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Tufts Medicare Preferred Provider Manual

Authorizations

Referral Authorizations

The Referral Authorization Request Form must be used to refer Tufts Health Plan Medicare Preferred HMO Members to specialty providers. This form demonstrates that the medical group has authorized the services indicated and allows the Tufts Medicare Preferred HMO Claims Department to reimburse the provider for services rendered. Internal referral management ensures that specialty care is provided only when medically appropriate and authorized by the medical group except in cases where the Member may self-refer for services. Note: Each medical group may determine its internal referral management process. Medical groups may choose to monitor utilization via the referral form or use a log system as a tracking mechanism. The following care and services require referral authorizations for claims payment:

· · Professional services in an outpatient setting of a clinic or hospital (excluding emergency services and urgently needed care). Outpatient contracted providers specialty care (excluding yearly routine eye care, routine OB/GYN services, mammograms, influenza, pneumococcal and hepatitis B vaccines, and services specified in a treatment plan) needed to treat serious and complex medical conditions. All non-contracted provider care (excluding emergency services, urgently needed care and renal dialysis services).

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Out-of-Area Services

Tufts Medicare Preferred HMO provides coverage without authorization to Members if they require emergency or urgently needed services, and also covers post stabilization services provided after an emergency to either maintain the stabilized condition or, under certain circumstances, improve or resolve the Member's condition. Post stabilization services are covered until one of the following occurs:

· · · · The Member is discharged (see Financial Programs). A contracting medical provider assumes responsibility for the Member's care. A contracting medical provider with privileges at the treating facility assumes responsibility for the Member's care. The non-contracting medical provider and Tufts Medicare Preferred HMO agree to other arrangements.

In some cases Members may be directed from an out-of-area provider to return to the out-of-area provider for a non-urgent or non-emergent follow-up visit. Any care outside of the Tufts Medicare Preferred HMO service area authorized by the medical group is the financial responsibility of the medical group.

Referral Authorization Process -- Tufts Medicare Preferred HMO

To ensure that appropriate specialty care is provided when medically necessary, the primary care provider (PCP) initiates and coordinates the referral management process as outlined in the following list:

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The PCP can authorize a standing referral authorization to a specialist in the Tufts Health Plan network indicating the specific services and number of visits to be provided to the Member when: - The PCP decides that such a referral authorization is medically necessary. - The specialist agrees to a treatment plan and provides the PCP with all necessary clinical and administrative information on a regular basis. - The health care services to be provided are consistent with the terms of the Member's benefit document.

· · · · ·

If the PCP is writing a referral to a non-contracted provider, the non-contracted provider must be participating with Medicare. Specialists must submit a summary report on a timely basis to the medical group following the Member's appointment. Any questions or problems regarding the referral authorization form should be directed to Tufts Medicare Preferred HMO Provider Relations at 1-800-279-9022. PCPs should not generate referral authorizations for urgent/emergency services. PCPs should contact the case manager (CM) to notify Tufts Medicare Preferred HMO of out-of-area care at 1-888-766-9818. Any non-urgent or non-emergent outpatient care outside the Tufts Medicare Preferred HMO service area reported to the case manager and authorized by Tufts Medicare Preferred HMO is the financial responsibility of Tufts Medicare Preferred HMO; if authorized by the medical group, care is the financial responsibility of the group. Any outpatient care outside the Tufts Medicare Preferred HMO service area (other than urgent or emergent care or renal dialysis services) requires approval by the PCP. If a contracting specialist provides a service without a referral authorization from the Member's PCP, the claim will be sent to the PCP for review and will be released for payment unless the PCP authorizes denial of payment.

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Notice of Financial Responsibility

Tufts Medicare Preferred HMO policy specifies that Members are responsible for obtaining referral authorizations for those services that require a referral. Contracting specialists have the right to bill Members who fail to obtain a referral authorization after the claim has been denied by Tufts Medicare Preferred HMO if the Member has signed a waiver regarding the services. For clarification of the procedures that contracting providers and facilities should follow prior to rendering care to Tufts Medicare Preferred HMO Members, see the Referral/Authorization Waiver Requirement. To confirm understanding of Tufts Medicare Preferred HMO policy, patients must sign the Notice of Financial Liability that notifies Members in advance that they may be financially responsible for the service. Contracting specialists cannot hold Members responsible for payment without having a signed copy of this notice.

