the only service performed, Amerigroup does not allow reimbursement for a minimal office visit i. We ll reimburse local health departments LHDs for the administration of vaccines regardless of whether or not the LHD is under contract with us. Note: We cover the administration fee only for members less than 21 years of age.
Please note: The specific service s needed for each member is listed in the report. Reports are based only on services received during the time the member is enrolled with us.
In accordance with these guidelines, services received prior to the specified schedule date do not fulfill EPSDT requirements. This list is generated based on our claims data received prior to the date printed on the list. In some instances, the appropriate services may have been provided after the report run date. To ensure accuracy in tracking preventive services, please submit a completed claim form for those dates of service to our Claims department at: Amerigroup Community Care P. Box Virginia Beach, VA Blood Lead Screening You re required to furnish a screening program consisting of a screening and a blood test for the presence of lead toxicity in children.
During well-child visits for children between the ages of six. Blood tests should be performed at 12 months and 24 months of age to determine lead exposure and toxicity. In addition, children over the age of 24 months up to 72 months should receive blood screening lead tests if there is no past record of a lead screening.
Supplies are provided at no charge to your office; once the sample cards are mailed back to MEDTOX, you can expect results delivered within 24 to 48 hours of receipt.
Bill with CPT code along with the applicable office visit code when submitting a claim for the procedure. Please see the blood lead risk forms located in Appendix A Forms. Members have access to most national pharmacy chains and many independent retail pharmacies. Walgreens and Rite Aid are not part of the pharmacy network.
If a member is transitioning to us from FFS or another managed care organization MCO , we will not terminate the member s current prescription without first consulting the prescribing provider. The provider must document the reason a drug is no longer medically necessary if a current prescription is terminated. The member will receive a transition benefit for a one-time fill during the first 30 days. After the member has used the transition benefit, providers will need to submit a prior authorization request for possible approval of the member continuing on this drug.
This is a list of the preferred drugs within the most commonly prescribed therapeutic categories. The PDL also includes several over-the-counter OTC products that are recommended as first-line treatment where medically appropriate. To prescribe medications that do. Prior Authorization Drugs We strongly encourage you to write prescriptions for products as listed on our complete formulary or our PDL.
Medications not listed in the formulary or PDL are considered to be nonformulary and are subject to prior authorization. Some medications listed on our formulary or PDL may have additional requirements or limitations of coverage.
These requirements and limits may include prior authorization, quantity limits, age limits or step therapy. Additionally, if a medication is available as a generic formulation, this will be Amerigroup s preferred agent, unless otherwise noted. If a brand name medication is requested when a generic exists, a prior authorization request will need to be submitted. If you have any questions about coverage of a certain medication, please contact the Amerigroup Pharmacy Department at Monday-Friday from 5 a.
Pacific time and Saturday from 7 a. Pacific time. To request prior authorization, the provider or member must contact the Amerigroup Pharmacy Department at Providers should be prepared to provide relevant clinical information regarding the member s need for a nonpreferred product or a medication requiring prior authorization.
Decisions are based on medical necessity and are determined according to certain established medical criteria. Please call Accredo at or visit to request a specific medication. A full listing of the medications supplied by Accredo can be found on our website at and is current at the time of printing. Certain medical injectables require precertification.
To determine whether the medication you are prescribing requires precertification, please refer to the Precertification Lookup Tool found at: If it is determined that the medication you are seeking to prescribe requires precertification, please contact the Pharmacy Department at When prescribing a specialty drug, please fax your request to Accredo at or call Accredo at , and they will coordinate shipment to your office or to the member s home.
You should not provide these drugs from your office stock without first obtaining precertification from us Behavioral Health Services Members may self-refer, or you may direct members to our network of behavioral health care providers for behavioral health services. We re responsible for arranging for the provision of mental health, alcohol and other drug abuse assessments and treatment services as follows: Inpatient mental health and substance abuse services Outpatient mental health and substance abuse services Mental health rehabilitative treatment services Residential Treatment Center RTC only a covered service for members 21 years of age and younger.
For Medicaid enrollees, we remain responsible for all services covered until the. Medicaid enrollees will be disenrolled effective the first administratively possible day of the next month following the RTC admission, and services will be reimbursed FFS thereafter. For Nevada Check Up members, we remain responsible for all services covered in the first month of admission. The RTC admission and bed-day rate will be covered by FFS for this population commencing on the first day of admission.
