Read Health Care Professional and Provider Manual - Manuals - Providers - First Choice - Select Health of South Carolina text version

Health Care Professional & Provider Manual

December 2011

Contents

Practice & Facility Changes Medicaid Managed Care Overview Quality Assessment and Utilization Management Requirements

NCQA HEDIS® Reporting Measures

1 1 1

6

Important Phone Numbers Contracting Requirements

Contracting Requirements Outlined Select Health Credentialing Requirements

Required Credentialing and Re-credentialing Documentation . Select Health Credentialing/Re-credentialing Actions . . . . . Delegated Credentialing Requirements . . . . . . . . . . . . . Health Care Professional/Provider Site Visit Requirements . . Credentialing ­ Health Care Professional/Provider Rights . . . Health Care Professional/Provider Appeals Process . . . . . . Specialist Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 6

6 7

. 7 . 7 . 7 . 8 . 8 . 8 . 9

Health Care Professional/Provider's Bill of Rights Culturally and Linguistically Appropriate Services (CLAS) Advances in Medicine Medical Affairs Department

Utilization Management Program

Adverse Determinations . . . . . . . . . . Medical Record Review Standards . . . . . Medical Record Documentation Standards Medical Record Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9 10 10 10

10

10 11 11 13

Referral and Authorization for Specialists, Hospitals and Ancillary Health Care Professionals/Providers

Participating Specialty Care Health Care Professionals/Providers . Non-Participating Health Care Professionals/Providers . . . . . . Services that Require Prior Authorization . . . . . . . . . . . . . . Services that DO NOT Require Authorization . . . . . . . . . . . . Services that Require Notification . . . . . . . . . . . . . . . . . .

14

14 14 14 15 15

Ancillary Services

Authorization for Ancillary Services Children's Rehabilitative Services and Baby Net Durable Medical Equipment Home Healthcare/Family Support Services Home Infusion/Specialty Pharmacy Speech, Physical and Occupational Therapies

15

15 15 15 15 16 16

Emergency/Urgent Care Services Family Planning Hysterectomy Inpatient Admissions/Outpatient Admissions or Procedures Mental Health/Substance Abuse under First Choice Well-Woman Exam Health Care Professional/Provider Disputes

Informal Disputes Formal Disputes Second Level Formal Dispute Review

16 16 16 16 17 17 17

17 18 19

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Table of Contents

i

Medical Review Determinations

Denials Appeal of Utilization Management and Claims Decisions Expedited Appeal Case Management Program

Intensive (Complex) Case Management . Disease Management Programs . . . . . Emergency Room Outreach Program . . Rapid Response/Episodic Care Program Healthy Moms and Babies Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

19 19 20 20

20 20 21 21 21

First Choice Member Information

Member Access Guidelines Enrollment Eligibility Verification Member Eligibility Member Disenrollment Member Transfer Member No Shows Medicaid Hotline Number Member Rights and Responsibilities

22

22 23 23 23 23 24 25 25 25

Member Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Member Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Advance Directives

26

Living Will and Power of Attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Outreach Services

EPSDT/Immunizations Outreach Foreign Language Interpretation Services

27

27 27

Primary Care Providers

Member Assignment After-Hours Care Use of Network Health Care Professionals/Providers Co-payments Member Transfer Member Grievances EPSDT and Adult Health Screenings Topical Fluoride Varnish Blood Lead Testing Immunizations Synagis

27

27 28 28 28 28 28 29 29 29 29 29

Pharmacy Services

Monthly Prescription Limits Coverage of Generic Products Over-the-Counter Drugs Co-payments Prior Authorization Preferred Drug List Appeal of Prior Authorization Denials

30

30 30 30 30 31 31 31

Claims and Payments

Claims Address Claim Format

31

31 31

ii

Select Health of South Carolina Health Care Professional & Provider Manual

Table of Contents

Primary Care Provider Encounter Data and Billing Fee-for-Service Payments First Choice Payments ­ as Payment in Full Capitation Payments and Reports Claims Payment Polices/Guidelines Claims Adjustment/Reconsideration Requests Corrected/Resubmitted Claims Refunds/Overpayments Third Party Liability Cost Avoidance/Third Party Liability (TPL/COB) Recovery Submitting Claims Electronically 835 Electronic Remittance Advice

32 32 32 32 32 32 33 33 33 34 34 35

Submitting Corrected Claims Electronically . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Electronic Funds Transfer (EFT)

Emdeon Payment Manager

36

36

Billing Requirements for Certain Services

The EPSDT Program EPSDT/Immunization Claims/Encounters Unlisted Procedure Codes AS Modifier Evaluation and Management Service and Q0091 Claims for Newborn Care Rural Health Center/Federally Qualified Health Center Encounters Family Planning/Elective Sterilization/Induced Abortion

Diagnosis Codes . . . . . . . . . . Procedure Codes . . . . . . . . . . Family Planning Services . . . . . Family Planning Procedure Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36

36 36 37 37 38 38 38 38

38 38 39 39

Components of an EPSDT Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Coding Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

First Choice Covered Services

Audiological Services Chiropractic Services Circumcision Communicable Disease Durable Medical Equipment Emergency, Non-Emergency Medical Transportation Hearing Aids and Hearing Aid Accessories Home Health Services Independent Laboratory and Radiology Services Inpatient Hospital Services Long-Term Care Facilities Maternity Care Mental Health, Alcohol and Other Drug Abuse Services Outpatient Services Physician Services Podiatry Services Prescription Drugs Rehabilitative Therapies Topical Fluoride Varnish Vision Services

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

40

40 40 40 40 40 40 40 41 41 41 41 41 41 41 42 42 42 42 42 42

Table of Contents

iii

Services Provided by Medicaid Fee-for-Service Exhibit Listing

Definitions SC Healthy Connections Card First Choice Member ID Card Chart, Periodic Health Guidelines for Children Chart, Periodic Health Guidelines for Adults Chart, Obstetrical Care Guidelines Chart, First Choice Prior Authorization Information Chart, First Choice Prior Authorization Information, page 2 Form, Drug Prior Authorization Request Form, Pregnancy Risk Assessment Information Form, 17-P Authorization Form, Hysterectomy Acknowledgement Form, Prior Authorization, General Form, Prior Authorization, DME Form, Prior Authorization, PT/OT/ST/Chiro Form, Member Consent to Provider Form, Overpayment Worksheet Form, Sample WIC Referral Sample Provider/Member Roster Sample Capitation Payment Roster Sample Select Health Remittance Advice

43 45

46 47 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

iv

Select Health of South Carolina Health Care Professional & Provider Manual

Table of Contents

· Improved health outcomes · Improved overall cost effectiveness of the Medicaid program Medicaid beneficiaries have a choice among models: TELEPHONE: 843.569.1759 FAX: 843.569.0702 · Managed Care Organizations (MCOs): The MCO model is a fully capitated plan that provides a core benefit package similar to that provided under the current Medicaid program. These models usually include enhanced benefits and services in addition to the core benefit package. · Primary Care Case Management (PCCM): The PCCM is a physician-driven managed care entity comprised of local physicians. The participating physicians and their practices make up the medical homes local network of health care professionals/ providers. · Traditional Medicaid Fee-for-Service: The Traditional Medicaid Fee-for-Service model is the traditional Medicaid program reimbursing by fee schedule. Health Care Professionals/Providers are strongly encouraged to check for MCO and PCCM enrollment prior to performing a service. If the beneficiary is enrolled in a PCCM, the health care professional/ provider will need a referral from the primary care health care professional/provider prior to rendering services. If the beneficiary is enrolled in an MCO, the health care professional/provider must be contracted with the managed care company or may need to obtain prior authorization in order to be reimbursed.

Practice & Facility Changes

Please provide practice, physician and/or facility changes to us in writing and on practice letterhead. Having your correct information is vital for accurate directories, claims payment and credentialing. Because of the critical need for accuracy, we are unable to process verbal requests. Changes requiring written notification include (but may not be limited to): · Practice opening and/or closing to new members · Physician name changes · Practice mergers resulting in name or tax identification number changes · Health Care Professional/Provider/Facility NPI numbers · Changes to or additional facility locations or telephone numbers · Changes to tax identification numbers or payee information · Changes in physician participation (doctors joining or leaving the practice with effective dates) Thank you!

Medicaid Managed Care Overview

Quality Assessment and Utilization Management Requirements

Select Health of South Carolina, Inc., is a stateapproved managed care organization (MCO) currently participating in the Healthy Connections Choices program. Healthy Connections Choices is a state program that helps Medicaid beneficiaries enroll in health plans to get Medicaid services. Through the coordination of services, managed care results in: · Improved health status of members · Increased access to primary and preventive care · Increased access to appropriate, coordinated, quality healthcare services

All managed care organizations (MCOs) that contract with the South Carolina Department of Health and Human Services (SCDHHS) to provide Medicaid MCO Program Services must have a Quality Assessment (QA) and Utilization Management (UM) process that meets the following standards: 1 . Comply with 42 Code of Federal Regulations (CFR) 438.240 which states that the MCO must have a quality assessment system that: a . Is consistent with the utilization control requirement of 42 CFR 456; b . provides for review by appropriate health 1

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Quality Assessment and Utilization Management Requirements

professionals of the process followed in providing health services; c. provides for systematic data collection of performance and patient results; d . provides for interpretation of this data to the health care professional/providers; and e . provides for making needed changes. 2 . Maintain and operate a Quality Assessment (QA) program which includes at least the following elements: a . A quality assessment plan which shall include a statement that the objective of the QA plan is to "monitor and evaluate quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems." QA efforts should be health outcome oriented and rely upon data generated by the MCO as well as that developed by outside sources. The plan must be organized and written so that staff members and health care professional/providers can understand the program's goals, objectives and structure and should incorporate information from customer service, appeals and grievances, medical management, credentialing and health care professional/provider relations. b . QA Staff - The QA plan developed by the MCO shall name a quality director, manager or coordinator responsible for the operation and success of the QA program. Such person shall be a registered nurse, have adequate and appropriate experience to conduct a successful QA program, and shall be accountable for QA in all of the MCO's own health care professionals/providers, as well as the MCO's subcontractors. The person shall spend at least 80% of his/her time dedicated to QA activities to ensure the success of the QA program. In addition, the medical director must have substantial involvement in QA activities. c. QA Committee - The MCO's QA program shall be directed by a QA committee which has the substantial involvement of the medical director and includes membership from: a variety of health professions (e.g., pharmacy, physical therapy, nursing, etc.); a variety of medical disciplines (e.g., medicine, surgery, radiology, etc.), with emphasis on primary 2

care including obstetric and pediatric representation; and MCO management or Board of Directors d . The QA committee shall be in an organizational location within the MCO such that it can be responsible for all aspects of the QA program. e . The QA committee shall meet at least quarterly and produce dated and signed written documentation of all meetings and committee activities. This documentation as well as documented QA activities and outcomes shall be submitted on a quarterly basis to the MCO Board of Directors and the SCDHHS authorized agents. f . The QA activities of MCO health care professionals/providers and subcontractors, shall be integrated into the overall MCO/QA program. The MCO QA Program shall provide feedback to the health care professionals/providers/ subcontractors regarding the integration of, operation of, and corrective actions necessary in health care professional/provider/subcontractor QA efforts.

g. The MCO shall have a written procedure for implementing the findings of QA activities, and following up on the implementation to determine the results of QA activities. Followup and results shall be documented in writing, and copies provided to both the MCO Board of Directors and the SCDHHS. h. The MCO shall make use of the SCDHHS utilization data or their own utilization data, if equally or more useful than the SCDHHS utilization data, as part of the QA program. i . Quality Assessment and Performance Improvement Program (QAPI): The MCO shall have an ongoing quality assessment and performance improvement program for the services it furnishes to members. At a minimum, the MCO shall: · Conduct performance improvement projects. These projects must be designed to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in clinical care and non-clinical care areas that are expected to have favorable effect on health outcomes and enrollee satisfaction. · Submit performance measurement data.

Select Health of South Carolina Health Care Professional & Provider Manual

Quality Assessment and Utilization Management Requirements

· Have in effect mechanisms to detect both under-utilization and over-utilization of services. · Have in effect mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs. j. Performance Measurements: Annually the MCO shall: · Measure and report to SCDHHS its performance using all NCQA defined HEDIS® measures applicable to Medicaid by June 15th of the following calendar year. · Reporting must use the NCQA definitions for that respective measurement year (i.e. 2009 data must use 2009 definitions). k. Performance Improvement Projects (PIP): Annually, the Contractor shall have an ongoing program of performance improvement projects (a minimum of one project and a maximum of three projects) that focus on clinical and non-clinical areas, and involve the following: · Quantitative and Qualitative measurements of performance using standard objective quality indicators. · Implementation of system interventions to achieve improvement in quality. · Evaluation of the effectiveness of the interventions. · Planning and initiation of activities for increasing or sustaining improvement. These projects must be designed to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in clinical care and nonclinical care areas that are expected to have favorable effect on health outcomes and enrollee satisfaction. l . In future contracts, pay-for-performance will be used to access the quality improvement measured in HEDIS® and CAHPS® survey.

meetings for physician office staff concerning on-site medical chart reviews, and encourage attendance at these meetings by MCO and physician office staff, as needed. The MCO will assist the SCDHHS and the EQRO under contract with the SCDHHS, as needed, in securing records needed to conduct off-site medical chart reviews. MCO will facilitate training provided by the SCDHHS to its health care professionals/ providers. MCO will allow duly authorized agents or representatives of the State or Federal government, during normal business hours, access to MCO's premises or MCO subcontractor premises to inspect, audit, monitor or otherwise evaluate the performance of the MCOs or subcontractors contractual activities. When deficiencies are found, the MCO will submit a Plan of Correction which includes the following: · Identifies each deficiency · Specifies the corrective action to be taken · Provides a timeline by which corrective action will be completed. 4 . Assure that all persons, whether they be employees, agents, subcontractors or anyone acting for or on behalf of the health care professional/provider, are properly licensed and/or certified under applicable state law and/or regulations and are eligible to participate in the Medicaid/ Medicare program. The MCO must have written policies and procedures for credentialing and recredentialing. The MCO may use its own Credentialing Form or the South Carolina Uniform Managed Care Health Care Professional/Provider Credentialing Application developed by the South Carolina Medical Association. The MCO may use its own Re-Credentialing Form or the South Carolina Uniform Managed Care Health Care Professional/ Provider Credentials Update Form also developed by the South Carolina Medical Association. Copies of these may be downloaded at the following site: http://www.scmca.org/download/UCA2004. pdf. The MCO shall maintain a copy of all plan health care professionals/providers current valid license to practice. The MCO shall have policies and procedures for approval of new health care professionals/providers and termination or suspension of a health care professional/provider. The MCO shall have a mechanism for reporting quality deficiencies which result in suspension or 3

3 . Assist the SCDHHS in its quality assurance activities. The MCO will assist, in a timely manner, the SCDHHS and the External Quality Review Organization (EQRO) under contract with the SCDHHS, as needed, in identification of health care professional/provider and recipient data required to carry out on-site medical chart reviews. The MCO will arrange orientation

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Quality Assessment and Utilization Management Requirements

termination of a health care professional/provider. 5 . The MCO must have systems in place for coordination and continuation of care to ensure well managed patient care, including at a minimum: a . Written policies and procedures for assigning every member a primary care provider. b . Management and integration of health care through primary care providers. The MCO agrees to provide available, accessible and adequate numbers of institutional facilities, service location, service sites, professional, allied, and paramedical personnel for the provision of covered services, including all emergency services, on a 24-hour-a-day, 7-day-a-week basis. c. Systems to assure referrals for medically necessary, specialty, secondary and tertiary care. d . Systems to assure provision of care in emergency situations, including an education process to help assure that members know where and how to obtain medically necessary care in emergency situations. e . Specific referral requirements for in and out of plan services. MCO shall clearly specify referral requirements to health care professionals/providers and subcontractors and keep copies of referrals (approved and denied) in a central file or the member's medical record. f . The MCO must assign an MCO qualified representative to interface with the case manager for those members receiving out of plan continuity of care and case management services. The MCO representative shall work with the case manager to identify what Medicaid covered services, in conjunction with the other identified social services, are to be provided to the member.

to maintain, individual medical records for each Medicaid member which make readily available to the SCDHHS and/or its designee and to appropriate health professionals all pertinent and sufficient information relating to the medical management of each enrolled member. Procedures shall also exist to provide for the prompt transfer of patient care records to other in or out-of-plan health care professionals/providers for the medical management of the member. b . Is readily available for MCO-wide QA and UM activities and provides adequate medical and other clinical data required for QA/UM.

c. Has adequate information and record transfer procedures to provide continuity of care when members are treated by more than one health care professional/provider. d . Contains information in accordance with the medical records standards for documentation (page 20). 7 . Submit Encounter Data as required on a monthly basis. This data shall be submitted in a format as specified by SCDHHS. a . The MCO must report EPSDT and other preventive visit compliance rates. b . All MCO contracts with network health care professionals/providers/subcontractors shall have provisions for assuring that data required on the encounter report is reported to the MCO by the network health care professional/provider/subcontractor. c. For the purposes of reporting individuals by age group, the individual's age should be the age on the date of service 8 . The MCO shall have written utilization management policies and procedures that include at a minimum : a . Protocols for denial of services, prior approval, hospital discharge planning and retrospective review of claims. b . Processes to identify utilization problems and undertake corrective action. c. An emergency room log, or equivalent method, specifically to track emergency room utilization and prior authorization (to include denials) reports. d . Processes to assure that abortions comply

6 . The MCO shall have a system for maintaining medical records for all Medicaid members in the plan, to ensure the medical record: a . Is accurate, legible and safeguarded against loss, destruction, or unauthorized use and is maintained, in an organized fashion, for all individuals evaluated or treated, and is accessible for review and audit. Also, the MCO shall maintain, or require its network health care professionals/providers and subcontractors 4

Select Health of South Carolina Health Care Professional & Provider Manual

Quality Assessment and Utilization Management Requirements

with 42 CFR 441 subpart E-Abortions, and that hysterectomies and sterilizations comply with 42 CFR 441 subpart F Sterilizations. 9 . The MCO shall furnish Medicaid members with approved written information about the nature and extent of their rights and responsibilities as a member of the MCO. The minimum information shall include: a . Written information about their managed care plan b . The health care professionals/providers providing their healthcare c. Information about benefits and how to obtain them d . Confidentiality of patient information e . The right to file grievance about the MCO and/or care provided f . Information regarding advance directives as described in 42 CFR 417.436 and 489.1 subpart I

MCO program member. Also for notifying the member who grieves, that if the member is not satisfied with the decision of the MCO, the member can make a request to the Division of Appeals and Hearings, SCDHHS for a state fair hearing. If the grievance or appeal is not resolved during the fair hearing, the grievant/appellant may request reconsideration by SCDHHS or file an appeal with the Administrative Law Judge Division. 11 . SCDHHS is required to evaluate each MCO's compliance with SCDHHS program's policies and procedures, identify problem areas and monitor the MCO's progress in this effort. At a minimum this will include, but is not limited to: a . SCDHHS will review and approve the MCO's written Quality Assurance Plan. The MCO must submit any subsequent changes and/ or revisions to its Quality Assurance Plan to SCDHHS for approval on or before April 30th annually. b . The SCDHHS will review and approve the MCOs written grievance and appeal policies and procedures. The MCO must submit any subsequent changes and/or revisions to its Grievance and Appeal Policy and Procedures to SCDHHS for approval prior to implementation. c. The SCDHHS shall review monthly individual encounter/claim data. Encounter claim data shall be reported in a standardized format as specified by SCDHHS and transmitted through approved electronic media to SCDHHS. d . The SCDHHS shall review quarterly quality measure reports. The reports will be submitted to SCDHHS in the format specified by SCDHHS. e . SCDHHS staff will review the MCO's reports of grievances, appeals, and resolution. f . SCDHHS staff will approve the MCO's Plan of Correction (POC) and monitor the MCO's progress with the corrective actions developed as a result of the annual external QA evaluation or any discrepancies found by the SCDHHS that require corrective actions.

g. Information that affects the members enrollment into the MCO 10 . Establish and maintain grievance and appeal procedures. The MCO shall: a . Have written policies and procedures which detail what the grievance system is and how it operates. The grievance procedures must comply with the guidelines outlined by SCDHHS. b . Inform members about the existence of the grievance processes. c. Attempt to resolve grievances through internal mechanisms whenever possible. d . Maintain a record keeping system for oral and written grievances and appeals and records of disposition. e . Provide to SCDHHS on a quarterly basis written summaries of the grievances and appeals which occurred during the reporting period to include: · · · · Nature of grievances and/or appeals Date of their filing Current status Resolutions and resulting corrective action

The MCO will be responsible for forwarding any adverse decisions to SCDHHS for further review or action upon request by SCDHHS or the Medicaid

12 . External Quality Assurance Review - Annually, SCDHHS will conduct an independent review of services provided or arranged by the MCO. The review will be performed by the External Quality Review Organization (EQRO) under contract with 5

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Quality Assessment and Utilization Management Requirements

SCDHHS. External quality assurance evaluation and EQRO responsibilities shall include: a . Readiness Review Survey. The EQRO will conduct a readiness review of the Contractor as designated by SCDHHS. The Medicaid Managed Care External Review Services Manual will serve as a guide for the readiness review survey. SCDHHS will receive a written report within 30 days of the survey. SCDHHS will convey the final report findings to the MCO with a request for a POC. b . Effective January 1, 2013, verify the most recent NCQA Accreditation survey and corresponding status. This survey is conducted every three years by NCQA and is required for plans to serve as contractors to SCDHHS. Prior to this date, verification of the most recent NCQA or URAC Accreditation survey and status with those organizations. c. With SCDHHS staff, conduct workshop and training for MCO staff regarding the abstraction of data for the quality of care studies and other features of the annual QA evaluation. SCDHHS will evaluate the MCO's compliance with the QA standards through an annual comprehensive QA evaluation. The Medicaid Managed Care External Review Audit Tool will serve as a guide for the annual review.