Referral Report

On a weekly basis, Tufts Medicare Preferred HMO sends PCPs the 10-day business report listing all outstanding claims that are pending for referral/authorization (see the sample Notice of Attestation of Authorization and Denial of Payment and Business Report -- Claims Report for All Referrals Pending). Providers have the opportunity to authorize or deny claims payment based on this information. If providers deny payment of the service, they must send their response to Tufts Medicare Preferred HMO within 10 business days of receipt of the report for proper adjudication of the claim, which meets the CMS clean claims requirement of within 30 days of the claim receipt date. The Notice of Attestation of Authorization and Denial of Payment must accompany the report and must include a valid reason for a denial. The form must be signed and dated by the Member's PCP, a covering physician, or the medical director. Note that a stamped signature is not appropriate. After 10 business days, any claims for which a response is not received are considered authorized.

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The acceptable responses that can be returned on the report are:

· · · Member Self-Referred, Medical Documentation Reviewed, Non-Urgent / Non-Emergent. Referral authorization on file is exhausted (dates/visits), or Other (must be specified).

If Tufts Medicare Preferred HMO does not receive a response from a provider within 10 business days of receipt of the report, the claims listed on the report will be adjudicated for payment on the 11th day.

Completing the Referral Authorization Request Form

The Referral Authorization Request Form requires information about the PCP, the patient, and the consulting provider. The following steps are required to complete the referral authorization request process:

1. The PCP must complete the Referral Authorization Request Form with the required information as shown in the following sections: · · · Primary Care Provider Information. Patient Information. Consulting Provider Information.

Note: If any required fields are left blank, the form will be returned to the PCP for missing information.

2. The PCP distributes copies of the form as follows: · · · · White copy to Tufts Medicare Preferred HMO as indicated in the Tufts Health Plan Claims Submission Guidelines. Canary copy to the specialty provider. Pink copy for the PCP's files. Goldenrod copy to the patient.

· The Tufts Medicare Preferred HMO Claims Department receives the form and enters the referral authorization in the system.

3. Tufts Medicare Preferred HMO Reviewers check the date of service on the referral authorization and attach the matching claim for adjudication. 4. For claims with no matching referral authorization, Tufts Medicare Preferred HMO Analysts investigate. If no matching referral authorization is found, Analysts hold the claim for AUREQ: Authorization/Referral Required; REFEX: Referral on file has been exhausted; or REFPD: referral on file does not match provider and/or group. 5. The Tufts Medicare Preferred HMO Claims Department sends the Tufts Medicare Preferred HMO Claims Report (listing all referral authorization-pending outpatient physician, home health and custodial claims) to medical groups for their response to either authorize or deny payment of the service.

Primary Care Provider Information

Include the following:

· · · · · · · Provider name (first and last). Provider ID number and/or NPI (National Provider Identifier). Date service was requested. Date determination was made. Date prepared. Name of preparer. PCP signature. requesting additional information.

Note: All information is required. Otherwise, the referral authorization form may be returned to the PCP with a cover sheet

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Patient Information

Include the following:

· · · · · Name of patient. Patient ID number. Date of birth. Telephone number. Reason for referral/diagnosis.

Note: Patient name, ID number, and date of birth are required for authorization and claim payment.

Patient information is available from the following sources: · · · · · · · Member ID card. Tufts Medicare Preferred HMO Individual Election Form. Tufts Medicare Preferred HMO Provider Relations Department at 1-800-279-9022. Tufts Medicare Preferred HMO Monthly Eligibility Listing Report. Tufts Health Plan Web site. Point of Service (POS) device. Integrated Voice Response (IVR) system.