This model ensures the provision of biopsychosocial services based on an individual s needs and strengths, is family-driven, client-centered and culturally competent.
Services are provided according to a written individualized treatment plan that contains measurable goals and objectives and includes access to an array of medically necessary outpatient mental health and rehabilitative mental health services across the continuum of care.
Our network providers must ensure services are community based, provided in the least restrictive, most normative setting possible, and include effective care coordination. Our network providers must ensure the parent or guardian of a minor enrollee who is referred for SED assessment or an adult who is referred for SMI assessment is fully informed of the reason why the assessment is necessary.
No other entity can make a determination on behalf of a Medicaid recipient enrolled with Amerigroup. If a non-designated entity makes a determination Amerigroup will reject the determination and ask that the enrolled recipient be referred to Amerigroup for a determination and services.
We will participate and have oversight of the transition of enrollees from managed care to FFS Medicaid and have final review and determination.
For recipients who have voluntarily elected to remain enrolled in managed care, the process for these redeterminations is the same as for the initial SED or SMI determination as stated above.
Within five business days, you re required to submit these forms to DHCFP per the instructions on the forms. Patient Patient is a read-only dashboard that gives you a robust picture of a patient s health and treatment history, and helps you facilitate care coordination.
Patient is available through our secure self-service website, which gives you instant access to detailed information about your Amerigroup patients. By clicking each tab in the dashboard, you can drill down to specific items in a patient s medical record. Information is available regarding a member s demographics, care summaries, claims details, authorization details, pharmacy and care management-related activities.
Patient is a multifaceted perspective on member utilization and pharmacy patterns. With this level of detail at your fingertips, you ll avoid duplicating services, identify care gaps and trends and coordinate care more effectively. In addition, accessing this data electronically will reduce the number of communications needed between PCPs and case managers, as well as significantly increase patient confidentiality. To access Patient 1. Log in at 2. Select Members from the navigation 3.
Select Patient Enter the Amerigroup member s information. Our Member Services representatives serve as advocates for our members. Members can find a list of these rights in the member handbook and on the member website at They can request a hard copy by calling Member Services at Below are our members rights and responsibilities: Member Rights An Amerigroup member has the right to: Be treated with respect, dignity and have their right to privacy respected.
This includes: o Knowing their medical records and discussions with their PCPs will be kept private and confidential o Being treated fairly Receive information about Amerigroup, its services, PCPs and providers, and member rights and responsibilities.
This includes: o Knowing how to choose and change their health plan and PCP o Choosing any health plan they want that is available in their area and choosing their PCP from that plan o Changing their PCP o Selecting a specialist to serve as their PCP if they have a chronic condition o Changing their health plan without penalty Participate in the decision-making process for their health care.
This includes: o Working as part of a team with their PCP to decide what health care is best for them o Taking part in an honest discussion on the proper or medically needed treatment options for their condition, without concern about the cost or benefit coverage o Deciding on care recommended by their PCP o Being told and understanding the results of the decision o Refusing treatment Express and expect resolution of grievances and appeals about: o Amerigroup o Our network PCPs and providers o The care we provide Create an advanced directive to tell their doctor the kind of care they want if they are not able to communicate their decisions.
Have access to their medical records in agreement with all federal and state laws, and be able to request the records be changed or corrected in agreement with federal and state laws. Make suggestions about the Amerigroup Member rights and responsibilities policy. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation. Receive information on available treatment options and alternatives that is presented in a way that they are able to understand.
Understand their health problems and work with their PCPs and providers to find an agreed upon plan to help treat their illness or condition, including: o Working as a team with their PCP to decide what health care is best for them o Understanding how what they do can affect their health o Doing the best they can to stay healthy o Treating PCPs and staff with respect Notify Amerigroup if they have other health insurance.
Carry their ID card at all times. Update demographic information with the Division of Welfare and Social Services Member Grievance We have a grievance resolution process in place for our members.
All members or persons acting on behalf of members have a right to voice dissatisfaction of any aspect of ours or a provider s operations. You can file a grievance on behalf of a member only after the member has granted you written permission to act as his or her personal representative. You must adhere to the same regulated time frames as we give the members.
Members are provided with the following information: If you have a problem with our services or network providers, we would like you to tell us about it. Please call Member Services. We will try to solve your problem on the phone. If we can t take care of the problem when you call us, you can file a grievance. You can: Write a letter to us and include information, such as: o The date the problem happened o The names of people involved o Details about the problem File a grievance on the phone Ask Member Services for help with writing a letter; include information such as the date the problem happened and the people involved.