· Medical Services Fax, toll free: 1.888.824.7788 · Medical Services Fax, Charleston area: 843 .863 .1297 · Medical Services Right Fax: 1.866.368.4562 For membership verification, member complaints, requests to transfer members and LSA interpretation services: · Member Services, toll free: 1.888.276.2020 · Member Services, Charleston area: 843.764.1877 · Member Services Fax, Charleston area: 843 .569 .4875 · Member Services Fax, toll free: 1.800.575.0419 For health care professional/provider services and administration, call: · Toll free: 1.800.741.6605 · Charleston area: 843.569.1759 · Fax, Charleston area: 843.569.0702 · For claims: 1.800.575.0418 · Website: www.selecthealthofsc.com

Contracting Requirements

Contracting Requirements Outlined

NCQA HEDIS® Reporting Measures

The following are requirements in all written agreements with health care professionals/providers: 1 . A listing of all individuals or entities who are party to the written agreement; 2 . Definitions for terms used in the agreement; 3 . Conditions for participation as a participating health care professional/provider; 4 . Obligations and responsibilities of the plan and the participating health care professional/ provider, including any obligations for the participating health care professional/provider to participate in the plan's management, complaint or other programs; 5 . Events that may result in the reduction, suspension or termination of network participation privileges; 6 . The specific circumstances under which the network may require access to members' medical records as part of the organization's programs or health benefits; 7 . Healthcare services to be provided and any related restrictions;

Use guidelines for HEDIS® measures defined by NCQA for that respective measurement year (i.e. measures reported in 2010 are for the 2009 measurement year and must follow the specifications published for that measurement year). Measures must be submitted to SCDHHS by June 15th of the following calendar year (the reporting year). Data must be submitted to SCDHHS in XML format. A timeline for submitting HEDIS® and CAHPS® survey measures is published by the NCQA, and should be followed to ensure timely submission.

Important Phone Numbers

For information related to prior authorizations, appeals, clinical questions, membership verification, case management, health management programs or to contact the medical director, call: · Medical Services, toll free: 1.888.559.1010 · Medical Services, Charleston area: 843.764.1988 6 Important Phone Numbers

Select Health of South Carolina Health Care Professional & Provider Manual

8 . Requirements for claims submission and any restrictions on billing of members; 9 . Participating health care professional/provider payment methodology and fees; 10 . Mechanisms for dispute resolution by participating health care professionals/providers; 11 . Term of the contract and procedures for termination of the contract; 12 . Requirements with respect to preserving the confidentiality of patient health information; 13 . Prohibitions regarding discrimination against members.

Select Health Credentialing/Re-credentialing Actions

Select Health will: · Verify state license through appropriate licensing agency. · Verify Board Certificate or residency training or medical education. · Query National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank. · Verify hospital privileges in good standing at a Select Health participating hospital. · Review five years of work history. · Review sanction activity from Medicare/Medicaid.

Select Health Credentialing Requirements

All physicians, physician extenders and ancillary service health care professionals/providers who serve Select Health plan members must complete the credentialing process prior to treating any members. All health care professionals, ancillary providers and organizational providers such as hospitals and home health groups are re-credentialed every three years.

Delegated Credentialing Requirements

The following functions are required by the plan when delegating credentialing activities to a health care professional/provider: · Services must be performed in accordance with the plan's requirements and plan's appointed accrediting organization's standards. · Notification of any material change in the health care professional/provider's performance of delegated functions must be submitted to the plan. · Plan may conduct surveys of health care professional/provider as needed. · Health care professional/provider agrees to submit periodic/annual file audits conducted by the plan regarding the performance of its delegated responsibilities. · Health care professional/provider agrees to submit to periodic file audits conducted by the plan's appointed accrediting organization. · Recourse and/or sanctions will apply if the health care professional/provider does not make corrections to identified problems within a specified period. · Health care professional/provider must obtain the plan's written approval prior to further delegation of organizational functions. · Should the health care professional/provider further delegate organizational functions, those functions shall be subject to the terms of the written agreement between the health care professional/provider and the plan and in accordance with the plan's appointed accrediting organization's standards . Contracting Requirements 7

Required Credentialing and Re-credentialing Documentation

· Copy of current state medical license · Copy of current Federal DEA · Copy of current State Controlled Substance · Copy of current malpractice insurance coverage · Copy of current Patient Care Compensation Fund (if applicable) · Copy of CLIA (if applicable) · Application ­ Each application includes a signed attestation and addresses the following: · Reasons for any inability to perform the essential functions of the position, with or without accommodation; · Lack of present illegal drug use; · History of loss of license and felony convictions; · History of loss or limitation of privileges or disciplinary activity; · The correctness and completeness of the application. All documents must be current within 180 days of the credentialing/re-credentialing decision. All documents needed for credentialing/re-credentialing can be found on the Select Health website, www. selecthealthofsc.com .

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Health Care Professional/Provider Site Visit Requirements

Site visits are performed at all health care professional/provider offices during the initial credentialing process. A satisfactory review must be completed prior to finalization of the credentialing process or when a participating OB/GYN or PCP physician opens a new office site. Site review evaluates the appearance and accessibility of the facility, record-keeping practices and safety procedures. A site visit will also be conducted when a complaint has been logged against a specific provider for concerns regarding medical record keeping, accessibility, availability or physical site quality. If areas are identified that require corrective action, the Contract Management Representative will work with the provider over time to improve these areas.

Health Care Professional/Provider Appeals Process

Credentialing ­ Health Care Professional/ Provider Rights

In the event a health care professional/provider is denied ongoing network participation or re-credentialing as a Select Health health care professional/provider by the health plan based on an administrative reason or for quality of care reasons, the health care professional/provider is offered a process to appeal the determination. The appeal process described below will be communicated via certified mail to the health care professional/provider within 5 (five) business days of Credential Committee determination. The certified letter defines the reason for the denial and the health care professional/ provider appeals rights. The health care professional/ provider is instructed to file for reconsideration by submitting a written appeal, submitting additional information, as appropriate, within thirty (30) days of the denial notification. · The health care professional/provider shall be given written notice stating that the health care professional/provider has been denied re-credentialing as a Select Health health care professional/provider and setting forth the reasons for the denial. The notice shall also state that the health care professional/provider has thirty (30) calendar days from the date of the notice to request a hearing before Select Health's Total Quality Management Committee (TQM) to appeal the denial, and shall contain a summary of the rights described in paragraphs 3 and 4, below. The request for a hearing must be in writing and must state the relief sought by the health care professional/provider submitting the request. · The TQM Committee will consist of at least three qualified individuals one of whom must be a participating health care professional/provider who is not otherwise involved in network management and is a clinical peer of the health care professional/provider filing the appeal. A clinical peer of the appealing health care professional/provider will be added if not otherwise represented within the TQM Committee. The clinical peer health care professional/provider selected must not have been otherwise involved in any previous review of the case appealed. · If a timely request for a hearing is made, Select Health shall give the health care professional/ provider a second written notice stating the place, time and date of the hearing;

Health care professionals/Providers have the right to: · Review information obtained through primary source verification for credentialing purposes. This includes information from malpractice insurance carriers and state licensing boards. This does not include information collected from references, recommendations and other peer review protected information. · Be notified if any credentialing information is received that varies substantially from application information submitted by the health care professional/provider will be notified of any of the following types of variances: e.g., actions on license, malpractice claim history, suspension or termination of hospital privileges, or board-certification decisions with the exception of references, recommendations or other peer-review protected information. Health care professional/provider will have the right to correct erroneous information if the credentialing information received varies substantially from the information that was submitted on his/her application. · Upon request, be informed of the status of their application ­ if application is current and complete the applicant can be informed of the tentative date that his/her application will be presented to the Credentialing Committee for approval.

8

Select Health of South Carolina Health Care Professional & Provider Manual

Contracting Requirements

· The hearing shall be held before Select Health TQM Committee. At the hearing the health care professional/provider shall have the right to: · Appear in person and present evidence relevant to their case · Submit a written statement to the TQM Committee at the close of the hearing. · Within five (5) business days the health care professional/provider will receive a written decision of the TQM Committee regarding the appeal (including a statement of the basis for the decision). · A health care professional's/provider's right to a hearing shall be forfeited if the health care professional/provider fails, without good cause, to appear at the hearing. · After the health care professional/provider is notified of the decision by the TQM committee to uphold the proposed action, the health care professional/provider has the right to seek arbitration as outlined in their health care professional/ provider contract pursuant to section 15-48-10 ET SEQ. of the South Carolina Code of Laws (The South Carolina Uniform Arbitration Act) as modified in their signed contract with Select Health of South Carolina . · In the event that the health care professional/ provider is terminated or scope of practice is limited by the plan, notification will be made to the proper agency/agencies. The plan will provide required notification to the proper agencies once the health care professional/provider has exhausted all appeal levels or once timeframes for initiating appeal process have expired.

Health Care Professional/ Provider's Bill of Rights

Each Select Health health care professional/provider shall be assured of the following rights: · A healthcare professional, acting within the lawful scope of practice, shall not be prohibited from advising or advocating on behalf of a member who is his/her patient, for the following: · The member's health status, medical care or treatment options, including any alternative treatment that may be self-administered. · Any information the member needs in order to decide among all relevant treatment options. · The risks, benefits and consequences of treatment or non-treatment. · The member's right to participate in decisions regarding his/her healthcare, including the right to refuse treatment and to express preferences about future treatment decisions. · To receive information on the grievance, appeal and fair hearing procedures. · To have access to Select Health's policies and procedures covering the authorization of services. · To be notified of any decision by Select Health to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested. · To challenge, on behalf of the First Choice members, the denial of coverage of, or payment for, medical assistance. · Select Health's health care professional/provider selection policies and procedures must not discriminate against particular health care professionals/providers that serve high-risk populations or specialize in conditions that require costly treatment. · To be free from discrimination for the participation, reimbursement or indemnification of any health care professional/provider who is acting within the scope of his/her license or certification under applicable state law, solely on the basis of that license or certification.

Specialist Termination

When a specialty group's contract with Select Health is terminated, it is the responsibility of the specialty group to notify Select Health members affected by the termination prior to the effective date. Members who will be affected by the termination are those members who are receiving an active course of treatment from any of the specialists within the group. The specialty group must also provide continuation of care through the lesser of the current treatment or up to 90 calendar days for members undergoing active treatment for a chronic or acute medical condition. PROVIDERS must provide continuation of care through the postpartum period for members in their second or third trimester of pregnancy.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Health Care Professional/Provider's Bill of Rights

9

Culturally and Linguistically Appropriate Services (CLAS)

Select Health has adopted the national standards for Culturally and Linguistically Appropriate Services (CLAS) as issued by the U. S. Department of Health and Human Services' Office of Minority Health. As a health plan focusing on the Medicaid population, we have an uncommon appreciation for the need to provide culturally and linguistically appropriate services for our members. As part of our commitment to diversity, Select Health will work to establish comprehensive policies and procedures, including a written Cultural Competency Plan, to ensure that members are served in the way that is responsive to their cultural or language needs. This commitment to diversity may require information from our health care professionals/providers as directed by Title VI of the Civil Rights Act of 1964 (65 Fed. Reg. 52762-52774, Aug. 30, 2000). At regular intervals, the Network Management staff will remind health care professionals/providers about the importance of cultural competence, effective communication with Limited English Proficiency (LEP) members and health care professionals/providers' responsibility for implementing appropriate measures that would ensure that languages, environment or other sensory barriers that could exclude, deny, delay or prevent timely delivery of healthcare or social services be removed.

management system within the scope of the Quality Improvement Program. UM activities are designed to assist the health care professional/provider in the organization and delivery of appropriate healthcare resources to members over the course of the member's illness within the structure of their benefit plan. The primary goal of all utilization management functions is to collaborate with health care professionals/providers, members and others involved in healthcare delivery, to provide quality, cost effective healthcare in the most appropriate setting for the intensity of services required. · UM staff is composed of licensed or registered nurses and triage technicians. · Determinations of approval or denial of payment for services is based on medical necessity, eligibility for outpatient and inpatient services and benefit guidelines. · Utilization management (UM) decision making is based only on the appropriateness of care and services and existence of coverage. Select Health does not reward health care professionals/ providers or other individuals conducting utilization review for issuing denials of coverage or services. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. The UM program utilizes licensed InterQual criteria and South Carolina State Medicaid Health care professional/provider/Hospital Guidelines for review of inpatient, surgical and outpatient procedures.

Advances in Medicine

When new medical treatment becomes available, Select Health follows the recommendations that are made by South Carolina's Department of Health and Human Services (SCDHHS) to cover a new procedure or treatment. Prior to making a decision the doctors at SCDHHS review all clinical and scientific facts available with the risks and benefits for the new procedure. Select Health will refer requests for new medical treatment not routinely covered to SCDHHS for determination of Medicaid coverage.

Adverse Determinations

Medical Affairs Department

Utilization Management Program

The Select Health Utilization Management (UM) program establishes a process for implementing and maintaining an effective, efficient utilization 10

In situations where available clinical information does not support medical necessity or appropriateness by criteria approved by Select Health, the request for services will be reviewed by Select Health's medical director. During the review process, the medical director may elect to discuss or consult with an external board certified same specialty physician from an NCQA certified independent review organization. The medical director, utilizing the plan's criteria, his/ her medical expertise and external resources determines if the request for payment of services will be approved or denied. All adverse determinations are communicated in writing to the member and requesting health care professional/provider. This communication provides clear reasons for denial and appeal process information. The requesting health care professional/provider

Select Health of South Carolina Health Care Professional & Provider Manual

Culturally and Linguistically Appropriate Services (CLAS)

may contact Select Health and request a copy of the criteria used in rendering the final determination. Additionally, plan medical directors are available to discuss medical necessity determinations with the requesting health care professional/provider. Health care professionals/providers may contact Medical Services to request a peer to peer discussion.

number, employer and next of kin, sponsor or responsible party. a . Record includes a page or form on which includes the member's name, identification number, date of birth, sex, address, telephone numbers, employer and next of kin, sponsor or responsible party. 3 . The record is legible by someone other than the writer. A second surveyor examines any record judged to be illegible by one surveyor. a . Handwritten entries are legible to a reader other than the author. b . Content of record is presented in a standard format that allows a reader other than the author to review w/o the use of a separate legend/key. 4 . Each page in the record contains the patient's name or ID number. a . Patient name or identification number is found on each page in the record. 5 . All entries, including each office or telephone encounter is clearly dated and initialed or signed by the service provider or author. a . If more than one person documents in the medical record, there must be a record on file as what is represented by which initials. b . All entries and or updates to the record are dated . c. All entries are initialed or signed by the author. Electronic medical records indicate authors by initials or automated system generated names. This applies to health care professional/providers and members of their office staff who contribute to the records. d . When initials are used there is a designation of signatures and status maintained in the office. e . Documentation of medical encounters must be in the record within 72 hours or three business days of the occurrence. 6 . Allergies and adverse reactions are prominently listed. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record as "NKA" or "None". a . A record of allergies or the statement "no known allergies" or NKA should be clearly found at a standard place on the chart (e.g. on the cover of the chart, on the first page of the Medical Affairs Department 11

Medical Record Review Standards

It is the policy of Select Health to set standards for the maintenance and content of patient records to ensure complete and consistent documentation. Medical records are an important source of patient information vital to the assessment of quality medical care. These standards are based on the National Committee for Quality Assurance (NCQA) and South Carolina Department of Health and Human Services (SCDHHS) and may be revised as needed to conform to new NCQA or SCDHHS requirements. Compliance with these standards will be audited by periodic review and chart samplings of the participating primary care offices. Health care professionals/ providers must achieve an average score of 90% or higher on the medical records review. Select Health will assist health care professionals/providers scoring less than 90% through corrective action plans and re-evaluation.

Medical Record Documentation Standards

Select Health has adopted the following medical record-keeping standards to ensure complete and consistent documentation of patient medical records which are vital to quality patient care. In order to assess compliance, Select Health monitors PCP sites for adherence annually. In addition to the following medical record documentation standards, Select Health reviews the overall PCP office site to ensure the confidentiality of patient medical records by maintaining records in a secure area that is only accessible to health care professional/provider's office staff. 1 . The member's medical record is kept in a separate file and located in a secure confidential area. a . Member's medical record is kept in a separate file and all papers are fastened together. All medical records are kept in a secure, confidential area. 2 . Member record contains the patient's name, ID number, date of birth, sex, address, phone

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

chart, on a medication list or the problem list). There should be an inquiry about allergies on the first visit. 7 . Past medical history is listed, includes operations, treatment and therapy prescribed and any medications administered or dispensed. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses. a . Initial history and physical exam for new patients are recorded within 12 months of the patient first seeking care or within three visits, whichever comes first. If applicable, there is written evidence that the health care professional/provider advised the patient to return for a physical exam. 8 . A current Problem List is in the chart, identifying health related conditions. a . Each patient record includes a Problem List, documenting any health related conditions or chronic conditions requiring ongoing monitoring and treatment. => N/A if pt has no chronic condition. 9 . Current medications are documented in the record and notes reflect that long-term medications are reviewed at least annually by the health care professional/provider and updated as needed . a . Information regarding current medication is readily apparent from review of the record. b . Changes to medication regimen are noted as they occur. When medications appear to remain unchanged, the record includes documentation of at least annual review by the health care professional/provider. 10 . There is evidence that preventative screening and services are offered in accordance with Select Health practice guidelines. a . Each patient record includes documentation that preventive services were ordered and performed, or that the health care professional/provider discussed preventive services with the patient and the patient chose to defer or refuse them. Health care professional/providers may document that a patient sought preventives services from another health care professional/provider (e.g. GYN). 11 . Patient's chief complaint or purpose for visit is clearly documented. 12 Medical Affairs Department

a . A patient's chief complaint or purpose for a visit as stated by the patient is recorded. The documentation supports that the patient's perceived needs/expectations were addressed . b . Telephone encounters relevant to medical issues are documented in the medical record and reflect health care professional/provider review. 12 . Clinical/physical assessment and/or objective findings are recorded. a . Clinical/ Physical assessment and objective findings are documented and correspond to the patient's chief complaint, purpose for seeking care and/or ongoing care for chronic illnesses . 13 . Appropriated working diagnoses or medical Impressions are recorded. a . Working diagnoses or medical impressions that logically follow from the clinical/physical examination are recorded. 14 . Plan of treatment: diagnostic tests, therapies, laboratory, medications and other prescribed regimens are listed for each visit. a . Treatment plans, diagnostic tests, therapies, laboratory tests, medications and other prescribed regimes are clearly documented for each visit and follow previously documented diagnoses and medical impressions. 15 . Plan of action/treatment are consistent with diagnosis. a . Rationale for treatment decisions appears medically appropriate and substantiated by documentation in the record. b . Laboratory tests are performed at appropriate intervals. 16 . Follow- up instructions and time frame for followup or next visit are recorded as appropriate. a . Return to Office in a specific amount of time is recorded at the time of visit, or as follow-up to consultation, laboratory or other diagnostic reports. b . Patient involvement in the coordination of care is demonstrated through patient education, follow up and return visits. 17 . Relevant hospital discharge summaries are included with the medical record. a . If the patient has been hospitalized a

Select Health of South Carolina Health Care Professional & Provider Manual

discharge summary from the facility is included in the chart. b . The discharge summary should include the reason for admission, the treatment provided and the instructions given to the patient on discharge. c. The discharge summary should be initialed or signed by the health care professional/ provider to indicate the health care professional/provider's review. d . If the patient has not yet been discharged or only discharged within the previous two weeks, the review should indicate a N/A. 18 . If a consultation is requested there is a note from the consultant in the record. Consult reports reflects health care professional/provider's review with initials or signature. a . If a consult has been ordered by the health care professional/provider, a report from the consulting provider has been placed in the record. b . The report should be initialed or signed by the health care professional/provider to indicate the health care professional/provider's review of the results of the consult or noted in the electronic medical record. If the request is less than three weeks old, reviewer should indicate a N/A. 19 . Diagnostic and laboratory reports reflect health care professional/provider's review with initials or signature. a . Results of all diagnostic and laboratory reports are documented in the medical record. b . Records demonstrate that the health care professional/provider reviews diagnostic and laboratory reports and makes treatment decisions based on report findings. Reports with the review are initialed and dated by the health care professional/providers or another system ensuring health care professional/ provider review is in place. Electronic medical records indicate health care professional/ provider's review by initials or automated system generated names. 20 . For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol, and substances. a . The health care professional/provider must have documentation in the record regarding

smoking habits and history of alcohol use and substance abuse for patients 12 years of age and older . 21 . Discussion of a living will or Advanced Directives, as appropriate. a . A note regarding discussing a living will or other advance directives should be present in the medical record, if appropriate* * Defined as patients who are terminally ill or those with a serious chronic illness. Terminally ill may be defined as advanced stages of cancer, Alzheimer's Disease, severe stroke, heart disease, lung disease, renal failure, or other fatal illnesses, all of which have a very limited prognosis. A serious chronic condition causes suffering and/or disability every day that will worsen over time and eventually cause death. 22 . Documentation in record of after-hour services to include: emergency care, after hour encounters, follow-up. a . Health care professional/providers must document any after hour services and/or telephone encounters with the patient into the permanent record. Emergency encounters should also be documented either in the form of the hospital emergency room record or a signed and dated notation as to when the patient was seen in the ER, the diagnosis and any recommendation.

Medical Record Retention

Select Health health care professionals/providers are required to comply with all medical record retention statutes in accordance with state and federal law. The South Carolina statute currently requires record retention for a period of 10 years for adults and 13 years for children after last documented visit. All Select Health members' medical records are to be maintained by physicians for a period not less than five years from the expiration date of the contract with Select Health, including any contract extensions and retained further if the records are under review or audit until the review or audit is complete. Said records are to be made available for fiscal audit, medical audit, medical review, utilization review and other periodic monitoring upon request of an authorized representative of South Carolina Department of Medical Affairs Department 13

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Health and Human Services (SCDHHS). Prior approval for the disposition of records must be requested from SCDHHS. If any litigation, claim or other action involving the records has been initiated prior to the expiration of the five-year period, the records shall be retained until completion of the action and resolution of all issues which arise from it or until the end of the five-year period, whichever is later.