Consulting Provider Information

Include the following:

· · · · · · · · · Consulting provider name (first and last). Consulting provider ID number and/or NPI (National Provider Identifier). Address. Telephone number (optional). Specialty group name and ID number, if applicable. OFF = Office SDC = Surgical Day Care OPD = Outpatient Department OTHER = Specify

Circle the appropriate Setting of Care abbreviation:

Requested Service

You must enter a general procedure description or CPT/HCPCS codes for specific procedures. Use of CPT/HCPCS codes is optional when procedure is not specified.

· · · · · · · Evaluation ONLY (1 visit). Second Opinion (1 visit). Evaluation and Treatment, Authorizes Hospitalization or Ambulatory Procedures (1 visit). Evaluation/Treatment/Follow-up (2 visits), Authorizes Hospitalization or Ambulatory Procedures. Multiple Visits (indicate number). Restricted Authorization/FOR SPECIFIC PROCEDURE(S) ONLY. Enter the procedure(s) name, and/or use the CPT/HCPCS codes.

Notes · The referral authorization is valid for one year if no time frame is specified. · The type of service must be marked to identify authorized visits. Otherwise, the referral authorization will default to one visit.

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Information from PCP to Accompany Referral Authorization

Enter the reason for the referral authorization and the primary diagnosis.

To Consulting Specialty Provider

This is a preprinted reminder to the consulting provider. No action is required by the referring office.

Physician Group Use Only

This field is for the medical group's internal use. The Member is authorized for treatment after the Utilization Management (UM) Committee has reviewed, approved and completed this section. It is not required for claim payment.

Distribution

If the PCP office does not submit referral authorizations electronically, the PCP office is responsible for distributing the four copies of the referral authorization form as follows:

White: Canary: Pink: Goldenrod: Tufts Medicare Preferred HMO Specialty Provider Primary Care Provider Patient

Electronic Referral Authorization Exclusions

Tufts Medicare Preferred HMO referral authorization policies apply to electronic referrals. However, certain services and/or specialties do not require referral authorizations, or they require alternative prior authorization or preregistration. Referral authorizations for the following should not be submitted electronically:

· · · · · · · · · · · · Mental health/substance abuse. Admission to any facility. Home care / durable medical equipment. Visiting Nurse Association (VNA). Oral surgeon, group or clinic. Community health center. Social worker / group. Ambulance services. Clinical specialist / group. Hospice provider. Home rehab / skilled nursing facility. Out-of-plan services.

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Services Not Requiring a Referral Authorization

Services not requiring a referral or prior authorization include the following:

· Emergency services: Covered inpatient or outpatient services that are furnished by an in-plan or out-of-plan provider who is qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition. Emergency medical conditions manifest themselves by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child, (2) serious impairment to bodily functions, or (3) serious dysfunction of any bodily organ or part. · Urgently needed services: Covered services provided when a Member is temporarily absent from the Medicare Advantage plan's service area when such services are medically necessary and immediately required (1) as a result of unforeseen illness, injury, or condition, and (2) it was not reasonable given the circumstances to obtain the services through the organization offering the Medicare Advantage plan. Routine care by plan providers: - OB/GYN care by in-plan providers (care including but not limited to mammography screening, pap smears, pelvic and breast exams). - Hearing and vision exams. - Colorectal and prostate screening exams. · · · · Observation care: Care by an attending physician who admits a patient for observation, or care by a physician who is consulting for a patient in observation. Certain vaccines administered by plan providers (for example, influenza, pneumococcal, and hepatitis B vaccines). Renal dialysis services. Qualifying clinical trials: Original Medicare covers routine costs of qualifying clinical trials. The Member is responsible for paying an Original Medicare cost-sharing amount for these services. A Member does not need to obtain a referral authorization to join a clinical trial and is not required to see in-network providers. However, it is recommended that the Member inform Tufts Medicare Preferred HMO before he or she starts a clinical trial. That way, Tufts Medicare Preferred HMO can keep track of the Member's health care services. Further information regarding clinical trials is included in these publications: - Medicare Clinical Trial Policies. - Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 310.1, "Routine Costs in Clinical Trials." - Tufts Medicare Preferred HMO Evidence of Coverage (EOC).