Send you a letter within five calendar days to let you know we received your grievance. Look into your grievance in a timely manner. Send you a letter within 90 calendar days of when you first told us about your grievance; the letter will advise you of our decision. Second Level Grievance Review If you are not happy with our decision, and your grievance is about your ability to receive benefit coverage, access to care, access to services or payment for services, you may file a second level grievance review.
Ask us for a second level grievance review in writing within 90 calendar days of the date on the grievance resolution letter we sent you as our initial grievance response.
Mail your second level grievance review request to the same address that you sent your initial grievance request. We will send you a letter within five calendar days to let you know we got your request. Your second level grievance review will be looked at by someone at a higher level than the reviewer who looked at your initial grievance request. We will send you a letter with our decision within 30 calendar days. The second level grievance review is the final level of review for grievances Authorization and Notice Timeliness Requirements We will provide standard authorization decisions as expeditiously as the member s health requires and within the state s established timelines that will not exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days if you or the member request the extension or Amerigroup justifies to the DHCFP a need for additional information and how the extension is in the member s interests.
For cases in which a provider indicates or we determine that following the standard timeframe could seriously jeopardize the member s life or health or ability to attain, maintain or regain maximum function, we will make an expedited authorization decision and provide a notice of action as expeditiously as the member s health condition warrants and no later than three calendar days after receipt of the request for service.
To ensure ease of understanding by non-english speaking or visually impaired members or members with limited reading proficiency, the written notice to the member must meet the language and format requirements of 42 CFR c and d. This time frame may be shortened to five days if probable member fraud has been verified.
We must give notice by the date of the action for the following circumstances: The death of the member A signed written member statement requesting termination or giving information requiring termination or reduction of services where the member understands that this must be the result of supplying that information The member s admission to an institution where he or she is ineligible for further services The member s address is unknown and mail directed to him or her has no forwarding address The member has been accepted for Medicaid services by another local jurisdiction The member s physician prescribes the change in level of medical care.
We must give notice on the date that the time frames expire when service authorization decisions are not reached within the time frames for either standard or expedited service authorizations. Untimely service authorizations constitute a denial and are thus adverse actions. These notices must include: The member s right to file an appeal if he or she disagrees with that decision.
The member s right to receive written resolution notice. In addition, reasonable efforts will be made to provide oral resolution notice Medical Necessity Appeals If you or the member does not agree with the adverse determination of medically necessary services made by Amerigroup, an appeal can be filed.
You may appeal on behalf of the member as long as you have received written authorization from the member. However, you do not need prior written authorization from the member if you or the member are making an expedited appeal on behalf of the member. Box Virginia Beach, VA We will process and resolve each medical necessity appeal and provide notice as expeditiously as the member s health condition requires within the time frames specified as follows: Standard resolution of appeals: 30 calendar days from the date of receipt of the appeal.
An oral appeal can be filed by contacting Member Services at The date the oral appeal is filed with Member Services will be used in calculating the resolution time period.
When an oral appeal is filed, it must be followed up in writing within 10 calendar days. If the written appeal is not submitted within the specified time period, the appeal will be closed. Upon receipt of the written appeal, Amerigroup will reopen the appeal with the date the written appeal was received as the new date to calculate the resolution time period. For cases in which a provider indicates that following the standard timeframe could seriously jeopardize the member s life or health, or ability to attain, maintain or regain maximum function, we request that you contact Provider Services at for assistance in submitting your appeal.
If we deny a request for expedited resolution of an appeal, we will transfer the appeal to the standard resolution time of appeals. We make reasonable efforts to give the member oral notice of resolution of an expedited appeal and follow up within two calendar days with a written notice. We ensure that punitive action is not taken against a provider who supports an expedited appeal. We are required to inform the member of the limited time available to present evidence and allegations of fact or law, in person or in writing, in the case of the expedited resolution.
These time frames may be extended up to 14 calendar days if the member requests such an extension or we demonstrate to the satisfaction of the DHCFP the need for additional information and how the extension is in the member s interests.
If DHCFP grants us a request for an extension, we must give the member written notice of the reason for the delay. We will notify the member and physician of the disposition of appeals in writing.
The written notice must include the results of the resolution process and the date it was completed. For appeals that are not wholly resolved in favor of the member, the notice must also state: The right of the member to request a state fair hearing from the DHCFP and how to do so The right to request to receive benefits while the hearing is pending and how to make this request The possibility the member may be held liable for the cost of those benefits if the state fair hearing officer upholds our action 5.