· Eyeglasses (second pair of eyeglasses for children) · Home healthcare (required after first 6 visits) · Home infusions (including injections $250 and greater; if medication is approved so is the administration) · Hyperbaric oxygen · Inpatient admission (including back transfers) · Non-participating health care professional/provider (all services including urgent care and office-based laboratory) · Medications (infusions/injectibles chemotherapy, PO and IV, Vitraset, Synagis) · Outpatient maternity/OB services · Outpatient surgical services: · · · · · · · · · · · · · · · · · Ablation Blepharoplasty Chemodenervation Cochlear implants (insertion and programming) ENT procedures Gastric bypass Vertical band gastroplasty Hysterectomy Implants Mastectomy for gynecomastia Mastoplexy Maxillofacial Panniculectomy Penile prosthesis Plastic surgery/cosmetic dermatology Reduction mammoplasty Septoplasty

Referral and Authorization for Specialists, Hospitals and Ancillary Health Care Professionals/Providers

Participating Specialty Care Health Care Professionals/Providers

Select Health encourages members to seek referral from their primary care provider (PCP) for specialty care when such care is necessary. Prior authorization from Select Health is not required for participating plan specialists for office visits. Some services offered at the participating specialist's office may require prior authorization. Participating specialists are advised to contact Medical Services prior to delivering a service if in doubt. For coordination and continuity of care, the specialty care physician is strongly urged to communicate all findings and any needs for follow-up care back to the PCP via a consultation record.

Non-Participating Health Care Professionals/ Providers

PCPs and plan participating specialists may refer members to a non-participating plan specialist if there is not a participating specialist in a particular field. However, plan health care professionals/providers who wish to refer members to any non-participating health care professional/provider must contact Select Health's Medical Services Department for prior authorization.

· Pain management services (external infusion pumps, implantable infusion pumps, spinal cord neurostimulators, radiofrequency ablation and nerve blocks) · Plastic surgery/cosmetic dermatology (see specific codes) · Therapy services: physical, occupational and speech therapies (evaluation, re-evaluation and first 48 units do not require prior authorization, per discipline) · Transplants (complete corneal transplant services, pre-transplant services provided prior to 72 hours of actual transplant and post transplant services) · Unlisted and Category III codes

Services that Require Prior Authorization

· Air ambulance (retrospectively reviewed) · Cardiac rehabilitation · Chiropractic (all services) · Circumcision (unless prior to delivery discharge) · Diagnostics (capsule endoscopy, MEG, neuropsychological testing, PET scans) · Durable medical equipment, DME (billed charges $500 and over includes prosthetics and orthotics) 14 Medical Affairs Department

Select Health of South Carolina Health Care Professional & Provider Manual

When services requiring prior authorization are necessary for a member, the health care professional/provider should contact Select Health Medical Services toll free at 1.888.559.1010 or 843.764.1988 in Charleston. A copy of the prior authorization grid may be obtained from the Exhibits section of this manual or from the Select Health website: www.selecthhealthofsc.com . Providers may not bill members for services which require prior authorization and the authorization was not obtained, resulting in denial of the claim. The PROVIDER is responsible for obtaining prior authorization. Authorization is not a guarantee of payment; other limitations or requirements may apply.

Authorization for Ancillary Services

1 . Identify the patient as First Choice Member 2 . Request prior authorization number from First Choice Medical Services Department if DME item is $500 or over 3 . Record the prior authorization number in your system so that it will appear in box 23 on CMS 1500 . Call Select Health at 1.888.559.1010 or 764.1988 (Charleston area) if you need assistance.

Children's Rehabilitative Services and Baby Net

Services that DO NOT Require Authorization

· Emergency ground transport ­ ALS, BLS · Emergency room services

Children's Rehabilitative Services (CRS) and Baby Net are Medicaid-sponsored programs for children with a chronic illness or disability. Children may be members of First Choice and CRS or Baby Net. CRS is responsible for requesting prior authorization from Select Health's Medical Affairs Department for the following covered services: · Orthotics · Prosthetics · DME items provided through CRS clinics · Family Support Services

· Behavioral Health ­ 90801, 90802 (up to one every six months)

· In-network gynecological and specialty physician office visits

Services that Require Notification

· Cardiac CT · Chest CT · Spiral CT (CAD) · Sinus CT/MRI · Observation

Durable Medical Equipment

Ancillary Services

Any needs for durable medical equipment (DME) exceeding charges of $500 are coordinated and authorized through Select Health's Medical Affairs Department. For plan members who are hospitalized, the Select Health Clinical Coordinator will coordinate these services with the requesting physician and discharge planner prior to discharge.

Ancillary health services are services provided to patients to aid in the diagnosis or treatment of an illness or injury. They may be either diagnostic or therapeutic in nature. Examples of diagnostic ancillary health services include: laboratory services, radiology, magnetic resonance imaging (MRI), etc. Examples of therapeutic ancillary health services include: durable medical equipment, home healthcare, home infusion therapy, physical therapy, specialty pharmacy services, speech therapy, surgical centers, transplant services, etc.

Home Healthcare/Family Support Services

Home healthcare provided to homebound members requires prior authorization from the Select Health Medical Affairs Department. Members are limited to 50 visits per fiscal year for Home healthcare Services. Home social work services received from Family Support Services (FSS) do not apply to the 50-visit limitation. Home healthcare services must be ordered by a physician as part of a written plan of care. The ordering health care professional/provider must review and sign the Select Health plan of care at least every 60 days. The objectives of the Select Health plan of care should be to improve the member's level Ancillary Services 15

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

of health, relieve pain and to prevent regression of member's stable condition. The Select Health plan of care should restrict such care to the minimum number of visits necessary to meet these objectives. The care must be appropriate to the home setting and to the patient's needs. The Select Health plan of care should have documented goals, needs and care rendered, identifying the treatment to be rendered: services, supplies, items or personnel needed by the patient and expected outcome. Select Health utilizes the FSS clinical indicators as the review tool for authorizing FSS services.

by the health plan. These services are available to members through South Carolina Medicaid Fee-forService. Refer to the claims payment section for appropriate billing.

Hysterectomy

Home Infusion/Specialty Pharmacy

Contact Select Health's Medical Affairs Department to coordinate Home Infusion Therapy/Services.

Speech, Physical and Occupational Therapies

Requests for coverage of hysterectomy procedures require prior authorization. The member's medical records and the federally mandated hysterectomy consent form signed by the member are to be provided to Select Health's Medical Affairs Department prior to performing the procedure. The hysterectomy authorization form may be obtained from the Exhibits section of this manual or the Select Health website: www.selecthealthofsc.com. If you have obtained prior authorization through CMR, please send all documentation to the Medical Affairs Department.

Select Health provides benefits for home-based and outpatient therapy services for members. Prior authorization from Select Health's Medical Affairs Department is required for therapy services. Members must be eligible for home-based services per established homebound criteria prior to receiving therapy services in a home setting. Outpatient therapy services provided to First Choice members by a private rehabilitation therapy clinic/ health care professional/provider are also a covered benefit.

Inpatient Admissions/ Outpatient Admissions or Procedures

Emergency/Urgent Care Services

Members are encouraged to utilize the closest emergency room in the event of a life-threatening illness/ condition. In other cases, members are encouraged to contact their primary care provider or the Nurse Help Line prior to the use of an emergency room or urgent care facility. Coverage of emergency room services is reimbursed at the appropriate level upon claims examination. Prior authorization is not required.

All non-emergent (scheduled) medical-surgical inpatient and outpatient admissions must receive prior authorization from Select Health's Medical Affairs Department. The primary care provider or specialist should contact the Medical Affairs Department three working days prior to the scheduled admission/procedure to confirm eligibility and secure an authorization. It is recommended that hospitals call the Medical Affairs Department when members are presenting for elective/outpatient services that require prior authorization to confirm authorization and/or member eligibility. Medical Affairs staff will collect appropriate medical information to substantiate medical necessity for the requested service. Clinical protocols recommended by InterQual will be utilized in the evaluation of the received clinical information to determine the appropriateness of the requested services. Medical Affairs staff members may consult with the medical director as needed . An authorization number is issued by telephone to the requesting health care professional/provider. The turn-around time for this procedure is monitored and reported on a regular basis. For prior authorizations of non-urgent care, determinations will be made

Family Planning

16

All family planning services including elective sterilization and induced abortions are not covered benefits Emergency/Urgent Care Services

Select Health of South Carolina Health Care Professional & Provider Manual

within 14 calendar days of receiving all the necessary information. All emergent/urgent inpatient admissions should be reported to the Medical Affairs Department by the next working day following admission. The Medical Affairs Department will evaluate the clinical information according to InterQual Criteria and either approve the case for admission and certify the number of inpatient days or refer the case to the medical director for review. Determinations for urgent care will be made within one business day. Concurrent review determinations will be made within 24­72 hours, depending on the expiration of the certified concurrent period, of receiving all the necessary information.

of those identified as psychiatric (CPT 90804-90899) and all anesthesia services associated with behavioral health will also be covered by Select Health. Medical services (physician services that are not mental health treatment services) provided by a psychiatrist or child psychiatrist are also covered by Select Health. Select Health will coordinate the referral of our members for services that are outside of the required core benefits and which will continue to be provided by enrolled Medicaid health care professionals/ providers. These services include, but are not limited to, targeted case management services, intensive family treatment services, therapeutic day services for children, out-of-home therapeutic placement services for children, inpatient psychiatric hospital and residential treatment facility services.

Mental Health/Substance Abuse under First Choice

Select Health will reimburse health care professionals/ providers providing the following services without authorization: · 90801: Psychiatric diagnostic interview exam--one assessment per member every six months · 90802: Interactive psychiatric interview--one assessment per member every six months Notes: · For these services, Nurse Practitioners are included as allowed provider types. · Select Health may authorize additional assessments at our discretion based on medical necessity. This applies to adults and children. In cases where the Department of Alcohol & Other Drug Abuse Services or the Department of Mental Health submit laboratory claims (under Provider Type 80 Independent Lab), Select Health is responsible for reimbursement. Should a First Choice member receive outpatient services in an emergency room setting for which the primary diagnosis is behavioral health (class code C), the emergency room visit (both professional and facility fees) shall be paid by Select Health. Medical services rendered to patients admitted with a psychiatric diagnosis are the responsibility of Select Health. We will be responsible for Medicaid covered inpatient Behavioral Health Services (DRGs 424-433 and 521-523). Professional charges with the exception

Well-Woman Exam

Prior authorization is not required for an annual well-woman exam when performed by a participating provider.

Health Care Professional/ Provider Disputes

Informal Disputes

An informal dispute is a verbal or written expression of dissatisfaction by a health care professional/ provider regarding a decision that directly impacts the health care professional/provider. Disputes are generally administrative in nature and do not include decisions concerning medical necessity. The health care professional/provider registers an informal dispute either verbally or in writing within 90 calendar days from original denial notification or action. Examples include: · Plan Service Issues ­ Failure by the plan to return a provider call, availability of the plan's Provider Service Representatives, lack of provider orientation/education and distribution of member rosters. · Plan Processes Issues ­ Failure to notify health care professional/provider of policy changes, dissatisfaction with the Plan's prior authorization process/ timeliness, dissatisfaction with the plan's provider dispute process. · Contracting Issues ­ Dissatisfaction with the Plan's reimbursement rate, incorrect capitation payments and incorrect information regarding the health Health Care Professional/Provider Disputes 17

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

care professional/provider in the plan's provider database . · Claims Issues ­ Incorrect claim processing (i.e. TPL, COB, eligibility, payment dispute, timely submission, claim editing, etc). · Member issues ­ Regarding member's behavior, non-compliance and non-adherence to treatment plans. To register an informal dispute in writing, please provide a written explanation of the issue to: Select Health of SC, Inc Claims Processing Dept. P O Box 7120 London, KY 40742 For accurate and timely resolution of claims issues, providers should include the following information: · Health care professional/provider name · Health care professional/provider number · A contact person's name, phone number and address for further correspondence · Number of claims involved · A sample of the claim(s) · A description of the denial issue To register an informal verbal dispute, health care professionals/providers may call the Provider Claim Service Unit (PCSU) at 1.800.575.0418 or your provider representative. If the informal dispute is not resolved at the first point of contact, a Select Health representative will resolve and respond to the dispute within 30 calendar days from date of receipt. The purpose of the provider informal dispute process is to allow health care professionals/providers and the plan to resolve disputes registered by health care professionals/providers in an informal manner that allows health care professionals/providers to communicate their dispute and provide clarification of the issues presented. Health care professionals/providers not satisfied with the Informal Provider Dispute resolution may pursue further via the Formal Provider Dispute process. The filing of a dispute with the plan's Informal Provider Dispute process is not a prerequisite to filing a Formal Dispute.

Formal Disputes

Health care professionals/providers may request a formal dispute in writing within ninety (90) calendar days of an adverse action by the plan, or within thirty (30) days of an informal dispute determination. If the health care professional/provider is dissatisfied with the outcome of the first level dispute determination, the health care professional/provider may request a second level formal dispute review. The plan conducts each level of review and communicates the determination to the health care professional/provider within thirty (30) calendar days of receipt of the dispute from the health care professional/provider. The request for formal dispute must be received in writing within ninety (90) calendar days of: · The date of the denial or adverse action by the plan, or the date of discharge, whichever is later, OR; · The date of communication by the plan regarding informal dispute resolution. The request for formal dispute should include all relevant documentation the health care professional/ provider wants the plan to consider during review. An acknowledgement letter will be sent to the health care professional/provider within five (5) business days of receiving the formal dispute request. The letter shall: 1 . Acknowledge the plan's receipt of the request; 2 . Advise the health care professional/provider that the dispute request has been classified as a first level formal dispute; and 3 . Set forth the timeframe for review of the dispute. The Formal Dispute file should contain the following information: From the plan: · Denial notification · Dispute letter From the health care professional/provider: · Medical records · Any additional information the health care professional/provider wants reviewed · Dispute request letter If supporting documentation was not received or is

18

Select Health of South Carolina Health Care Professional & Provider Manual

Health Care Professional/Provider Disputes

incomplete, the dispute nurse will prepare and send a letter to the health care professional/provider requesting the missing information. The provider dispute nurse will forward a response to the health care professional/provider advising of the first level formal dispute determination, including the clinical rationale for the decision, and the health care professional/provider's second level formal dispute rights. If the initial determination is upheld on first level formal dispute, the health care professional/provider may request a second level formal dispute review.

staff will communicate the final determination to the requesting health care professional/provider, offering him/her the opportunity to supply additional information. The medical director may refer a case for peer review with a same- or similar-specialty physician external to the health plan prior to the final determination. If the requested service is not approved, a letter of denial of payment will follow. This letter informs the health care professional/provider of his/her right to an appeal (See Health Care Professional/Provider Appeal of Utilization Management and Claims Decisions) and clearly documents the reason for denial. The denial notification additionally explains how a health care professional/provider can discuss the case with a Medical Director or obtain the criteria used in making the determination. A copy of the letter of denial is sent to the member, primary care provider and all other health care professionals/providers as necessary.

Second Level Formal Dispute Review

The request for a second level formal dispute review must be received, in writing, within thirty (30) calendar days of the date of the first level formal dispute response letter. The provider dispute coordinator will prepare the file for presentation at the second level provider dispute committee. The provider dispute coordinator sends an acknowledgement letter to the provider within five (5) business days of receipt of the dispute request. The letter will: 1 . Acknowledge the plan's receipt of the dispute request; 2 . Advises the health care professional/provider that the dispute request has been classified as a second level formal dispute; and 3 . Set forth the time-frame for review of the formal dispute. If the final determination is upheld on a second level formal dispute review, the health care professional/ provider may review terms of arbitration as described in select health provider agreement. Note: Claims payment disputes are not appeals. Select Health encourages providers to contact your provider representative or the provider claim service unit (PCSU) at 1.800.575.0418 to resolve questions.

Appeal of Utilization Management and Claims Decisions

A member or a health care professional/provider with member consent may submit an appeal of any service denied by Select Health based on a medical necessity/ appropriateness determination. A coverage determination is defined as the denial or limited authorization of a requested service, including the type or level of service; reduction, suspension, or termination of a previously authorized service; denial, in whole or in part, of payment for a service; failure to provide services in a timely manner, failure to act within specified timeframes; denial of a request to obtain services outside the network for specific reasons . Health care professionals/providers submitting appeals on the behalf of a member must file the appeal within 90 calendar days (effective 02/01/11) of denial or action notification. Appeals must contain a written request, a contact person's name, address for further correspondence, a copy of the claim or EOB, member written consent to appeal, complete medical record and a summary of any additional details or documentation applicable for review of the appeal. Member consent must coincide with action giving rise to appeal therefore the health care professional/ provider cannot obtain written consent prior to service. We have developed a form for providers to Medical Review Determinations 19

Medical Review Determinations

Denials

In cases that do not meet medical necessity criteria for approval, professional staff will refer the case to the Select Health medical director for a final review and determination. A member of Select Health's

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

use to obtain member consent. The form can be found on the Select Health website, www.selecthealthofsc. com and is also Exhibit 15 in this manual. Select Health requires written confirmation of verbal requests for appeal along with member written consent in order to complete the appeal review. Requests without this information will not be processed. Select Health's Appeals Coordinator will send the appealing health care professional/ provider and member written notification of the appeal determination within 5 calendar days of determination. Appeals and supporting documentation should be mailed to: Select Health of South Carolina, Inc. Attn: Appeals Coordinator PO Box 40849 Charleston, SC 29423 Select Health has one appeal level, members who wish to appeal any decision made by Select Health's Appeals Committee will be referred to the South Carolina Department of Health and Human Services Division of Appeals and Hearings. The State Fair Hearing process must be requested by the member. After requesting a State Fair Hearing, a member may give the health care professional/provider written consent to represent him/her at the State Fair Hearing. Members are provided instructions on accessing a State Fair Hearing in a written appeal determination letter.

· Improve the coordination of care for our members ­ to include more consistent use of primary care providers (PCPs) and more appropriate use of specialists. · Facilitate more efficient use of resources ­ including the appropriate level of care (setting and intensity). · Improve the access to healthcare for our members. · Increase the empowerment of our members to embrace self-care behaviors. Within our Case Management Department we have several programs which allow us to meet the specific needs of our member population. Each program's focus is to maintain and/or improve the targeted population's health status through assessment, coordination of resources and promotion of self-management through education. We welcome referrals from our health care professionals/providers If you think any of your patients who have First Choice would benefit from our programs, please call us at 1 888 559 1010, ext 55251

Intensive (Complex) Case Management

This program targets our members with complex medical conditions. These members may have multiple co-morbidities or may have a single serious diagnosis like HIV or cancer. Our nurses work one-on-one with these patients to meet their care needs. The following are some of the interventions provided by our nurse case managers: · Coordination of care: making sure the member is seeing their PCP, assisting with referrals to specialists and making sure the PCP is aware of other care the member is receiving (specialists, ER, etc.). · Patient education: making sure the member understands the disease and treatment regimen. · Self-Management: guidance that motivates the member toward compliance and self-management.

Expedited Appeal

A member or a health care professional/provider acting on behalf of a member (with the member's written consent) may initiate an expedited appeal. This process is initiated when a delay in decisionmaking or standard medical appeal process may seriously jeopardize the life or health status of the member. An expedited review is granted to a provider or member upon verbal or written request. If this process is initiated for a concurrent review determination, the service is continued without liability to the member until the member is notified of the decision.

Disease Management Programs

Case Management Program

The overall goal of our Case Management Program is to improve the health and welfare of our members. The following specific objectives direct our activities: · Improve the health outcome measures of our members (as reflected by HEDIS® scores). 20 Medical Review Determinations

We have several disease-specific management programs. Interventions range from one-on-one nurse interaction for high-risk members to periodic educational mailings for low-risk members. The goal of all of our disease-specific management programs is to improve the quality of life for the involved members. We strive to accomplish this goal by providing risk-appropriate case management and education services, with a special emphasis on promoting self-management.

Select Health of South Carolina Health Care Professional & Provider Manual

· Breathe Easy ­ asthma management program for members of all ages with asthma. We especially promote member compliance with controller medications. Our program is based on current asthma practice guidelines from the National Heart Lung and Blood Institute, accessible by the link below:

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Rapid Response/Episodic Care Program

· In Control ­ diabetes management program for members of all ages ­ with the goal of preventing or reducing long-term complications. Our program is based on current diabetes practice guidelines from the American Diabetes Association, accessible by the link below:

http://professional.diabetes.org/CPR_search.aspx

This program is designed to meet the short-term or episodic needs of our members, especially members with recent hospitalizations. This program serves those members who are generally healthy and do not need a long-term case management program but have had recent healthcare issues and need short-term follow-up by one of our nurses to make sure they get the services they need for a complete recovery. Examples of members in this program include the following: · Member discharged from the hospital with shortterm home IV therapy. · Member with recent trauma requiring short-term physical or occupational therapy. · Member with dehisced surgical wound requiring wound VAC therapy. Our Rapid Response nurses make sure our members get the appropriate care in the appropriate setting ­ in a timely manner ­ sometimes preventing unnecessary readmissions.