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Special Authorization Rules

Medicare-Approved Facility Requirement

Medicare has issued several national coverage determinations (NCDs) providing coverage for services and procedures of a complex nature, with the stipulation that the facilities providing these services meet certain criteria. These criteria usually require, in part, that the facilities meet minimum standards to ensure the safety of beneficiaries receiving these services. Certification as a Medicare-approved facility is required for performing the following procedures. See the Medicare National Coverage Determination Manual (NCD manual) for coverage criteria:

· · Lung volume reduction surgery: NCD manual, Section 240. Carotid artery stenting (CAS) with embolic protection: NCD manual, Section 20.7. Note that this requirement does not apply to CAS performed in a Medicare-covered Category B IDE study or post-approval study. Ventricular Assist Device (VAD) destination therapy: NCD manual, Section 20.9. Bariatric surgery: NCD manual, Section 100.1.

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In addition to these procedures, there is also a long-standing requirement that all heart, heart-lung, liver, intestinal/multivisceral, kidney, and pancreas transplants be performed at a Medicare-approved facility. The transplant work-up evaluation must also be performed in a Medicare-approved transplant facility. Refer to the following information in CMS to determine if a facility is Medicare-approved to perform a particular service.

· · · LVRS, bariatric surgery, carotid artery stenting with embolic protection, and VAD as destination therapy: See http://www.cms.hhs.gov/MedicareApprovedFacilitie/ Heart, heart-lung, lung, liver, and intestinal transplants: See http://www.cms.hhs.gov/ApprovedTransplantCenters/ Kidney and pancreas transplants: See http://www.cms.hhs.gov/ESRDGeneralInformation/02_Data.asp#TopOfPage

Not all Tufts Medicare Preferred contracted providers who perform these services are Medicare-approved. Tufts Medicare Preferred will not pay for services rendered at a non-Medicare-approved facility and contracted providers cannot hold the Member liable for these services. For a listing of Medicare-approved facilities that are also contracted with Tufts Medicare Preferred for each of the services above, refer to the Tufts Health Plan Medicare Preferred Medicare Approved Facilities document, available on the Tufts Health Plan Web site at www.tuftshealthplan.com. In addition to the Medicare-approved facility requirement, all plan precertification, authorization, in-network and out-of-network plan rules apply. Medical groups must be sure Members are referred only to Medicare-approved facilities for these services. To the extent a medical group/PCP is involved in referring a Member to a non-Medicare-approved facility, the medical group will be financially liable for the associated costs. Because these services must be provided in a Medicare-approved facility to be covered, the costs of services in a non-Medicare-approved facility cannot be paid using Medicare funds.

Home Care Authorization Policy

Authorization for home care services by delegated medical groups must be noted on the Home Care/DME Log and submitted to the Tufts Medicare Preferred HMO Claims Operations Department to ensure claims payment. Authorizations for non-delegated groups are entered directly into the case management documentation system by the case management department after authorization by the Tufts Medicare Preferred case manager. Tufts Medicare Preferred case managers and delegated case managers are instructed to use the Medicare coverage criteria as well as the Tufts Medicare Preferred HMO Evidence of Coverage (EOC) to determine benefit coverage for these services. Authorizations are reviewed with the PCP/group medical director as needed to make final coverage decisions. To submit referrals/authorization in hardcopy format using the Tufts Medicare Preferred HMO Medical Group Homecare Authorization Log (available at www.tuftshealthplan.com/providers), the following procedures must be followed:

· · · · The case manager is responsible for completing the Homecare Authorization Log. The log must be legible (typed forms and printouts are preferred). Updated logs are submitted to the Tufts Medicare Preferred HMO Claims Operations supervisor, at least weekly, to enter into the claims system for payment. All fields must be completed.

On a daily basis, Tufts Medicare Preferred HMO Claims may send requests to the Tufts Medicare Preferred case manager or delegated case manager regarding homecare services, because Tufts Medicare Preferred was unable to identify an authorization for such services, or the authorization on file does not cover all services.

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Delegated case managers will receive a Delegated Medical Group Authorization Form that gives the medical group the opportunity to authorize or deny claims payment.