Members are informed of the following: You have the right to ask for a fair hearing from the state after the Amerigroup Community Care appeal process has been exhausted. You may ask for a fair hearing within 90 calendar days from the date of the appeal letter saying we denied coverage of services. Nevada Medicaid and Check Up members can ask for a fair hearing by sending the Member State Fair Hearing form that Amerigroup sent you with the notice of decision or a letter asking for a state fair hearing along with the Amerigroup notice of decision to: Nevada Division of Health Care Financing and Policy Hearings E.
William St. Or if you have questions regarding the fair hearing, you may call the hearings supervisor at , ext , in the Las Vegas area or if you live in the Carson City area. Or call the toll-free number: , ext If you ask for a fair hearing, you will get a letter from the state telling you the date and time of a hearing preparation meeting. The hearing preparation meeting will be held by phone, and you can explain why you disagree with the decision made by Amerigroup. If you proceed to a fair hearing, you must attend the fair hearing in person unless you get the hearing officer s consent to attend by phone.
You do not have to pay any costs to take part in the hearing. Amerigroup accordingly maintains a program, led by Amerigroup s Special Investigations Unit SIU , to combat fraud, waste and abuse in the health care industry and against our commercial plans as well as the integrity of publicly-funded programs including Medicare and Medicaid.
Prevention and detection of fraud, waste and abuse is in accordance with applicable state and federal law. Pre-Payment Review Program One method Amerigroup uses to detect fraud, waste and abuse is through pre-payment claim review. For example, Amerigroup uses computer algorithm software tools designed to identify providers or facilities whose billing practices, including billing or coding practices, indicate conduct that is unusual or outside the norm of the provider s or facility s peers.
Once a claim, provider or facility is identified as an outlier, further investigation is conducted by the SIU to determine the reason s for the outlier status or any appropriate explanation for an unusual claim, coding or billing practice. If, despite the provider s or facility s response, Amerigroup continues to believe the provider s or facility s actions involve fraud, waste or abuse, or some other inappropriate activity, the provider or facility will then be notified the provider or facility is being placed on pre-payment review.
This means that the provider or facility will be required to submit medical records with each claim so Amerigroup can review the services being billed. Failure to submit medical records to Amerigroup in accordance with this requirement will result in a rejection of the claim under review. The provider or facility will remain subject to the pre-payment review process until Amerigroup is satisfied that any inappropriate activity has been corrected. If the inappropriate activity is not corrected, the provider or facility could face corrective measures, up to and including termination from our network.
Finally, subject to the terms of your provider contract, providers and facilities are prohibited from billing covered individuals for services we have determined are not payable as a result of the pre-payment review process, whether due to fraud, waste or abuse, any other coding or billing issue, or for failure to submit medical records as set forth above. Providers or facilities whose claims are determined to be not payable may make appropriate corrections and resubmit such claims in accordance with the terms of the applicable provider or facility agreement and state law.
Providers or. Understanding Fraud, Waste and Abuse Combating fraud, waste and abuse begins with knowledge and awareness. Fraud: Any type of intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to the person committing it or any other person. The attempt itself is fraud, regardless of whether or not it is successful.
Abuse: Any practice inconsistent with sound fiscal, business or medical practices that results in an unnecessary cost to the Medicaid program including administrative costs from acts that adversely affect providers or members. If you suspect a provider e. Medicaid number of the provider and facility, if you have it Type of provider doctor, dentist, therapist, pharmacist, etc.
Names and phone numbers of other witnesses who can help in the investigation Dates of events Summary of what happened When reporting possible fraud, waste or abuse involving a member, include: The member s name The member s date of birth, Social Security Number or case number, if you have it The city where the member resides Specific details describing the fraud, waste or abuse The name of the person reporting the incident and his or her callback number will be kept in strict confidence by investigators.
Anonymous Reporting of Suspected Fraud, Waste and Abuse Any incident of fraud, waste or abuse may be reported to us anonymously; however, our ability to fully investigate an anonymously reported matter may be handicapped.
As a result, we encourage you to provide as much detailed information as possible HIPAA The Health Insurance Portability and Accountability Act HIPPA was signed into law in August The legislation improves the portability and continuity of health benefits, ensures greater accountability in the area of health care fraud, and simplifies the administration of health insurance.