· Living Well ­ heart failure management program with an emphasis on self-management interventions such as daily weights and medication compliance. Our program is based on current heart failure guidelines from the American College of Cardiology Foundation/American Heart Association, accessible by the link below:

http://circ.ahajournals.org/cgi/reprint/ CIRCULATIONAHA.109.192065

· Sickle Cell Program ­ assisting our members with sickle cell disease to get the care they need to better manage this disease. Our program is based on current sickle cell disease practice guidelines from the National Heart Lung and Blood Institute, accessible by the link below:

http://www.nhlbi.nih.gov/health/prof/blood/sickle/index.htm

Healthy Moms and Babies Program

This program is designed to improve the health outcomes of our pregnant members and their babies. Prenatal Risk Assessment Form and Care Authorization Members may obtain prenatal care without a referral from their primary care provider. The OB provider is responsible for contacting Select Health to obtain an authorization for prenatal care. This prenatal care authorization covers all prenatal and postpartum services (exams, testing, etc) provided by the OB provider in the OB office setting. Fetal biophysical profiles, non-stress tests and amniocentesis are allowed when medically necessary. Three ultrasounds are allowed without authorization; four or more, while they still do not require authorization, will require a high risk diagnosis. This requirement applies to all OB providers, even Maternal Fetal Medicine. · To obtain the prenatal care authorization, OB providers are asked to fax a completed Prenatal Risk Assessment form (see Exhibit) to 1 866 533 5493 A Prenatal Outreach Representative will fax the provider an authorization number once the risk assessment information is received. Please call our prenatal outreach staff at 1.888.559.1010, ext. 55251 with any questions about this process. Medical Review Determinations 21

Emergency Room Outreach Program

This program provides outreach to members who are frequent ER users, directing them to more appropriate sources of care, such as their PCP or Urgent Care Center. The program was designed to improve patient health outcomes while reducing utilization of costly emergency room services. The objectives of the program include the following: · Reduce emergency room utilization and costs. · Provide member education about appropriate emergency room use and promote self-management behaviors. · Increase the rate of PCP utilization. · Identify and address barriers to primary care for individual members. · Identify members with ongoing chronic conditions and refer them to the appropriate case management program.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Additional authorization is required for inpatient hospital care (including the delivery) and other services (including testing) provided outside of the OB provider's office. OB providers may call Select Health's Medical Affairs Department to secure any additional authorizations for service at 1.888.559.1010. 17-P Injection Authorization Select Health does pay for 17-P injections for women who meet the medical necessity criteria. Please fax the completed 17-P Authorization Form (see Exhibit) to 1.866.533.5493. One of our prenatal case managers will contact your office for follow-up in these cases. Prenatal Outreach and Case Management Early identification of pregnant members and their prenatal risk factors play a significant part in the Healthy Moms and Babies program. The Prenatal Risk Assessment Form provides risk-screening information that routinely is obtained during the first prenatal visit. Based on this information, our pregnant members are stratified as either low-risk or high-risk. Low-risk members receive appropriate educational materials with contact numbers to call with any questions or concerns during their pregnancy. Highrisk members are followed by a registered nurse for risk-appropriate education and case management. Examples of education topics and services provided by our high-risk prenatal case managers include the following: · Diabetes/Gestational Diabetes · HTN/Pre-eclampsia · Preterm labor · Assistance with community resources · Screening for 17-P injections We support all of our pregnant members to make healthy choices and to be active participants in their prenatal care. NICU Program Healthy Moms and Babies program nurses also follow our newborns that require NICU admission. While in the NICU, the nurses follow the newborn's course of treatment to make sure they receive the appropriate care in the appropriate setting without unnecessary delays. The nurses also work with the parents or guardians of these babies, making sure they learn to take care of their special newborns upon discharge. 22 First Choice Member Information

If you have any members that would benefit from one of our programs, please call the Case Management Department at 1 888 559 1010, ext 55251

First Choice Member Information

Member Access Guidelines

First Choice is Select Health's managed healthcare plan for Medicaid members. The following guidelines apply to scheduling procedures at all health care professionals/providers' offices: · Routine visits are scheduled within four to six weeks. · Urgent, non-emergency visits within 48 hours. · Emergency visits immediately upon presentation at a service delivery site. Waiting times should not exceed 45 minutes for scheduled appointments of a routine nature. Walk-in patients with non-urgent needs should be seen if possible or scheduled for an appointment consistent with written scheduling procedures. Walk-in patients with urgent needs should be seen within 48 hours. Physicians will assure that access to emergency medical care is available to members 24 hours a day, seven days a week. This may be accomplished via telephone coverage, instructing First Choice members on where to receive emergency and urgent healthcare. Primary care practices will provide at least one primary care physician full time equivalent per 2,500 members (First Choice, Medicaid and commercial members). Accessibility guidelines will be monitored in a number of ways: · Site visits conducted at credentialing · Member satisfaction surveys · Member grievances and appeals · Telephone accessibility surveys Members are educated about the importance of keeping appointments. If you experience a problem with a particular patient, please notify Member Services immediately at 1.888.276.2020. We will

Select Health of South Carolina Health Care Professional & Provider Manual

provide one-on-one counseling with the member. When a member misses two consecutive appointments, the member is sent a letter explaining that the third appointment missed may lead to their disenrollment from First Choice.

Membership may be verified by calling Select Health's Member Services Department. First Choice members should present their Healthy Connections ID card at each visit. In addition, PCPs should confirm member eligibility by checking the First Choice provider roster. This roster is routinely mailed to the practice location at the first and middle of each month.

Enrollment

· All member enrollments are without regard to healthcare status. · Effective date of enrollment takes two to six weeks. · Each member selects a primary care provider (PCP) upon enrollment. · All members receive a copy of the First Choice Member Handbook containing comprehensive information, which includes: a . Member Rights and Responsibilities b . Terms and conditions of enrollment c. Description of covered services d . How to access "out-of-plan" emergency services e . Member grievance procedures f . Disenrollment rights and procedures g. Select Health's Member Services toll-free number: 1.888.276.2020 A copy of the First Choice member handbook is included with each health care professional/ provider manual at initial orientation. If you would like an updated copy, call Provider Services at 1 .800 .741 .6605 .

Member Eligibility

The following categories of Medicaid recipients are eligible for First Choice membership: · TANF ­ Temporary Assistance for Needy Families · SOBRA ­ Women who are eligible for Medicaid because of pregnancy · SSI without Medicare- Social Security Income without Medicare All other Medicaid categories are ineligible to join First Choice. A newborn child of a First Choice mother is automatically enrolled for healthcare services in First Choice.

Member Disenrollment

A First Choice member's coverage begins on the first day of the month and lasts for a period of 12 months contingent upon their continued Medicaid eligibility. Disenrollment may be requested by the member or SCDHHS or First Choice. Members may request disenrollment once, without a specific reason, at any time during the 90 days following their initial enrollment or re-enrollment. After 90 days they must provide a specific reason to leave First Choice. The following are considered cause for a member to request disenrollment at any time: · Member moves out of the First Choice service area; · First Choice does not, because of moral or religious reasons, cover the service member wants; · The member needs related services to be performed at the same time and not all related services are available in the network; the PCP or another provider determines that receiving the services separately would put the member at unnecessary risk; · Other reasons, including but not limited to, poor quality of care, lack of access to services covered First Choice Member Information 23

Eligibility Verification

Each member will have two identification cards. · Healthy Connections ID cards are mailed to each head of household by the state. · All health care professionals/providers should review the Healthy Connections ID card during each visit. Please see the sample Healthy Connections ID card in the Exhibits section of this manual. · Each member receives a First Choice ID card within two weeks of the effective date of plan membership. This card notes PCP, PCP phone number and member ID. Please see the sample First Choice ID card in the Exhibits section of this manual. Eligibility information is available through the NaviNet web portal, www navinet navimedix com, and other electronic verification systems.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

under First Choice's contract with SCDHHS, or lack of access to providers experienced in dealing with the member's health care needs. First Choice may be notified of an involuntary disenrollment by the SCDHHS due to any of the following reasons: · Loss of Medicaid eligibility or Medicaid MCO program eligibility; · Death of member; · Member's intentional submission of fraudulent information; · Member becomes an inmate of a public institution; · Member moves out of state; · Member elects hospice; · Member becomes Medicare eligible; · Member becomes institutionalized in a long term care facility/nursing home for more than 30 continuous days; · Member elects home and community based waiver programs; · Loss of Medicaid MCO participation in the Medicaid managed care organization program or in the member's service area; · Member becomes age 65 or older; · Member enrolls in a commercial HMO; · Member is placed out of home [i.e. intermediate care facility for the mentally retarded (ICF/MR), psychiatric residential treatment facility (PRTF)] · Member's behavior is disruptive, unruly, or uncooperative and prevents First Choice from providing the services to member or other enrolled members. First Choice can request SCDHHS to disenroll member from the First Choice plan for the following reasons: · First Choice no longer participates in the Medicaid managed care organization program or in the member's service area; · Member dies; · Member becomes an inmate of a public institution; · Member moves out of state or the First Choice service area; · Member elects hospice; · Member becomes institutionalized in a long term care facility/nursing home for more than 30 continuous days; 24 First Choice Member Information

· Member elects home and community based waiver programs; · First Choice determines that member has Medicare coverage; · Member becomes age 65 or older · Member's behavior is disruptive, unruly, abusive, or uncooperative and prevents First Choice from providing services to member or other enrolled members; · Member is placed out of home [i.e. intermediate care facility for the mentally retarded (ICF/MR), psychiatric residential treatment facility (PRTF)] Health care professionals/providers are requested to document non-medical problems such as the above on separate sheets in the medical record and to notify Member Services as soon as possible for assistance. First Choice members may not be disenrolled for preexisting medical conditions, change in health status or high utilization of services.

Member Transfer

First Choice members may change primary care providers (PCPs) by calling Member Services. The effective date of the change will be as follows: · Through the 25th of the month, change is effective on the 1st of the next month. · From the 26th-31st of the month, change is effective on the 1st day of the month after next. If it is determined that Select Health has inappropriately assigned a member to the wrong PCP, we will make the adjustment on a case-by-case basis. The PCP may request a member be transferred to another practice for any of the following reasons: · Repeated disregard of medical advice · Repeated disregard of member responsibilities · Personality conflicts between physician and/or staff with member Again, health care professionals/providers are requested to document such problems as these and contact Member Services as soon as possible for assistance, and the transfer will take place on the first day of the following month. The transferring health care professional/provider must transfer copies of the member's medical record to the new health care professional/provider.

Select Health of South Carolina Health Care Professional & Provider Manual

Member No Shows

All First Choice "no shows" must be reported to Member Services. There are procedures in place to control the no show frequency of our members. In order to initiate these procedures, please contact Member Services at 1.888.276.2020 to report all no show appointments.

7 . To receive all information--enrollment notices, informational materials, instructional materials, available treatment options and alternatives in a manner and format that is easily understood. 8 . Receive assistance from both SCDHHS and First Choice in understanding the requirements and benefits of the health plan. 9 . Receive oral interpretation services free of charge for all non-English languages, not just those identified as prevalent. 10 . Be notified that oral interpretation is available and how to access those services. 11 . As a potential member, to receive information about the basic features of managed care; which populations may or may not enroll in the program and First Choice's responsibilities for coordination of care in a timely manner in order to make an informed choice. 12 . Receive information on First Choice services, to include, but not limited to: · Benefits covered. · Procedures for obtaining benefits, including any authorization requirements. · Any cost sharing requirements. · Service area. · Names, locations, telephone numbers of any non-English language spoken by current contracted providers, including at a minimum, primary care physicians, specialists, and hospitals. · Any restrictions on your freedom of choice among network health care professionals/ providers. · Health care professionals/providers not accepting new patients. · Benefits not offered by First Choice but available to you and how to obtain those benefits including how transportation is provided. 13 . Receive a complete description of disenrollment rights at least annually. 14 . Receive notice of any significant changes in the benefits at least 30 days before the intended effective date of the change. 15 . Receive information on the grievance, appeal and fair hearing procedures. 16 . Receive detailed information on emergency and after-hours coverage, to include, but not limited to: First Choice Member Information 25

Medicaid Hotline Number

A hotline has been established by the State of South Carolina Department of Health and Human Services for immediate health care professional/provider and member access to report problems or ask questions. This number is 1.888.549.0820.

Member Rights and Responsibilities

Select Health provides members with both written and verbal information regarding their rights and responsibilities as members of First Choice. All members are mailed a member handbook upon enrollment that outlines their rights and responsibilities in writing, and they are distributed annually via the member newsletter. Member Services representatives also attempt to contact each member household to discuss plan benefits and member rights and responsibilities.

Member Rights

You [the member] have the right to: 1 . Be treated with respect and with consideration for your dignity and privacy. 2 . Participate in decisions regarding your healthcare, including the right to refuse treatment. 3 . Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as stated in the Federal regulations on the use of restraints and seclusion. 4 . Request and receive a copy of your medical records and request that they be amended or corrected. 5 . Receive healthcare services that are accessible, are comparable in amount, duration and scope to those provided under Medicaid Fee-for-Service and are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished. 6 . Receive services that are appropriate and are not denied or reduced solely because of diagnosis, type of illness or medical condition.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

· What are emergency medical conditions, emergency services, and post-stabilization services. · That emergency services do not require prior authorization. · The process and procedures for obtaining emergency services. · The locations of any emergency settings and other locations at which health care professionals/providers and hospitals furnish emergency services and post-stabilization services covered under the contract. · Your right to use any hospital or other setting for emergency care. · Post-stabilization care services rules as detailed in 42 CFR 422.113(c). 17 . Receive the First Choice policy on referrals for specialty care and other benefits not provided by the member's PCP. 18 . Have your privacy protected in accordance with the privacy requirements in 45 CFR 160.202/203 subpart B and CFR 164.502, to the extent that they apply. 19 . Exercise these rights without adversely affecting the way First Choice, its health care professionals/ providers or SCDHHS treat members. 20 . To have a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage. 21 . To voice grievances or appeals about First Choice or the care it provides. 22 . To make recommendations regarding First Choice's member rights and responsibilities.

6 . See your doctor regularly for preventive services such as, prenatal care, well-child visits, adult physicals and well-woman exams. 7 . Provide, to the extent possible, information that First Choice and its health care professionals and providers need in order to care for you. 8 . Treat your PCP(s) and their staff(s) with kindness and respect. 9 . Help your PCP(s) obtain all your medical records and fill out new ones. 10 . Participate in understanding your health problems and follow the recommended treatment of care from your doctor. You must let the doctor know the reasons the treatment cannot be followed as soon as possible. 11 . Obtain a referral from your PCP(s) before you go to a specialist or to the hospital. Only go to the ones your PCP(s) recommended. 12 . Not to go to the emergency room for routine care. 13 . Call your PCP(s) as soon as you or a family member feels ill. Do not wait. If you feel you have a life-threatening emergency, go to your closest hospital. 14 . Be on time for all appointments. If you cannot make an appointment, please cancel at least 24 hours in advance of your originally scheduled time. 15 . Notify First Choice if your or your child/children's name, address or phone number changes. 16 . Inform First Choice of any change in your legal status regarding your authority to make decisions on behalf of your child or children.

Member Responsibilities

Advance Directives

Living Will and Power of Attorney

South Carolina and federal law give all competent adults, 18 years or older, the right to make their own healthcare decisions, including the right to decide what medical care or treatment to accept, reject or discontinue. If members do not want to receive certain types of treatment or wish to name someone to make healthcare decisions for them, they have the right to make these desires known to their doctor, hospital or other healthcare providers, and in general, have these rights respected. Members also have the right to be told about the nature of their illness in terms that they can understand, the general nature of the proposed treatments, the risks of failing to undergo these treatments and any alternative

It is up to you [the member] to: 1 . Establish your or your children with a primary care provider (PCP) within 30 days of entering the plan. 2 . Not change your PCP without approval from First Choice. 3 . Inform First Choice of any loss or theft of your ID card. 4 . Present your ID card whenever you see any doctor, hospital, clinic or pharmacy. 5 . Become familiar with First Choice procedures. If you have any questions or require additional information, contact the First Choice Member Services Department. 26 First Choice Member Information

Select Health of South Carolina Health Care Professional & Provider Manual

treatments or procedures that may be available to them. State law mandates that the Lt. Governor's Office on Aging provide information to the public about advance directives or living wills and healthcare powers of attorney. The South Carolina legislature has approved forms for both a living will and a healthcare power of attorney.The living will form that the legislature approved is called a Declaration of a Desire for a Natural Death.Members may be directed to get these forms from the local Area Agency on Aging or by contacting the Lieutenant Governor's Office on Aging at 1 .800 .868 .9095 or 803 .734 .9900 . Health care professionals/providers should discuss these options with their patients and have the discussion documented in the patient's medical record.

unsure of the language, tell the representative right away and a Language Services Associates (LSA) interpreter will be available within 60 seconds to assist. After hours (after 9:00 pm M-F & after 6:00 pm Sat & Sun) call the Nurse Helpline at 1.800.304.5436 and they will assist with getting you connected to this service.

Primary Care Providers

The primary care provider (PCP) functions as a "gatekeeper" who arranges primary care, specialty and ancillary services to meet members' healthcare needs. The PCP manages the medical care of the member by: · Meeting primary care needs · Promoting quality and continuity of care · Arranging for appropriate referrals to in-network health care professionals/providers · Coordinating the overall healthcare for plan members · Conducting adult health screenings and/or EPSDT visits as needed PCP specialties may include: · General practice · Family medicine · Internal medicine · Pediatrics · Nurse practitioner · Obstetrics/Gynecology

Outreach Services

The Quality Improvement and Member Services departments are responsible for the promotion of preventive health services for all members and prenatal services for pregnant members. It is our goal to identify members eligible for preventive services, notify these members and track and report utilization of services.

EPSDT/Immunizations Outreach

The objectives for EPSDT outreach include: · Notify all members eligible for screening and immunizations. · Follow up with members not receiving the recommended EPSDT service. · Act as a resource to First Choice EPSDT providers. · Improve plan EPSDT and Immunization utilization. · Review submitted EPSDT records for identified risk factors, immunizations not up-to-date and identified referrals.

Member Assignment

Foreign Language Interpretation Services

The Member Services Department is available to assist with non-English-speaking members. To access this free service, please call the Member Services Department toll free at 1.888.276.2020 or at 843.764.1877 in the Charleston area. Please tell the Member Services representative the language that requires interpretation. If you are

A provider roster is mailed to the PCP prior to the first of each month and on the 15th of each month. The provider roster lists assigned members' names, addresses, Medicaid ID number and phone numbers. The provider roster mailed at the first of the month is preliminary. The roster mailed on the 15th may reflect additional members who regained eligibility late in the prior month or transferred into the practice. It may also reflect member movement out of the practice. The health care professional/provider should contact new members indicated on the roster within 90 days of the member's enrollment to schedule adult physicals or EPSDT exams. If a provider roster has not been received for the current month, please contact Select Health at 1.800.741.6605. Please review the sample Primary Care Providers 27

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

provider roster included in the Exhibits section.

To verify membership in a PCP practice, always check the provider roster and member ID card when a member arrives for a scheduled appointment or call Member Services at 1 888 276 2020 or visit the Select Health website at www selecthealthofsc com

collect the co-payment from the beneficiary to receive full reimbursement for a service.

Member Transfer

A primary care provider (PCP) may request a member be transferred to another practice for any of the following reasons: · Repeated disregard of medical advice · Repeated disregard of member responsibilities · Personality conflicts between physician and/or staff with member Health care professionals/providers are requested to document such problems as these and contact Member Services as soon as possible for assistance, and the transfer will take place on the first day of the following month. The transferring health care professional/provider must transfer copies of the member's medical record to the new health care professional/ provider. First Choice members may change PCPs by calling Member Services.

After-Hours Care

Primary care services must be accessible after hours to members when medical conditions require medical attention before the next day of scheduled office hours.

Use of Network Health Care Professionals/Providers

Select Health provides a complete network of specialist, hospital and ancillary health care professionals/providers. PCPs must refer to network health care professionals/providers. Please contact Select Health Medical Services if the use of a non-network health care professional/provider is required.

Member Grievances

Co-payments

Some adult members will need to pay a small amount (co-payment) for certain services: · Chiropractic: $1.15 · Clinic visits: $3.30 · Home health: $3.30 · Inpatient hospital: $25.00 · Medical equipment: $3.40 · Office visits*: $3.30 · Outpatient hospital: $3.40 · Prescription drugs: $3.40 There will be no co-payment for children less than 19 years of age, pregnant women, individuals receiving emergency services or federally recognized Native Americans. * Includes: doctors, nurse practitioners, licensed midwifes and optometrists. A Medicaid beneficiary may not be denied services if they are unable to pay the co-payment at the time the service is rendered, however this does not relieve the beneficiary of the responsibility for the co-payment. It is the provider's responsibility to 28 Primary Care Providers

Grievances are defined by 42 CFR 438.400 as any dissatisfaction expressed by the member, or a representative on behalf of a member, about any matter other than a proposed action. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee's rights. Members or health care professionals/providers acting on behalf of the member may report grievances at any time by calling Member Services at 1.888.276.2020. Member Services will document the grievance and coordinate the response and/or resolution with the appropriate departments. Health care professionals/providers acting on behalf of the member may report a grievance with member consent. The member and the health care professional/provider who reports a grievance on behalf of a member will receive a copy of both the grievance acknowledgement letter and grievance decision letter. Members may file a grievance with the SCDHHS Division of Appeals and Hearings, 1.803.898.2600, after exhausting Select Health's internal grievance process.

Select Health of South Carolina Health Care Professional & Provider Manual

EPSDT and Adult Health Screenings

analysis using the CPT code 83655. If your office is using the ESA LeadCare Blood Lead Testing System to analyze the blood lead samples internally, your office should bill us directly using CPT code 83655.

PCPs who provide care to members from birth through age 21 will provide EPSDT (Early and Periodic Screening, Diagnosis and Treatment) examinations and required immunizations. A baseline visit is recommended and encouraged for all new First Choice members. Further visits should be scheduled according to relevant guidelines as outlined in the Exhibits section or as needed. Select Health does utilize the EPSDT periodicity schedule as a standard for delivering EPSDT services. However, properly completed EPSDT claims falling outside of the standard will be paid. Delivery of clinical preventive services should not be limited only to visits for health maintenance but also should be provided as part of visits for other reasons such as acute and chronic care. A baseline visit is recommended and encouraged for all new First Choice adult members. Further visits should be scheduled according to relevant guidelines outlined in the Exhibits section or as needed.

Immunizations

Effective July 1, 2011, the VAFAC (Vaccine Assurance for All Children) program was transitioned to the Vaccines For Children (VFC) program. All health care professionals/providers including those currently enrolled in the former VAFAC program, must complete the enrollment process to be eligible to receive federally funded VFC vaccine. Practices with multiple office locations must enroll each office as a separate South Carolina VFC program provider if that site will be offering immunization services using VFC vaccines. The South Carolina Department of Health and Environmental Control (SCDHEC) is now offering the SC STATE Vaccine Program as a supplement to the VFC program. Health care professionals/providers must be enrolled in the VFC program as a prerequisite to enrollment in the STATE Vaccine Program. Health care professionals/providers may opt to participate in the VFC program only or both the VFC and STATE Vaccine programs. Health care professionals/providers wishing to enroll in the VFC program and/or the SC STATE Vaccine Program may do so by visiting the Enrollment website at: http://www.scdhec.gov/health/disease/immunization/vfc-enrollment.asp . Select Health reimburses for vaccine administration. For accuracy and program compliance SCDHHS requires that claims for vaccinations include the Current Procedural Terminology code (CPT) for the vaccine product that is administered, however only the administration code is reimbursable.

Topical Fluoride Varnish

The best practices of the American Academy of Pediatrics recommend that children up to three years old who are at high risk for dental caries should receive fluoride varnish application in their primary care physician's office during their EPSDT visit two times per year (once every six months) and in their dental home two times per year (once every six months). The American Dental Association has established a new Current Dental Terminology (CDT) procedure code, D1206, for the application of topical fluoride varnish. The primary care physician will bill this procedure to Select Health on the CMS1500 claim form.