· If payment of a service is denied, this denial must be sent to Tufts Medicare Preferred HMO within 10 business days of receipt of the form for proper adjudication of the claim, which meets the CMS clean claims requirement of within 30 days of the claim receipt date. If Tufts Medicare Preferred HMO does not receive a response within 10 business days of receipt of form, the claim will be paid on the 11th business day.

·

Non-delegated case managers will receive such requests through established internal Tufts Health Plan communication methods.

Medications Covered by Original Medicare

Tufts Medicare Preferred covers all drugs covered by Original Medicare. Note: Medications covered by Original Medicare are not part of the Member's Part D prescription drug benefit. Original Medicare-covered medications include the following:

· Drugs that usually are not self-administered by the Member and are injected while receiving physician services. For additional information, see the Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 50.2, "Determining Self-Administration of Drug or Biological." · · · · · · · · Drugs Members take using durable medical equipment (such as nebulizers) that were authorized by Tufts Medicare Preferred HMO. Clotting factors Members give themselves by injection if they have hemophilia. Immunosuppressive drugs, if the Member had an organ transplant that was covered by Medicare. The Member is responsible for 20% of the Medicare-approved charge for covered immunosuppressive drugs. Injectable osteoporosis drugs, if the Member is homebound, has a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self-administer the drug. Antigens. Certain oral anti-cancer drugs and anti-nausea drugs. Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, Erythropoietin (Epogen) or Epoetin alpha, and Darboetin Alpha (Aranesp). Intravenous Immune Globulin (IVIG) for the treatment of primary immune deficiency disease in the Member's home.

Additional Drug Coverage

Other outpatient prescription drugs are covered by Tufts Medicare Preferred HMO, such as antibiotics and high blood pressure medication for Members enrolled for Medicare Prescription Drug Coverage. This benefit is explained in Section 6 of the Tufts Medicare Preferred HMO Evidence of Coverage (EOC). This section also includes information about which drugs are not covered under this benefit.

Pharmacy Medical Review Requests

If you are requesting a formulary or tiering exception for a Member, you must provide a statement to support your request. You can submit the request using the Tufts Health Plan Universal Pharmacy Medical Review Request Form or the Medicare Part D Coverage Determination Request Form, available at www.tuftshealthplan.com.

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Tufts Medicare Preferred Provider Manual

The form requests information regarding diagnosis and what other drug, if any, has been prescribed for the diagnosis and why it has not worked. You can submit the form in two ways:

· · Fax the completed form to: 1-617-972-9409 Mail the completed form to: Tufts Medicare Preferred 705 Mount Auburn Street Watertown, MA 02472 Attention: Precertification Department

You can also provide an oral supporting statement by calling Tufts Health Plan Medicare Preferred Provider Relations at 1-800-701-9000 (TDD 1-800-208-9562), Monday - Friday, 8:00 a.m. - 8:00 p.m. Standard review requests must be made within 72 hours from the time the Tufts Medicare Preferred Precertification Department receives the request with supporting statement from the prescribing provider. Expedited review requests must be made within 24 hours from the time the Tufts Medicare Preferred Precertification Department receives the request with supporting statement from the prescribing physician. Tufts Health Plan's Precertification Department reviews the information submitted on the request form and can either approve or deny the request. If the Precertification Department denies the request, the Member can appeal the decision. For additional information about Member appeals, see Grievances, Organization Determinations, and Appeals.

Support Documents

The following sample documents (such as forms, letters, policies, reports) support the information in this chapter. · Referral Authorization Request Form · Notice of Attestation of Authorization and Denial of Payment · Business Report -- Claims Report for All Referrals Pending · Delegated Medical Group Authorization Form

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Figure 1:

Referral Authorization Request Form

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Figure 2:

Notice of Attestation of Authorization and Denial of Payment

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Figure 3:

Business Report -- Claims Report for All Referrals Pending

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Tufts Medicare Preferred Provider Manual

Figure 4:

Delegated Medical Group Authorization Form

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Chapter last updated 01/2010. Revision dates may not be reflective of actual policy changes. 14 Tufts Health Plan Medicare Preferred www.tuftshealthplan.com/provider

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