Contracted providers are mandated to have appropriate procedures implemented to demonstrate compliance with the HIPAA privacy regulations. We recognize our responsibility under the HIPAA privacy regulations to only request the minimum necessary member information from providers to accomplish the intended purpose.
Conversely, you should only request the minimum necessary member information required to accomplish the intended purpose when contacting us. However, please note that the privacy regulations allow the transfer or sharing of member information, which may be requested by Amerigroup to conduct business and make decisions about care, such as a member s medical record, to make an authorization.
Such requests are considered part of the HIPAA definition of treatment, payment or health care operations. Fax machines used to transmit and receive medically sensitive information should be maintained in an environment with access restricted to individuals who need member information to perform their jobs. When faxing information to us, verify that the receiving fax number is correct, notify the appropriate staff at Amerigroup and verify that the fax was appropriately received.
Internet unless encrypted should not be used to transfer files containing member information to us e. Such information should be mailed or faxed.
Please use professional judgment when mailing medically sensitive information such as medical records. The information should be in a sealed envelope marked confidential and addressed to a specific individual, P. Box or department at Amerigroup. Our voic system is secure and password protected. When leaving messages for our associates, you should only leave the minimum amount of member information required to accomplish the intended purpose.
When contacting us, please be prepared to verify the provider s name, address, NPI number, and tax identification number TIN or Amerigroup provider number. During the welcome call, new members are educated regarding the health plan and available services. Additionally, Member Services representatives perform a Health Needs Assessment to identify issues that need special attention such as pregnancy care.
They also offer to assist the member with any current needs such as scheduling an initial checkup or clarifying benefits under their plan. You are expected to respond to our member s needs and requests in a timely manner. The Nurse HelpLine provides triage services and helps direct members to appropriate levels of care. This ensures members have an additional avenue of access to health care information when needed. Features of the Nurse HelpLine include: Constant availability 24 hours a day, 7 days a week Information based upon nationally recognized and accepted guidelines Free translation services for different languages and for members with difficulty hearing Education for members about appropriate alternatives for handling nonemergent medical conditions The nurse will fax the member s assessment report to provider s office within 24 hours of receipt of the call.
Amerigroup partners with CulturaLink which provides interpretative services for language and hard of hearing deaf. Our relationship with this company assists in improving patient-centered care and create an effective, diverse workforce through services.
Educational materials are developed or purchased and disseminated to our members and network providers who are contracted with Amerigroup. We manage projects that offer our members education and information regarding their health. Ongoing projects include: A semiannual member newsletter Creation and distribution of Ameritips, the Amerigroup health education tool used to inform members of health promotion issues and topics Health Tips on Hold educational telephone messages while the member is on hold Relationship development with community-based organizations to enhance opportunities for members 6.
You, on behalf of the member, may request participation in the program. Comprehensive Member Assessment A case manager will conduct a comprehensive assessment to further determine members needs. The assessment will include a range of questions that identify and evaluate the member s medical and behavioral health condition, functional status, goals, life environment, support systems, emotional status, capability for self-care and the current treatment plan.
Using the structured online assessment tool, case managers will conduct telephone interviews to collect and assess information from the members or their representatives. Individualized Plan of Care Case managers will use information from the assessment to determine appropriateness of care management services and guide, develop and implement a care plan in collaboration with the member, his or her family and the member s provider.
Our experience has shown that members are more likely to comply with treatment planning if they are empowered to make their own health care decisions.
Case managers will consider members needs for social, educational, therapeutic and other non-medical support services such as personal care, WIC and transportation vendors, as well as the strengths and needs of the family.
When the nonmedical needs are extensive or complex, case manager clinicians will collaborate with case manager social workers. Case managers will also coordinate with member advocates or outreach associates to contact difficult-to-reach members and coordinate with community resources. If a member is already receiving care management services from another entity, such as a community services organization, the plan will define processes for coordinating medical, mental health and substance abuse, and social service components of care management and the roles of each team.
Case managers will forward written care plans to practitioners via fax or mail. The components of our approach, which is defined through an Integrated Medical Management Model IM 3 , include continuous monitoring and evaluation.
We typically identify catastrophic cases during daily rounding on the inpatient census, monitoring each case on admission and when a patient s situation changes. A prioritized list of high-risk members with their Chronic Illness Intensity Index, our proprietary predictive model that factors in manageable physical and behavioral health conditions that drive cost and utilization specific to each of these populations Medicaid and Nevada Check Up , is generated monthly using multiple data sources.