Blood Lead Testing

The screening blood lead test is required as part of the EPSDT service. The finger or heel stick collection of the blood lead sample is covered by the EPSDT rate. Therefore, no additional reimbursement is available. However, the lab analysis is covered as a separate service. Reimbursement for the lab analysis is not part of the EPSDT service rate. If your office sends the blood lead samples to an outside laboratory for analysis, the laboratory should bill directly for the blood lead

Synagis

Synagis is reimbursed on a fee-for-service basis. The administration fee is included in the reimbursement. Health care professionals/providers must call Select Health's Medical Affairs Department at 1.888.559.1010 for prior authorization before administering Synagis. Payment for Synagis is based on the number of units Primary Care Providers 29

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

billed. Determination of units is based upon a 50 mg dosage. If the member receives multiples of the 50 mg dosage, the health care professional/provider should list units per 50 mg dose, not to exceed four units per day. For example, if a member receives 150 mg, this would equal 3 units. Select Health will reimburse according to the rates established by the Department of Health and Human Services. Health care professionals/providers must use the dosage that is appropriate for each child according to his/her weight. The administrative fee (procedure code 90722) is payable in addition to the drug.

· Cancer · Cardiac disease · Diabetes · End stage lung disease · End stage renal disease · HIV/Aids · Hypertension · Organ transplant To request a prescription limit override for any other condition, the prescriber should contact Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or fax to 1.866.610.2775.

Pharmacy Services

Pharmaceutical services provide First Choice members with needed pharmaceuticals as ordered through valid prescriptions from licensed prescribers for the purpose of saving lives in emergency situations or during short term illness, sustaining life in chronic or long term illness or limiting the need for hospitalization. Members have access to most national chains and many independent pharmacies. · All members are covered for prescription and certain over-the-counter (OTC) drugs/items with a prescription written by a doctor. · Medications are prescribed to cover a maximum 31-day supply. · Pharmacy benefits are managed through our Pharmaceutical Benefits Manager (PBM), Perform Rx. · Direct pharmacy claims questions (technical online processing) to Argus at 1.800.522.7487. · Prior authorization and other pharmacy services related questions should be directed to Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or faxed to 1.866.610.2775.

Coverage of Generic Products

Select Health does not cover brand name products for which there are "A" rated, therapeutically equivalent, less costly generics available unless prior authorization is secured. Prescribers who wish to prescribe brand name products must furnish documentation of generic treatment failure prior to dispensing. The treatment failure must be directly attributed to the patient's use of a generic of the brand name product. Exceptions to the generic requirement include brand name products of: digoxin, warfarin, theophylline (controlled release), levothyroxine, pancrelipase, phenytoin, carbamazepine and continued treatment utilizing clozapine.

Over-the-Counter Drugs

Monthly Prescription Limits

All members are covered for certain over-the-counter (OTC) drugs with a prescription written by a doctor. For adult members, these prescriptions will apply toward the monthly limit. Products will be dispensed generically when available as outlined above. Many items may be ordered by the member through the personal healthcare items benefit by calling Member Services at 1.888.276.2020.

First Choice members who are younger than 21 years of age are eligible for unlimited prescriptions or refills. First Choice members who are 21 years of age and older are limited to four prescriptions or refills per month with certain exceptions. Medications used to treat the following conditions are exempt from the four prescriptions limit: · Acute sickle cell disease · Behavioral health disorder 30 Pharmacy Services

Co-payments

Members who are 19 years of age or older are subject to a $3.40 co-payment per prescription. The following members are exempt from the co-payment: · 18 years of age or younger · Pregnant and the medicine is related to pregnancy · Live in a nursing home or group home · Receiving hospice, emergency or family planning services

Select Health of South Carolina Health Care Professional & Provider Manual

· Receiving home- and community-based waiver services

Appeal of Prior Authorization Denials

Prior authorization denials may be appealed. Please see the section entitled "Medical Review Determinations" to review the appeal process.

Prior Authorization

In a continuing effort to improve patient care and pharmaceutical utilization, Select Health, in conjunction with its PBM, Perform Rx, has implemented a prior authorization (PA) program for the initial prescription of certain medications. Requests for PA medications should be directed to Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or faxed to 1.866.610.2775. In most cases where the prescribing health care professional/provider has not obtained prior authorization, members will receive a five-day supply of the PA medication and Perform Rx may make a request for clinical information to the prescriber. All requests must be completed within five days from initial request . To obtain the prior authorization request form, see the Exhibits section or go to the Select Health website at www.selecthealthofsc.com .

Claims and Payments

Health care professional/provider Tip: Always check member eligibility before rendering services and submitting claims to Select Health to ensure that your patient is a First Choice member

Claims Address

If you are unable to submit claims electronically, please mail all Select Health claims: Select Health of South Carolina, Inc. Claims Processing Department P.O. Box 7120 London, KY 40742 For questions regarding claims or bills, please call the Claims Department at 1.800.575.0418.

Preferred Drug List

Claim Format

Select Health maintains a Preferred Drug List (PDL). The PDL represents therapeutic recommendations based on documented clinical efficacy, safety and cost-effectiveness. All non-preferred medications will require prior authorization. Select Health's criteria require a trial and failure or intolerance of one to three preferred medications, depending on the class. Please visit our website for a complete list of preferred products. Requests for prior authorization medications should be directed to Select Health/AmeriHealth Mercy Pharmacy Services at 1.866.610.2773 or faxed to 1 .866 .610 .2775 . Providers may request the addition of a medication to the list. Requests must include the drug name, rationale for inclusion on the list, role in therapy, and medications that may be replaced by the addition. Please direct such requests to the Pharmacy and Therapeutics Committee at Select Health, PO Box 40849, Charleston, SC 29423. NOTE: Experimental drugs, procedures or equipment not approved by Medicaid are excluded.

Hospitals should use the UB 04 All other health care professionals/providers should use the CMS 1500 (See "Claims Filing Manual" for an explanation of required fields)

To ensure timely processing of claims, please make sure your claims provide the following information: · Correct member name and Medicaid ID number. · Ancillary or hospital should use the facility ID number assigned by Select Health in Box 51 (UB 04). · Facility NPI number in Box 56 (UB 04). · Prior authorization number Box 63 (UB 04), if required . · The attending health care professional/provider's individual (not group) Select Health health care professional/provider ID number and NPI number Box 76 (UB 04). · If there is a NPI number entered in box 56, enter the taxonomy code for the facility in Box 81 (UB 04). · Prior authorization number, if required (Box 23 on CMS 1500 form). · The treating health care professional/provider's individual (not group) Select Health health care Claims and Payments 31

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

professional/provider ID number and NPI number (Box 24J on CMS 1500 form). · The Payee Information in Box 33 with the "pay to" NPI number (this could be an individual or a group, box 33a on CMS 1500) and taxonomy code (box 33b on CMS 1500). · Use valid diagnosis, revenue and CPT codes. Some health care professionals/providers inadvertently submit invalid codes not recognized by Medicaid. If your contractual agreement with Select Health indicates health care professional/provider specific codes, please use the specific codes indicated in your agreement. · Claims improperly or incorrectly submitted may be returned .

Capitation Payments and Reports

Capitation checks are mailed or transmitted electronically by First Choice to primary care provider's remittance addresses at the beginning of each month. The Payment roster, which should be used for reconciling the capitation payment is also mailed at the beginning of each month. The payment roster is the official roster for the month. Capitation will be paid for members added mid-month on the following month's capitation check via a "retro add." Capitation will be recovered for members leaving the practice at mid-month on the following month's capitation check via a "retro term." Capitation paid or recovered with greater than one month's retroactivity will appear as a manual adjustment. Please review the sample Payment roster, located in the Exhibits section.

Primary Care Provider Encounter Data and Billing

Primary care providers (PCPs) must report both capitated services and those services that are reimbursed on a fee-for-service basis on the CMS1500 claim form. Regardless of payment mechanism, all PCP services must be reported to the above address.

Claims Payment Polices/Guidelines

First Choice has enhanced clinical editing processes to promote correct coding and to put into practice outpatient payment polices that are national in scope, simple to understand and that come from highly respectable sources, such as: · CMS' medical coding policies · AMA CPT coding guidelines · Local and Regional Medicare policies First Choice's payment polices focus on areas such as: · National bundling edits including the Correct Coding Initiative (CCI) · Modifier usage · Global Surgery concept · Add On code usage · Age/Gender appropriateness · CMS' National Coverage Determinations · OPPS bundled and packaged services concept

Fee-for-Service Payments

Fee-for-service payments are mailed or transmitted electronically via electronic funds transfer (EFT) by First Choice to the health care professional/provider with access to a remittance advice that will detail claims being paid, pended and/or denied, along with accompanying reasons. Please review the sample remittance advice located in Exhibits section. The electronic remittance advice is available through NaviNet or Emdeon's (the First Choice clearinghouse) payment manager.

First Choice Payments ­ as Payment in Full

In accordance with guidelines established by SCDHHS, once a health care professional/provider has accepted assignment of benefits for a First Choice member, the health care professional/provider must accept the amount paid by First Choice or paid by a third party (if equal to or greater than that allowed by First Choice and in accordance with any contractual agreement with the third party payor) as payment in full. The member or member's representative may not be balance billed for any services provided.

Claims Adjustment/Reconsideration Requests

If a health care professional/provider believes there was an error made during claims processing or if there is a discrepancy in the payment amount, he/she may submit a written request for reconsideration. The request should include a copy of the claim, the remittance advice showing the denial and any supporting documentation and should be mailed to: Select Health of South Carolina, Inc. Claims Processing Department

32

Select Health of South Carolina Health Care Professional & Provider Manual

Claims and Payments

P.O. Box 7120 London, KY 40742 Or the health care professional/provider may call the Provider Claims Service Unit (PCSU) at 1.800.575.0418. Our representatives can help you resolve the issue, reprocess a claim via the phone, or advise whether a corrected claim or a written appeal needs to be submitted

Refunds/Overpayments

If a health care professional/provider is overpaid by First Choice, we ask that an overpayment request worksheet be completed giving the details of the overpayment, to assist us in adjusting the affected account. The overpayment request worksheet may be found in the Exhibits section of this manual and on the Select Health website: www.selecthealthofsc.com . If you would like us to recoup (take back) the overpaid amount from future payments mail only the completed overpayment worksheet to the claims processing department in London, KY. If you choose to issue a refund for the overpayment, mail the completed overpayment worksheet along with any refund checks to: Select Health of South Carolina, Inc. Cost Containment and TPL Department PO Box 7320 London, KY 40742

Corrected/Resubmitted Claims

A corrected professional claim (CMS 1500) should only be submitted for claims on which there was an error made on the original claim but a payment was still issued. Claims that were completely denied and had no payment issued can be resubmitted via normal processing (electronic or paper) and do not need to have the words "corrected" or "resubmitted" on them. For corrected claims that are submitted via hardcopy, the word "corrected" must be noted on the claim as appropriate (for example): · Claims with missing or incorrect charges but payment was issued, should be submitted as "corrected" claims · Claims with incorrect coding but some lines paid and some did not, should be submitted as "corrected" claims · Claims originally denied for missing or invalid information, for inappropriate coding or DX missing 4th or 5th digit, should be submitted as "resubmitted" claims · Claims originally denied for additional information should be sent as a resubmitted claim. In addition to writing "resubmitted" on the claim, the additional/ information should be attached. Corrected and resubmitted claims are scanned during reprocessing. Please remember to use blue or black ink only, and refrain from using red ink and/or highlighting that could affect the legibility of the scanned claim. Corrected/Resubmitted claims should also be sent to: Select Health of South Carolina, Inc. Claims Processing Department P.O. Box 7120 London, KY 40742 Note: You also have the option of submitting corrected CMS 1500 claims electronically. See page 35, "Submitting Corrected Claims Electronically."

Third Party Liability

Third Party liability is the legal responsibility of other available resources to pay claims before the Plan pays for the care of an individual eligible for First Choice. Medicaid is always the payer of last resort. Third party payers include: private health insurance, Medicare, employment-related health insurance, courtordered health insurance from non-custodial parents, worker's compensation, long-term care insurance, liability insurance, other state and federal programs and first party probate-estate recoveries. First Choice is a Medicaid Managed Care program and the payer of last resort. Therefore, First Choice will consider the primary insurer's payments when calculating payment due the health care professional/ provider. As a First Choice health care professional/ provider you have agreed to accept First Choice's payment as payment in full. Members receiving Medicaid-covered services may not be balanced billed. First Choice Health Plan coordinates benefits with primary insurers for covered services and will pay the lesser of: · Primary carrier's allowed amount up to First Choice's allowable, or · The deductible, co-pay, and coinsurance total (patient liability) from the primary insurer not to exceed First Choice's allowed amount Claims and Payments 33

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

It is expected that the primary payer's contractual obligations are considered when seeking reimbursement for secondary payment. Secondary claims must be submitted as hard copy with the other insurer's explanation of benefits (EOB) and reason/denial codes attached in order to ensure proper consideration. Certain services (e.g. Department of Health and Environmental Control (DHEC) under Title V) are not subject to the standard coordination of benefits. However, health care professionals/providers are encouraged to make every effort to obtain other insurance coverage information from their patients because health care professionals/providers are an important source of third party information.

a nine month period after the first date of the overpayment, not to exceed the one year timely filing deadline. However, recovery may be conducted on overpayments beyond this timeframe if: · There is evidence of fraud, · The health care professional/provider has established a pattern of inappropriate billing, or · A system error has been identified that supports said recovery.

Submitting Claims Electronically

Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submission for providers. EDI, performed in accordance with nationally recognized standards, supports the health care industry's efforts to reduce administrative costs. The benefits of billing electronically include: · Reduction of overhead and administrative costs. EDI eliminates the need for paper claim submission. It has also been proven to reduce claim re-work (adjustments). · Receipt of clearinghouse reports makes it easier to track the status of claims. · Faster transaction time for claims submitted electronically. An EDI claim averages about 24 to 48 hours from the time it is sent to the time it is received. This enables providers to easily track their claims. · Validation of data elements on the claim form. By the time a claim is successfully received electronically, information needed for processing is present. This reduces the chance of data entry errors that occur when completing paper claim forms. · Quicker claim completion. Claims that do not need additional investigation are generally processed quicker. Reports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt. All the same requirements for paper claim filing apply to electronic claim filing · Health care professional/providers should contact their vendor and confirm that the vendor will transmit the claims to Emdeon, the First Choice claims clearinghouse. · Health care professional/providers should confirm with vendor the accurate location of Select Health Health care professional/provider ID number.

Cost Avoidance/Third Party Liability (TPL/COB) Recovery

Cost Avoidance refers to the practice of denying a claim based on knowledge of an existing health insurance policy which should cover the claim. Like Medicaid fee-for-service, First Choice is required by the federal government to adhere to the cost avoidance policy. Providers must report primary payments and denials to First Choice to avoid rejected claims. A provider who has been paid by First Choice and subsequently receives reimbursement from a third party must repay First Choice the difference between the primary carrier's contractual obligation and the patient liability. First Choice reviews Third Party Liability (TPL/COB) information on a routine basis. Potentially overpaid claims are identified and providers will receive notification of our intent to recover overpayments if the aggregate total of claims recovery is greater than $250 .00 . First Choice will send a 60-day notice letter to health care professionals/providers notifying them of any overpayment recovery and will include with the letter a list of claims affected by the recently received TPL information. This information should assist the health care professional/provider in reconciling claims. Health care professionals/providers will have 45 days to submit a check or allow the recoupment process to initiate after 60 days. First Choice will seek recovery for claims within 34 Claims and Payments

Select Health of South Carolina Health Care Professional & Provider Manual

· Submit with Payor ID 23285 for standard claims and 25176 for Behavioral Health claims · Health care professional/provider should check the claims status report after each submission for any rejections. If rejections are noted, correct and resubmit. Questions regarding electronically submitted claims should be directed to Provider Claim Services at 1.800.575.0418. Here you may obtain information about submitting claims electronically to First Choice or information regarding claims that have already been submitted electronically to First Choice. If you would like assistance in resolving submission issues reflected on either the Acceptance or R059 Unprocessed Claims reports, contact the Emdeon Provider Support Line at 1.800.845.6592.

If you do not currently have the capability to submit claims electronically, but are interested in doing so, contact the Emdeon Provider Support Line at 1.800.845.6592, or any EDI software vendor you choose. Instructions for paper submissions are available under Corrected/Resubmitted claims .

835 Electronic Remittance Advice

Select Health/AmeriHealth Mercy has partnered with Emdeon and HDX as clearinghouses for the 835 electronic remittance advice transactions. Emdeon and HDX are leaders in processing transactions for vendors, health care professionals/providers and health plans in the HIPAA compliant standardized formats. Health care professionals/providers may choose either clearinghouse from which to receive their 835 Electronic Remittance Advice. The health care professional/provider's current EDI vendor should be contacted for additional information prior to contacting HDX or Emdeon. HDX Contact Information: 1 610 219 3331 HDX Electronic Remittance Service [email protected] Emdeon Contact Information: 1.800.845.6592 (Health care professional/provider Help Desk) Payer ERA enrollment forms are located at www.Emdeon.com, payer registration forms. Health care professionals/providers should be prepared to supply the following information during the set-up phase: · EDI vendor and submitter ID · Group/facility name · Contact name, phone number and e-mail address · Address · Tax ID · Payee ID A copy of the 835 Companion Guide is available on the Select Health website, under HIPAA information: www.selecthealthofsc.com . Additional assistance may be obtained by contacting Provider Services at 1.800.741.6605. Claims and Payments 35

Submitting Corrected Claims Electronically

*A corrected claim is defined as a resubmission of a claim with a specific change that you have made, such as changes to CPT codes, diagnosis codes or billed amounts. It is not a request to review the processing of a claim. For UB04 claims, corrections can be submitted electronically by just changing the bill type to 117 or 137. For Professional claims (claims filed on a CMS 1500 claim form) your EDI vendor or clearinghouse will need to do the following: · Use "6" for adjustment of prior claims or "7" for replacement of a prior claim utilizing bill type in loop 2300, CLM05-03 (837P) · Include the original claim number in segment REF01=F8 and REF02=the 13 digit original claim number; no dashes or spaces · Include the plan's claim number in order to submit your claim with the 6 or 7 · Use this indicator for claims that were previously processed (approved or denied) · Do not use this indicator for claims that contained errors and were not processed (rejected upfront) · Do not submit corrected claims electronically and via paper at the same time For more information, please contact the EDI Hotline at 1.877.234.4271 or [email protected] Providers using our NaviNet portal, (www.navinet.navimedix. com) can view their corrected claims faster than available with paper submission processing.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Electronic Funds Transfer (EFT)

Select Health and Emdeon Business Services have partnered to offer you direct deposit for your claims payment. Health care professionals/providers interested in receiving electronic payments through Emdeon may get additional information through the Emdeon website, www.Emdeon.com/epayment or by contacting Select Health Provider Services at 1 .800 .741 .6605 .

If you are interested in Electronic Remittance Advice (ERA), Emdeon's customer service staff can assist you in signing up by calling Emdeon at 1.877.363.3666.

Billing Requirements for Certain Services

The EPSDT Program

The EPSDT program was initiated as a comprehensive and preventive child health program for Medicaid recipients. First Choice members under age 21 qualify for EPSDT program benefits, including regular health screenings, immunizations, treatment and follow-up care for problems diagnosed during screenings.

Emdeon ePayment can simplify the payment process by: · Providing fast, easy secure payments · Reducing paper · Not requiring you to change your preferred banking partner · Simplifying your bank connectivity when multiple banks are required · Managing health care professional/provider enrollment and authentication · Eliminating checks lost in the mail · Enabling you to view multiple payers in one easyto-use application You will need the following information to enroll in the EFT Program: · Your Select Health assigned Health care professional/provider ID number · The Select Health Payor ID: 23285 · Bank name and address · Bank account type · Nine-digit routing/ABA number · Full account number with leading zeros · Primary account holder name · Tax ID number of account holder · Payee ID (on your current remittance advice) · The last two Select Health remittances, including cover sheet and payment amounts

Components of an EPSDT Exam

· A comprehensive health and developmental history · An assessment of physical and mental development · A comprehensive unclothed physical examination · Appropriate immunizations · Health education, including anticipatory guidance · Vision, hearing and dental screenings · BMI percentile · Lead screening by child's second birthday Laboratory tests are not part of the screening package and may be billed and reimbursed as additional claim lines. However, screening components cannot be fragmented and billed separately.

EPSDT/Immunization Claims/ Encounters

EPSDT claims/encounters are submitted on the CMS1500 claim form utilizing the following standard applicable CPT codes: New Patients: 99381 Preventive visit, 12 months or younger 99382 Preventive visit, age 1-4 99383 Preventive visit, age 5-11 99384 Preventive visit, age 12-17 99385 Preventive visit, age 18-21

Emdeon Payment Manager

Once you begin receiving your payments electronically, your paper remittance advice will be discontinued after 90 days. However, you can always view and print your remittance advice online at Emdeon's website using Payment Manager. For more information, visit: www.emdeon.com/ProviderSolutions/ provider_services_era.php . 36 Electronic Funds Transfer (EFT)

Select Health of South Carolina Health Care Professional & Provider Manual

Established Patients: 99391 Preventive visit, 12 months or younger 99392 Preventive visit, age 1-4 99393 Preventive visit, age 5-11 99394 Preventive visit, age 12-17 99395 Preventive visit, age 18-21 Effective February 15, 2011 for claims with date of service on or after January 1, 2011 for vaccine administration, for members 19 and older, you must use: · 90471 - One immunization · 90472 - Each additional immunization. Use 90472 in conjunction with 90471. This code can only be used twice per visit, regardless of the number of additional vaccines administered. Intra-nasal/oral Immunization administration: · 90473 - One immunization. · 90474 - Each additional immunization. Use 90474 in conjunction with 90473. This code can only be used twice per visit regardless of the number of additional vaccines administered. For members under 19 years of age, you must use the new administration codes: · 90460 ­ Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component (one unit per date of service) · 90461 ­ Each additional vaccine/toxoid component (two units per date of service) PLEASE NOTE: CPT advises to bill the above codes based on the number of components. At this time, SCDHHS will continue to use these codes per administration of each vaccine/toxoid and not per component for the VFC program. The administration of VFC vaccines is limited to a maximum of three units per date of service regardless of the number of additional vaccines administered CPT codes 90460 and 90461 are covered codes for recipients under 19 years of age.