This list assigns each member to a management group based on his or her score so that members who are at highest risk are flagged for immediate case management by an interdisciplinary team.
This algorithm also allows identification of members for Disease Management Centralized Care Unit programs. Medical management nurses use their clinical expertise to identify members with health factors, such as chronic illness or behavioral health issues, who would benefit from care coordination services. Our case management staff will routinely conduct systematic review of paid claims, encounter, utilization and pharmacy data, as well as daily census reports, to gain a full picture of members identified for case management.
We will interface with the Pharmacy Benefits Manager to identify candidates for case management based on drug utilization and defined thresholds. Additionally, release from the inpatient setting can be an automatic trigger for case management.
The programs include a holistic, member-centric care management approach that allows care managers to focus on multiple needs of members.
Earning National Committee for Quality Assurance NCQA disease management accreditation is an indication that a disease management program is dedicated to giving patients and practitioners the systems support, education and other help necessary to ensure good outcomes and good care. Members are identified through continuous case finding efforts to include, but not limited to, continuous case finding welcome calls, claims mining and referrals.
Pacific time, Monday through Friday; however, confidential voic is available 24 hours a day. The committee strives to ensure materials and programs meet cultural competency requirements, are easily understood by members and address the health education needs of the member. Members are offered the opportunity to be included on this council. The responsibilities of the Consumer Advocacy Council are: Identifying health education needs of the membership based on review of demographic and epidemiologic data Identifying cultural values and beliefs that must be considered in developing a culturally competent health education program Assisting in the review, development, implementation and evaluation of the member health education tools for the outreach program Reviewing the health education plan and making recommendations on health education strategies Assist the plan in decision making in the areas of member grievances, marketing, member services, case management, outreach, health needs and cultural competency; Provide input into the annual review of policies and procedures, QM program results and outcomes, and future program goals and interventions.
He or she is responsible for providing, managing and coordinating all aspects of the member s medical care and providing all care that is within the scope of his or her practice. We promote the medical home concept to all of our members. Providers in the medical home are knowledgeable about the member s and family s special, health-related social and educational needs and are connected to necessary resources in the community that will assist the family in meeting those needs.
If a newborn is discharged less than 24 hours after delivery, we will reimburse newborn follow-up visits in the physician s office up to four days post-circumcision. When notified that an enrollee has been transferred to another MCO or to FFS, you must have written policies and procedures for transferring relevant patient information, medical records and other pertinent materials to the other plan or FFS provider. Prior to transferring a recipient, you must send the receiving plan or provider information regarding the member s condition.
For most children this would be the school district, and services are provided for the child through an Individual Education Program IEP. When an enrollee is transferred to you from another MCO or FFS, you should request medical records and other pertinent materials from the former provider. New Enrollees Who are Pregnant A pregnant woman who enrolled with us while pregnant must be allowed to remain in the care of a non-network provider if at all possible.
I have a project to understand and modified. I need to know which password encryption technique is using in this project. My web. Add a Solution. Accept Solution Reject Solution. A little Google can get you so far Permalink Share this answer.
Posted Oct pm Kornfeld Eliyahu Peter. Muhammad Taqi Hassan Bukhari Oct am. Kornfeld Eliyahu Peter Oct am. You are really not using your keyboard Now search for hashAlgorithmType You better talk to us with code!!! Does it connected to the original question? Why do you do yourself the hashing? The membership provider does it alone already. Possible there is the problem - you password goes thru hashing twice, one for your and one for the membership provider Actually I have to convert this project in php and mysql.
As there is not such membership class facility in php mysql. NET provider's result Why manually? Can I play with db, means set passwordFormat value to 0 that is clear. Add your solution here. OK Paste as. Treat my content as plain text, not as HTML. Existing Members Sign in to your account. This email is in use. Do you need your password? Submit your solution! For information about using the ASP.
The membership feature requires using a SQL Server database to store the user information. The feature also includes methods for prompting with a question any users who have forgotten their password. Windows Communication Foundation WCF developers can take advantage of these features for security purposes. On the service, WCF security authenticates the user based on the user name and password, and also assigns the role specified by the ASP.
NET role. In the Web. The name attribute is used later as a value in the configuration file. The following example sets it to SqlMembershipProvider. NET membership provider. Set the membershipProviderName attribute to the name of the provider specified when adding the provider in the first procedure in this topic.