· Primary care physicians can bill for topical fluoride varnish treatments, CPT code D1206 as part of the EPSDT exam. · Claims for VFC vaccine administration must include: · The appropriate vaccination product CPT code · The appropriate vaccination administration code · For this code combination, only the administration code will be reimbursable · When billing First Choice, Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) must also submit CPT codes for the vaccination products. · When billing for vaccines that are not covered under the VFC program or for beneficiaries over the age of 19, the provider may bill for the vaccine and the administration code 96372. · If you detect a health problem during a well visit, do not change the coding from a well exam to a sick visit. When billing, use V20.2 as the first diagnosis. The second diagnosis is determined by the detected problem. If the EPSDT screening and immunizations can be completed, bill the EPSDT code with modifier 25 and list any additional services. Do NOT bill an office visit on the same date of service.

Unlisted Procedure Codes

Unlisted procedure codes are services performed by a physician that are not specifically defined in the CPT book. These codes: · Require prior authorization. · A special report including description of the nature, extent and need for the procedure is submitted to our Utilization Management team. · A comparative CPT code should be included in the report to determine reimbursement. · If the code is for a drug or equipment, the manufacturer's invoice is required.

AS Modifier

Coding Tips

· Modifiers 01 and 02 are not required for EPSDT claim submission to First Choice.

Assistant Surgery Services (AS modifier) will no longer be accepted by Select Health. Health care professionals/providers must use the modifiers: 80, 81 or 82. CPT codes with the use of one of these modifiers will only be paid to MDs (not PAs or CNPs).

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Billing Requirements for Certain Services

37

Evaluation and Management Service and Q0091

Diagnosis Codes

635.00 ­ 635.92 636.00 ­ 636.92 637.00 ­ 637.92 779 .6 V15.7

1

If a significant, separately identifiable evaluation and management service to evaluate other medical problems and a screening Pap smear are performed at the same visit, the health care professional/provider may report both the Evaluation and Management (E&M) code for the exam and the Q0091 for the screening Pap smear. By appending a 25 modifier to the E&M code, the health care professional/provider is indicating that a separately identifiable service was rendered and is payable according to the National Correct Coding Initiative.

Legally induced abortions Illegally induced abortions Unspecified abortion Termination of pregnancy Personal history of contraception Encounters for contraceptive management Insertion of IUD/sterilization/menstrual extraction Contraception surveillance Contraception surveillance, necessary Family planning device Contraceptive management, necessary Contraceptive management, NOS Genetic counseling on procreative management Procreative management counseling Testing of male for genetic disease carrier status Other procreative management, counseling/advice Tubal ligation status Vasectomy status Encounter for assisted reproductive fertility procedure cycle Other specified procreative management Follow-up, post insertion of contraceptive device Routine vaginal delivery with bilateral tubal ligation

V25.0 ­ V25.9 V25.1 ­ V25.3 V25.40 ­ V25.43 V25.49 V25.5 V25.8 V25.9 V26.31 V26.4 V26.34 V26.49 V26.51 V26.52 V26.81 V26.89 V45.5 ­ V45.59 DRG 3742

1

Claims for Newborn Care

A newborn child of a First Choice mother is automatically enrolled for health care services in First Choice. The claim for baby must include the baby's date of birth and Medicaid number as opposed to the mother's date of birth. Newborns must be billed separately from the mother. If the baby has not been named, insert "Girl" or "Boy" in front of the mother's last name as the baby's first name. Verify that the appropriate last name is recorded for the mother and baby. On claims for twins or other multiple births, indicate the birth order in the patient name field: for example, Baby Girl Smith A, Baby Girl Smith B, etc.

Rural Health Center/Federally Qualified Health Center Encounters

The South Carolina Department of Health and Human Services requires that Select Health submit encounter data to the state using standard ICD-9 and CPT coding. Select Health is not permitted to submit encounter data, which consists of the Rural Health Center or Federally Qualified Health Center "T" code. Claims received with the "T" code will be denied with instructions to refile using CPT codes. Evaluation and Management services and lab charges should be billed on separate claim forms.

SCDHHS considers these to be family planning diagnoses. Select Health considers them to be either family planning or medical diagnoses. Select Health will not pay for these diagnoses for South Carolina Medicaid members. Because a tubal ligation is sometimes performed with this DRG (DRG 374) when a bilateral tubal ligation is included, will be considered family planning, i.e. carved out of the capitation paid by South Carolina to Select Health. Select Health will not pay for DRG 374 when a bilateral tubal ligation is included for South Carolina Medicaid members.

2

Procedure Codes

Family Planning/Elective Sterilization/ Induced Abortion

Family planning, elective sterilization and induced abortion claims should be submitted to South Carolina Medicaid for payment. Applicable codes are: 38 Billing Requirements for Certain Services

On the following page is a list of procedure codes that carry a family planning, abortion, or sterilization indicator. As a general rule, these codes are considered outside the Select Health core benefits. In some rare cases, it may be appropriate for a code to be utilized for a medical (non-family planning, non-abortion, or non-sterilization) procedure. In such cases, the service will be considered a covered service.

Select Health of South Carolina Health Care Professional & Provider Manual

Family Planning Services

Family Planning services rendered but utilizing a procedure code that is not indicated on the list on the following page are non-covered services under the ethical limitations of the plan. These services should be billed to regular Medicaid Fee-for-Service. Also, the health care professional/provider is always encouraged to check the monthly Fee Schedule to ensure that they have the most current listing. Please see the listing that follows.

Family Planning Procedure Codes (cont.)

H1011 H2000 H2001 J1051 J1055 J1056 J7300 J7302 J7303 J7304 J7306 J7307 S0181 S4981 S4989 S4993 S9445 S9446 T1023 55250 55450 58565 58600 58605 58611 58615 58670 58671 58672 58983 59100 59840 59841 59850 59851 59852 59855 59856 59857 59866 59870 FAMILY ASSESSMENT BY LIC BEHAV COMPREHENSIVE MULTIDISCIPLINAR REHABILITATION PROGRAM, PER 1/2 INJECTION, MEDROXPROGESTERONE AET INJ MEDROXYPROGESTERONE AETAT IN,MEDROXYPROGEST ACET/ESTR CY INTRAUTERINE COPPER ONTRACEPT LEVONORGESTRL-RELEAS IU CONTRA CONTRACEPTIVE, HORMONE W/VAGI CONTRACEPTIVE, HORMONE PATCH LEVONGESTREL IMPLANT SYS, INC SUP ETONOGESTREL IMPLANT SYS INC SUP ONDASETRON HYDROCHORIED, ORAL 4 M INSRT LEVONORGESTREL, RLS INTRAUT CONTRACEPTIVE INTRAUTERINE DEV CONTRACEPTIVE PILLS FOR BIRTH CO PATIENT EDUCATION, NOT OTHERWIS PATIENT EDUCATION, NOT OTHERWIS SCREENING TO DETERMINE THE APPR VASECTOMY UNI/BIL (SEP PRO)INC P LIGATION(PERCUTAN)VAS DEFERNS U HYSTEROSCOP, SURG W/BILAT FALOP TRANSECT FALLOPIAN TUBE UNIL & B TRANSECT FALLOPIAN TUBE POSTPA LIGATION TRANSEC FALLOP TUBE W/ OCCLUSION FALLOP TUBE(S)BY DEV LAP SURG FULGURATION OVIDCT W/ LAP SURG OCCL OVIDUCTS DEV EG B LAPAROSCOPY SURGICAL W/ FIMBRI LAPARASCOPY VISUAL W/OCCLUSION HYSTEROTOMY ABDOM (e.g. HYATIDIFO) INDUCED ABORTION PER D&C INDUCE ABORT, DILATION & EVAC INDUCE ABORT,BY INJECT INCLD HOS INDUCE ABORT,D&C &/OR EVACUATI INDUCED AB BY AMNIO INJ W HYSTE INDUCE ABORT BY VAG SUPPOSIT INC INDUCE ABORT VAG SUPPOS HOSP AD INDUCE ABORT VAG SUPPOS HOSP AD MULTIFETAL PREGNANCY REDUCTIO UTERINE EVAC&CURETTAGE FOR HY

Family Planning Procedure Codes

1197 11976 11977 11981 11982 11983 54900 54901 55200 55300 57170 58300 58301 58340 58350 58750 58760 58825 58920 74740 89300 89310 89320 89322 89331 99401 A4261 A4266 A4267 A4268 A4269 G0027 H1010 INSERT, IMPLANTABLE CONTRACEPT REMOVAL IMPLANTABLE CONTRACE REMOVE W/REINS IMPLANT CONTRAC INSERT NON-BIODEGRADE DRUG DELIV REMOVE NON-BIODEGRADE DRUG DELIV REMOVE/REINSRT NON-BIO DRUG DELIV EPIDIDYMOVASOSTOMY ANASTOM E EPIDIDYMOVASOSTOMY ANASTO EPI VASOTOMY CANNULI W/WO INCIS VA VASOTOMY VASOGRAM SEMINAL VE DIAPHRAGM FITTING W INSTRUCTION INSERTION OF INTRAUTERINE DEVICE REMOVAL OF INTRAUTERINE DEVICE CATH&INTRO SALINE OR CONTR MAT CHROMOTUBATION OF OVIDUCT INC TUBAL REANASTOMOSIS FIMBRIOPLASTY TRANSPOSITION OVARY(S) WEDGE RESECTION UNIL BILAT PERCUTANEOUS HYSTEROGRAM SEMEN ANALYSIS W/HUHNER SEMEN ANALYSIS MOTILITY & COUNT SEMEN ANALYSIS COMPLETE SEMEN ANALYSIS VOLUME CNT, MOTLTY SPERM EVAL FOR RETRO EJAC, UA E/M PREVENT MED COUNSELING, IND CERVICAL CAP FOR CONTRACEPTIVE USE DIAPHRAGM FOR CONTRACEPTIVE U CONTRACEPTIVE SUPPLY, CONDOM CONTRACEPTIVE SUPPLY, CONDOM CONTRACEPTIVE SUPPLY, SPERMICID SEMEN ANALY; PRESENCE/MOTIL SPE NON-MEDICAL FAM PLAN ED, PER SE

Sterilization Procedure Codes

Abortion Procedure Codes

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Billing Requirements for Certain Services

39

Family Planning Procedure Codes (cont.)

S0191 S0199 X0191 X0199 63 .82 65 .22 66 .79 66 .8 66 .91 MISOPROSTOL,ORAL,MCG MEDICALLY INDUCED ABORTION BY MISOPROSTOL,ORAL,MCG MEDICALLY INDUCED ABORTION BY 66 .93 66 .94 66 .95 66 .96 66 .99 69 .7 69 .91 69 .92 87 .82 87 .83 87 .91 96 .17 97 .24 97 .71 97 .73 99 .96

Communicable Disease

Surgical Procedure Codes

An array of communicable disease services are available to help control and prevent diseases such as tuberculosis (TB), syphilis and other sexually transmitted diseases (STDs) and HIV. Communicable disease services include examinations, assessments, diagnostic procedures, health education and counseling, treatment and contact tracing, according to the Centers for Disease Control standards. In addition, specialized outreach services are provided such as directly observed therapy for TB cases. Eligible individuals should be encouraged to receive TB, STD and HIV/AIDS services through their primary care provider (PCP) or by appropriate referral to promote coordination of these services. However, individuals have the freedom to receive these services from any public health agency without restriction. If the member receives these services through their PCP, First Choice will cover these services. If services are received through non-participating health care professionals/providers, Medicaid Fee-for-Service will cover these services.

First Choice Covered Services

Audiological Services

Several audiology services are covered under the Select Health contract up to the limits specified below: 92552 92557 92557/52 92567 92568 92584 92585 92585/52 92587 92588 92590 92592 92592/52 92626 V5011 6 every 12 months 1 every 12 months 6 every 12 months 6 every 12 months 2 every 12 months 1 per implant No limit No limit No limit No limit 6 every 12 months 6 every 12 months 6 every 12 months 10 per year 6 every 12 months

Durable Medical Equipment

Durable medical equipment includes medical products, surgical supplies and equipment such as wheelchairs, prosthetic and orthotic devices and hearing aid services when ordered by a physician as medically necessary in the treatment of a specific medical condition. Luxury and deluxe models are restricted if standard models would be appropriate. Repairs to medical equipment are covered if reasonable.

Emergency, Non-Emergency Medical Transportation

Chiropractic Services

Chiropractic services are available to all recipients. Chiropractors specialize in the detection and correction of structural imbalance, distortion or subluxation in the human body. Select Health will cover authorized services up to 6 visits per state fiscal year.

Medical necessity for ambulance transport is established when the recipient's condition warrants the use of ambulance transportation and the use of any other method is not appropriate. These trips may be routine or non-routine transports to a Medicaid-covered service. Types of services include ambulance, nonemergency medical vehicles and air ambulances.

Circumcision

Hearing Aids and Hearing Aid Accessories

· L8615 · L8619

Newborn circumcision will be covered if done prior to the delivery discharge. Circumcisions performed after that point will only be covered if medically necessary. 40 First Choice Covered Services

Select Health is responsible for providing the following for members under age 21:

Select Health of South Carolina Health Care Professional & Provider Manual

· L8621 ­ L8624 · V5030 ­ V5267 · L9900

Maternity Care

Home Health Services

Home health services are healthcare services delivered in a person's place of residence, excluding nursing homes and institutions and include intermittent skilled nursing, home health aide, physical, occupational and speech therapy services up to 50 visits per year.

Maternity services include high levels of quality care for pregnant members. Maternity care service benefits include prenatal, delivery, postpartum services and nursery charges for a normal pregnancy or complications related to the pregnancy. Note: Select Health follows the American Medical Association (AMA) guidelines when considering initial obstetrical exams for existing patients. These guidelines state that new patient E&M coding is not to be used for each initial OB exam for an existing patient. The initial OB exam should be billed at a higher level E&M code based on the level of complexity.

Independent Laboratory and Radiology Services

Benefits cover laboratory and x-ray services ordered by a physician and provided by independent laboratories and free-standing x-ray facilities. An independent laboratory and x-ray facility is defined as a facility licensed by the appropriate state authority and not part of a hospital, clinic or physician office. Select Health uses the South Carolina Medicaid Health care professional/provider List to determine if a health care professional/provider is an independent lab or a free-standing x-ray facility.

Mental Health, Alcohol and Other Drug Abuse Services

Select Health provides for the following mental health and alcohol and other drug abuse medical assessment services: · 90801 -- Psychiatric diagnosis interview exam, one assessment per member every six months · 90802 -- Interactive psychiatric interview (private psychiatrist only), one assessment per member every six months Select Health is also responsible for: · Department of Alcohol & Other Drug Abuse Services or the Department of Mental Health laboratory claims (submitted under Provider Type 80 Independent Lab) · Outpatient services in an emergency room setting for which the primary diagnosis is behavioral health (class code C), the emergency room visit (both professional and facility fees) · Inpatient behavioral health services (DRGs 424-433 and 521-523) · Professional charges (with the exception of those identified as psychiatric CPT 90804-90899) · Anesthesia services associated with behavioral health · Medical services (physician services that are not mental health treatment services) provided by a psychiatrist or child psychiatrist

Inpatient Hospital Services

Inpatient hospital services are those items and services provided under the direction of a physician, furnished to a patient who is admitted to a general acute care medical facility for institutional and professional services on a continuous basis and for which admission is expected to last for a period greater than 24 hours. Among other services, inpatient hospital services encompass a full range of medically necessary diagnostic, therapeutic care including surgical, medical, general nursing, radiological and rehabilitative services in emergency or non-emergency conditions. Additional inpatient hospital services would include room and board, miscellaneous hospital services, medical supplies and equipment.

Long-Term Care Facilities

The first consecutive 30 days of confinement in a long-term care facility/nursing home are covered by Select Health. Services include skilled nursing care or skilled rehabilitative services at the skilled or sub-acute intermediate level of care. After the first 30 days, payment for long-term care services will be reimbursed by Medicaid Fee-for-Service.

Outpatient Services

Outpatient services are defined as those preventive diagnostic, therapeutic, rehabilitative, surgical and emergency services received by a patient for the First Choice Covered Services 41

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

treatment of a disease or injury at an outpatient/ ambulatory care facility for a period of time generally not exceeding 24 hours. Enrolled First Choice members do not have any limitations on the number of outpatient visits they may receive in any given time.

prior authorization at 1.866.610.2773 or fax to 1.866.610.2775. Health care professionals/providers may obtain the PDL and authorization forms from the Select Health website: www.selecthealthofsc.com.

Physician Services

Rehabilitative Therapies

Physician services include the full range of preventive care services, primary care medical services and physician specialty services. All services must be medically necessary and appropriate for the treatment of a specific diagnosis as needed for the prevention, diagnostic, therapeutic care and treatment of the specific condition. Physician services are performed at the physician's office, patient's home, clinic or skilled nursing facility. Technical services performed in a physician's office are considered part of the professional services delivered in an ambulatory setting unless designated as a separate service.

Rehabilitative therapy services include: speech pathology, physical and occupational therapies. Services are provided through private rehabilitation clinics/health care professionals/providers up to 300 units or 75 hours per year (this limit applies to the rehabilitative services combined).

Topical Fluoride Varnish

Podiatry Services

Podiatry services are those services medically necessary for the diagnosis and treatment of foot conditions. Services are limited to specialized care of the foot for members with a diagnosis of diabetes. Podiatrists must include the appropriate diabetic diagnosis on the claim to ensure payment.

The best practices of the American Academy of Pediatrics recommend that children up to 3 years old who are at high risk for dental caries should receive fluoride varnish application in their primary care physician's office during their EPSDT visit two times per year (once every six months) and in their dental home two times per year (once every six months). The American Dental Association has established a new Current Dental Terminology (CDT) procedure code, D1206, for the application of topical fluoride varnish. The primary care physician will bill this procedure to Select Health on the CMS1500 claim form.

Prescription Drugs

Vision Services

Covered pharmaceutical services include most legend (prescription) and certain non-legend (over-thecounter) products. Select Health sponsors reimbursement for unlimited prescriptions or refills for First Choice members younger than 21 years old, and up to four prescriptions or refills per month for members 21 years and older. However, certain items are exempt from the monthly prescription limit. The exemptions to the monthly limit are as follows: insulin syringes; home parental therapies; aerosolized pentamidine; Imitrex, Betaseron, epinephrine and diabetic emergency kits and clozapine therapy. Where appropriate, medications are prescribed to cover a maximum of 31 days. Select Health does not cover brand name products for which there are "A" rated, therapeutically equivalent, less costly generics available unless prior authorization is secured. Prior authorization is required for select pharmaceuticals. Please see the Select Health plan's Preferred Drug List for a complete listing. Health care professionals/providers may contact Select Health/AmeriHealth Mercy Pharmacy Services for 42 First Choice Covered Services

Routine eye exams are included in the core benefits provided by First Choice for members under the age of 21. Prior authorization is not required for participating health care professionals/providers; non-participating health care professionals/providers are required to obtain authorization. Select Health covers vision services for all members with a medical diagnosis regardless of age. Select Health will cover a replacement pair of eyeglasses for members under the age of 21. The replacement pair of glasses will be provided by Robertson's Optical, the same vendor that SCDHHS uses for the initial pair. To assist our health care professionals/providers with the administration of this benefit, Robertson's Optical will submit claims for eyeglasses directly to Select Health. The initial pair of glasses for these members will be covered by Medicaid Fee-for-Service. The following codes: V2500V2599, 92070, 92310, 92311, 92312, 92313 and 92340 will also be billed to Medicaid Fee-for-Service for members under the age of 21.

Select Health of South Carolina Health Care Professional & Provider Manual

Services Provided by Medicaid Fee-for-Service

Select Health primary care providers (PCPs) or Select Health case managers may identify services required for members that are outside of the benefits package available to First Choice members. Medicaid Fee-forService may cover these services, and the Select Health Medical Services staff may assist the health care professional/provider and member in contacting the appropriate agency to access these services. The following is a summary list of Medicaid Fee-forService benefits that may be coordinated by Select Health and the Department of Health and Human Services: · Dental Services: Routine dental services are available to those under 21 years of age. Emergency dental services are available to all members. · Developmental Evaluation Services: defined as medically necessary comprehensive neurodevelopmental and psychological developmental, evaluation and treatment services for recipients between birth and age 21. Developmental Evaluation Services may be provided through the plan's network health care professionals/providers, which may include but shall not be limited to one of the two tertiary level Developmental Evaluation Centers (DEC) located within the The University School of Medicine, USC in Columbia or the Medical University of South Carolina at Charleston. · Elective Sterilization: Select Health will not provide coordination of these services. · Family Planning: An array of family planning services is available. PCPs will coordinate access to family planning services. · Fluoride Varnish Applications: The purpose of applying fluoride varnish during an EPSDT wellchild visit is to increase access to preventive dental treatment in an effort to intercept and prevent early childhood caries in children at moderate to high risk for dental caries. If this service is rendered in the dentist's office it is covered by Medicaid Fee-for-Service. · Gardasil Vaccine: This is the only cervical cancer vaccine that helps protect against four types of human papillomavirus (HPV): 2 types that cause 70 percent of cervical cancer cases and 2 more types that cause 90 percent of genital warts cases. Gardasil is for girls and young women ages 9 to 26. · Home- and Community-Based Waiver Services:

Targets members with long-term care needs and provides recipients access to services that enables them to remain at home rather than in an institutional setting. Waivers currently exist for the following special needs populations: · Persons with HIV/AIDS · Persons who are elderly or disabled · Persons with mental retardation or related disabilities · Persons who are dependent upon mechanical ventilation · Person who are head or spinal cord injured · Induced Abortion: Select Health will not provide coordination of these services. · Long-Term Care/Nursing Home: after the first 30 days. · Mental Health and Alcohol/Drug Services: Some mental health, alcohol and other drug abuse treatment services will be reimbursed by Medicaid fee-for-service. SCDHHS considers the following to be mental health, alcohol and other drug abuse treatment services: · Hospital services (UB-04 claims): Outpatient services not rendered in an emergency room setting with a primary diagnosis of behavioral health (class code of C) · Services provided by the Department of Alcohol and Other Drug Abuse Services (DAODAS) · Services provided by the Department of Mental Health (DMH) · Psychiatric services as outlined in the Physicians, Laboratories, and Other Medical Professionals Provider Manual, Section 2, Psychiatric and Counseling Services, except the assessment codes detailed in the Psychiatric Assessment and Psychiatric Emergency Services section (CPT 90804 ­ 90899) · Non-Emergency Medical Transportation: Coordinated with the transportation broker in the member's county of residence. · Organ Transplants: Includes pre-transplant services (72 hours preadmission), the event (hospital admission through discharge) and posttransplant services up to 90 days from the date of discharge. For information concerning the referral for medical evaluation and transplant arrangements, please contact the following: Services Provided by Medicaid Fee-for-Service 43

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Transplant Coordinator MUHA (Medical University Hospital Authority) 843 792 2123 The following are not considered to be standard transplant services and remain the responsibility of First Choice: · Corneal transplants · Pre-transplant services rendered prior to 72 hours preadmission · Post-transplant follow-up services · Post-transplant pharmaceutical services · Pregnancy Prevention Services: Medicaid Fee-forService will reimburse directly to enrolled Medicaid health care professionals/providers for these services. The following programs are available: · MAPPS Family Planning Services: Medicaid Adolescent Pregnancy Prevention Services provides Medicaid-funded family planning services to at-risk youths. These services are provided in local South Carolina Department of Social Services offices, schools, office settings, homes and other approved settings. · Targeted Case Management Services: Consist of services that will assist an individual eligible under the state plan in gaining access to needed medical, social, educational and other services. A systematic referral process to health care professionals/ providers for medical education, legal and rehabilitation services with documented follow up must be included. Case management services ensure that necessary services are available and accessed for each eligible patient. Case management services are offered to alcohol and substance abuse individuals, children in foster care, chronically mentally ill adults, emotionally disturbed children, children in the juvenile justice system, sensory impaired individuals, individuals with mental retardation or a related disability, individuals with a head or spinal cord injury or a related disability and adults in need of protective services. Medicaid reimbursable Targeted Case Management programs available to recipients are administered by the following: · Department of Mental Health: Services for mentally ill adults and children with serious emotional disturbances. · Department of Alcohol/Drug Abuse Services: Services for substance abusers/dependents. · Department of Juvenile Justice: Services for 44 Services Provided by Medicaid Fee-for-Service

·

· ·

· ·

children from birth to age 21 who are within the juvenile justice system. Department of Social Services (DSS): Services to emotionally disturbed children 0-21 in the custody of DSS and placed in foster care and adults 18 and over in need of protective services. Continuum of Care for Emotionally Disturbed Children: Children from birth to age 21 who are severely emotionally disturbed. Department of Disabilities and Special Needs: Services to individuals with mental retardation, developmental disabilities and head and spinal cord injuries. South Carolina School for the Deaf and the Blind: Services to sensory impaired children from birth to age 6. Sickle Cell Foundations and Other Authorized Health care professionals/providers: Services to individuals with sickle cell disease and/ or trait. Medical University of South Carolina provides services to individuals with this disease .

· Vision Care: Medicaid Fee-for-Service will cover eyeglasses and contacts for members under age 21 (codes V2020, V2500-V2599) and dispensing fees, codes: 92070, 92310-92313 and 92340.

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibit Listing

1 . Definitions 2 . SC Healthy Connections ID Card 3 . First Choice ID Card 4 . Chart, Periodic Health Examinations in Children 5 . Chart, Periodic Health Examinations in Adults 6 . Chart, Obstetrical Care 7 . First Choice Prior Authorization Information 8 . Drug Prior Authorization Request Form 9 . Pregnancy Risk Assessment Information 10 . Pregnancy 17-P Authorization Information 11 . Hysterectomy Acknowledgement Form 12 . Request For Prior Authorization/General 13 . Request For Prior Authorization/DME 14 . Request For Prior Authorization/PT/OT/ST/Chiro 15 . Member Consent for Appeal Form 16 . Overpayment Request Worksheet 17 . Sample WIC Referral Form 18 . Sample Provider/Member Roster 19 . Sample Capitation Payment Roster 20 . Sample Select Health Remittance Advice

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibit Listing

45

Definitions

Claim Form: A statement for covered services provided hereunder by hospital/health care professional/provider and which is on a form or in a format acceptable to plan (UB04 or CMS1500). Compensation: Remuneration to the participating health care professional/provider for services rendered to plan members through fee for service, capitation and/or other services payment for the procedures as listed herein: a . Capitation payment means monthly remuneration according to the participation agreement for services provided by the health care professional/provider and covered by the plan, but subject to plan member access, quality assurance and utilization criteria retroactive review by the plan. b . Other services payment means remuneration paid by the plan for services listed in the participation under attachment A, according to attachment B and/or subsequently approved by the plan at a negotiated rate. Remuneration to be paid subject to receipt and processing of other services claim. Covered Services: Those health services and benefits to which plan members are entitled and that the health care professional/provider has agreed to provide plans members as set forth on attachments A and B, of the participation agreement and in accordance with the Title XIX SC State Medicaid Plan. Medical Director: A physician designated by plan to monitor and review covered services to members provided or requested by a healthcare health care professional/provider. Medically Necessary: Those medical services or supplies as provided by a hospital, skilled nursing facility, physician or other medical health care professional/provider who are required to identify, treat or avoid an illness or injury to a member and which, as determined by plan's participating physician, medical director or utilization review process, are: a . consistent with the symptoms or diagnosis and treatment of the member's condition, disease, ailment or injury; b . appropriate with regard to standards of good medical practice; c. not solely for the convenience of the member, 46 Exhibits: Definitions

his or her participating physician, hospital, or other healthcare health care professional/ provider; and d . the most appropriate supply or level of service that can be safely provided to the member. When specifically applied to a potential inpatient member, it further means that the member's medical symptoms or condition require that the diagnosis or treatment cannot be safely provided to the member as an outpatient. Member: A person for whom premium payment has been made to and received by plan. Non-Participating Health Care Professional/Provider: Any healthcare health care professional/provider who has not contracted with Select Health to provide professional services to members. Participating Health Care Professional/Provider: Hospitals, physicians, nurse-midwives, midwives, birth centers, home health agencies, dentists, nurses, optometrists, physician assistants, clinical psychologists, social workers, pharmacists, occupational therapists, physical therapists and any other healthcare health care professionals/providers who/which are licensed, practice under an institutional license or are certified to practice under other authority consistent with the laws of South Carolina and who/which have been approved by plan or with whom plan has contracted to provide professional or health services to members. Physician: A doctor of medicine or osteopathy, podiatrist, chiropractor, psychologist or mental health professional duly licensed to practice in the state of South Carolina. The following physician designations are used within the context of the participation agreement: participating physician, participating primary care physician and participating specialist physician. a . Participating Physician: Either a participating primary care physician or participating referral specialist physician who has contracted with Select Health to provide professional services to members. b . Participating Primary Care Physician: A participating physician who provides primary care services to members (e.g., general practitioner, family physician, general internist or pediatrician or such other physician specialty

Select Health of South Carolina Health Care Professional & Provider Manual

as may be designated by the health plan) and is responsible when medically indicated for referrals of members to participating specialist physicians, other participating health care professionals/providers and, if necessary, non-participating health care professionals/providers. Except as otherwise provided herein, each member shall select or have selected on his or her behalf a participating primary care physician. c. Participating Specialist Physician: A participating physician who is responsible for providing physician specialist services upon referral by a participating primary care physician and prior authorization by plan. Prior Authorization Number: A number provided by the health plan that the health care professional/ provider utilizes to receive payment for services rendered to a member. South Carolina Department of Health and Human Services (SCDHHS): The state agency responsible for administering South Carolina's Medicaid program.

providers encourage beneficiaries to call their eligibility worker or 1.888.549.0820 if they do not receive a new card.

First Choice Member ID Card

JOHN DOE 12345678 M 01/01/01 1234567890 01/01/02 ABC Pediatrics 12345678 843-555-1234 600428 02180000

Member's name, primary care health care professional/provider (PCP), PCP's phone number and effective date of enrollment are on the front of card. Health care professional/provider information, authorization and claim information are on the back of card. Eligibility may also be verified through the NaviNet website at www.navinet.navimedix.com .

SC Healthy Connections Card

JOHN Q CITIZEN DOB 01/01/01 Medicaid Member Number:

0000000000000

Request Insurance ID Card. Follow applicable instructions. You must verify eligibility on each visit through the IVRS system at 1.888.809.3040, online through Medifax or you may visit the Select Health website at www.selecthealthofsc.com. On the IVRS or Medifax, a message will indicate at the end of verification if this person is on a managed care plan. Various swipe machines are available for a fee to verify eligibility through a printout. The name of managed care plan will be noted at the end of the printout. While the blue and yellow Partners for Health card will remain valid, we ask that health care professionals/ Exhibits: SC Healthy Connections Card 47

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Chart, Periodic Health Guidelines for Children

A baseline visit is recommended and encouraged for all new plan members. Further visits should be scheduled according to relevant guidelines outlined below or as needed. Delivery of clinical preventive services should not be limited only to visits for health maintenance but also should be provided as part of visits for other reasons such as acute and chronic care.

2 to 4 weeks

12 months

15 months

18 months

4 months

24 months

6 months

2 months

9 months

5 years

3 years

History Nutrition Screening Measurements Height or Length and Weight Head Circumference Body Mass Index (BMI) Blood Pressure Sensory Screening Vision Exam Hearing Exam Developmental & Behavioral Assessment Physical Exam Dental Assessment Dental Referral Immunization Assessment Procedures--General Hematocrit or Hemoglobin Urinalysis Lead Screening Procedures--Patients at Risk Pelvic Exam or Pap Smear Chlamydial Infection Screening Sickle Cell Screening Tuberculin Testing Parasite Testing

Birth

Preventive Health Guidelines

4 years

6 years

Every year Every year

Every year

Every year Every year

Every year Every year Every year

Every year Every year

Every year

At age 13 At age 16

Within three years of first vaginal intercourse or no later than 21 years of age Each year for all sexually active non-pregnant young women from 16 to 24 years of age Indicated by family or medical history or in the presence of anemia Upon recognition of high risk factors When indicated by medical history, physical exam or a positive result of previous test

Preventive Counseling and Anticipatory Guidance Nutrition--2 years and younger Nutrition--2 years and older Injury and Violence Prevention Dental Health Skin Cancer Parental Concerns Immunization Schedules Childhood Adolescent Catch-up for children 4 mo. to 18 yrs.

http://www.cdc.gov/vaccines/recs/schedules/downloads/child/0-6yrs-schedule-pr.pdf http://www.cdc.gov/vaccines/recs/schedules/downloads/child/7-18yrs-schedule-pr.pdf http://www.cdc.gov/vaccines/recs/schedules/downloads/child/catchup-schedule-pr.pdf

Encourage mothers to breast-feed for 6-12 months if possible. Encourage use of iron-rich food, formula and cereal. Counsel parents about vitamin supplements. Counsel parents that children need a balanced diet that is low in fat and includes a variety of foods. Encourage parents and children to use sugar and salt only in moderation. Counsel parents and children about the importance of maintaining a healthy weight. See age appropriate counseling for injury prevention. Includes seat belt usage, bicycle helmet usage, installing smoke detectors, safe storage of firearms and monitoring hot water temperatures (<120 degrees) with infants. Brush with fluoride toothpaste, floss daily and visit a dentist regularly. Children 6 months to 12 years using well water should take a fluoride supplement. Avoid excess sun exposure, especially those at high risk (fair-hair, light skin, easy to burn, freckles). Use sunscreen when in the sun. Encourage parents to discuss any concerns regarding their child's health, safety and behavior.

Approved: 7/03, 3/05, 3/07, 8/08, 3/09, 12/11

Source: Report of the US Preventive Services Task Force, American Academy of Family Practice, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, US Department of Health and Human Services, Centers for Disease Control and Prevention.

48

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Chart, Periodic Health Guidelines for Children

7 to 21 years

Children's

Chart, Periodic Health Guidelines for Adults

A baseline visit is recommended and encouraged for all new plan members. Further visits should be scheduled according to relevant guidelines outlined below or as needed. Delivery of clinical preventive services should not be limited only to visits for health maintenance but also should be provided as part of visits for other reasons such as acute and chronic care.

Adult Preventive Health Guidelines

Physical examination Blood pressure Body Mass Index (BMI) Cholesterol

Age 20-29

Consider age, sex and risk factors.

Age 30-39

Consider age, sex and risk factors.

Age 40-49

Consider age, sex and risk factors.

Age 50-59

Consider age, sex and risk factors.

Every 2-3 years

Every 2-3 years

Every 2-3 years

Every 1-3 years

At least every 1-2 years

Or as suggested by your doctor. Patients with positive risk factors should be monitored more frequently. Annual cervical cytology should begin about 3 years after initiation of sexual intercourse but no later than 21 years. Women younger than 30 years should undergo annual cervical cytology screening. All sexually active non-pregnant young women age 24 and younger

At least every 1-2 years

Or as suggested by your doctor. Patients with positive risk factors should be monitored more frequently.

At least every 1-2 years

Or as suggested by your doctor. Patients with positive risk factors should be monitored more frequently.

At least every 1-2 years

Or as suggested by your doctor. Patients with positive risk factors should be monitored more frequently.

Every year

Every year

Every year

Every year

Every 4-5 years

Every 4-5 years

Every 4-5 years

Every 4-5 years

Pap smear/pelvic exam

30 years and older | No history of CIN 2 or CIN 3 | Not immunocompromised | HIV negative | Not exposed to DES

Repeat pap every 2-3 years in women:

Otherwise, annual cytology is recommended

Chlamydial Infection Screening Mammogram Physician breast exam Self breast exam Physician testicular exam Prostate-specific antigen (PSA) Self testicular exam Skin exam Tuberculin skin test

Routine lab (UA, CBC, blood chemistry, STD screening)

All older non-pregnant women who are at increased risk Every year for high risk women

beginning at the age of 35.

Baseline at age 40 then every 1-2 years Every year Monthly Every year Every year

Every year Every year Monthly Every year Every year Monthly Every year All high-risk individuals Yearly as appropriate Yearly Initial screening at age 50,

every 5-10 years depending on family history and findings.

Every year Monthly Every year

Every year Monthly Every year

Monthly Every 3 years All high risk individuals Yearly as appropriate

Monthly Every 3 years All high-risk individuals Yearly as appropriate

Monthly Every year All high-risk individuals Yearly as appropriate Yearly for patients with a family

history of colorectal cancer

Fecal occult blood Colonoscopy Preventive Counseling

Tobacco cessation Alcohol/Drug treatment Diet and exercise Injury prevention Skin cancer Dental health Folic acid Self examination Depression

Hazards of tobacco use. Seek counseling to stop smoking and/or chewing tobacco.

Every 5-10 years depending on

family history and findings.

Hazards of alcohol and/or drug use. Avoid excessive alcohol use and do not drive while under the influence of alcohol. Limit fat and cholesterol, maintain caloric balance and emphasize grains, fruits, vegetables and adequate calcium intake for women. Lap and shoulder belts, smoke detectors, safe storage and removal of firearms and back injury prevention. Avoid excess sun exposure and use a sunscreen when in the sun.

Approved: 7/03, 3/05, 3/07, 3/09, 12/11

Regular visits to the dentist floss and brush. All women who are planning or capable of pregnancy should take a daily multivitamin containing the recommended amount of folic acid. Breast, skin and testes. Assessment and screening Refer to the CDC website for the recommended adult immunization schedule: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/mmwr-adult-schedule.pdf

Adult Immunizations

Sources: Report of the U.S. Preventive Services Task Force, American Academy of Family Practice, American College of Obstetricians and Gynecologists, U.S. Department of Health and Human Services Public Health Service, Center for Disease Control and Prevention.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Chart, Periodic Health Guidelines for Adults

49

Chart, Obstetrical Care Guidelines

Obstetrical care guidelines comprise services normally provided in uncomplicated obstetric care. Women with medical or obstetric problems may require closer surveillance; the appropriate intervals between visits are determined by the nature and severity of the problems.

Obstetrical Guidelines

Frequency of visits

The frequency of follow-up visits is determined by the individual needs of the woman and the assessment of her risks. Generally, a woman with an uncomplicated pregnancy is examined every 4 weeks for the first 32 weeks of gestation, every 2-3 weeks until 36 weeks of gestation and weekly from 37 weeks until delivery.

Recommended intervals for routine tests and tests indicated as medically necessary for individual patients during pregnancy:

Time (in weeks) Assessments

¬

Initial visit, as early as possible

History and risk assessment; obtain obstetric database that contains information regarding the patient's: ½ Last menstrual period ½ Current pregnancy and past obstetric outcomes ½ Medical and social history ½ Dietary assessment ½ Physical findings ½ Estimated date of delivery (EDD) ½ Laboratory tests (including HIV screening) ½ Risk assessment (SCDHHS Pregnancy Form 204[P])

¬ ¬

Hemoglobin or hematocrit measurement

Hemoglobin electrophoresis for African American or Asian patients

Urine culture Blood group and Rh type determinations Antibody screen Rubella antibody titer measurement Syphilis screen Cervical cytology Hepatitis B virus screen Testing for sexually transmitted disease and HIV Cystic Fibrosis Evaluation of edema Measurement of fundamental height Evaluation of fetal heart tones and rate Chronic villus sampling Offer nuchal translucency screening (between 10­13 wks) Offer quad screen (if not completed in 1st trimester)

¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬

Subsequent prenatal visits 8­18 16­18 18­22 26­28 28 32­36 35-37

¬ ¬ ¬ ¬ ¬ ¬ ¬

Blood pressure management Urinalysis for glucose/albumin Weight measurement and cumulative weight gain Fetal movement Ultrasound Amniocentesis Maternal serum alpha-fetoprotein after 1st trimester nuchal translucency. Anatomy screening Diabetes screening Prophylactic administration of Rho(D) immune globulin for Rh Neg patients Testing for sexually transmitted disease Group B strep screening Counseling is an ongoing and continuous process throughout the prenatal period. These items should be addressed as early as possible during prenatal care and continually reassessed: ½ Signs and symptoms to be reported to the physician ½ Timing of subsequent visits ½ Educational programs (childbirth education) ½ Analgesia and anesthetic options ½ Balanced nutrition, ideal caloric intake and weight gain, vitamins, folic acid and calcium intake Weight Blood pressure Breasts Abdomen

¬ ¬ ¬

¬ ¬ ¬

¬ ¬ ¬

¬

Fetal movement counting instruction Repeat hemoglobin or hematocrit measurement

¬ ¬ ¬

¬

½ ½ ½ ½ ½

Patient education and information (ongoing)

½ ½

½ ½ ¬ ¬ ¬ ¬

Use of seatbelts Home safety Infant safety seats Over-the-counter drug use Personal safety: domestic violence, psychological stress Exercise and daily activity Hazards of smoking, alcohol and drug consumption Breast feeding Postpartum care

Adopted: 9/98 Approved: 4/99, 4/01, 7/03, 3/05, 3/07, 3/09, 10/11

Postpartum Care, 21­56 days following delivery

¬ ¬ ¬ ¬

Pelvic examination Patient concerns Family spacing Signs of depression

Source: American College of Obstetricians and Gynecologists

50

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Chart, Obstetrical Care Guidelines

Chart, First Choice Prior Authorization Information

Prior Authorization Information

January 2012

Authorization Required CPT Codes Revenue Codes

Air Ambulance retrospectively reviewed

A0430 A0431 A0435 545

Authorization Required CPT Codes Revenue Codes

Outpatient Surgical Services as listed:

Ablation: 19105, 34675­79 Blepharoplasty: 15822, 15823 Chemodenervation: 61614 Cochlear Implantation: 69930 ENT: 69710­11, 69714­15, 69717, 30130, 30140, 30220, 30630, 31582, 31588 Gastric Bypass/Vertical Band Gastroplasty: 43842­48, 43644, 43645, 43770­71, 44055 Hysterectomy: 51925, 58150­294, 58541­58554, 58950­58956, 58570­58573 Implant: 11983, 62351 Mastectomy for Gynecomastia: 19300 360­369 360­369 360­369 360­369 360­369 490 490 490 490 490 499 499 499 499 499

Cardiac Rehabilitation

All codes applicable 943

Chiropractic Care

All codes applicable All codes applicable

Circumcision unless performed prior to delivery discharge

All codes applicable All codes applicable

Diagnostics

Capsule Endocopy: All codes MEG: All codes Neuropsychological Testing: All codes PET: All codes 762 762 762 762 769 769 769 769

360­369

490

499

360­369

490

499

360­369 360­369 360­369

490 490 490

499 499 499

DME $500 and over

All codes applicable All codes applicable

Home Health required after first 6 visits

All codes applicable All codes applicable

Mastopexy: 19316, 19324­25, 19340­42, 19357­69 Maxillofacial: All codes applicable Panniculectomy: 15830­39 Penile Prosthesis: 54400­17 Plastic Surgery/Cosmetic Dermatology: See code listing on reverse side Reduction Mammoplasty: 19318 Septoplasty: 30520

360­369 360­369 360­369 360­369

490 490 490 490

499 499 499 499

Home Infusions & Injections $250 and over

99601 99602 All codes applicable

Hyperbaric Oxygen

99183 413

Medications infusions/injectables, chemotherapy, PO & IV Vitrasert, Synagis

Authorized by PerformRx. All J codes $250 and over. 90378 96549 All codes $250 and over

360­369 360­369

490 490

499 499

Pain Management external infusion pumps, spinal cord

All codes applicable 27096 62280­82 62310­19 62350 62360­62 63045 63650 63655 63663­64 63685 64479­84 64490­95 64550­55 64560­65 64573­90 64600­10 64612­14 64620 64622­23 64626­27 64630 64632 64640 64680­81 64999 96522 All codes applicable

Inpatient Admissions including back transfers

All codes applicable

neurostimulators, implantable infusion pumps, radiofrequency ablation and nerve blocks

Non-Participating Provider including urgent care and

non-participating laboratory

All codes applicable All codes applicable

Outpatient Maternity/OB Services

99201­15 All codes applicable

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Chart, First Choice Prior Authorization Information

51

Chart, First Choice Prior Authorization Information, page 2

Authorization Required (continued) CPT Codes Revenue Codes

the first 48 units per discipline

97799 92506­08 97012­36 97001­04 97110­542 420 424 430 434

Does NOT Require Authorization

Emergency Ground Transportation (ALS, BLS) Behavioral Health (90801­02, one per six months) Emergency Room Services Participating Gynecological and Specialty Physician Office Visits X-rays

Therapy Services PT, OT, ST requires authorization after

440 444

complete corneal transplant services, pre-transplant services provided prior to 72 hours of actual transplant, post-transplant services

Transplants

All codes applicable

All codes applicable

Unlisted and Category III Codes

All codes applicable All codes applicable

Contact Us

PerformRx: Claims:

Medical Services:

Phone 888.559.1010 Fax 866.368.4562 Phone 866.610.2773 Fax 866.610.2775 Phone 800.575.0418 Address Claims Processing Dept. PO Box 7120 London, KY 40742 www.selecthealthofsc.com

Plastic Surgery and Cosmetic Dermatology CPT Codes listed below:

11200­01 11920­22 11950­54 11960 11970­71 15778­76 15780­93 15819­23 15830 15832­39 15847 17106­08 17360 19300­04 19316 19318 19324­25 19328 19330 19340 19342 19350 19355 19357 19370­71 19380 19396 21076 21082 21084 21086 21089 21120-23 21125 21127 21137­39 21141­47 21150­51 21154­55 21159­60 21172 21175 21179­84 21188 21193­96 21208­10 21215 21230 21260­61 21263 21267­68 21270 21275 21280 21282 21345­48 21360 21421­23 21431­33 21435­36 30120 30400 30410 30420 30430 30435 30450 30460 30462 31830 36470­71 40650 40652 40654 40700 54300 54304 54360 56805 57291­96 57335 67900­04 67906 67908­09 67911 67923 67950 69300

Website:

Visit NaviNet to verify member eligibility and claim status. navinet.navimedix.com

Requires Notification CPT Code Revenue Code

Cardiac CT

75571 350 352 359

Chest CT

71250 71270 350 352 359

Observation

All codes applicable 762 769

Sinus CT/MRI

70480­82 70540 70486­88 70542­43 350 351 359

Spiral CT (CAD)

71260 71270 71275 350 352 359

52

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Chart, First Choice Prior Authorization Information, page 2

Form, Drug Prior Authorization Request

Drug Prior Authorization Request

www.selecthealthofsc.com

Member Information

Member name Select Health member ID# Date Date of birth

Prescriber Information

Name Address City, state, zip NPI# Specialty Phone Fax

Request Information

Drug name Directions Rationale*

*Please do not answer "drug of choice" for rationale.

Dosage form (tablet, cream, etc.)

Strength

Quantity

Duration of therapy

Diagnosis/ICD-9 code Previous therapy tried (please complete all fields): Drug name Strength Frequency Duration

Additional Information

Select Health notes to prescriber Prescriber notes or additional information to Select Health

Sign Here & Form Submittal Instructions

Authorizing signature Please FAX this form to 1.866.610.2775. Or mail this form to: Select Health/PerformRx Pharmacy Services 200 Stevens Drive Philadelphia, PA 19113 Date For questions, please call 1.866.610.2773.

Drug Prior Auth Form Revision 1/2012

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Form, Drug Prior Authorization Request

53

Form, Pregnancy Risk Assessment Information

Pregnancy Risk Assessment Information

Please fax this form to Select Health of South Carolina at 866.533.5493 If you have questions, please call Healthy Moms and Babies at 888.559.1010

Provider Information

Provider Name Address Phone Fax Tax ID #

Member Information

Member Name Address Date of Birth Tobacco Use Average number of cigarettes smoked per day.

If none enter 0; 1 pack = 20 cigarettes

Medicaid ID #

Language preferred Pre-Pregnancy 1st Trimester

Phone 2nd Trimester 3rd Trimester

Pregnancy Information & History

Date of first prenatal visit EDC Abortions: Gest. Age Spontaneous: Gravida Induced: 17P Candidate Para Three consecutive abortions Yes No Living Pre-term

Last Pregnancy

Low birth weight < 2500 grams Gestational diabetes Pre-term delivery (gest. age: Congenital anomaly: Other (specify)

)

History of incompetent cervix Premature ROM Classical incision previous C-section

Fetal death greater than 20 weeks Pre-eclampsia/Eclampsia IUGR

STD history Postpartum depression Hx of DVT/PE

Current Pregnancy

Multiple gestation: Twins Triplets Other: Premature labor Diabetes Placenta previa Heart disease Premature rupture of membranes Hypertension STD (sexually transmitted disease) Previous delivery within 1 year of EDC IUGR 2nd/3rd trimester bleeding Seizure disorder Asthma Other (specify)

Pre-eclampsia RH sensitization Sickle cell disease Incompetent cervix Late and/or inconsistent prenatal care Periodontal disease HIV

Eclampsia Renal disease Abnormal ultrasound Alcohol or drug problems Poor weight gain PIH No current risk

Active Mental Health Conditions

No mental health conditions Other (specify)

Schizophrenia

Bipolar

Depression

Social, Economic and Lifestyle Issues

No identified social, economic or lifestyle issues Homelessness Opiod therapy Mental/physical/sexual abuse (current or hx. of)

Eating disorder Substance abuse (specify type)

Intellectual impairment

Please call Healthy Moms and Babies or fax an updated form if the member has any changes in condition during pregnancy. This updated information can assist Healthy Moms and Babies with member outreach.

Maternity Authorization # Covering dates of service

to

54

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Form, Pregnancy Risk Assessment Information

Form, 17-P Authorization

17-P UNIVERSAL AUTHORIZATION FORM

MCO Prior Authorization Requests: Fax the completed form to the patient's MCO. Absolute Total Care BlueChoice HealthPlan First Choice by Select Health Unison Health Plan P: 803-933-3689 P: 866-902-1689 P: 888-559-1010 x55251 P: 877-651-2217 F: 866-918-4451 F: 800-823-5520 F: 866-533-5493 F: 866-639-7785

Drug Prior Authorization Request Form

Member Information

Provider Information:

Member name

Today's date Birthdate

Provider Name Select Health member ID# (Please Print) Address

Physician Information Phone

Patient/Member Information:

City/State/Zip Fax NPI Subspecialty

Physician ID# Phone

MFM/Perinatology

Other:

Tax ID Physician name

Address

Patient/Member Name City, state, zip Member Plan ID

Medicaid ID (Please Print) DOB Phone Number City/State/Zip

Fax

Request Address

G T

Information

P A L

Pregnancy Information & History: Medication name and strength requested

(Note: A=abortions both spontaneous & medically induced) EDC Yes No

Yes No Experiencing Preterm Labor Bed Rest Yes No Major Fetal or Uterine Anomaly (Home administration available if on bed rest.) Directions Singleton Pregnancy Multiple Pregnancy

Days

At least 16 weeks gestation Yes No

Months

Yes

No

Previous spontaneous singleton preterm birth between 20 ­ 36 weeks Medication Allergies: therapy: Anticipated length of

Diagnosis Other Pertinent Clinical Information:

No known drug allergies Chronic maintenance therapy

Preferred medication tried/previous therapy for this diagnosis (PLEASE include strength, frequency and duration)

17-P Criteria & Pharmacy Information: Women eligible for 17-P must meet the following criteria: · History selecting this medication (PLEASE do not answer "DRUG OF CHOICE") Rationale forof previous spontaneous singleton preterm birth between 20 and 36 weeks · · At least 16 weeks gestation at initiation of therapy No major fetal or uterine anomaly

Pharmacy:

Sign Here & Formaddress Instructions Ship to provider's SubmittalEnd Date of Service

Shipping Preference: Authorizing signature Regular Mail Ground Ordering Physician's Signature:

Ship to patient's home address End Date of Service

Overnight

Please fax this form to:

Or mail this form MCO Use Only: to:

Approved Dates of Service: Denied

Fax 866.610.2775 Select Health/PerformRx Pharmacy Services 200 Stevens Drive 17-P Authorization # PA 19113 Philadelphia,

Number of Injections:

For questions, please call 866.610.2773.

Drug Prior Auth Form Revision 02/2011

Please note that our review applies only to the authorization of medical necessity and benefit coverage. This authorization is not a guarantee of payment unless the member is eligible at the time the services are rendered. 4.2010

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Form, 17-P Authorization

55

Form, Hysterectomy Acknowledgement

Acknowledgement of Receipt of Hysterectomy Information

Hysterectomy Acknowledgement Form

Always Complete This Section

Recipient name Physician's name Medicaid ID# Date of hysterectomy

Complete only one of the remaining sections. Please complete ALL blanks in that section.

Section A: This section is for a recipient who acknowledges receipt prior to hysterectomy.

I acknowledge receipt of information, both orally and in writing, prior to the hysterectomy being performed: that is, once a hysterectomy is performed on me it will make me permanently unable to reproduce (have children). Patient's signature Witness' signature Interpreter's signature (if necessary) Date Date Date

Physician Statement: It has been explained to the above patient and/or her representative by me prior to surgery both orally and in writing that the hysterectomy to be performed is medically necessary and not for the sole purpose of rendering her incapable of bearing children (reproducing), nor is the hysterectomy for medical purposes which by themselves do not mandate a hysterectomy. Physician's signature Date

Section B: Complete this section when any of the exceptions listed below are applicable.

I certify that before I performed the hysterectomy procedure on the recipient listed above (check one): 1) I informed her that this operation would make her permanently incapable of reproducing. This certification is for a retroactively eligible recipient only; a copy of the Medicaid card which covers the date of the hysterectomy, or a copy of the retroactive approval notice must accompany this form before reimbursement can be made. 2) She was already sterile due to: Cause of sterility 3) She had a hysterectomy performed because of a life-threatening situation due to: Describe situation and the information concerning sterility could not be given prior to the hysterectomy. For the reason(s) above, I am requesting an exception to the acknowledgement requirement for the hysterectomy. Physician's signature Date

56

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Form, Hysterectomy Acknowledgement

Form, Prior Authorization, General

Request for Authorization

General

Member Information

Last, first MI Medicaid ID # Today's Date DOB

Practice/Facility Information

Practice/Facility name Contact person Fax # Practice/Facility ID# Call back #

Procedure & Physician Information

Procedure Planned date of service Physician last name, first name, MI Address, city, state zip Physician NPI # Code

Notes

FAX completed request form along with documentation supporting the medical necessity of the requested service(s) to 866.368.4562. Providers will be notified of determination via phone. Approvals are valid for 180 days from the date of issue.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Form, Prior Authorization, General

57

Form, Prior Authorization, DME

DME Request for Authorization

From

From E-mail Fax Phone Date

Member Information

Last, first MI Medicaid ID # DOB

Procedure Information

Please select ONE of the following:

Diagnosis ICD9 code HCPCS code

DME

Medical supplies

Service start Quantity Service end Purchase Lease

Provider Information

Provider name: last, first MI Address, city, state zip Contact person Fax Call back # Provider ID #

Practitioner Information

Practitioner name: last, first MI Address, city, state zip Contact person Fax Call back # State ID #

FAX request form with supporting clinical documentation to 866.368.4562. Select Health Use Only

Case number Given by Date Ext.

58

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Form, Prior Authorization, DME

Form, Prior Authorization, PT/OT/ST/Chiro

PT/OT/ST/Chiro Request for Authorization

From

From E-mail Fax Phone Date

Member Information

Last, first MI Medicaid ID # DOB

Procedure Information

Please select ONE of the following: Physical Therapy

Diagnosis CPT code ICD9 code visits requested

Occupational Therapy

Speech Therapy

Service start Service end

Chiropractor

Provider Information

Provider name: last, first MI Address, city, state zip Contact person Fax Call back # Provider ID #

Practitioner Information

Practitioner name: last, first MI Address, city, state zip Contact person Fax Call back # State ID #

FAX request form with supporting clinical documentation to 866.368.4562. Select Health Use Only

Case number Given by Date Ext.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Form, Prior Authorization, PT/OT/ST/Chiro

59

Form, Member Consent to Provider

Patient Consent for Provider to File an Appeal

Provider Information

Provider name Group name Address, city, state zip Description of service(s) that may be appealed: Date(s) service was provided: NPI # Phone

Member Information and Consent

I agree to allow the provider listed above to file an appeal for me with First Choice for the services listed*. I have read this consent or have had it read to me and it has been explained to my satisfaction. I understand the information in the consent form and give my consent to this provider to file an appeal for me. Patient name (print) Address Patient signature *Consent cannot be dated before the service(s) in question. Date of birth Member ID # Phone Date*

Consent from a Designated Representative

The patient listed above is unable to sign this consent form because of the reason(s) listed below and I consent for the patient:

Representative name (print) Representative signature Witness name

Relationship to patient Date Signature Date

60

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Form, Member Consent to Provider

Form, Overpayment Worksheet

Provider Overpayment Worksheet

Provider Information

Provider Name NPI # Tax ID# Today's Date

A copy of the primary insurance company's payment must accompany all refunds submitted for COB adjustment

Select Health Check Number Select Health Check Amount Select Health Claim # Member Name Date of Service Select Health Paid Amount Refund Amount

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

Comment/reason for refund:

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Form, Overpayment Worksheet

61

Form, Sample WIC Referral

Sample WIC Referral Form

PL103 448, §204(e) requires States using managed care arrangements to serve their Medicaid beneficiaries to coordinate their WIC and Medicaid Programs. This coordination should include the referral of potentially eligible women, infants, and children and the provision of medical information to the WIC Program. To help facilitate the information exchange process, please complete this form and send it to the address listed below. Thank you for your cooperation.

Name of Person Being Referred

Address

Telephone Number

The following classifications describe the populations served by the WIC program. Please check the category that most appropriately describes the person being referred: Pregnant woman Woman who is breast-feeding her infant(s) up to one year postpartum Woman who is non breast feeding up to six months postpartum Infant (age 0 1) Child under age 5 States may consider using this space to either include specific medical information or to indicate that such information can be provided if requested by the WIC Program.

Provider's Name

Provider's Phone

I, the undersigned, give permission for my provider to give the WIC Program any required medical information.

(Signature of the patient being referred or, in the case of children and infants, signature and printed name of the parent/guardian)

Send completed form to: WIC Program Contact Address Phone Number

62

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Form, Sample WIC Referral

20000856 Montgomery Family Services 1856 North Creek Road Middlebrook, SC 853-945-3267

FIRST CHOICE SELECT HEALTH OF SOUTH CAROLINA, PROVIDER ROSTER FOR:

Member # 2435 WHITEHALL RD, APT 5 3456 LANTERN RD 3456 LANTERN RD 21 OAK BROOK RD P O BOX 76 2390 THRUSH LANE 32 CROSS KEYS ROAD 29 BLACK ROCK RD 4730 RAINEY BLVD 4730 RAINEY BLVD 23 ORCHARD ROAD 33 LEMON STREET 33 LEMON STREET 44 CHAINEY AVE. 22 RIVER ROAD 22 RIVER ROAD 892 JOHNS HIGHWAY CHARLESTON, SC 29406 N CHARLESTON, SC 29418 N CHARLESTON, SC 29418 CHARLESTON, SC 29407 JOHNS ISLAND, SC 29455 JOHNS ISLAND, SC 29455 JOHNS ISLAND, SC 29455 JOHNS ISLAND, SC 29455 JOHNS ISLAND, SC 29455 JOHNS ISLAND, SC 29455 CHARLESTON, SC 29407 HOLLYWOOD, SC 29449 WADMY, SC 29487 595-3476 876-0934 756-9032 786-4562 347-0920 347-0920 735-2013 578-3450 578-3450 578-5698 578-9874 578-9874 598-2345 HOLLYWOOD, SC 29449 985-7903 HOLLYWOOD, SC 29449 987-7151 F M F M F M F F F F M F F F F HOLLYWOOD, SC 29449 987-7151 M CHARLESTON, SC 29407 756-8510 F

Name

Address

City, State, Zip

Phone

Sex

DOB 1/10/1993 2/28/1986 5/23/1989 09/23/1992 3/8/1993 3/31/1987 10/31/1986 6/03/1988 01/20/2002 11/14/1988 10/28/1996 8/13/1989 12/18/1987 11/8/1991 9/24/1968 10/22/1992 10/22/1995

Member PCP Eff Age Eff Date 10Y 17Y 13Y 10Y 10Y 15Y 16Y 14Y 1Y 14Y 6Y 13Y 15Y 11Y 34Y 10Y 7Y

Date 11/1/2001 11/1/2001 1/1/2002 1/1/2002 1/1/2002 1/1/2002 1/1/2002 1/1/2002 11/1/1998 8/22/2001 1/1/2002 1/1/2002 12/1/2001 12/1/2001 11/1/1998 7/25/2001 6/1/2002 6/1/2002 5/1/2002 5/1/2002

1111111111

DOE, JANE

2222222222

DOE, JOHN

3333333333

DOE, JANE

Sample Provider/Member Roster

4444444444

DOE, JOHN

5555555555

DOE, JANE

6666666666

DOE, JOHN

7777777777

DOE, JANE

8888888888

DOE, JOHN

9999999999

DOE, JANE

1010101010

DOE, JOHN

1212121212

DOE, JANE

1313131313

DOE, JOHN

8/1/2002 11/20/200 2 5/1/2002 4/1/2002 5/1/2002 5/1/2002 5/1/2002 5/1/2002 6/1/2000 4/1/2002 4/1/2002 4/1/2002 4/1/2002 3/5/2002

1414141414

DOE, JANE

1515151515

DOE, JOHN

1616161616

DOE, JANE

1717171717

DOE, JOHN

1818181818

DOE, JANE

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Sample Provider/Member Roster

Total Membership for Provider/Group Service Address

17 Tax ID Number: 853670143

63

64

FIRST CHOICE SELECT HEALTH OF SOUTH CAROLINA, INC. CAPITATION CYCLE: 09/01/08

LINE OF BUSINESS: 2400 Anywhere, SC 28431 238 Main Street, Anywhere, SC 29425 Check Date: 09/01/08 Payee Tax ID: Net Amount: xxxxxxxxx $163.85 CAP EARN CAP AMT MM ADDRESS CITY, ST, ZIP PHONE PCP ID S E X A G E EFF DATE W/PCP MEMBER ADDRESS MEMBER ADDRESS MEMBER ADDRESS MEMBER ADDRESS MEMBER ADDRESS MEMBER ADDRESS North side Pediatric Primary Care CHARLESTON, SC 29403 N CHARLESTON, SC 29418 HOLLYWOOD, SC 29449 SUMMERVILLE, SC 29483 GOOSE CREEK, SC 29445 NORTH CHARLESTO, SC 29405 xxx-xxx-xxx xxx-xxx-xxx xxx-xxx-xxx xxx-xxx-xxx xxx-xxx-xxx xxx-xxx-xxx 30008961 30008961 30008961 30008961 30008961 30008961 F F F F F F 0 7 0 6 2 4 8/1/2002 12/31/20 11/5/200 2/1/2000 12/6/200 12/1/200 1/1/2003 1/1/2003 1/1/2003 1/1/2003 1/1/2003 1/1/2003 ($16.60) ($8.94) ($16.60) ($8.94) ($12.77) ($12.77) ($76.22) -1.00 -1.00 -1.00 -1.00 -1.00 -1.00 -6.00 2003020120400002 : PAGE: 2

SELECT HEALTH CAPITATION PAYMENT ROSTER

CHECK REFERENCE ID: 2003020120400002 CAPITATION TYPE: Primary PAYEE: 3000000 North side Pediatric Primary Care PO Box 72345 CAPITATED PROVIDER: 300001 Pediatric Medical Associates

Sample Capitation Payment Roster

Select Health of South Carolina Health Care Professional & Provider Manual

Exhibits: Sample Capitation Payment Roster

MEMBER NAME

MEMBER ID

Retro Term DOE, JANE DOE, JANE DOE, JANE DOE, JANE DOE, JANE DOE, JANE

225897592 122236895 445987562 224598775 225897522 225554789

Totals

Retro Term for

3000000

Sample Select Health Remittance Advice

Select Health of South Carolina PO Box 40849 Charleston, SC 29423-0849

SAMPLE ONLY

For further inquiries on this remittance advice contact: Select Health of SC, Inc. Airport Business Center 200 Stevens Drive Philadelphia, PA 19113 or call 800.575.0418

Forwarding Service Requested

JOHN DOE, MD 123 MAIN STREET ANYWHERE, SC 55555

Payee ID: 1234567 Tax ID: 123-45-6789 NPI #: 10111011011 Check #: 50000676 Check Ref: 20011002101019 Payment: 0.00 Date: 07/01/08

Remittance Advice

Provider ID Provider Name

Date of Service 12/1/03 - 12/1/03

123456 Doe, John

Proc/Rev/ DRG Code 99213 Mod

Member ID Member Name

Description Office or other outpatient visit Qty 001

987654321 Smith, Jane

Charged Amount 65.00 Allowed Amount 32.00

Patient ID Claim ID

OIC 0.00 Coins 0.00

27930108089 01227B042500

COB 0.00 Amount Paid 0.00

*COB*

Adj/Den R36

Interest Paid Prior Payment Claim Total 65.00 32.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00

Statement Total Please note that these sections are located at the end of the remit, after the Statement Totals.

Charged Amount 65.00

Allowed Amount 32.00

OIC 0.00

COB 0.00

Coins 0.00

Interest Payment 0.00

Deductible 0.00

Amount Paid 0.00 0.00 0.00 0.00 0.00

Claim Count 001 000 001

Claims Reversed Net General Claims Total Less Other Transactions Total Paid to Payee

Coordination of Benefits

Member Name Claim Number Other Insurance Address Group No. Policy No.

Payment Reduction Summary

Patient ID Date of Original Reduction Explanation Original Amount of Reduction Date of Service (#13) Provider Receipts Check Date (#14) Applied to Current Claims Check Number (#15) Claim Reduction Amount Recovered to Date Claim ID Provider Receipts to Date Remaining Balance

Messages R36 Capitated Service

The Payment Reduction Summary will now include the original Date of Service, Check Date andCheck Number.

Less Other Transactions captures payment retractions and other reductions, which are detailed in the Payment Reduction Section.

www.selecthealthofsc.com |Toll free 1.800.741.6605 | Charleston 843.569.1759

Exhibits: Sample Select Health Remittance Advice

65

Select Health of South Carolina | PO Box 40849, Charleston, SC 29423 | www selecthealthofsc com Provider Services 1 800 741 6605 Charleston 843 569 1759

Information

Health Care Professional and Provider Manual - Manuals - Providers - First Choice - Select Health of South Carolina

72 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

327064

You might also be interested in

BETA
HM LIFE INSURANCE COMPANY
untitled
Sample Letter claims underpayment
Physical Therapy.docx